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What is Diabetes Mellitus?
- A chronic multi-system disease related to abnormal insulin production or impaired insulin
What are the 4 risk factors for type 1 diabetes?
•Medication Induced; removal of pancreas
Does Type 1 Diabetes pts have insulin?
Absent or insufficient insulin
What are the 8 risk factors for type 2 diabetes?
–Family Hx. of diabetes
–Obesity esp. abdominal and visceral adiposity.
- •Hispanics more prone to having diabetes
–GDM or babies > 9 lbs.
- –HTN > 140/90 mm Hg
- •73% of adults will have
–Triglycerides > 200mg/dL
–Prev. impaired glucose tolerance
BMI greater than what is a risk factor for type 2 diabetes?
HTN greater or equal to what, you are at risk of type 2 diabetes?
What are the 3 Metabolic processes?
What is glycolysis?
Glycolysis: the process through which glucose is broken down into water and carbon dioxide with the release of energy
Why are the 3 metabolic processes important?
They are important in ensuring a supply of glucose for body fuel.
What is glycogenolysis?
the breakdown of stored glycogen (from the liver or skeletal muscles)
Glycogenolysis is controlled by what 2 hormones?
epinephrine and glucagon
What does epinephrine do?
Epinephrine breaks down glycogen in the muscle
What does glucagon do?
breaks down glycogen in the liver
What is gluconeogesis?
- The building of glucose from new sources like amino acids, lactate and glycerol can
- be converted into glucose.
What 3 hormones stimulate gluconeogensis?
Glucagon, Glucocorticoids, Thyroid
Where does gluconeogensis mostly occur?
What do counterregulatory hormones do?
They work to oppose the effects of insulin. These hormones work to increase blood glucose levels by stimulating glucose production and output by the liver and decreasing the movt of glucose into the cells.
What are the 4 counterregulatory hormones?
What does insulin do?
- Controls blood glucose levels by regulating glucose production and storage in the liver
- and muscle
Beta cells produce what?
produce insulin in the islets of langerhans
When is insulin normally released?
normally released in small increments when food is ingested
How can the amount of insulin a person is secreted be tested?
The amt of insulin a person is secreting can be tested by checking the levels of C peptide
What is the stimulus for insulin?
high blood glucose
- Depends on what blood sugars are on
- how much the body is going to be making insulin
2nd beta cell hormone
What are the two effects of amylin?
- •Amylin and insulin work together to
- suppress the secretion of glucagon by the liver
- •Amylin slows the transfer of nutrients to
- the intestine
Glucagon acts in the opposition of what?
What is produced by the alpha cells?
What does glucagon stimulate?
Stimulates the break-down of glycogen and fats to glucose and promotes gluconeogensis from fats and proteins.
What are the two catecholamines?
epinephrine and norepinephrine
Epinephrin and norepinephrine maintain glucose levels during stressful situations by?
Inhibiting insulin release and decreasing movement of glucose into the cells
How many types of diabetes are there?
Type 1, type 2, gestational
Secondary diabetes is due to what?
injury to the pancreas
–Form estrogen containing preparations
–Once you stop the medication or correct the problem then the blood sugar should go back to normal
Pre-diabetes is a fasting blood sugar of what?
Type 1 diabetes involves destruction of what?
Destruction of their pancreatic cells, genetic, immunologic, and possibly environment
Destruction of beta cells by auto immune antibodies= what?
no insulin= rapid onset=life-threatening condition called DKA
Type 1 diabetes used to be called what?
•Used to be called juvenile diabetes
•Insulin dependent diabetes mellitus (IDDM)
•Now known as Type 1
Dramatic weight loss is associated with which type of diabetes?
Type 1 Diabetes
What are the reasons for weight loss in type 1 diabetes?
–2. Loss of fluids from vomiting
- –3. Loss of body tissue because body has to use fat stores and cellular protein as
- fuel source because of lack of insulin.
Does type 1 diabetes have a slow or rapid onset?
What are the 3 P's?
Which type of diabetes are they a S/S of?
–Polydipsia- extreme thirst caused by dehydration
–Polyuria produced by osmotic effect of glucose, glycosuria >excessive loss of F & E > dehydration
- –Polyphagia-cellular malnutrition body starving for energy turns fat to fat
- stores and protein
type 1 diabetes
Weakness and fatigue are a manifestation of which type of diabetes?
type 1 diabetes
Honeymoon phase (remission) is a characteristic of which type of uncontrolled diabetes?
uncontrolled type 1 diabetes
What is honeymoon phase (remission)?
- time of diagnosis of type 1 with symptomatic hyperglycemia
–Remaining functioning beta cells heavily stressed.
- –Once insulin is started cells recover reducing insulin injections but is only
How long does honeymoon phase (remission) last?
–Honeymoon lasts only a short time weeks to months before needing insulin again.
Why can hypoglycemia occur many hours after exercise with type 1 diabetes?
- (Up to 48 hours) due to depletion of glycogen stores is a contributing factor of
How many grams= 1 carb
If a type 1 diabetic pt is going to exercise what should you do?
