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when a person has a chronic problem with hyperglycemia due to an abnormal production of insulin and/or impaired utilization of insulin
Why does a person with DM have a hard time sustaining a normal metabolism?
because the pancreas doesn't produce enough insulin or the cells are insulin resistant.
What other diseases does DM cause?
- adult blindness
- end stage renal disease
- non traumatic lower limb amputations
DM is a major contributor to these two deadly problems....
Top 3 ethnicities who get DM
- Native Americans
- African Americans
People who get Type I DM are usually how old?
Under 40.....used to be called juvenile or insulin dependent diabetes
Signs of Type DM (4)
- ketoacidosis (not in type 2 typically)
Type I DM requires....
People who get Type II DM are usually how old?
over 40....however it is now changing to much younger. Seeing it now more in children and people overweight
What are the different issues between Type I and Type II DM?
Type I it is from a dysfunction of the Beta cells causing hyperglycemia
Type II is from the pancreas producing an insufficient amount of insulin, or the tissues inability to use the insulin
Which DM is not insulin dependent?
Which DM has the issue of Diabetic Ketoacidosis
3 factors in Type II DM
- insulin resistance
- decreased production of insulin by the pancreas
- inappropriate production of glucose by the liver
What is insulin resistance?
it is an alteration in glucose and lipid metabolism in which insulin receptors on skeletal muscle, fat, and liver cells are unresponsive. Therefore glucose does not get in to the cells to adequately, so glucose stays in the blood causing hyperglycemia
What is metabolic syndrome?
it is a cluster of abnormalities that act together to greatly increase a persons risk for cardiovascular disease and diabetes.
How does metabolic syndrome cause cardiovascular disease?
- the person will have:
- high triglycerides
- increased LDL
- decreased HDL
How does metabolic syndrome cause diabetes?
the person will be insulin resistant and have elevated insulin levels
What is a pre diabetic?
a person who has an increased risk for developing diabetes because their blood glucose levels are higher than normal, but not high enough to be called diabetic
Three tests for DM and what are the pre diabetic ranges?
Fasting Glucose Test 100-125mg/dL
Oral Glucose Test 140-199mg/dL
Which test is best to redo to determine if a persons diabetic?
Risk factors for diabetes
- Waist size +40 (m) +35 (f)
- Overweight-BMI +25
- Family History
- Decreased HDL and Increased Triglycerides
- History of Gestational Diabetes
- Ethnic Background
If you are pre diabetic and you do nothing to change your lifestyle....how long till you become diabetic?
What can you do to drastically decrease your changes of getting Type II DM?
change your diet, exercise regularly and lose weight.
If you lose 10% of your weight you will decrease your changes by 58%
Patho of Type II DM
the stomach changes food in to glucose, the glucose enters the bloodstream. The pancreas makes insulin and it enters the bloodstream. Glucose cant get in to the cells of the body so it builds up in the blood vessels causing hyperglycemia.
Clinical manifestations of HYPOglycemia
- Excessive Hunger
Full bounding rapid pulse
Clinical Manifestations of HYPERglycemia
- Dry skin
- Deep Rapid Labored Breathing
Weak rapid pulse
Sign of Kussmaul Respirations
- acetone breath-sweet
- fruity odor
- Hyperventilation-rapid and shallow initially but turns in to deep, labored and gasping
How does the Hgb A1C test work?
you draw blood and see how much sugar is attached to Hgb, if the level is high then there has been a problem for a while.
RBC's last 120 days....so you cant fool this test
How does the Oral Glucose Test work?
You have them drink a disgusting sugar loaded drink, then 2 hours later you check their blood glucose level.
75g of sugar in this awful orange drink!!
If you have a random glucose test done and the levels are above this...plus you have polyuria, polydipsia and unexplained weight loss, you probably have DM
Name 2 Rapid Acting Insulins
- Onset 15 min
- Peak 1-1.5 hrs
- Duration 3-4 hrs.
Name 2 Short Acting (Regular) Insulins
- Onset 30-60 min
- Peak 2-3 hrs.
- Duration 3-6
Name an Intermediate Acting Insulin
- Onset 2-4 hrs.
- Peak 4-10
- Duration 10-16 hrs.
Name the 2 Long Acting Insulins
- Onset 1-2 hrs.
- Peak....doesn't peak
- Duration 24+ hrs.
Collaberative Management of DM
- Provide, assist and teach the client about drug therapy (oral and insulin)
- nutritional therapy
- glucose monitoring
- prevention/delay of long term complications
How do you promote healthy living to prevent DM?
ID, monitor and educate at risk populations
Teach them about weight loss, increasing their exercise
How do you help a person stay healthy with DM?
