Diabetes

Explain diagnosis for diabetes using Casual Plasma Glucose Test.

blood is drawn anytime, without regard to meals. >200mg/ml or higher suggests diabetes.

Explain diagnosis for diabetes using fasting plasma glucose levels.

blood is drawn at least 8 hours after the last meal. IF FPG is greater than 126 mg/dl on at least 2 occations=diabetes

leading cause of blindness in persons between 20-70 years

diabetic retinopathy

Cataracts and Glaucoma are also associated with diabetes, caused by ____.

increased accumulation of sorbitol due to lack of insulin.

What is the treatment for DKA?

- IV insulin (Regular) -IV fluids (2 lines, one for fluid one for insulin)-Normal Saline to dilute sugars. After BS is <300mg/dl may switch to D5W b/c we dont want hypoglycemia. Might need to add potassium -Hourly BS -Hourly I&O (Polyura-->Oliguria-->Anuria)-kidneys aren't working -ABG's- Metabolic Acidosis -EKG b/c of shifting K+; Na Bicarb only temporary

S&S of Diabetes: -Weightloss (cell starvation) despite normal or increased appetite is a common occurrence in a person with uncontrolled Type ___ diabetes. -2 Reasons include:____

-1 -loss of body fluids and body tissue is lost b/c lack of insulin forces the body to use fat store and cellular proteins as sources of energy.

Sulfonyureas: -Oral agent to lower plasma glucose level for Type 2 DM only. -Onset: _____ -Duration:____ -Mechanism of Action:____ -Can cause ___ but not as severe as insulin. -Examples: ____ (most common)

-1-6 hour -12-24 hour -cause the pancreas to secrete more insulin -hypoglycemia -Glucotrol (Glipizide)

Insulin's Function: -Insulin works to decrease blood glucose levels by what two things? -An insulin receptor and a specific glucose transporter (GLU 4) are involved. This transporter does what? -Insulin ____ as blood glucose levels rise and ___ when blood glucose levels decline.

-1. facilitating transport of glucose across cell membranes into the muscle and adipose tissues. 2. inhibiting gluconeogenesis (liver makes glucose from other substances) -removes insulin from the blood and shuttles it across the cell membrane into the cell to use for energy. -increases; decreases

-only type __ diabetes can take oral medications -in type 1, w/o insulin, ____ won't work -both types of DM need _____.

-2 -oral meds -glucose control

Incretin Mimetics: -Mechanism of Action: -NOT ___, available form: _____ -Examples:____ -Adjuvant therapy for Type ___ diabetics who are taking a ___ or ___.

-improve beta cell responsiveness -ORAL; SubQ injection -Exenatide (Byetta) -2; Biguanide or Sulfonyurea *not insulin!

DKA: -A blood glucose level above ___mg/dl and ___ are warning signs of DKA. -Under normal conditions, ketoacidosis can be utilized by neural and muscle tissue in ___. But if continually produced; pt. develops ___ accompanied by ____. -In an attempt to compensate for metabolic acidosis (ketoacidosis), respirations will ____ (chracterized by prolonged _____) to blow of CO2. Breathing deep and labored is known as ____. -Breath is "fruity" or "sweet smelling" due to _____. -____ develops (acetone (ketones) in urine)

-240; ketones in the urine -energy metabolism; metabolic acidosis accompanied by hyperkalemia (at risk for heart problems b/c of quick shifting of K+) -increase (expiratory period); Kussmaul's Respirations -acetone formed during ketosis -Ketouria

Gestational Diabetes: -Should be screened for diabetes between __ and ___ week of pregnancy -Do not need to be screened if _____.

-24th and 28th -under 25, of normal body weight before pregnancy, have no history of diabetes, and not a high-risk ethic group (Hispanic, Native American, Asian, African American)

What are the signs and symptoms of Diabetes?

