Collaborative care of diabetes

Insulin pens are designed to administer multiple doses to just one person. They are never to be used

on multiple patients, as there is no guarantee of preventing cross-contamination between individuals. One pen = one person.

If a patient is taking metformin and having a diagnostic test with intravenously administered dye, the patient or nurse must

withhold the drug the day of the test and for 48 hours after the test. This is to prevent renal damage because the dye in combination with the drug can cause acute kidney injury.

Which instruction should the nurse give to a patient who is scheduled for a fasting blood glucose test?

"Do not eat or drink anything for 8 hours before the test."

Sulfonylureas

Include glipizide, glyburide, and glimepiride. Work to increase pancreatic insulin production. Most common side effects are weight gain and hypoglycemia

The nurse administers a dose of NPH insulin to a patient at 8:00 am. At which time should the nurse provide a snack or meal?

12:00 pm

Protein

15%-20% of total daily intake. Foods high in protein are meats, fish, poultry, dairy, nuts, and legumes. High-protein diets should not be implemented to induce weight loss.

Which dietary instruction should the nurse include when reviewing dietary needs with a patient newly diagnosed with diabetes?

40 to 60 grams of carbohydrates per day

Mixed Insulin Administration

A patient may receive more than one type of insulin at a time. It is common to administer a long-acting insulin as a "basal" insulin dose and either a rapid-acting or short-acting insulin with meals to provide an extra bolus to control blood glucose levels. Premixed insulins (for example, Novolin 70/30) contain both NPH (a long-acting insulin) and Regular (a short-acting insulin) in one vial. They come prepackaged from the manufacturer this way and eliminate the need for multiple injections.

OGTT

A plasma glucose level ≥200 mg/dL or 11.1 mmol/L 2 hours after oral ingestion of a 75-g glucose load confirms a diagnosis of diabetes.

A patient reports a new onset of increased thirst, hunger, and frequent urination. Which action should the nurse take first?

Obtain a random plasma glucose level

FPG

An FPG level ≥126 mg/dL (7.0 mmol/L) confirms a diagnosis of diabetes. Fasting is defined as no caloric intake for at least 8 hours.

The nurse is providing patient education to a high school athlete with diabetes who was seen in the emergency department after a syncopal episode during a basketball game. Which teaching interventions are appropriate for the nurse to provide?

Carry a source of quick-acting carbohydrate with you." "Obtain a capillary blood glucose level before you exercise." ***sugar should be check every 30 mins

Meglitinides

Include repaglinide and nateglinide, which increase insulin production. Work to increase pancreatic insulin production. Fast absorption rates. Should be administered within 30 minutes before a meal. Should not be taken if the patient skips a meal. Most common side effects are weight gain, photosensitivity, and hypoglycemia.

Inhaled Insulin Administration

Inhale insulin is a rapid-acting insulin given when the patient begins to eat or within 20 minutes of eating. Not a substitute for long-acting insulin. Not recommended for patients who smoke or have chronic obstructive pulmonary disease because it can cause bronchospasms. Common side effects include hypoglycemia, cough, and throat pain/irritation.

A patient with newly diagnosed type 1 diabetes tells the nurse that he or she likes to go camping, but is now afraid to go because of insulin needs. Which information should the nurse provide to the patient?

Insulin can be stored at room temperature.

Biguanides

Most widely used of all of the oral agents. Best "first-line" treatment for type 2 diabetes. Metformin is the only biguanide available in the United States. Reduce glucose production by the liver. Used for patients with prediabetes and type 2 diabetes who are overweight because it facilitates weight loss. Instruct the patient to take with food. Instruct the patient to avoid drinking large amounts of alcohol while taking this medication. Most common side effects are gastrointestinal upset and diarrhea.

Exercising for 30 minutes per day, 5 days per week will accomplish the following:

Decrease insulin resistance Lower blood glucose levels Promote weight loss Reduce triglyceride and cholesterol levels Lower blood pressure Improve circulation Prevent complications (e.g., obesity, fatty liver disease)

Intermediate-Acting examples

NPH

Noninsulin injectable agents are the third category of GLAs used in the management of diabetes.

