334-Metabolism-Exam 3

An excess of these hormones, the blood sugar will then be high. -glucagon, epinephrine, GH and cortisol -oppose effects of insulin -stimulate glucose production and release by the liver -decreased movement of glucose into the cells -help maintain normal blood glucose levels

Counterregulatory Hormones

Level higher than 126mg/dl

Fasting plasma glucose level

This acute complication is caused when there is too much insulin in proportion to glucose in the blood, a BG level of <70mg/dl, neuroendocrine hormones released, ANS activated. Untreated hypoglycemia can progress to loss of consciousness, seizures, coma, and death, symptoms can also occur when high glucose levels fall too rapidly.

Hypoglycemia

Morning hyperglycemia present on awakening may be due to the release of counterregulatory hormones in predawn hours: GH and cortisol. Blood sugar levels high between 2-4 am.

Dawn Phenomenon

What are the goals of diabetes management?

Decrease symptoms, promote well-being, prevent acute complications, delay onset and progression of long-term complications.

This is very important for a diabetic patient, changing someones eating habits can be very challenging. Counseling, education-registered dietician, ongoing monitoring, interprofessional team, nutritional therapy goals-diabetics can often eat the same food as the "general public", but they must eat safely.

Nutritional Therapy

lispro (numalog), aspart (novolog), glulzine (apidra). Onset of 10-30 minutes, peak of 30 minutes-3 hours, duration of 3-5 hours.

Rapid Acting

These people do not have endogenous insulin, therefore, need to be given insulin therapy. An autoimmune disorder with a genetic link. Autoantibodies are present for months to years before symptoms occur. THe pancrease can no longer produce insulin. After this patients initial treatment, they may have temporary remission of symptoms, very important to continue with treatments.

Type 1 DM

A patient with type 1 diabetes calls the clinic with complaints of nausea, vomiting, and diarrhea. It is most important that the nurse advise the patient to 1. Withhold the regular dose of insulin 2. Drink cool fluids with high glucose content 3. Check the blood glucose level every 2-4 hours 4. Use a less strenuous form of exercise than usual until the illness resolves

3

Increase blood glucose level is secondary to counterregulatory hormones, frequent monitoring of blood glucose: ketone testing if glucose levels exceeds 240 mg/dl, report glucose levels exceeding 300 mg/dl twice or moderate to high ketone levels. Increase insulin for type 1 diabetes, type 2 diabetes may necessitate insulin therapy, maintain normal diet if possible, increase non-caloric fluids, don't want these patients to get dehydrated, continue taking antidiabetic medications, if normal diet not possible, supplement with CHO containing fluids while continuing medications.

Acute Illness and Surgery

This inhibits gluconeogenesis. Limit intake to a moderate amount-1/day for women, 2/day for men. Inhibition of glyconeogenesis by the liver which can cause severe hypoglycemia. Blood glucose levels should be monitored closely when consuming alcohol, may want to eat carbohydrates while drinking and thinking about what you are drinking. Sugar free mixes, dry/light wines.

Alcohol

This is often a local inflammatory reactions to insulin, a true allergy is very rare.

Allergic Reaction

The overall goal is to enable patient and/or caregiver to reach an optimal level of independence in self-care activities: increased risk for other chronic conditions, successful interaction with interprofessional team. Assess patient's ability to perform SMBG and insulin injection: use of assistive devices NPO. Assess pt/caregiver knowledge and ability to manage diet, medication and exercise. Teach manifestations and how to treat hypo/hyperglycemia: know how symptoms differ so we know how to treat.

Ambulatory Care

This is used to manage glucose levels in between meals and overnight. Long acting (basal)-insulin glargine (lantus) and detemir (Levemir), released steadilty and continuously with NO PEAK for many people, administered once or twice a day, DO NOT MIX WITH OTHER INSULIN OR SOLUTION. Intermediate acting (basal)-NPH (cloudy), must roll in hands before injection, duration of 12-18 hours, peaks from 4-12 hours, can mix with short and rapid acting insulins, given once or twice a day.

Background Insulin

This most closely mimics endogenous insulin production. Rapid or short acting (bolus) insulin before meals. Intermediate or long acting (basal) background insulin once or twice a day.

