Diabetes Mellitus

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Diabetes Mellitus
2013-09-15 15:11:07

Diabetes Mellitus
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  1. Define DM
    when a person has a chronic problem with hyperglycemia due to an abnormal production of insulin and/or impaired utilization of insulin
  2. 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.
  3. What other diseases does DM cause?
    • adult blindness
    • end stage renal disease
    • non traumatic lower limb amputations
  4. DM is a major contributor to these two deadly problems....
    • heart disease
    • stroke
  5. Top 3 ethnicities who get DM
    • Native Americans
    • African Americans
    • Hispanics
  6. People who get Type I DM are usually how old?
    Under 40.....used to be called juvenile or insulin dependent diabetes
  7. Signs of Type DM (4)
    • polydipsia
    • polyuria
    • polyphagia
    • ketoacidosis (not in type 2 typically)
  8. polydipsia
    excessive thirst
  9. polyuria
    frequent urination
  10. polyphagia
    excessive hunger
  11. Type I DM requires....
    exogenous insulin
  12. 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
  13. 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
  14. Which DM is not insulin dependent?
    Type II
  15. Which DM has the issue of Diabetic Ketoacidosis
    Type I
  16. 3 factors in Type II  DM
    • insulin resistance
    • decreased production of insulin by the pancreas
    • inappropriate production of glucose by the liver
  17. 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
  18. What is metabolic syndrome?
    it is a cluster of abnormalities that act together to greatly increase a persons risk for cardiovascular disease and diabetes.
  19. How does metabolic syndrome cause cardiovascular disease?
    • the person will have:
    • high triglycerides
    • increased LDL
    • decreased HDL
    • Hypertension
  20. How does metabolic syndrome cause diabetes?
    the person will be insulin resistant and have elevated insulin levels
  21. 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
  22. Three tests for DM and what are the pre diabetic ranges?
    Fasting Glucose Test 100-125mg/dL

    Oral Glucose Test 140-199mg/dL

    HgbA1C  5.7-6.4%
  23. Which test is best to redo to determine if a persons diabetic?
    Fasting Glucose....
  24. Risk factors for diabetes
    • Waist size +40 (m) +35 (f)
    • Overweight-BMI +25
    • Family History
    • Decreased HDL and Increased Triglycerides
    • HTN
    • History of Gestational Diabetes
    • Ethnic Background
  25. If you are pre diabetic and you do nothing to change your lifestyle....how long till you become diabetic?
    10 years
  26. 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%
  27. 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.
  28. Clinical manifestations of HYPOglycemia
    • Tachy
    • Irritable
    • Restless
    • Excessive Hunger
    • Diaphoresis/Depression

    Full bounding rapid pulse
  29. Clinical Manifestations of HYPERglycemia
    • Dry skin
    • Drowsy
    • Deep Rapid Labored Breathing
    • Dehydrated

    Weak rapid pulse
  30. Sign of Kussmaul Respirations
    • acetone breath-sweet
    • fruity odor
    • Hyperventilation-rapid and shallow initially but turns in to deep, labored and gasping
  31. 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
  32. 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!!
  33. 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
  34. Name 2 Rapid Acting Insulins

    • lispro-Humalog
    • aspart-Novolog

    • Onset 15 min
    • Peak 1-1.5 hrs
    • Duration 3-4 hrs.
  35. Name 2 Short Acting (Regular) Insulins

    • Humulin R
    • Novolin R

    • Onset 30-60 min
    • Peak 2-3 hrs.
    • Duration 3-6
  36. Name an Intermediate Acting Insulin


    • Onset 2-4 hrs.
    • Peak 4-10
    • Duration 10-16 hrs.
  37. Name the 2 Long Acting Insulins


    • Onset 1-2 hrs.
    • Peak....doesn't peak
    • Duration 24+ hrs.
  38. Collaberative Management of DM
    • Provide, assist and teach the client about drug therapy (oral and insulin)
    • nutritional therapy
    • exercise
    • glucose monitoring
    • prevention/delay of long term complications
  39. How do you promote healthy living to prevent DM?
    ID, monitor and educate at risk populations

    Teach them about weight loss, increasing their exercise
  40. How do you help a person stay healthy with DM?
    • help them balance their drug therapy
    • diet
    • exercise
    • monitor blood sugar
    • minimize complications
  41. What is the best food planning guideline for a person with DM?
    Food Pyramid
  42. What is used to control glucose levels when it comes to eating?
    carb counting.....