Examples include exenatide and liraglutide. These medications imitate a hormone found to be decreased in patients with type 2 diabetes. Administration of these medications results in an increase in the production of endogenous insulin, slower gastric emptying, and creation of a feeling of fullness after meals. Can be used alone or with an OA but cannot be combined with insulin administration. Supplied in prefilled pens and administered one to two times daily. The nurse should instruct the patient to take any prescribed oral medications 1 hour before injection to facilitate absorption of oral medications.

Precautions During Exercise

Exercise lowers blood glucose levels, so the nurse should instruct the patient to carry a 15-g carbohydrate source and assess blood glucose levels before exercise, every 30 minutes during exercise, and after exercise. Blood glucose levels can continue to fall for 48 hours after exercise. If the exercise is too strenuous, it can stress the body and actually increase blood glucose levels.

Fat

Fat should be <7% of total daily intake. Minimize amount of trans-fats. Dietary cholesterol should be <200 mg/day. Two or more servings of fish per week.

Which source of fat should the nurse instruct the patient with diabetes to include in the diet at least twice a week?

Fish

Long-Acting examples

Glargine (Lantus) Detemir (Levemir)

Which diagnostic test result will the nurse review to evaluate a patient's blood glucose control over an extended period?

Glycosylated hemoglobin (HgbA1c)

Hgb A1c is also referred to as a glycosylated hemoglobin. HgbA1c ≥6.5% confirms a diagnosis of diabetes.

HgbA1c measures what percentage of hemoglobin is coated with glucose (glycated). Once glycated, a hemoglobin molecule will remain so for the remainder of the red blood cell's lifespan—approximately 120 days. The higher the HgbA1c, the higher the patient's blood glucose levels have been over the past 90 days. HgbA1c is used to monitor diabetes control over the past 3 months. The goal set by the American College of Endocrinology is to maintain a patient's HgbA1c below 6.5% to prevent micro- and macrovascular complications associated with hyperglycemia specifically and diabetes in general.

When Not to Exercise

If the patient has an elevated blood glucose level >250 mg/dL and ketones are present in the urine, exercise should be postponed until these conditions have been resolved. It is not necessary to postpone exercise when blood glucose levels are elevated in the absence of ketosis.

Factors that can result in a false-negative diagnostic screening result:

Impaired gastrointestinal absorption Medication use (e.g., selective serotonin reuptake inhibitors, aspirin, metoprolol) Recent alcohol use

Alpha-Glucosidase Inhibitors

Include acarbose and miglitol. Known as starch blockers because they slow down carbohydrate absorption. Should be taken with the first bite of each main meal to be most effective. Nursing considerations include treating hypoglycemia with 8 oz of skim milk or glucose gel or tablets, since both acarbose and miglitol block the action of other fast-acting sources of sugar. Most common side effects are flatus, abdominal pain, and diarrhea.

Insulin Storage

Insulin pens and vials may be kept at room temperature. Insulin should not be stored in hot or freezing cold environments as temperature changes the molecular structure of the insulin.

The nurse should instruct the patient in ways to reduce complications resulting from chronic, persistent hyperglycemia and diabetes. These include:

Keeping blood glucose levels under control Following a healthy, well-balanced diet Taking medications as prescribed Engaging in exercise a minimum of 5 days per week Getting routine medical check-ups and vaccinations Practicing stress management techniques Getting annual vision and hearing screening examinations Quitting smoking Wearing well-fitting shoes Inspecting feet daily for cuts or sores Notifying the health care provider of any illness Understanding signs of hyper- and hypoglycemia and implementing necessary interventions

Rapid-Acting examples

Lispro (humalog) Aspart (Novolog) Glulisine(Apidra SoloStar)

Traditional Multidose Vial Insulin Administration

Many insulins are packaged in multidose vials requiring the nurse to withdraw the medication with an insulin syringe. Only an insulin syringe can be used to draw up and administer insulin subcutaneously. This syringe is labeled in units and correlates to how insulin is prescribed.

The nurse is caring for a patient with diabetes who underwent magnetic resonance imaging with and without intravenous (IV) contrast dye yesterday. Which medication should the nurse withhold?