- help them balance their drug therapy
- monitor blood sugar
- minimize complications
What is the best food planning guideline for a person with DM?
What is used to control glucose levels when it comes to eating?
an appropriate serving size is 15g with a total of 45-60 g/meal.
total carb intake amount is dependent on age, weight, activity and medications
Nutritional Therapy for the person with Type I DM
- increased calories to maintain a good body weight
- diet + insulin for glucose control
- must plan carbs in each meal and make adjustments for insulin
- consistent timing of meals with insulin is important
- Snacks btwn meals and at bedtime are normal
- eat more carbs for moderate physical activity
Which drug requires a person to be consistent with their timing of meals and administration of insulin?
Nutritional Therapy for the person with Type II DM
- for overweight/obese pt reduce calories to lose weight
- diet alone may be sufficient for glucose control
- low fat diet
- consistent with carbs at meals
- NO SNACKS....(usually overweight)
If a person is on Sulfonylureas or insulin what may be necessary for them to take?
What is a preventative measure that is being used to detect a pre-diabetic?
screening of everyone when they turn 45
What's the glycemic index?
tells you how quickly different foods will increase a persons blood sugar levels.
Carbs with a high glycemic index will sharply raise blood glucose levels and consequently the pt will crash (potatoes, white/bread/rice).
Carbs with a low glycemic index will raise blood glucose more slowly and will sustain the patient longer without a severe crash (brown rice, multigrain breads)
What is the goal of diet/nutrition with a diabetic?
to be able to balance carbs, fats and proteins without sharp increases/decreases of blood glucose levels
Gerentology considerations for the diabetic
- appetite decreases
- may not realize they haven't eaten
- may not recognize signs of hypoglycemia
How do you help an elderly diabetic stay healthy with their diet?
make a schedule for meals
What is the benefit of exercise for the diabetic?
- it decreases insulin resistance by increasing insulin receptor sensitivity
- contributes to weight loss that also decreases insulin resistance. It also:
- Decreases blood glucose, triglycerides and LDL cholesterol levels
- Decrease BP
- Improves circulation
When is hypoglycemia most likely to occur with a person with DM?
- if increased physical activity occurs at peak time of insulin, sulfonylureas or meglitinides
- if insufficient calories have been consumed to maintain glucose levels
- if don't take supplemental carbs during or after exercise.
What does very strenuous exercise do to the diabetic?
it can be perceived as a stressor and can stimulate counter-regulatory hormones which will raise blood sugar levels.
Should check their blood sugar levels prior to exercise and modify as indicated
How do you minimize complications with DM?
- BLOOD GLUCOSE CONTROL (Best)
- Personal hygiene
- Foot Care
- Medical ID bracelet
What is meant by good personal hygiene for the diabetic?
- diligent skin care
- regular baths and foot care
- good dental hygiene
Why do diabetics need to go to the dentist?
Cuz have an increased risk for periodontal disease
What is meant by good foot care for a diabetic?
- wear closed toe shoes that fit properly
- let a podiatrist to nail and skin care of feet
- use a mirror to inspect feet daily
- treat sores right away on the feet
- have a monofilliment test yearly
What is a monofilliment test?
it is done at home and it detects levels of neuropathy, nerve damage and areas of the feet that a diabetic loses sensation in
Acute complication of DM
Chronic problems of diabetes
- angiopathy (damage to blood vessels)
- neuropathy (sensory problems)
- autonomic infections
- circulation issues with lower extremities
What do you use on a diabetics feet to keep them from drying out?
Lanolin....don't put it btwn the toes
What is Hyperosmolar Hyperglycemic Syndrome?
a life threatening syndrome that occurs in the diabetic who can make enough insulin to prevent DKA, but not enough to prevent:
- osmotic diuresis
- extracellular fluid depletion
Who usually gets Hyperosmolar Hyperglycemic Syndrome? (HHS)
60+ years old with Type II DM
- UTI infections
- any acute illness
- newly diagnosed type 2 diabetic
Main difference btwn HHS and DKA
HHS doesn't get DKA
What are the results of the super high blood glucose levels with HHS?
- somnolence (sleepy)
- hemiparesis (weak on one side of the body)
What is aphasia?
disturbance of the comprehension and formulation of language caused by a dysfunction in specific brain regions
What is DKA (Diabetic Ketoacidosis)?
- it is caused by a profound deficiency of insulin and is characterized by
Most likely seen in Type I, but can be seen in Type II
What can cause a person to go in to DKA?