Basal-Bolus Regiment

Short or rapid acting insulin can be mixed with intermediate acting insulin in same syringe, provieds mealtime and basal coverage in on injection, commercially premixed or self mix. The clear insulin has to stay clear when drawing up with NPH

Combination Insulin Therapy

A chronic multisystem disease characterized by hyperglycemia related to abnormal insulin production, impaired utilization or both. 7th leading cause of death, affects 29.1 million people.

Diabetes Mellitus

This is the leading cause of adult blindness, end-stage renal disease, non-traumatic lower limb amputations-long term effect of not controlling diabetes. The major contributing factors are heart disease and stroke.

Diabetes Mellitus

A combination of causitive factors. It is genetic-type I genetics is found to be the biggest factor. Auto immune. Can be related to environmental obesity, ingested good from diet. Absent/insufficient insulin and/or poor utilization of insulin regardless of the type.

Diabetes Mellitus Etiology

Manifestations of this acute complication include dehydrate: poor skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension. Lethargy and weekness (early), skin dry and loose, eyes soft and sunken, abdominal pain, anorexia, N/V, Kussmal respirations as an attempt to reverse metabolic acidosis and exhaling CO2, sweet, fruity breath odor. BG levels of >250 mg/dl, blood pH lower than 7.30, serum bicarbonate level <16 mEq/L. Moderate to high ketone levels in urine or serum

Diabetic Ketoacidosis (DKA)

This acute complication is caused by a profound deficiency of insulin. Characterized by hyperglycemia, ketosis, acidosis, dehydration. This is most likely to occur in type 1 DM. It is likely to be caused by illness, infection, inadequate insulin dosage, undiagnosed type 1 diabetes, poor self-management (most likely), neglect. Less severe forms may be treated on an outpatient basis, hospitalized for severe fluid and electrolyte imbalance, fever, N/V/D, altered mental state, also, if communication with healthcare provider is lacking.

Diabetic Ketoacidosis (DKA)

Damage to small blood vessels that supply the glomeruli of the kidney, leading cause of end-stage renal disease, risk factors (important to maintain BG levels): HTN, genetics, smoking, chronic hyperglycemia.

Diabetic Nephropathy

Nerve damage due to metabolic derangements of diabetes, 60-70% of patients with diabetes have o=some degree of neuropathy, reduced nerve conduction and demyelination, sensotry or autonomic, often leads to neurotrophic ulceration.

Diabetic Neuropathy

Microvascular damage to the retina, the most common cause of new cases of adult blindness, initially no changes in vision, annual eye examinations with dilation to monitor, maintain healthy blood glucose levels and manage HTN. Laser photocoagulation, vitrectomy.

Diabetic Retinopathy

Dietitian initially provides instruction. Carbohydrate counting is important source of energy, fiber, vitamins and minerals. Serving size is 15 g of CHO, typically 45-60 g per meal, insulin dose based on number of CHOs consumed, patient teaching essential

Diet Teaching

Start this slowly after medical clearance, monitor blood glucose, glucose lowering effect up to 48 hours after exercise, exercise 1 hour after meal, snack to prevent hypoglycemia, do not exercise if BG level> 300mg/dL and if ketones are present in urine.

Exercise

This form of insulin is not created by the body. Insulin from an outside source, required for Type I diabetes, prescribed for patients with type II diabetes who cannot manage blood glucose levels by other means. Oftentimes this is not the first line of treatment for diabetics.

Exogenous Insulin

What are risk factors for gestational diabetes?

Family hx, DM, advanced maternal age

6.5%-7%. This shows glucose levels over past 2-3 months, show's what's been happening with blood glucose. It is used to diagnose, monitor response to therapy, and screen patients with prediabetes.

Hemoglobin A1C

This is genetically engineered in laboratories and derived through common bacteria or yeast cells and altered by DNA.