- •Need to monitor BS before, during and after exercise to determine alterations in
- food or insulin
•Food amount varies from person to person.
If a type 1 diabetic is participating in long periods of exercise what should you teach the pt to do?
- –Check blood sugar before, during and after exercise period and snack on carbohydrate
- snacks as needed to maintain blood glucose level.
Which diabetes is the most prevalent and most common?
Type 2 diabetes
Does type 2 diabetes have a rapid or gradual onset?
What is the #1 predictor of type 2 diabetes?
What are the two main problems with type 2 diabetes?
–Impaired insulin secretion
- –Inappropriate glucose production by liver
–Alteration in the production of hormones and cytokines by adipose tissue.
Comparison and contrast of type 1 & 2
S/S of type 2 diabetes
•Recurrent vaginal yeast infections
•Prolonged wound healing
A1C greater or equal to what is positive type 2 diabetic?
greater than or equal to 6.5%
What is a fasting plasma glucose?
test done to test for type 2 diabetes, fast 8 hrs prior to being testing and if you have 2 tests that are greater than or equal to 126 mg/dL you have diabetes
A two hour oral glucose tolerance testing is done to test for what?
What are the levels that means your a diabetic?
Test for being a diabetic. You admin glucose and then test every hour to see what it is doing to your levels
Greater than 200 mg/dL using a 75 g glucose
What lab values are positive for a diabetic for a casual plasma glucose?
Greater than or equal too
What history assessment do you want to look into for a Diabetic pt..
–Signs related to Dx. Of DM
- –Signs- hyperglycemia
- •How often are they having these symptoms and do they know s/s
- •How often are they having these symptoms and do they know s/s
–Monitor frequency, timing, severity and resolution
–Status of symptoms
- –Adherence to Tx. Regimen
- •Are they taking their meds and what kind
- –Lifestyle.Culture, psychosocial and economic factors
- •What do they do for a living
–Effects of complications
A physical exam should include what things for a diabetic pt?
–B/P sitting and lying-(orthostatic chg.)
–Dilated eye exam
- –Oral exam
- •Recommend they see a dentist q 6 months, brush teeth 2x a day, floss
What is A1C?
glucose testing from blood cell over the last 120 days (3-4 months)
What labs and other things do you need to do if monitoring a diabetic pt?
- –Hgb A1C
- –Average over the past 120 days of blood glucose
- –Fasting lipid profile
- –Cholesterol elevated, triglycerides, low
- HDL, high LDL
- –Check for proteins bc protein damage in
- the kidneys
- –Damage filtration site of the kidney
- –Serum Creatine
- –Checking kidney fxn
- –Making sure they don’t have a UTI
- –Bc they have a higher risk of
- cardiovascular problems
- –Referrals-Opthal., Podiatry, Dietician
- –Ophthalmologist- seeing if they have
- retinopathy, need to have dilated
- eye exam to look at back of the eye and
- look at blood vessels and see that they
- are not bleeding
- –Podiatrist- take care of feet, cut nails
- –Dietician: they need to have an
- individualized meal plan that works for
- –Need to reduce 500 calories a week
- to lose a pound a week
- Baking, grilling, boiling, steaming is
- good. Frying is bad
What are the goals for treatment for a diabetic pt?
•Be an active participant
- •To experience few or no episodes of acute
- hyper/hypoglycemia emergencies
•Maintain BS levels as close to normal
•Prevent, minimize or delay complications
•Adjust lifestyle to decrease stress
What is the recommended weight loss percentage and exercise recommendation for a diabetic pt?
- DPP showed a modest wt. loss of 5-10% of body wt. with regular exercise-30 min
Metabolic syndrome is increased with type 2 DM and is characterized by what?
•Elevated insulin levels
•Decreased HDL levels
•Increased LDL levels
What is metabolic syndrome?
Recommended lipid (cholesterol) levels
HDL, LDL, Tryglycerides
- •Total Cholesterol < or equal to 200mg/dl
- –HDL < or equal to 50 mg/dl
- –LDL < 100mg/dl (<70mg/dl ideal)
- –Triglycerides < or equal to 150
What is the cause of secondary diabetes?
- –Damage/injury/interference or destruction
- of pancreas
- •Recurrent pancreatitis
- •Use of parenteral nutrition (TPN)
- –Has a lot of calories, a lot od sugar
- –Pt taking steroids
Medications that can cause secondary diabetes include:
- –Resolves when treatment of underlying
- condition is treated
What are the 5 components of diabetes management?
- –Any kind of movement is better
- than no movement
- •March in place
- •Pharmacologic Management
- –They have to take the medication that
- is working for them. If it isn’t
- working, they need to go back and
- see Dr.
Only what kind of insulin is used?
What is conventional therapy?
One or more injections of short and intermediate insulin
What is intensive therapy?
–Three injections of rapid acting insulin
–Plus a long acting insulin
What are the major types of insulin?
Humalog, Novolog (LISPRO, Aspart, Glulisine are what classification of insulin?
Rapid, acting insulin
What is the onset of rapid-acting insulin?
Onset 10 – 30 min.
What is the peak of rapid-acting insulin?