    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
  43. 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
  44. Which drug requires a person to be consistent with their timing of meals and administration of insulin?
  45. 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)
  46. If a person is on Sulfonylureas or insulin what may be necessary for them to take?
    nutritional supplements
  47. What is a preventative measure that is being used to detect a pre-diabetic?
    screening of everyone when they turn 45
  48. 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)
  49. 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
  50. Gerentology considerations for the diabetic
    • appetite decreases
    • may not realize they haven't eaten
    • may not recognize signs of hypoglycemia
  51. How do you help an elderly diabetic stay healthy with their diet?
    make a schedule for meals
  52. 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
  53. 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.
  54. What does very strenuous exercise do to the diabetic?
    Causes HYPERglycemia

    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
  55. How do you minimize complications with DM?
    • Personal hygiene
    • Foot Care
    • Medical ID bracelet
  56. What is meant by good personal hygiene for the diabetic?
    • diligent skin care
    • regular baths and foot care
    • good dental hygiene
  57. Why do diabetics need to go to the dentist?
    Cuz have an increased risk for periodontal disease
  58. 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
  59. 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
  60. Acute complication of DM
    • hypoglycemia
    • hyperglycemia
    • infections
  61. Chronic problems of diabetes
    • angiopathy (damage to blood vessels)
    • neuropathy (sensory problems)
    • autonomic infections
    • circulation issues with lower extremities
  62. What do you use on a diabetics feet to keep them from drying out?
    Lanolin....don't put it btwn the toes
  63. 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:

    • hyperglycemia
    • osmotic diuresis
    • extracellular fluid depletion
  64. Who usually gets Hyperosmolar Hyperglycemic Syndrome? (HHS)

    60+ years old with Type II DM

    • UTI infections
    • pneumonia
    • sepsis
    • any acute illness
    • newly diagnosed type 2 diabetic
  65. Main difference btwn HHS and DKA
    HHS doesn't get DKA
  66. What are the results of the super high blood glucose levels with HHS?
    • somnolence (sleepy)
    • coma
    • seizure
    • hemiparesis (weak on one side of the body)
    • aphasia
  67. What is aphasia?
    disturbance of the comprehension and formulation of language caused by a dysfunction in specific brain regions
  68. What is DKA (Diabetic Ketoacidosis)?
    • it is caused by a profound deficiency of insulin and is characterized by
    • hyperglycemia
    • ketosis
    • acidosis
    • dehydration

    Most likely seen in Type I, but can be seen in Type II
  69. What can cause a person to go in to DKA?
    • illness
    • infection
    • inadequate insulin dosage
    • undiagnosed Type 1
    • poor self management
    • neglect
  70. Behaviors/Clinical Manifestation of DKA
    • BG above 250
    • dehydrated
    • Urinary frequency
    • flushed/dry skin
    • restlesness
    • anorexia and N/V
    • Kussmaul Respirations
  71. Behaviors/Clinical Manifestations of HHS
    • BG higher than 600
    • Infection trigger
    • osmotic diuresis....dehydration
    • neuro changes
    • may look like a stroke
  72. 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?
  73. 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
  74. What is a persons speech like when experiencing hypoglycemia?

    slurred speech

    visual disturbances and a headache
  75. 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
  76. 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
  77. What will happen to the unconscious patient with hypoglycemia if you give them Glucagon and D50W
    Rebound Hypoglycemia
  78. What do you evaluate with a person who you treated for hypoglycemia?
    Is their blood glucose normal? 