-3 P's: Polyuria, Polydipsia, Polyphagia -Fatigue -Glucosuria -Blurred vision -Dehydration/hyperkalemia/hyponatremia with diuresis -Hypovolemia -Skin infections/yeast infections

Clinical manifestations of Hypoglycemia -Defined as blood glucose less than _____. -___ decline in blood glucose -Can be caused by____ or ___. -Hypoglycemia causes activation of the ____. S&S related to adrenergic stimulation: ______- -If hypoglycemia occurs gradually, symptoms are ___ in origin: _______ -In cases of severe hypoglycemia, ___ function can be severely impaired: _______

-50 mg/dL -Abrupt -Fasting coupled with exercise (exercise increases the usage of glucose by skeletal muscle) and Insulin overdose -Sympathetic Nervous System; S&S: Diaphoresis, weakness, nervousness, sudden onset of hunger, headache (as a result of alteration of blood flow (hypoperfusion) and changes in water balance) -CNS; S&S: H/A, confusion, drowsiness, and fatigue -neurologic; S&S: confusion, disorientation, bizarre behavior, stupor, convulsions, death

Diagnosis of Diabetes- Impaired Fasting Glucose: -Those individuals with a FPG ____ but ___, or -OGTT ___ but ___ in the 2 hour sample -*At risk for Diabetes

->110mg/dl but <126 mg/dl ->140mg/dl but <200mg/dl

Hyperglycemic, Hyperosmolar, Nonketotic Coma (HHNK) -Looks like ____, but minimal ___. -Type ___ diabetics get this because _____. -Characterized by _____(____mg/dl) and ____(___mOsm/kg) -Combined with ___, eventually leads to ____. -Cellular dehydration can lead to _____. -If any Ketoacidosis, it is much less severe compared to DKA. Why? -Will they develop Metabolic Acidosis? -Will they develop Kussmaul Respirations? -What is the treatment?

-DKA; ketosis -2; they have some insulin-not going to have ketones -extreme hyperglycemia (800-2000) and hyperosmolality (>350) -osmotic diuresis; hyperosmolar dehydration -altered consciousness (coma) -If a person is able to secrete some insulin, then it prevents mobilization of fat from tissues and the release of ketone bodies. -No -No -insulin and fluids

Biguanides: -Mechanism of action:____ -Common SE:___ -Rarely causes ____. -Can cause _____(rare)- use caution in patients with ____. (Hold for 48 hours following contrast dye studies) -Especially effective for _____. -Examples: ____

-Decreases the liver's glucose production and decreases glucose absorption in the GI tract -Diarrhea -Hypoglycemia -lactic acidosis; renal insufficiency -obese patients who are insulin resistant -Glucophage (Metformin)

Catecholamines: -___ and ___ help to maintain blood glucose levels during periods of stress. -During exercise and types of stress, epinephrine _____ insulin release and thereby ___ the movement of glucose into muscle cells, it stays in ____. -Exercising muscle has increased insulin sensitivity, which facilitates glucose uptake for as long as ____ hours after exercise (therefore insulin demand is _____)

-Epinephrine and Norepinephrine -inhibits; decreases; blood stream -16; lowered

Agents used to RAISE glucose: -____ and ____ -Used to raise glucose levels in emergency situations. -What is the normal FBS (fasting blood sugar)?

-Glucagon and D50 -70-100 (normal); 80-120 (diabetic)

Combination Oral Antidiabetic Agents: -Combination Products of Fixed Combinations -Examples: ___(a ___ and a ____) -Combination products are common today in ___ management.

-Glucovance (a sulfonamide and a biguanide) -Type 2

Macrovascular disease: -increased risk of: ____ -caused by ____ -result from ____

-HTN, MI, CAD, and stroke (d/t vessel damage) -atherosclerosis -alterations in lipid metabolism, rather than hyperglycemia

Diagnosis of Diabetes: -____! -Diagnostic test include: ____

-HYPERGLYCEMIA! -Oral glucose tolerance test (OGTT) -Fasting plasma glucose (FBG) -Casual plasma glucose test -HA1C

What are the major problems in DKA?

-Hyperglycemia: leads to osmotic diuresis, dehydration, and critical loss of electrolytes -Breakdown of fats and proteins: leads to -Increased ketones (Ketoacidosis) and metabolic acidosis -Can progress to coma.