Peak 60-120 min
What is the duration of rapid-acting insulin?
Duration 3-6 hrs
What is rapid- acting insulin used for?
- reduce glucose level
- –Treat postprandial hyperglycemia
- –Happens 2hrs after eating
–Prevent nocturnal hypoglycemia
Name the 4 short-acting insulins.
Humulin R, Novolin R, ReliOn R, Aprida
What is the onset of Short-acting insulin?
Onset: 30 minutes- 1hr
What is the peak of short-acting insulin?
peak 2-4 hrs
What is the duration of short-acting insulin?
Duration: 4-6 hrs
When should you administer short-acting insulin?
20-30 mins before eating
If mixing a short-acting with NPH, which do you draw up first?
you draw up the Regular short-acting insulin before NPH
Clear to Cloudy
Name the Intermediate- acting insulins:
NPH, Novolin N, Humulin N, ReliOn N
NPH is the only ____ insulin?
cloudy, roll the vial between hands to mix
What is the onset of NPH?
Onset 1-2 hrs
What is the peak of NPH?
Peak 4-12 hrs
What is the duration of NPH?
Duration: 16-24 hrs
When should NPH be taken?
30-45 minutes before they eat
What are the long-acting insulins?
•Glargine (Lantus) clear
•Detemir (levemir) clear
What is the onset of long-acting insulins?
Onset 1-2 hours
What is the peak of long-acting insulins?
What is the duration of long-acting insulins?
12-24 hrs +
You should not get hypoglycemia with which type of insulin? Why?
Long-acting insulin bc it has NO PEAK and is around for a long time
You cannot mix what type of insulin with other insulins?
Which insulin cannot be prefilled?
What does insulin effectiveness reflect?
effectiveness depends on the clients absorption of the drug
Insulin can be stored at room temp for how many days?
Insulin should be stored where until it is ready to be distributed to a pt?
in the refrigerator until expiration date
Pre-filled pens last how many days, where?
30 days in the refrigerator
Pre-filled pens with insulin mixture are usually good for how many days?
What two alterations should you avoid with insulin?
–In and out of refrigerator
–Don’t leave in hot car
REMEMBER: don't keep insulin in glove box and have pens handy at all times
If insulin has flocculation (whitish coating) before being opened, what should you do?
Return to pharmacy
If insulin has flocculation (whitish coating) after it has been used once, what should you do?
Should not do what two things with insulin?
Freeze or keep out in direct sunlight
It is recommended that you do not use the dame sit for insulin injections more than how many times in how many weeks?
more than once in 2-3 weeks
You should not inject insulin into?
a limb that will be used to exercise
Best practice says to use which site and when?
use same anatomic area at the same time of the day
Which 4 sites can you inject insulin?
•Abdomen- more stable and rapid absorption
•Arms- posterior surface
•Thighs anterior surface
What are the types of syringes available for insulin injection?
–1 ml-holds 100 units
–0.3 ml-holds 30u
It is important that insulin syringes selected match what?
What the 4 complications with insulin therapy?
•Local allergic reaction(itching, erythema, and burning around inject site
•Systemic allergic reactions-hives (urticaria and antiphylactic shock)
•Insulin lipodystrophy(atrophy of tissue)
How long does lipodystrophy last?
6 months, do not use that are during that time
Teach to rotate sites to prevent what?
What are the 3 causes of morning hyperglycemia?
- •Dawn Phenomenon-hyperglycemia that
- is present when awakening from release of counterregulatory hormones in the predawn hours. (growth hormone)
•More severe when growth hormone is peaking (Adolescence and young adulthood)
•Treatment- adjustment in timing of insulin or an increase in insulin
Elevated blood sugars require what?
What is the Dawn Phenomenon?
Phenomenon-hyperglycemia that is present when awakening from release of counterregulatory hormones in the predawn hours. (growth hormone)
What is the Somogi Effect?
–Rebound effect –overdose of insulin produces hypoglycemia
–During the hours of sleep
- –Counterreglatory hormones released, stimulate lipolysis, gluconeogensis, and
- glycogenolysis and in turn produce rebound hyperglycemia and ketosis.
How do you know if you have Dawn-phenomenon?
Relatively normal blood glucose until about3 AM, when the level begins to rise
What can you do to prevent morning hyperglycemia?
•Insulin Waning- progressive rise in glucose from bedtime until morning
–Can occur if evening NPH dose is taken before dinner
–So...Move evening dose of NPH or basal acting insulin to bedtime
What are the two Glitazone sister and what do they do?
- –Actos (pioglitazone)
- •Improve muscle receptor sensitivity to
- insulin with 2nd effects in the liver
- •May slow progression of disease
- –Avandia (rosiglitazone)
- •Restricted distribution program (MI
- –Ristricted but still can be used with
What are the problems with Gliatzones (Actos)?
Volume expansion, heart failure, anemia, weight gain (peripheral not central)
Bigger Problem?? Can exacerbate CHF
What are the old oral medications used for diabetes?
- –Glipizide ( Glucotrol), glimipride ( Amaryl)
- •Increase secretion of insulin by pancreas
- •Increase receptor sensitivity
What are the problems with Sulfonylureas?