Human insulin

This acute condition is much less common than DKA, these patients produce enough insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis and extracellular fluid depletion. It is a lifethreatening syndrome that occurs with type 2 diabetes. Can often be caused by UTI's, pneumonia, sepsis, acute illness, newly diagnosed type 2 DM, impaired thirst sensation and/or inability to replace fluids. Enough circulating insulin to prevent ketoacidosis, fewer symptoms lead to higher glucose levels (>600 mg/dl), more severe neurologic manifestations because of increased serum osmolality, ketones absent or minimal in blood and urine. It is considered a medican emergency, with a high mortality rate. Therapy is similar to that for DKA: IV insulin and NaCl infusion, more fluid replacement needed, monitor serum potassium and replace as needed. Correct underlying precepitating cause.

Hyperosmolar Hyperglycemia Syndrome (HHS)

The causes of this acute complication include too much insulin or oral hypoglycemic agents, too little food, delaying time of eating, too much exercise.

Hypoglycemia

The common manifestations of this acute complication includes shakiness, palpitations, nervousness, diaphoresis, anxiety, hunger, pallor, altered mental functioning.

Hypoglycemia Manifestations

NPH (humulin), looks white/cloudy/milky in color. Onset 1.5-4 hours, peak 4-12 hours duration if 12-18 hours.

Intermediate Acting

Most common treatment for diabetic retinopathy. Lasers destroy ischemic areas of the retina that produce growth factors that encourage neovascularization, stopping areas affected in the retina.

Laser Photocoagulation

Related to altered lipid metabolism of diabetes, ulceration and amputation of the lower extremities.

Macrovascular

Diseases of large and medium sized blood vessels, greater frequency and earlier onset in patients with diabetes, CVS, CVD, PVD. Decrease risk factors (yearly screening): obesity, smoking especially significant for DM patients increasing risk for stroke or lower limb amputation, HTN, high fate intake, sedentary lifestyle. Screen for and treat hyperlipidemia.

Macrovascular Angiopathy

Important to perform frequent oral care, food care daily: avoid going barefoot, proper footwear. How to treat cuts and travel needs that include medication, supplies, food and activity, medical alert.

Nursing Implementations for DM patients

Meal planning-based on usual food intake and preferences day to day consistency is very important, balanced with insulin and exercise patterns. Day-to-day consistency makes it easier to manage blood glucose levels, more flexibility with rapid-acting insulin, multiple daily injections, and insulin pump-have to consider exercise habits with this, don't take a bunch of insulin and then go exercise.

Nutritional Therapy Type I DM

Emphasis on achieving glucose, lipid, and BP goals, weight loss (modest weight loss, even a little will help with insulin meals), nutritionally adequate meal plan with decreased fat and CHO, spacing meals throughout the day so there is continuous nutrient intake, regular exercise.

Nutritional Therapy Type II DM

These devices hold and deliver insulin, it is like a continuous pod, much more convenient for patients.

OmniPad Insulin Management System

These patients have an increased risk for developing type 2 DM. Impaired glucose tolerance giving somebody glucose and seeing how the body handles it (OGTT 140-149mg/dl). Impaired fasting glucose (IFG) someone comes into the hospital when they haven't eaten anything for several hours(IFG 100-125 mg/dl). Intermediate stage between normal glucose homeostasis and diabetes, asymptomatic but long-term damage already occurring. THEY DO NOT HAVE THE DISEASE, MANAGEMENT BEFORE DISEASE -screening, manage risks, monitor symptoms, maintain healthy weight, exercise, healthy choices.

Prediabetes

Rapid acting (bolus) - lispro, aspart, glulisine, onset within 15 minutes, injected within 15 minutes of mealtime Short acting (bolus) - regular with onset action 30-60 minutes, injected 30-45 minutes before meal, onset of action 30-60 minutes.

Mealtime Insulin (Bolus)

Elevated glucose levels, abdominal obesity, elevated BP, high levels of triglyceride, decreased levels of HDL, sedentary lifestyle.

Metabolic Syndrome

The processes of biochemical reactions occurring in the body's cells that are necessary to produce energy, repair, and facilitate the growth of cells, and maintain life. How the body maintains homeostasis.

Metabolism

Rebound effect in which an OVERDOSE OF INSULIN causes hypoglycemia, release of counterregulatory hormones (cortisol and GH) causes rebound hyperglycemia. When we check blood sugar in the hormone and it is high, so the more insulin we give, may lead to overdose. It usually happens when you take too much or too little insulin before bed, or when you skip your nighttime snack. When that happens, your blood sugar can drop sharply overnight. Your body responds by releasing hormones that work against insulin. That means you'll have too much blood sugar in the morning. It's also called rebound hyperglycemia. Blood sugar between 2-4 am is low.