Growth Hormone: -____ available glucose from the liver. - It has many metabolic effects: what are three of them? -Exercise, stresses, including anesthesia, fever, and trauma, ___ growth hormone. - Increased growth hormone = ___ blood glucose

-Increases -increases protein synthesis in all cells of the body, mobilizes fatty acids and antagonizes effects of insulin -increase -increase

-What are the 3 types of Rapid-Acting Insulin? -Onset:_____ -Peak:_____ -Duration:_____ -There is no defense in court of law for adminstered rapid-acting insulin without food immediately available. Cannot be administered more than ____ minutes before a meal.

-Lispro (Humalog), Novolog (Aspart), Apidra (Glulisine) -10-30 minutes -1-3 hours -3-5 hours -5

Thiazolidinediones: -Mechanism of Action: -Has effect of plasma lipid levels: ____, ___, and ____. -Contraindicated with history of ____. -Examples:____

-Lowers blood glucose by improving tissue response to insulin. Decreases insulin resistance (makes the cells more sensitive to insulin, so less insulin is needed to move glucose) -1. Raises low-density lipoproteins (LDL) cholesterol (up to 13%) which is bad. 2. Raises high-density lipoproteins (HDL) cholesterol (up to 16%) which is good. 3. Lowers triglycerides (up to 26%) which is good -heart disease b/c is raises LDL -Avandia (Rosiglitazone) and Actos (Pioglitazone)

-What are the types of Intermediate-acting Insulin? -Onset:____ -Peak:___ -Duration:____ -Only longer acting insulin that is suitable for mixing with ____ insulin. Mixing insulins may alter ___ rates. -Usual dose: _____.

-NPH, Lente, Humulin L, Novolin N - 1-2 hour - 6-12 hour -18-24 hour -short acting; absorption -injected twice daily to provide control between meals and at night.

-What are the types of Short-Acting Insulin? -___ acting agent and has ____ duration. -Regular -Onset:___ -Peak:___ -Duration:___ -Commonly used insulin, also used for control with ____ dosing in patient's admitted to hospital. (Often hospitalization and illness is a source of stress, which increases ___ release, which ____ blood glucose. Also used for patients on ______) -Only form of insulin that can be given ____.

-Regular (Humulin R, Novolin R, Exubera)-unmodified human insulin -fast; short -0.5-1 hour -2-4 hour -6-8 hour -Sliding Scale (cortisol; increases; high dose glucocorticoid therapy) -IV

-What are the types of oral hypoglycemics? -Are these effective for Type 1 DM? Why?

-Sulfonyureas, Biguanides, Alpha-glucose Inhibitors, Thiazolidinediones, Meglitinides, Incretin Modifiers, Amylin Analog, Combinations -No because they don't have insulin

Amylin Analog: -May be used in the management of ___ and ___. -____ injection; NEVER IN ___ -When do you give it? -Examples: _____ -Complements the effects of insulin as a supplement to insulin. NOT a form on insulin!

-Type 1 and Type 2 -SubQ; ARM -Prior to large meals -Pramlintide (Symlin)

Diabetic Ketoacidosis (DKA) -____ diabetics most prone to DKA: Continued insulin deficiency results in ____. Both ___ and ___ are metabolized. As fat stores are metabolized, ____ are produced. The resulting fatty acids undergo transformation in the liver to _____. -Anything that ____ can throw a pt. into DKA (such as ____ or ___)

-Type 1; lipolysis (breakdown) or body tissues); proteins and fats; fatty acids; ketoacids -increases BS; illness or skipping insulin

Injection sites for insulin: -___ considered ideal site for absorption -rotate sites -If not rotated, a continuously used site will develop a __ and absorption will be ___.

-abdomen -fatty lump; erratic

What is the dosing schedule for Continuous SC Insulin Infusion?

-accomplished using a portable infusion pump connected to an indwelling SC catheter. -uses regular insulin, infused at a slow and steady rate to maintain a basal level. -additionally may take insulin before eating.