- Weight gain, hypoglycemia
- --Be careful with the elderly who don't eat and aren't as active
What is the #1 oral medication for diabetes??
Metformin (Glucophage) Biquanide
What does Metformin(Glucophage) Biquanide do?
–Decreased hepatic glucose production
–Increases glucose uptake by muscle
–Increase insulin sensitivity
–Lowers B/P; Increase HDL; Lowers LDL
What is the problem with Meformin?
•GI Blues bloating
•Need functioning organs, especially kidneys and heart
- –Avoid in patients with S/S CHF, heavy alcohol use
- –Hold 48 hrs. before IV contrast dye and 48 hrs. after
- –COMPLICATION- lactic acidosis- DEADLY
People who take which oral diabetic medication tend to lose weight?
What does Byetta- Exenatide do?
–Synthetic peptide stimulates release of insulin from pancreatic B cells.
–Suppression of glucagon, decrease glucose from liver
–Slowing of gastric emptying
- –Not indicated with insulin use
- –Administer SubQ
- –Come form the saliva of gila monster
- –People who take this tend to lose weight
- –Not an insulin
What is a once glucagon like peptide?
Victoza is indicated as an adjunct to diet and exercise to improve what in who?
Indicated as an adjunct to diet, and exercise to improve glycemic control in adults with Type 2 DM
Victoza should be administered how?
Pts also tend to lose weight while on?
Victoza come in what?
Pre-filled multiple dose pen
•Doses- 0.6mg;1.2mg; or 1.8mg
Orak agents for type 2 Diabetes?
What are the 4 benefits of exercising?
•Lowers blood glucose
•Decrease Cardiovascular risk factors.
•Psychological well being.
•Improvement in insulin secretions.
Before starting any exercise regimen it is important to get it approved by who?
their healthcare provider
How does exercise lower blood glucose?
–Increases uptake of glucose by body muscles
–Improves insulin sensitivity
–Improves circulation and muscle tone
How does exercise decrease cardiovascular risk factors?
–Improved functioning of the cardiovascular system.
–Improved strength and physical activity capacity
–Reduced risk factors of coronary artery disease
Resistance strength training increases ____ ____ ____ thereby increase resting ____ ____.
lean muscle mass
Exercise helps to decrease what 3 things?
Also helps to decrease weight, decrease stress, and maintains well being.
Exercise alter blood ___ levels?
How does exercise alter blood lipid levels?
–Increases levels of high density lipo-protein (HDL)
–Decreases total cholesterol and triglyceride levels
- Important to patients with diabetes with
- an increase risk of cardiovascular disease.
If blood glucose levels are what you should not exercise until they come down to a normal range?
greater than 250 mg/dL
It is important that diabetic pts have what kind of shoes when exercising?
proper fitting shoes
If a pt has what in their urine they should not exercise?
•Should not exercise until urine test negative for ketones
When is the best time to exercise?
1-2 hrs after a meal
Exercise does what to blood glucose?
Exercising increases blood glucose when it is elevated prior to exercising
How does exercising increase blood glucose?
Exercising increases the secretion of glucagon, growth hormone and catecholamines
- Liver releases more glucose resulting in
- an increase in blood glucose level.
Carbs need to be replaced during exercise, True or False?
What does exercise do for obese people with type 2?
–Exercise and dietary management improves glucose metabolism and enhances loss of body fat
–Improves insulin sensitivity and may decrease the need for insulin or oral agents.
What are the 3 recommendations for exercising?
•Exercise at the same time each day.
•Exercise the same amount of time each day.
•If patient has diabetes complications, alter the exercise type and amount as necessary. Increased B/P assoc. with exercise may aggravate diabetic retinopathy
How many minutes a day is recommended to exercise? Can you break this time up?
30 mins a day and yes you can break this time up
Exercising can cause hemorrhage to what part of the body?
eyes, so make sure you know your pts risk
True or False, you should start slowing and gradually increase your exercise?
ADA recommendations of physical activity?
The ADA recommends to advise people with to perform at least 150 min/wk of moderate-intensity aerobic physical activity (50-70% of max. heart rate), spread over at least 3 days a week with no more than 2 consecutive days w/o exercise
In absence of contraindications, people with type 2 DM should be encouraged to perform resistance training at least 2 times per week
Is self-monitoring of blood glucose recommended by the ADA?
Yes, Blood glucose monitoring is a cornerstone in diabetes management
When picking a glucometer, what should the pt consider?
Glucometers-Pick the one that best suits the patient. Consider ease of use, skill level,cost of strips, visual numbers etc….
Potential hazards of SMBG- patients may report erroneous blood glucose values as a result of using incorrect technique such as what 4 things?
•Improper application of blood-most common
•Improper meter cleaning
•Damage to reagent strips
•Coding of meter
The newer glucometers do not require what two things?
cleaning or coding
When a pt receives a glucometer it is essential that a nurse does what after explaining to the pt about it?
Nurses should evaluate the technique of patient’s while they use the SMBG for the first time
Candidates for SMBG include what 5 types of pts?