    Are they without S&S of hypoglycemia?
  79. Macrovascular Changes from DM
    • Coronary Artery Disease
    • Cerebral Vascular Disease
    • Peripheral Vascular Disease
  80. Microvascular changes from DM
    • Retinopathy
    • Nephropathy
  81. Neuropathy complications form DM
    • Sensory (Affects PNS)
    • Autonomic 9Affects all body systems
  82. Infections from DM
    • Ulcerations
    • Amputations
  83. How do you prevent Coronary Artery Disease?

    • Prevent: Stop smoking, control HTN, Low fat and cholesterol diet....weight control
    • Interventions: meds and surgical intervention
  84. Describe behaviors seen with Cerebral Vascular Disease
    • memory lapses
    • abrupt loss of vision
    • abrupt loss of strength "TIA signs"
  85. How do you prevent Cerebral Vascular Disease?

    Prevention:  Control Blood sugar and HTN

    Interventions: antiplatelets and anticoagulants
  86. Describe behaviors seen with Peripheral Vascular Disease
    Intermittent claudication (painful and impaired walking-felt in the legs)
  87. How do you prevent Peripheral Vascular Disease?

    Prevention: Stop smoking, regular exercise, daily foot care/inspection

    Interventions:  Encourage exercise and teach proper foot care
  88. 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)
  89. Describe behaviors seen with Nephropathy
    • Proteinuria
    • fluid accumulation
    • increased incidences of hypoglycemia
  90. How do you prevent Nephropathy?

    Prevention: aggressive treatments of UTI, control HTN and blood glucose levels

    Interventions:  low protein diet, dialysis, renal transplant
  91. What med will you give a person to control HTN that has Nephropathy?
    Ace Inhibitor (Lisinopril...."pril")
  92. Describe Neuropathy
    numbness, tingling or pain in the extremities
  93. How do you prevent Neuropathy?

    Prevent:  Control Blood Sugar

    • Interventions:  Drug Therapy....tricyclic anti depressants, antiseizure meds, topical creams
    • Neurontin
  94. Common drug given to help with pain from Neuropathy
  95. Complications seen with the Autonomic Nervous System:

    How do you prevent them?
    • Complications:
    • Hypoglycemia
    • unawareness
    • Bowel Incontinence
    • Gastroparesis
    • Postural Hypotension
    • Sexual dysfunction
    • Urinary Retention

    Prevention:  Control Blood Glucose
  96. What does Urecholine treat?
    urinary retention
  97. How do you prevent ulcerations and amputations with a diabetic?
    • Stop smoking
    • Prevent PVD and neuropathies
    • Proper foot wear
    • Dilligent skin and foot care
  98. Why does the incidence of diabetes increase the older a person gets?
    • Reduced beta cell function
    • Reduced insulin sensitivity
    • Altered Carb metabolism
  99. What are the meds that older people are on that impair insulin action?
    • Corticosteroids
    • Antihypertensives
    • Phenothiazines
  100. What are the s/s of diabetes that look normal in an aging person?
    • Low energy levels
    • falls
    • dizzy
    • confused
    • chronic GU infections
  101. Aka's for DKA
    • Diabetic Acidosis
    • Diabetic Coma
  102. People in DKA will have ABG's reflective of
    Metabolic Acidosis
  103. People in HHS can be mistaken for having a
  104. Macrovascular is a disease of???
    • Lg and medium blood vessels
    • CAD
    • CVD
    • PVD
  105. Microvascular is a problem with???

    Specific to?
    Thickening of vessel membranes in the capillaries and arterioles


    • Retinopathy
    • Nephropathy
    • Neuropathy
  106. What may be the first sign that a person has diabetes?
    Recurrent infections
  107. 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