- inadequate insulin dosage
- undiagnosed Type 1
- poor self management
Behaviors/Clinical Manifestation of DKA
- BG above 250
- Urinary frequency
- flushed/dry skin
- anorexia and N/V
- Kussmaul Respirations
Behaviors/Clinical Manifestations of HHS
- BG higher than 600
- Infection trigger
- osmotic diuresis....dehydration
- neuro changes
- may look like a stroke
How do you evaluate a person after interventions that has HHS?
- Have their blood glucose levels returned to normal?
- Is the patient asymptomatic for S&S of hyperglycemia?
What can cause hypoglycemia?
- Too much insulin/oral meds
- Not enough food in the blood
- Not eating/taking meds on time
- Too much exercise
- ALCOHOL intake without food
- Loss of weight without change in meds
What is a persons speech like when experiencing hypoglycemia?
visual disturbances and a headache
How would you treat a conscious person experiencing hypoglycemia?
- give 4-8 oz of fruit juice or 8 oz of low fat milk
- avoid carbs with fat
- avoid large amounts of quick acting carbs
Eat a 1/2 a turkey sandwich and eat crackers
Recheck glucose within one hour of treatment
Interventions for an unconscious patient with hypoglycemia
- determine blood glucose
- give Glucagon 1mg IM or SQ (IM quicker response)
- D50W 20-50mL (hypertonic-best in central line)
- Give complex carbs as soon as they are conscious to avoid hypoglycemia
What will happen to the unconscious patient with hypoglycemia if you give them Glucagon and D50W
What do you evaluate with a person who you treated for hypoglycemia?
Is their blood glucose normal?
Are they without S&S of hypoglycemia?
Macrovascular Changes from DM
- Coronary Artery Disease
- Cerebral Vascular Disease
- Peripheral Vascular Disease
Microvascular changes from DM
Neuropathy complications form DM
- Sensory (Affects PNS)
- Autonomic 9Affects all body systems
How do you prevent Coronary Artery Disease?
- Prevent: Stop smoking, control HTN, Low fat and cholesterol diet....weight control
- Interventions: meds and surgical intervention
Describe behaviors seen with Cerebral Vascular Disease
- memory lapses
- abrupt loss of vision
- abrupt loss of strength "TIA signs"
How do you prevent Cerebral Vascular Disease?
Prevention: Control Blood sugar and HTN
Interventions: antiplatelets and anticoagulants
Describe behaviors seen with Peripheral Vascular Disease
Intermittent claudication (painful and impaired walking-felt in the legs)
How do you prevent Peripheral Vascular Disease?
Prevention: Stop smoking, regular exercise, daily foot care/inspection
Interventions: Encourage exercise and teach proper foot care
How do you prevent Retinopathy?
Prevention: control blood glucose, eye exams every 6 months
Intervention: Laser Therapy, Vitrectomy (removal of vitreous humor from the eye)
Describe behaviors seen with Nephropathy
- fluid accumulation
- increased incidences of hypoglycemia
How do you prevent Nephropathy?
Prevention: aggressive treatments of UTI, control HTN and blood glucose levels
Interventions: low protein diet, dialysis, renal transplant
What med will you give a person to control HTN that has Nephropathy?
Ace Inhibitor (Lisinopril...."pril")
numbness, tingling or pain in the extremities
How do you prevent Neuropathy?
Prevent: Control Blood Sugar
- Interventions: Drug Therapy....tricyclic anti depressants, antiseizure meds, topical creams
Common drug given to help with pain from Neuropathy
Complications seen with the Autonomic Nervous System:
How do you prevent them?
- Bowel Incontinence
- Postural Hypotension
- Sexual dysfunction
- Urinary Retention
Prevention: Control Blood Glucose
What does Urecholine treat?
How do you prevent ulcerations and amputations with a diabetic?
- Stop smoking
- Prevent PVD and neuropathies
- Proper foot wear
- Dilligent skin and foot care
Why does the incidence of diabetes increase the older a person gets?
- Reduced beta cell function
- Reduced insulin sensitivity
- Altered Carb metabolism
What are the meds that older people are on that impair insulin action?
What are the s/s of diabetes that look normal in an aging person?
- Low energy levels
- chronic GU infections
Aka's for DKA
- Diabetic Acidosis
- Diabetic Coma
People in DKA will have ABG's reflective of
People in HHS can be mistaken for having a
Macrovascular is a disease of???
- Lg and medium blood vessels
Microvascular is a problem with???
Thickening of vessel membranes in the capillaries and arterioles
What may be the first sign that a person has diabetes?
When you are in metabolic acidosis what kind of breathing will you be experiencing?
initially rapid and shallow, but as acidosis worsens it will go to deep, labored and gasping