•A tendency for hypoglycemia
•Patients on insulin
- •During illness
- –Illness leads to higher blood glucose
What 5 things are the diabetics pts using SMBG really monitoring for?
–To identify and treat hypoglycemia
–To make decisions regarding food intake and med adjustment when exercising
–Determine the effect of food/glucose
–To manage intermittent illness
What is glycated hemoglobin?
•Referred to as HgbA1c or A1C
•Reflects average blood glucose levels over a period of approximately 2 to 3 months, (ADA, 2004)
3.8-6.3 Normal =
BS > 300
An acute complication of a diabetic pt is?
Hypoglycemia-Abnormally low blood glucose level 50-70mg/dL)
What are the cause of hypoglycemia?
–Too much insulin or oral hypoglycemic agents
–Too little food or excessive exercise
- –Delayed or skipped meals
- •Should eat at same time and amount
- –Only way they will know if what they
- are doing is working
Why is hypoglycemia an issue with the elderly?
Bc of their decreased appetite
What are the 3 acute complications of diabetes?
•Diabetic Ketoacidosis (DKA)
•Hyperglycemia Hyperosmolar Nonketotic Syndrome (HHNS)
What is adrenergic hypoglycemia?
Mild hypoglycemia- sympathetic nervous system is stimulated- surge of epinephrine and norepinephrine
What are the S/S of adrenergic hypoglycemia?
S/S- sweating, tremor, tachycardia, palpitations, nervousness, and hunger.
What is moderate hypoglycemia and what system does it include?
Central nervous system
Moderate hypoglycemia- deprives the brain cells of needed fuel for functioning
What are the S/S of moderate hypoglycemia?
S/S- inability to concentrate, headache, lightheadedness, confusion, memory lapse, numbness of the lips and tongue, slurred speech, impaired coordination, emotional changes, irrational or combative behavior, double vision and drowsiness
What are the 6 cause of hypoglycemia?
•Frequent insulin adjustment
•Irregular timing of insulin dosage
•Failure to lower dose when eating less
•Irregular timing of meals
•Delaying of meal after taking insulin
Treat hypoglycemia using the rule of what?
Rule of 15?
What 3 things should you teach a hypoglycemic pt?
–Teach patients to carry some form of simple sugar with them at all times.
–Avoid over treating hypoglycemia
–Consistent pattern of eating and administering of insulin
For pts who are unconscious and cannot swallow, you should give what?
Glucagon 1 mg injection can be given sub q
It is important to give a pt what after glucagon? Why?
Remember: pt is given complex carbohydrate after to help restore liver glycogen and prevent continued hypoglycemia
What is hypoglycemia unawareness?
–No warning signs and symptoms of hypoglycemia
Why is hypoglycemia unawareness not good?
Increase risk of dangerously low BS
What drug masks symptoms of hypoglycemia?
- Beta Blockers (olol) propranolol (Inderal)
- –Mask S/S of low blood glucose
Hypoglycemic unawareness is related to what kind of neuropathy?
- Autonomic neuropathy:
- Gastroparesis can present itself with
- bloating after eating.
- •Unexplained swings of
What are the 3 potential complication of hypoglycemia unawareness?
•Fluid Overload- Administering fluids rapidly to treat DKA or HHNS
- •Hypokalemia-due to treatment of DKA-loss of potassium- may need K+ replacement
- -- May result form dehydration and excess urine output
•Cerebral Edema-cause unknown, may be by rapid correction of hyperglycemia- resulting in fluid shift- assess mental status.
What is diabetic ketoacidosis?
A metabolic derangement in type 1 diabetes that results from deficiency of insulin, highly acidic ketone bodies are formed, resulting in acidosis, requiring hospitalization for treatment. IV fluids and insulin drip.
DKA is mostly seen in who, when?
Seen mostly in adolestants, a lot of young girls don’t want to gain weight from insulin so they stop taking insulin and go into DKA.
Patho of DKA
Insulin deficit promotes metabolism of fat stores which produce large amounts of acidic ketones leading to metabolic acidosis
What are the 3 causes of DKA?
–DKA caused by an absence or markedly inadequate amounts of insulin.
–Disorders in the metabolism of fats, CHO, and proteins.
–Illness or infection
How does illness or infection cause DKA?
Insulin resistance→Increase hormones (glucagon, epinephrine cortisol)→increase glucose production by liver→ interfere with glucose usage by muscle & fat tissue.
- Undiagnosed and untreated DKA may be initial manifestation of
If a pt is N/V, replace fluids with what?
carbohydrate juices to prevent DKA
What are the S/S of DKA?
–Due to Na and K+ loss in urine clients experience
•Cardiac arrhythmias can lead to cardiac arrest
•Acidosis-fruity breath, tachycardia and hypotension
Why is dangerous if DKA or acidosis is not corrected?
If acidosis is not corrected it can lead to a coma of severe acidosis
What are the main causes of DKA?
–Decreased or missed dose of insulin
–Not drawing adequate dose
–Illness or infection
–Undiagnosed or untreated diabetes
- •IV fluid and electrolyte replacement
DKA treatment involves correcting what two things?