Glucagon: -Hormone secreted by the ____ of the pancreas, important in the regulation of ____. -The action of glucagon is ____ to that of insulin, and its secretion results in a ____ in blood glucose concentrations. -Glucagon maintains blood glucose by ____ and promotes ____.

-alpha cells; carbohydrate metabolism -opposite; increase -increasing the release of glucose from the liver into the blood; gluconeogenesis

Type 1 DM: -No insulin, glucose build up in the ____. -The cells are starving so they ______. -When you breakdown fat the byproduct is ____. -What is the acid/base imbalance that occurs from the breakdown of fat? -If I am acidotic do I want to keep or blow off CO2? -So, I'm going to breathe fast or slow? -We call these respiration's _____.

-blood -breakdown fats and proteins -ketones -metabolic acidosis -blow off CO2 -fast -Kussmal Respirations

Diagnosis of Diabetes with Oral Glucose Tolerance test: -Measures _____. Administration of glucose load after a ___ hour fast followed by a measurement of ____ levels at specified intervals. OGTT _____ on at lease 2 occasions =diabetes.

-body's ability to remove glucose form the blood; 12; serum glucose; >200mg/dl after 2 hours

Glucose Metabolism: -Most cells, including ____ and the ____ rely on glucose as a fuel source. -Because the brain cannot synthesize or store more than a few minutes' supply of glucose, normal cerebral function requires _____. -Severe or prolonged ____ can cause brain death and dysfunction. This the coma associated with diabetes.

-brain; nervous system -a continuous supply from the circulation -hypoglycemia

Microangiopathy: -A specific lesion of diabetes that affects _____, ____, and ____. -Since the chemical components of the basement membrane can be derived from glucose, hyperglycemia causes _______. These cells do not require ___ for glucose use. (becomes thicker-damage)

-capillaries and arterioles of the retina (diabetic retinopathy), peripheral nerves (diabetic neuropathy), and muscles and skin. -an increased rate of formation of basement membrane cells; insulin.

Gestational Diabetes: -State of ___ that is first detected during pregnancy (2-5% of pregnancies) -Pregnancy causes changes in ___ (b/c of hormonal changes) -Resembles ___ diabetes; weight gain contributes to ______. -Normally during pregnancy, need ____ insulin -Women with gestational diabetes are unable to _____. -___ is 3X higher with pregnancy. (body is stressed)

-carbohydrate intolerance -metabolism -Type 2; insulin resistance -2-3 times as much -produce sufficient amounts of insulin -Cortisol

Type 1 DM: -___ have the highest rate of Type 1 -Type 1 develops more in _____. What triggers? -Accounts for __% of all DM. -Generally diagnosed after __% of beta cell mass has been destroyed.

-caucasians -winter months and colder climates; viruses (autoimmune disorders) -10 -90

Principals of Insulin Therapy: -Regular insulin is ___-others MAY be ____. -Suspensions are absorbed more ____- peak times are ___ than regular insulin. -Keep in ___ areas and away from ____. -Gently mix by rolling between palms of hands- to prevent ____. -To avoid contaminating regular insulin vial with other types of insulin, ALWAYS withdraw ___ first. draw up "clear to cloudy"

-clear; clear or cloudy -slowly; longer -cool; sunlight -"foaming of suspensions" -regular insulin

Diabetes: -S&S are caused by insulin___, insulin___ or ___. -Also seen with ___, ___, or ___. -All of these cause blood glucose to increase -When there is "no insulin" glucose cannot enter into muscle and adipose tissue. So the serum glucose level is ____, but there is functional cell starvation because ____. -The ___ and ___ are spared from glucose deprivation since they do not need insulin for glucose entry.

-deficiency, resistance, hyporesponsiveness -hypercortisolemia, high dose glucocorticoids, excess in growth hormone -elevated; its not in the cell -brain and RBC's

-Glucose is ingested through the ____ -Between meals, the ___ releases glucose as a means of maintaining blood glucose within normal range -Glucose is an optimal fuel for tissues such as ____, ____, and ____. -Glucose that is not needed for energy is stored as ____ or converted to ____. -When glucose levels rise, _______. When blood glucose levels fall, _____.