Metformin

Carbohydrates

Minimum of 130 g/day or 50%-60% of total daily intake. One carbohydrate serving is 15 g. A patient should have between 45 and 60 g per meal. Include fruits, vegetables, grains, legumes, and low-fat milk. Use carbohydrate counting, exchange lists, or portion size control to manage overall body weight. Foods containing sucrose can be substituted for other carbohydrates. Artificial sweeteners are safe when consumed according to Food and Drug Administration guidelines. Fiber intake should be 25 to 30 g/day.

Alcohol

One drink per day for women; two drinks per day for men. Any alcohol should be consumed with food to avoid the risk of hypoglycemia.

An insulin pump delivers insulin via a subcutaneous needle left in the tissue, attached to a small, mechanized pump device, worn at the patient's waistline.

Only delivers rapid-acting insulin. Delivers a basal rate so the patient is receiving a continuous amount of insulin throughout the day. The patient can program the pump to administer insulin boluses based on carbohydrates ingested. Closely mimics insulin release in a healthy person who does not have diabetes. Allows for tighter blood glucose control.

Onset, Peak, Duration of long-acting examples

Onset: 0.8-4 hr Peak: no pronounced peak Duration: 24+ hr

Onset, Peak, Duration of intermediate insulins

Onset: 1.5-4 hr Peak: 4-12 hr Duration: 12-18 hr

Onset, Peak, Duration for rapid acting insulins

Onset: 10-30 min Peak: 30 min-3 hr Duration: 3-5 hr

Onset, Peak, Duration for short acting insulin

Onset: 30 min-1 hr Peak: 2-5 hr Duration: 5-8 hr

The nurse is caring for a patient with diabetes who is also receiving treatment for chronic obstructive pulmonary disease. The nurse should obtain capillary blood glucose levels based on documentation of which medication in the patient's chart?

Prednisone

Which laboratory finding warrants a repeat test to confirm a diagnosis of diabetes?

Random blood glucose value of 250 mg/dL

A nurse is preparing a patient with suspected diabetes for a fasting blood glucose test. The nurse should ask the patient about which factors?

Recent acute illness History of alcohol use History of recent exercise

Factors that can result in a false-positive diagnostic screening result:

Recent acute illness Medication use (e.g., oral contraceptives, corticosteroids) Restricted activity, such as prolonged bed rest

Which subjective assessment finding indicates a need for further patient education about reducing the risk of developing complications from diabetes?

Reports walking barefoot only when it is warm outside

Insulin Pen Administration

Some insulins are prepackaged by the manufacturer in a pen form that contains 300 units of insulin. This pen is designed to administer multiple doses. The patient attaches a disposable needle to the pen to administer the dose. The patient will turn the dial to the correct dose, inject the needle into the skin, and push the button on the top of the pen to administer the dose.

Dipeptidyl Peptidase-4 Inhibitors

The main drug in this category is sitagliptin. These medications increase insulin production and decrease hepatic glucose production. The nurse should assess baseline renal function before administration. The most commonly reported side effects are rhinitis, headache, and back pain.

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors

The main medications in this class are canagliflozin, dapagliflozin, and empagliflozin. These medications block renal reabsorption of glucose and increase glucose excretion. Nursing considerations include assessing urinary function before administration. Side effects include urinary tract infections and hypoglycemia.

A 16-year-old patient with diabetes reports to the nurse that morning blood glucose levels have been averaging around 200 mg/dL but are within an acceptable range the rest of the day. Which situation should the nurse suspect?

The patient is experiencing the dawn phenomenon.

The nurse is responsible for educating the patient about all aspects of insulin administration to prevent infection and ensure that the full dose of insulin is delivered. Important considerations are as follows

The patient should determine the blood glucose level before administering insulin. Instruct the patient to wash his or her hands first and clean the injection site. When insulin is being administered, most health care facilities require two nurses to verify that the dose and type of insulin in the syringe are correct. Bolus dose insulin should be administered around the patient's meal schedule and should be withheld if the blood glucose level is <70 mg/dL. Rapid-acting insulin should be given when the patient is eating. Short-acting insulin should be given within 30 minutes of a meal. Long-acting insulin is given at a scheduled time. Insulin is administered subcutaneously (either a single injection or continuously with an insulin pump). Regular insulin has traditionally been the only insulin that is administered intravenously and typically only in emergency situations, not as part of routine management. Current literature states that aspart, lispro, and glulisine are also being administered intravenously (Lehne, 2013). If the nurse is mixing insulins, he or she will inject air into the intermediate-acting insulin first, then into the short-acting insulin and will withdraw the short-acting insulin first and the intermediate-acting insulin second. This prevents contamination of the short-acting insulin with the intermediate-acting insulin.