•Correct fluid and electrolytes
DKA treatment involves providing what?
- •Provide adequate insulin
- –When giving insulin drip monitor for
- –Do not infuse fluids too rapidly to
- prevent cerebral edema 1-2 L in 1-2
What are the treatment goals of DKA?
Treat K but the main thing is to hydrate!
Treatment goals for DKA include:
•Provide adequate fluid to dehydrate Correct dehydration first
•Provide adequate insulin to restore and maintain normal glucose metabolism
•Correct electrolyte deficits and acidosis
•Provide source of glucose when needed
•Provide patient education
All pts with DKA need what?
All pts with DKA will need insulin (use insulin drip more often)
When glucose reaches 250, then they will go to 5-10% dextrose added to normal saline
Potential complications of DKA are these 3 things?
- •Hypokalemia-due to treatment of DKA- loss of potassium
- –If potassium is low need to correct this first.
- •Cerebral Edema
- –Cause unknown, may be by rapid correction of hyperglycemia- resulting in fluid shift-assess mental status
A DKA pt needs to monitor their blood glucose how often in order to have a successful treatment?
Monitor blood glucose 1-2 hrs in order to have successful treatment
Sick day rules for Type 1 and type 2 diabetes:
What is Hyperglycemia hyperosmolar nonketotoic syndrome (HHNS)?
•Serious condition – Blood glucose 800-1000 mg/dl
•Ketosis usually minimal or absent
- •Defect or lack of effective insulin (insulin resistance)
- –Persistent hyperglycemia→ osmotic diuresis → glycosuria →and
- & increased osmolarity
•Usually occurs in older adults
What are the causes of HHNS?
•Medications that exacerbate hyperglycemia (thiazides)
S/S of HHNS:
•Variable neurological signs
•Morality rate- 10% to 40%
•Treatment-fluid replacement and correct electrolytes
Nursing management of HHNS:
•Monitor V/S closely
•Maintain safety and prevent injury
•I/O –high risk of renal failure due to dehydration
•Assess cardiovascular, pulmonary and renal function
- –Rapid fluid resuscitation to maintain cardiovascular integrity
- •Need to administer 6 L of fluid over 24 hrs
What are the 4 ways to treat HHNS?
- 1. Provide adequate fluids to rehydrate
- •Guideline: infuse half of the fluid deficit over the first 12 hours and the remaining during the following 12-24 hours.
2. Correct Electrolyte Deficits
3. Provide adequate insulin to restore and maintain normal glucose metabolism
4. Provide complications
Why is rehydration so essential to blood glucose?
Glucose can drop as much as 80-200 mg/dL per hour from rehydration.
Hydration is essential to lower glucose levels.
Following hydration, what should be administered to lower BS
Insulin administration to lower BS
What are macrovascular complications?
Diseases of large and medium-size vessels
Atherosclerosis is and example of what, what is atherosclerosis, what is the treatment?
- •From altered lipid metabolism
- –Hardening of arteries leads to occlusion of vessel leads to MI
Cerebrovascular disease and peripheral vascular disease are what kind of complications?
Adults with DM have what kind of increased risk of heart and cerebral vascular risk?
2-4 times increased risk of heart and cerebral vascular
It is more common for clients with cerebrovascular diseases to get it when?
at an earlier age
What is the mortality rate of DM pt with cerbrovascular disease?
Morality rate is 3 to 5x greater in DM
S/S of cerebrovascular disease are:
- –Intermittent dizziness
- –Transient loss of vision
- –Slurring of speech
- –Paresthesia or weakness of one limb
- –Occurrence of a stroke
- •Mild or TIA sometimes before having full blown stroke
- –Give ASA, or take to ER
Picture of cerebrovascular disease?
Peripheral disease is common in which kind of diabetics?
type 2 diabetic mellitus
Peripheral disease is what kind of complication?
Peripheral disease is characterized by what things?
- –Pain in the buttock, calf, or thigh that occurs during exercise and relieved with
- rest. (intermittent claudication)
- –Cold foot or limb, shiny skin
- •Shiny skin esp in lower legs
–Discolored or blue mottled appearance
–Decreased pulses, and absence of hair
What is the treatment for peripheral disease?
- –Lessing s/s by decreasing blood flow
- –If all else fails have a bipass
Picture of peripheral disease
What are the risk factors for macrovascular disease?
•Treatable risk factors
Smoking one cigarette causes spasm of the artery for how long?
Smoking increases what lipid?
2 areas infected by microvascular diseases are?
Retina and Kindeys
What are things to teach a diabetic pt to prevent retinopathy?
Every pt should have dilated eye exam q/yr
- Looking for any bulging or aneurysm
- behind the eye
S/S of retinopathy:
Sudden lose of vision
Recommendations of Retinopathy screening:
should have what kind of eye exam?
- •The ADA recommends an initial dilated and comprehensive eye examination by an
- ophthalmologist or optometrist
- –Adults and children aged 10 years or older with type 1 diabetes
- •Within 5 years after diabetes onset
- –Patients with type 2 diabetes
- •Shortly after diagnosis
- –Bc want to have a baseline
Diabetic retinopathy result from what?