-diet -liver -muscles; adipose tissue; and the liver -glycogen; fat -glucose is removed from the blood and converted to glycogen; the liver glycogen stores are broken down and released into the circulation.

Principals of Insulin Therapy: -Insulin cannot be given orally because _____. -"No pill"- must be given by injection, pump, or inhaled. -Insulin works by ____. -Concentration: most common concentration is _____. -Most given ____. -___ can be given IV because its a "true solution"-most other preparations consist of particles in suspension. -Use insulin syringes that correspond to ____.

-digestive enzymes in the stomach will break it down -promoting the uptake of glucose into cells -U-100 (100 units/ml) -SC -Regular Insulin -units

Diabetes Classification System: -New system in 1997- eliminates use of "insulin-dependent" and "noninsulin dependent" DM. -Based on ___ rather than "drugs needed" -Uses ___ instead of Roman number system

-disease etiology -Arabic

S&S of Diabetes: -Tissues do not have glucose available. -Neural tissue in the brain responds to this emergency by promoting _____ -_____(excessive hunger) -Does this help?

-eating behavior -Polyphagia -No

Glucocorticoid Hormones: -The glucocorticoid hormones are critical to survival during periods of ___ and ____. -But, prolonged elevation of glucocorticoid hormones can lead to ___ and development of _____. -____(accounts for 95% of all glucocorticoid activity) increases during periods of stress, such as infection, pain, trauma, surgery, exercise, and acute anxiety. -Cortisol stimulates ____ and interferes with the action of insulin. -Increased glucocorticosterioids= ___ blood glucose.

-fasting and starvation -hyperglycemia; diabetes mellitus -Cortisol -gluconeogenesis -increased

Type 1: -Thought to be caused by a ____. Type 1 patients have autoimmune markers (HLA's), including ___. Auto-antibodies build up in the blood and attack ____. -In most cases, onset is ____. -Because of loss of beta cell function and complete lack of insulin, all people with Type 1A diabetes require insulin replacement to ____, ___, and ____.

-genetic predisposition; islet cell auto-antibodies; pancreatic beta cells (pancreas stops producing insulin) -abrupt -reverse catabolic state, control blood levels, and prevent ketosis.

Kidney Disease: - Renal failure caused by ___, ____, and ___ from glycogen and fatty changes -Early manifestations or nephropathy are ___ and ___. As the loss of functioning nephrons progresses, patients develop ___ and ____. Patients may require ___ or ____. -PRO (protein) in urine = ____. -___and ___ are at higher risk for CRF. -Risk is higher in type ___ diabetics.

-glomerular lesions, renal vascular atherosclerosis, and renal tubular alterations -proteinuria and hypertension; renal insufficiency and uremia; dialysis or renal transplantation. -renal failure/disease -Native Americans and African Americans -1

Secretion of Insulin: -The principle stimulus for insulin release is ___. -Insulin stimulates cellular transport (uptake) of glucose, amino acids, nucleotides, and ____. -Insulin deficiency puts the body into a ____ mode, glycogen is converted to ____, proteins into ____, and fats to ___ and ____.

-glucose -potassium (insulin moves K into cells. K in blood drops->at risk for hypokalemia) -catabolic; glucose; amino acids; glycerol and fatty acids (increase insulin could cause hypoglycemia and hypokalemia)

S&S of Diabetes: -When the maximum tubular absorptive capacity of the kidney is exceeded (about 180), ____ is lost in the urine, resulting in ____(water moves toward high solute concentration) -____ (frequent and excessive voiding) -Hypovolemia results because:

-glucose; osmotic diuresis -Polyuria -

HgbA1C: -___ is essentially irreversible, and the level of glycosulated hemoglobin present in the blood provides an index of blood glucose levels over the previous 2-3 months -Without diabetes, HbgA1c levels are __%. If diabetic can keep their level at __% or less, significantly fewer complications

-glycosylation -5; 7

-Insulin is classified according to ____. -___ is how soon the insulin starts working -___ is when insulin is working most effectively -___ is how long the insulin lasts in the body.