Somogyi Effect

Do not heat or freeze, in-use vials may be left at room temperature for up to 4 weeks, extra insulin should be refrigerated, avoid exposure to direct sunlight, extreme heat or cold, store prefilled syringes upright for 1 week if 2 insulin types, 30 days if there is one type.

Storage of Insulin

Damage to small vessels that supply the renal glomeruli, microaneurysms and detruction of retinal capillaries, capillary and arteriole membrane thickening specific to diabetes.

Microvascular

Thickening of vessel membranes in capillaries and arterioles in response to chronic hyperglycemia, specific to diabetes and includes: retinopathy, nephropathy, dermopathy. Usually appears 10-20 years after diagnosis.

Microvascular Angiopathy

200 mg/dl (with glucose load of 75g)

Two-hour plasma glucose level during OGTT

3 P's (Polyuria, Polydipsia, Polyphagia), weight loss can occur becuase body doesn't have glucose and turns to fat cells and other things needed for energy, weakness and fatigue.

Type 1 DM Manifestations

The most prevalent form of DM. There is an increasing prevalence in children, and in certain ethnic groups. The pancreas continues to produce endogenous insulin, but the body does not use the insulin effectively. There is a gradual onset of this, a person has likely had the condition for 6 years before diagnosis. Often discovered with routine laboratory testing.

Type 2 DM

Nonspecific symptoms, classic symptoms of type 1 may manifest (3 P's), fatigue, recurrent infection, recurrent yeast infections, prolonged wound healing, visual changes.

Type 2 DM Manifestations

Aspiration of blood, membrane, and fibers inside the eye through a small incision just behind the cornea. Drugs to block the action of vascular endothelial growth factor (VEGF).

Vitrectomy

The nurse is caring for a patient with Type I DM who is admitted for diabetic ketoacidosis. The nurse would expect which laboratory test result? 1. Hypokalemia 2. Fluid overload 3. Hypoglycemia 4. Hyperphosphatemia

1

A diabetic client who is taking insulin lispro (Humalog) injections would be advised to eat: A.Within 30 minutes after the injection B. 1 hour after the injection C. At anytime, because timing of meals with lispro injections is unnecessary D. 2 hours before the injection

a

After a thorough evaluation, a nurse concludes that the efforts of a client with type 2 diabetes mellitus (DM) to control blood glucose levels have been highly effective over the last 3 months. Which finding supports the nurse's conclusion? a.Hemoglobin A1C level of 5% b.No incidence of diabetic ketoacidosis (DKA) c.No ketones in the urine d.Negative oral glucose tolerance test (OGT

a

A patient screen for diabetes at a clinic has a fast plasma glucose level of 120 mg/dl. Which statement by the nurse is best? 1. "You will develop type 2 dm within 5 years." 2. "You are at increased risk for developing diabetes." 3. "The test is normal, and diabetes is not a problem." 4. "The laboratory test result is positive for type 2 diabetes."

2

The nurse plans a class for patients who have newly diagnosed Type II DM. Which goal is most appropriate? 1. Make all pts responsible for the management of their disease 2. Involve the family and significant others in the care of these patients 3. Enable the patients to become active participants in the management of their disease 4. Provide the patients with as much information as soon as possible to prevent complications

3

A client is having their blood sugar checked in the clinic where you work. The client states their fasting blood sugar is 118 mg/dl. The client wants to know why the physician instructed them to watch their diet and exercise to prevent diabetes. Your explanation to the client is based on the knowledge that prediabetes: a.will always lead to a diagnosis of diabetes. b.can be prevented or delayed with proper diet and exercise. c.have fasting blood sugar levels between 130 and 150 d.have less incidence of developing complications of diabetes

b

A nurse administers 15 units of glargine (Lantus) insulin at 2100 hours to a Hispanic client when the client's fingerstick blood glucose reading was 110mg/dL. At 2300 hours, a nursing assistant reports to the nurse that an evening snack was not given because the client was sleeping. Which instruction by the nurse is most appropriate? a."You will need to wake he client to check he blood glucose and then give a snack. All diabetics get a snack at bedtime." b."It is not necessary for this client to have a snack because glargine is absorbed very slowly over 24 hours and doesn't have a peak." c."The next time the client wakes up, check a blood glucose level and then give a snack." d."I will need to notify the physician because a snack at this time will affect the client's blood glucose level and the next dose of glargine insulin.