Results from chronic hyperglycemia
80% of pts with type 2 DM will have this after 15 years with DM.
Diabetic retinopathy can be a complication of which two kinds of diabetes?
type 1 and type 2 with prevalence related to the duration of the disease
Longer they have it without the treatment the more severe retinopathy can be
Non-proliferative is which form of diabetic retinopathy?
most common form
Proliferative is which form of diabetic retinopathy?
most severe form
What is non-proliferative retinopathy?
- Partial occlusion of small blood vessels in the retina-develop microanueryms. Vision can be affected if Macula is involved.
- –Should avoid dramatic physical activity that increase BP
What is proliferative retinopathy?
- Retinal capillaries become occluded, hemorrhage. If blood vessels pull retina can cause a tear or partial or complete detachment of retina.
- –Without treatment more than ½ will go blind
what is visual blindness?
A visual acuity that is <20/200 in the better eye with corrective lenses and or a visual acuity field of < 20 degrees.
What is the key to retinopathy?
Prevention is key
If vision loss occurs, nursing education must address the patient’s adjustment to vision impairment
Medical management of diabetic retinopathy include what 3 things?
•Control of blood glucose
•Control of hypertension
•Cessation of smoking
2 other ophthalmic complications include?
Glaucoma & cataracts
What is glaucoma?
increased ocular pressure has damaged the optic nerve causing vision loss
What is cataracts?
- Opacities of the lens.
- –Ppl with diabetes are more prone to cataract at a younger age
Nephropathy is what kind of complication?
What is nephropathy?
Damage to small blood vessels that supply glomeruli of the kidney
Nephropathy is the leading cause of what?
end-stage renal disease
What are the risk factors for nephropathy?
- •Chronic hyperglycemia
- –Some pts you will not be able to control it
•Studies DCCT and UKPDS showed significant reduction when near-normal blood glucose control was achieved and maintained
Acute renal failure has what kind of onset?
S/S of acute renal failure (ARF):
Acute renal failure (ARF)-rapid onset on symptoms including > in blood urea nitrogen (BUN), creatinine, electrolytes and minimal urinary output.
Chronic kidney disease depends on?
severity of disease
What is considered one of the most challenging conditions of nephrology?
- Nephrotic syndrome:
- –Changes in glomerular basement membrane that occur secondary to diabetes then glomerular nephritis that lead to profound urine leading to kidney disease
What assessment should be done to monitor kidneys?
Test for albumin (Protein that leaks into the urine)
--Check annually if microalbumin present and it exceeds >30mg in 24 hours on two consecutive random urine, treatment is needed
What is goal of treating nephropathy?
- Aggressive B/P management
- –Goal: lower blood pressure to <120/80 mm/Hg
- •Antihypertensive agents
- –Ace Inhibitors-(pril)
- –Beta blockers
HTN can be successfully treated by making what changes?
lifestyle and dietary changes
When ACEI, ARBS, or diuretics are used monitor what for the development of what?
When ACE inhibitors, ARBs, or diuretics are used, monitor serum creatinine and potassium levels for the development of increased creatinine and hyperkalemia
It is recommend that during nephropathy treatment that you continue to monitor what also?
- Continuing monitoring of urine albumin excretion to assess response to therapy and progression of disease.
- –If having problems
- •Might consider sending to nephrologist
- –The earlier you send them the better
Definitions of Abnormalities in Albumin Excretion
What two things may elevate albumin over value?
Exercise and CHF
Pre-prandial plasma glucose is recommended to be what?
Post-prandial plasma glucose is recommended to be what?
What are the 3 primary treatment options of pts who experience ESRD?
There are three primary treatment options for individuals who experience ESRD:
1. Hemodialysis:changes your lifestyle
2. Peritoneal Dialysis: can be done at home but have to be careful to watch for infection (use sterile area)
3. Kidney Transplantation
Prevention of Chronic Kidney Disease (CKD) include:
•Blood pressure control
•Blood glucose control
•Lipid levels for CVD risk
•Serum markers of bone and mineral metabolism
What is diabetic neuropathy?
About 60-70% of people with diabetes have mild to severe forms of nervous system damage, including:
- -Impaired sensation or pain in the feet or
-Slowed digestion of food in the stomach
-Carpal tunnel syndrome
-Other nerve problems
More than 60% of nontraumatic lower-limb amputations in the United States occur among?
people with diabetes
What are the risk factor of diabetic neuropathy?
•Duration of diabetes
•Damage to blood vessels
•Mechanical injury to nerves
- •Lifestyle factors
The two main risk factors for diabetic neuropathy include?
•Duration of diabetes
Pathogenesis of diabetic neuropathy include what 3 things?
- •Metabolic factors
- –High blood glucose
- –Advanced glycation end products
- –Abnormal blood fat levels
•Nerve fiber repair mechanisms
What does the autonomic neuropathy affect?
- Affects the autonomic nerves controlling internal organs
- •GI tract
What is sudomotor neuropathy?