-how it works in the body -onset -peak -duration

Type 2 diabetes: -Type 2 diabetes describes a condition of fasting ____ that occurs despite the availability of insulin. Not associated with HLA markers of autoantibodies. -Both ___ and ___ are thought to contribute to the pathogenesis of the disorder. -Some other drugs that are thought to elevate blood glucose include: ______.

-hyperglycemia -hereditary and environmental factors -thiazide diuretics, Diazoxide, glucocortiosteriods, levodapa, oral contraceptives, sympathomimetics, phenothiazines, phenytoin, and total parenteral nutrition.

S&S of Diabetes: -Glucose accumulates in the blood- the blood becomes ____ and pulls water from the _____. Intracellular dehydration stimulates ____ in the ____ -_____(excessive drinking/thirst)

-hyperosmolar; intracellular compartment; thirst in the hypothalamus -Polydipsia

Gestational Diabetes: -Complications to fetus include ___ and ___. why? -These women have a higher tendency to develop ___ 5-10 years after delivery.

-increased birth weight- increased sugar, baby gets fat -neonatal hypoglycemia- baby was accustomed to increased blood sugar and when came out it was still making lots of insulin. they don't have enough sugar b/c it is all being used up by the insulin. -type 2 diabetes

Incretin Modifiers: -Mechanism of Action:____ -Adjunct with ___ and ____. -Examples:___

-increases incretin hormones, increases insulin secretion, decreases Glucagon secretion -diet and exercise -sitagliptin phosphate (Januvia)

What is the dosing schedule for Intensified Conventional Control? (insulin) What is the advantage?

-injection of intermediate-acting insulin in the morning and evening (basal level of insulin) and also injects regular insulin prior to each meal (for acute needs). -advantage is that you get tight control because the dose of regular insulin is based on capillary glucose levels.

Type 2 (used to be called NIDDM or Type II) -Onset ____ -Usually occurs after ___ , and 70-80% of those with type 2 diabetes are ___ and ____. -Currently are seeing and increase in Type 2 DM in children and teens d/t ____. -U.S. ethnic groups most at risk include: ____ -__ and ___ are strong risk factors.

-insidious -30; obese and older -diet and lifestyle -African Americans, Mexican Americans, Pima Indians -family history and obesity

-What are the two categories of antidiabetic agents? -Type ___ will need exogenous insulin replacement therapy. -Type ___ will be on one or more agents (including insulin if needed)-oral hypoglycemics.

-insulin and oral medications -1 -2

Diabetes Mellitus: -Diabetes is a disorder of carbohydrates, protein, and fat metabolism resulting from an imbalance between ___ and ____. - What 4 things can it represent? -A person with uncontrolled diabetes is unable to transport glucose into fat and muscle cells; as a result the bodys cells are ___, and the breakdown of fat and protein is ____. -Diagnosed by the presence of chronic ____.

-insulin availability and insulin need - an absolute insulin deficiency, impaired release of insulin, inadequate or defective insulin receptor, or the production of inactive insulin -starved; increased -hyperglycemia (ketone production)

What is the dosing schedule for Conventional Therapy? (insulin) What is the disadvantage?

-insulin is given 15-30 minutes before breakfast and supper. -typically 2/3 of the total daily dose is given in the morning and the remainder in the pm. -Disadvantage is no adjustment is made on daily basis.

Urine glucose monitoring: -Used to monitor for ____- not accurate reflection of glucose in blood. If negative for glucose, only tells you that blood glucose is below 180mg/dl, the typical threshold for _____(will start having positive urine test for glucose at 180mg/dl)

-ketones; spilling glucose from blood to urine

Retinopathy: -Damage to the retina resulting from ___ -With hypoxia, ___ and __ formation occurs.

-lack of oxygen -scarring and microaneurysm

Meglitinides: -Mechanism of Actions:___ -Contraindicated with history of ____. -Because of possible hypoglycemia, it is imperative that patients eat within ____ min of drug administration -Examples: ______

-like sulfonylureas, it lowers glucose levels by stimulating release of insulin from the pancreas -liver disease -30 -Prandin (Repaglinide)

Principals of Insulin Therapy: -Rotate injection sites (same area?) to avoid ____. -Give at ___ temperature -Goal is _____(____mg/dl) -____ dose for infection, stress, obesity, adolescent growth spurt, and 2nd and 3rd pregnancy. -___ dosage for exercise and first trimester -Given to all diabetic type ___ and some type ___ diabetics.