b

A nurse is teaching a client who has been newly diagnosed with type 2 diabetes mellitus (DM). Which teaching point should the nurse emphasize? a.Use the arm when self-administering NPH insulin b.Exercise for 30 minutes daily, preferably after a meal c.Consume 30% of the daily calorie intake from protein foods d.Eat a 30-gram carbohydrate snack prior to strenuous activity.

b

A client is scheduled for a preprandial blood sugar check. The blood sugar is 224 mg/dl. According to the sliding scale insulin schedule, the client is to receive 4 units of Regular insulin for a blood sugar from 201- 250 mg/dl. You, the nurse prepare the insulin as ordered. Upon taking the insulin into the client's room, the client is vomiting and refuses to eat lunch. What would be an appropriate nursing action? a.Give the 4 units of Regular insulin and recheck the blood sugar in 30 minutes b.Give only 2 units of the Regular insulin because the client is vomiting c.Hold the 4 units of Regular insulin and notify the physician of client vomiting d.Hold the 4 units regular insulin and wait until the client is able to eat and drink and then give the insulin.

c

A client is scheduled for surgery the following morning and calls you, the nurse, who works for the client's primary care physician. The client wonders if he should take his scheduled insulin dosage before surgery the next morning. Your response is: a. "Yes, you may take your scheduled dose of insulin before surgery and we will check your blood sugar when you arrive at the ambulatory care center." b. "No, do not take any insulin before surgery because you will not eat or drink anything after midnight to prepare you for surgery." c. "I will check with your physician about if or how much insulin he/she would like you to take before surgery." d. "Check your blood sugar tomorrow morning before surgery and if it is > 120 mg/dl, take one half of the prescribed dose of your insulin."

c

A clinic nurse is evaluating a client with type 1 diabetes who intends to enroll in a tennis class. Which statement made by the client indicates that the client understands the effects of exercise on insulin demand? a."I will carry a high-fat, high-calorie food, such as a cookie." b."I will administer 1 unit of lispro insulin prior to playing tennis." c."I will eat a 15-gram carbohydrate snack before playing tennis." d."I will decrease the meal prior to the class by 15-grams of carbohydrates

c

The home care nurse is visiting a child newly diagnosed with DM. The nurse is instructing the child and parents regarding actions to take if hypoglycemic reactions occur. The nurse tells the child to: A. Drink 8 ounces of diet cola at the first sign of weakness B. Report to the ER if the blood glucose is 60mg/dL C. Carry hard candies whenever leaving home in case of hypoglycemic reaction occurs D. Administer glucagon immediately if shakiness is felt

c

What are potential risk factors for type 2 DM

overweight, obesity, advanced age-as organs get older and do not operate like when they are young, family hx

Candida Albicans

yeast infection

The patient isn't diabetic yet, it can be stopped before it progresses. The patient teaching at the stage is important as secondary prevention measures.

Prediabetes

Give via SubQ injection, regular insulin may be given IV in an ICU setting, cannot be taken orally, absorption is fastest in abdomen (Preferred) followed by arm, thigh and buttock, do not injected in a site that will be exercised, rotate injections within and between sites, uaully available as U100 insulin, no alcohol swab needed for a self injection, wash with soap and water, 45-90°, always use a 5/8 inch needle

Administration of Insulin

Damange to blood vessels secondary to chronic hyperglycemia, leading cause of diabetes related death, macro/microvascular, tight glucose levels can prevent or minimize complications.

Angiopathy

The body develops antibodies against insulin and/or pancreatic B cells that produce insulin, there simply is not enough insulin to survive.