Many patients with type 2 diabetes, under normal or nonacute conditions, are prescribed oral GLAs. OAs improve the mechanisms by which the body produces and uses insulin and glucose. OAs are used in the following cases:

The patient's pancreas produces some endogenous insulin but not enough to maintain healthy blood glucose levels. The patient displays insulin resistance at the cellular level. The patient has increased production of glucose in the liver.

A patient with diabetes asks the nurse about the option of using inhaled insulin because of a fear of self-administered injections. Which finding in the medical record would prevent the patient using this form of insulin?

Tobacco use (1 pack of cigarettes per day)

The patient with new-onset type 2 diabetes asks the nurse about ways to lose weight. Which instruction should the nurse include in patient education?

Use portion control.

A nurse is providing dietary teaching to a patient with diabetes. Which patient action indicates a good understanding of dietary restrictions?

Using artificial sweeteners for beverages

Which actions should the nurse take when administration of NPH and regular insulin is required for a patient with diabetes?

Withdraw the regular insulin first, then the NPH, in the same syringe. Assess the patient's capillary blood glucose level before the injection. Have a second nurse check the insulin type and dosage before administration.

Allergic reactions can occur,

manifested by local itching and a rash or even full anaphylaxis.

Capillary blood glucose monitoring is typically the preferred

diagnostic method used in the management of diabetes in both the acute care setting and the home setting. The patient who has already been diagnosed with diabetes will perform self-monitoring of blood glucose levels with capillary blood regularly at home as a means of tracking effectiveness of therapy and assessing for complications when he or she is not feeling well.

Hypoglycemia occurs if

insulin dosing is excessive or the patient is not balancing insulin administration with caloric intake.

The dietician should be consulted to help the patient and family develop plans for healthy, well-balanced meals and snacks. Instead of forcing the patient to conform to strict dietary restrictions, meal planning should be based

on the patient's usual food intake and preferences. These food choices should be balanced with glucose-lowering agents (GLAs) (insulin, oral agents [OAs], and noninsulin injectable agents) and exercise patterns. A GLA regimen should be prescribed and administered with the patient's eating habits and activity pattern in mind.

The Somogyi effect is an

overcompensation by the body in response to extremely low blood sugar levels occurring during the night, resulting in early morning hyperglycemia. The body releases stored glucagon in reaction to the untreated nighttime hypoglycemia. This is typically managed by instituting a bedtime snack and/or by decreasing the evening insulin dose.

A random plasma glucose value ≥200 mg/dL or 11.1 mmol/L is highly indicative of diabetes in a patient with:

polyuria/polydipsia/polyphagia/unexplained weight loss hyperglycemic crisis

A large component of diabetes management involves the patient following a

recommended diet and incorporating exercise into his or her daily routine. Dietary changes can be complicated to understand, so the nurse will need to teach the patient how to read labels and understand the different food groups, especially carbohydrates. An initial consultation with a clinical dietician can be very beneficial in setting the stage for best nutritional practices.

Short acting insulin example

regular

In a patient with no symptoms of diabetes and a random plasma glucose value ≥200 mg/dL, the test must be

repeated and/or confirmed with one of the other diagnostic tests. If the patient has a random plasma glucose value ≥200 mg/dL and is having symptoms of diabetes, that one abnormal value is considered diagnostic of diabetes

Lipodystrophy occurs if the patient

repeatedly administers the insulin in the same area. To prevent this, the nurse will instruct the patient to rotate injection sites. This allows for improved, more predictable insulin absorption.

The dawn phenomenon is also early morning hyperglycemia caused by

the release of cortisol and growth hormone during the early morning hours. It tends to happen to younger patients during periods of growth. This is typically managed by increasing the evening insulin dose.