-lipohypertrophy (insulin will not absorb with scar tissue) -room -tight glucose control (80-120) -increase -decrease -1;2

-About 2/3 of the glucose that is ingested with a meal is removed from the blood and stored in the ___ as ____. -Blood glucose levels reflect the difference between ___and _____. -Body tissues obtain glucose from the ____. -In nondiabetic patients, fasting blood glucose is tightly regulated between _____mg/dL. After a meal, the blood glucose levels ___ and ___ is secreted in response.

-liver; glycogen -the amount of glucose released into the blood stream by the liver and the amount of glucose taken up by the cell for energy -blood -70-100; rise; insulin

What are the long-term complications of diabetes? How long does it take to develop?

-long-term sequelae of diabetes takes years or even decades to develop. -**vessel damage** -The long-term vascular complications of diabetes involve microangiopathy (small vessels) and macroangiopathy (middle and large-sized vessels)

Treatment for Type 1 Diabetes: -goal is to _____. -glycemic control is accomplished with and integrated program of ___, ___, and ____. -___ increases cellular responsiveness to insulin (need ___ insulin for glucose control) -Diet should be ____% carbs (complex not simple), ___& fat (mostly unsaturated) to __% proteins. -Why is PRO (protein) decreased?

-maintain glucose levels within an acceptable range -diet, exercise, and insulin replacement -exercise -55-60, 30, 12 -because of kidney problems

Treatment for Type 2 Diabetes: -goal is to _____. -control with ___, ___, and ___. -Often the patient's initial medication will become ___ and have to be modified. Possibly ___. -What contributes to this?

-maintain glucose levels within an acceptable range -oral antidiabetic agents, diet and exercise -less effective; insulin

Infection: -ability to inspect skin for intactness (especially feet) -tissue hypoxia -many ____ proliferate in glucose. -decrease blood supply=decreased ____ to site to fight infection

-pathogens -WBC

Insulin: -Insulin is a ____ -It is essential for normal carbohydrate, fat, and protein ____. -Helps produce ____ and plays a role in the storing of excess energy as ____. For example, in the liver and muscles. -Output of insulin is regulated mainly by ____ through a negative feedback mechanism. Begin to rise within minutes after a meal, reaches peak in ____minutes and then returns to baseline within ____ hours. (increase blood glucose=increased release of insulin)

-protein -metabolism -energy; glycogen -blood glucose levels; 3-5; 2-3

Urine Albumin: -If ___ in the urine, may indicate early signs of chronic renal failure. -Why would they develop renal failure?

-protein -rise and fall of BP damages vessels (kindeys=very vascular); glucose damages blood vessels. *patients with uncontrolled diabetes will end up with renal failure.

Type 2 diabetes: -Glucose receptors in cell walls that are normally opened by insulin fail to function properly. As a result of receptor failure, glucose levels in the blood ___. (Insulin "opens the door") -____ make more insulin in attempt to decrease glucose levels. With Type 2 DM approximately __% of the Beta cells are destroyed at the time of diagnosis, and approximately __% are destroyed each year thereafter unless it's controlled. -Increased insulin production can be maintained for years, but eventually the islet cells "burn out" and the patient requires ____.

-rise -islet cells; 50; 4-10 -exogenous insulin

Premixed Insulin: -2 types of insulin mixed together in one vial. Usually one insulin is ___ and the other is ____. -What are two examples?

-short-acting; long-acting -Humalog Mx 75/25 and Humulin 70/30 *larger # is long-acting; smaller # is short-acting

Type 2 diabetes: -During the several year period when glucose levels are elevated but partially compensated for, the patient may be relatively ____. BUT ___ is already occurring. -More difficult to diagnose than Type 1 on the basis of symptoms b/c their body tries to _____. -They still have some ___.