Autoimmune disorder (type 1 DM)

This can affect nearly all body systems. Gastroparesis-delayed gastric emptying. Cardiovascular abnormalities-postural hypotension, resting tachycardia, painless MI. Sexual function-erectile dysfunction one of the first signs in males, decreased libido, vaginal infections Neurogenic Bladder-urinary retention, empty frequently use crede's maneuver, medications, self-catheterization

Autonomic Neuropathy

Urinary retention, N/V, painless MI, Male impotence

Autonomic Neuropathy

Afrezza, rapid-acting inhaled insulin, administered at beginning of each meal or within 20 minutes after starting a meal, not a substitute for long-acting insulin, don't want to use with a patient who has respiratory issues.

Inhaled Insulin

Microvascular and macrovascular diseases increased the risk for injury and infection. Sensory neuropathy and PAD are major risk factors for amputation. Also, clotting abnormalities, impaired immune function, autonomic neuropathy, smoking increases risk, patient teaching: proper footwear, avoidance of foot injury, skin and nail care, daily inspection of feet, prompt treatment of small problems. Diligent wound care for foot ulcers, neuropathic arthropathy (Charcot's foot).

Foot Complications (DM)

Usually, BG levels normal 6 weeks post-partum. 63% chance of developing type 2 diabetes within 16 years post-pregnancy delivery. 5-10% of pregnancies.

Gestational Diabetes

Defect in mobilization of inflammatory cells and impaired phagocytosis, recurring or persistent infections, treat promptly and vigorously, patient teaching for prevention: hand hygiene, flu and pneumonia vaccine.

Infection

This is produced by b cells in islets of langerhan in the pancreas. It has the ability to stabilize glucose levels in rnage of 70-100 mg/dl

Insulin

This promotes glucose transport from blood across the cell membrane to the cytoplasm of the cell. Insulin cells break down the glucose to make energy, if the body is not producing enough insulin, the patient becomes lethargic. THe liver and muscle cells store excess glucose as glycogen-gluconeogenesis. Skeletal muscle and adipose tissue are considered insulin-dependent tissues.

Insulin

A continuous SubQ infusion, battery-operated device, connected to a catheter inserted into SubQ tissue in abdominal wall, program basal and bolus doses that can vary throughout the day, potential for keeping blood glucose levels in a tighter range, the only time the basal insulin can be rapid acting is when they are using a pump.

Insulin Pump

Atrophy or hypertrophy of the subcutaneous tissue. This is why it is important to rotate sites, Since we now use human insulin, the incidences of this event has increased, usually this is very specific to a site where the insulin is injected.

Lipodystrophy

Glargine (lantus), detamir (levemir), degludec (tresiba). Onset 0.8-4 hours, peak is not exact, duration is 16-24 hours/ This should not be diluted together with another insulin.

Long Acting

These work on 3 defects of type 2 diabetes: insulin resitance, decreased insulin production, increased hepatic glucose production, can be used in combination.

Oral Agents

A pregnancy individual at low risk for gestational diabetes is screened when?

Second Trimester

This enables decisions regarding diet, exercise, and medication, accurate record of glucose fluctuations, helps identify hyper/hypoglycemia, maintanence of glycemic goals, must for insulin users, continuous glucose monitoring displays glucose values with updating every 1-5 minutes most effective way to show fluctuations and trends, helps identify trends and track patterns, alerts to hypo/hyperglycemia.

Self-Monitoring Blood Glucose

Atrophy of small muscles of the hands and feet, pain and paresthesia of the legs, foot ulcers without patient feeling pain.

Sensory Neuropathy

Regular (numulin R, novolin R). Onset of 30 minutes -1 hours, peak 2-5 hours, duration 5-8 hours.

Short Acting

What tissues are considered insulin-dependent tissues?

Skeletal muscle and adipose tissue

T/F: All patients with type 1 diabetes require insulin.

TRUE

A home-health nurse is planning the first home visit for a 60-year-old client newly diagnosed with type 2 diabetes mellitus. The client has been instructed to take 70/30 combination insulin in the morning and at suppertime. Which interventions should be included in the client's plan of care for diabetics? SELECT ALL THAT APPLY. CREDIT GIVEN ONLY FOR ALL CORRECT ANSWERS. a.Instruct the client to inspect the feet daily b.Ensure that the client eats a bedtime snack c.Assess the clients ability to read small print d.Teach the client to perform a hemoglobin A1c test daily.

a, b, c