- absence of sweating of the extremities with a compensatory increase in upper body
In autonomic neuropathy what happens to the sexual dysfunction of males and females?
Women lose the desire to have sex and men become impotent
which care is essential to pt with autonomic neuropathy?
Foot examinations should be done how often with health care professional?
–Annually for all patients
–Patients with neuropathy - visual inspection of feet at every visit with a health care professional
You should advise the pt to use lotion to prevent what? But should not put lotion here?
- –Use lotion to prevent dryness and cracking
- •No lotion between toes
A diabetic pt should cut their toenails weekly or as needed, if they or a family member can; if they cannot, it is best to see who?
If a pt is going to file calluses they should use what?
a pumice stone, never a knife!
A diabetic pt should always wear what?
Always wear socks and well-fitting shoes
Remember: Notify their health care provider immediately if any foot problems occur
Complications of DM contribute to what?
an increased risk of foot infections
Is a foot infection preventable?
•A foot infection is a preventable infection.
50 % of foot care problems could be prevented if pts checked their feet
A nurse should teach their pt to practice what on a daily basis?
Foot care measures should be practiced on a daily basis.
To test for loss of sensations what can be done?
Test for loss of sensation: 10 gauge monofilament plus testing any one of
–Vibration using 128HZ tuning fork
–Vibration perception threshold
What are some of the complications with diabetic feet?
Diabetic foot ulcers
What are diabetic foot ulcers
–Begins with soft tissue injury of foot.
–Formation of fissure between toes or in area of dry skin.
- –Formation of callus.
- •Sometimes take callus off and there is tunneling underneath
–Cracks in skin
–Venous insufficiency is a contributing cause of foot ulcers
True or False; you should never use a heating pad for a diabetic pt with neuropathy.
TRUE! It can damage the skin and the pt not be aware of it
What three types of injuries can you do to the feet?
S/S of foot infections?
–Redness (cellulites of leg)
Treatment of foot ulcers includes what 4 things?
•Good control of blood glucose (usually increases with infection).
If patient has ____, ulcers may not heal due to the decreased ability of oxygen,
nutrients, and antibiotics to reach the injured tissue.
What is skin-acanthosis nigricans?
dark, coarse, thicken skin on the neck
What is dibabetic dermatopathy?
red-brown flat-topped papules
What are granuloma annulare?
type 1- autoimmune- partial rings of papules, often in dorsal surface of hands and feet
DM pt are more susceptible to infections like recurrent yeast infections why?
Defect in the mobilization of inflammatory cells and an impairment of phagocytosis.
What is periodontal disease?
A chronic, progressive bacterial infection that destroys the supporting tissues of the teeth.
What other care is also a must for DM pts?
good oral care is a must!
What special issue are you to considering for a pt undergoing surgery?
–During stress such as surgery, blood glucose levels rise as a result of an increase level of stress hormones.
–If hyperglycemia is not controlled- osmotic diuresis may lead to excessive loss of fluids and electrolytes.
–Hypoglycemia- withhold SQ insulin morning of surgery
What factors effect hyperglycemia?
–Changes in treatment regimen
–Medications (eg. Glucocorticoids)
–Overly vigorous treatment of hypoglycemia.
What factors effect hypoglycemia?
–Overuse of sliding scale
–Lack of dosage changes when dietary intake is changed.
–Overly vigorous treatment of hyperglycemia
- –Delayed meal after lispro or aspart insulin
- •Which is novolog or humalog
If a client is NPO, what do you have to do for the insulin dosage for a type 2?
insulin dose may need to be changed
If a client is NPO, what do you have to do for a type 1?
may need to administer insulin
It is important when tube feeding to do what with insulin?
important to administer insulin at regular intervals
Promoting self care involves:
•Address any underlying factors affecting diabetes control.
- the treatment regimen
- regimen to meet patient’s request.
- positive reinforcement and encouragement.
What are some barriers to to adherence to diabetes management?
–Degree of life changes and the complexity of management plan
–Cost of care
–Lack of family support
–Lack of Knowledge
What are some strategies to increase adherence to diabetes management?
•Encourage patient and family to take charge of their health
•Simplify the regimen
•Focus on the normal not the differences
•Teach the tools and help pt. get supplies
•Provide a safe harbor
•Provide adequate education
What are some nursing diagnosis related to diabetes?
•Deficient knowledge r/t diabetes self care skills/information.
•Potential self care deficit r/t physical impairments or social factors.
•Anxiety r/t loss of control, fear of inability to manage diabetes, misinformation r/t diabetes, fear of diabetes complications.
•Risk for infection r/t potential sensory loss in feet.
•Imbalanced Nutrition Related to increase in stress hormones
•Risk for impaired skin integrity related to immobility and lack of sensation.
What are the goals of diabetes management?
•Improved nutritional status
•Maintenance of skin integrity
•Ability to perform basic diabetes self-management.
•Prevent short and long term diabetes complications
Can a person with diabetes live a long healthy life?
Persons with diabetes mellitus can live a long and healthy life if they control their diabetes instead of letting the diabetes control them!!
What would you like to do?
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