-symptom free; organ damage -compensate -insulin

Roles of the liver: -In addition to mobilizing its glycogen stores, the liver ____ from noncarbohydrate sources such as amino acids, lactic acid, and the glycerol part of triglycerides. -When blood glucose levels fall below normal, glycogen is broken down by a process called ____ and ____ is released. -In addition to mobilizing its glycogen stores, the liver synthesizes glucose from amino acids, glycerol, and fatty acids in a process called _____.

-synthesizes glucose -glycogenolysis; glucose -gluconeogenesis

Hypoglycemia: -The most effective treatment of an insulin reaction is ______. -If unconscious, give ______ -Follow this simple sugar with a _____.

-the immediate ingestion (if alert) of a concentrated carbohydrate source such as glucose, honey, candy, or orange juice. -also milk -Glucagon IM or subQ or glucose IV, D50W -complex carbohydrate

The Role of the Pancreatic Hormones: -The endocrine portion of the pancreas, _____, is embedded between exocrine units like small "islands" -The islets contain 3 major types of cells which empty their secretions into the blood stream. What are they and what does each secrete? -____ are responsible for insulin production

-the islets of Langerhans -Alpha (glucagon), Beta (insulin), Delta (somatostatin) -Islets of Langerhans

Microvascular Disease: -Basement membrane of capillaries ____, casing blood flow in the microvascular to ____. -Poor circulation can be prominent in the _____, resulting in _____.

-thickens; decline -lower limbs; chronic skin ulcers and even gangrene

Alpha-glucosidase Inhibitors: -Mechanism of Action:___ -Common SE include:____ -Does it cause hypoglycemia? -Can cause ____- monitor liver function tests q3 months first year and periodically thereafter. -Have to take _____ to be effective -Examples: _____

-work in the intestines to delay absorption of carbohydrates from the gut. -flatulence, cramps, abdominal distention, and diarrhea -no -liver dysfunction -every meal -Precose (Acarbose) and Glyset (Miglitol)

Long -acting: 24 hour coverage: 1. ______ -cannot be mixed with other insulins (delays onset) 2. _____ -Advantage: avoids peaks and valleys, onset 1 hour, peakless, duration: 24 hours 3. _____ -Onset: 3-4 hours -Peak: 6-8 hours -Duration: 12-24 hours

1. Clean insulins 2. Lantus (Glargine) 3. Levemir (Detemir)

Alternative methods of Administration of insulin: 1.____ :devices shoot directly through the skin (no needle) 2. ____: needle that looks like a fountain pen -has pre-filled syringe 3._____ -Deliver basal (constant) and mealtime boluses (additional doses) -Match metabolic rate -Needle moved every 1-3 days 4. ____: external telemetry

1. Jet injectors 2. Pen injectors 3. Portable insulin pumps 4. Implantable insulin pumps

What are some long-term complications of diabetes?

1. Micro/macroangiopathy 2. Microvascular disease 3. Kidney Disease 4. Neuropathy 5. Retinopathy 6. Microaneurysms 7. Diabetic retinopathy 8. Cataracts and Glaucoma 9. Nocturnal diarrhea, delayed gastric emptying, erectile dysfunction 10. infection 11. CVA (stroke)

HHNK Vulnerable Patients include: ____ -Symptoms: ____

1. Older patients with type 2 diabetes and acute problem 2. Undiagnosed with acute problem 3. Persons on TPN (total parental nutrition)- increased glucose -Similar to DKA but don't have fruity breath (from Kussmaul's) b/c trying to blow off CO2

1.____: autoimmune destruction of pancreatic cells. -____: immune-mediated diabetes; majority of cases -____: idiopathic diabetes (unknown cause) 2. ___: describes a condition of fasting hyperglycemia that occurs despite the availability of insulin.

1. Type 1 diabetes -1A -1B 2. Type 2 diabetes

Type 2 DM is caused by factors contributing to what 3 things?

1. inadequate insulin secretion-the pancreas "gives out" 2. insulin resistance-defect in the response of peripheral tissues to insulin 3. increased hepatic glucose production

What are the 4 types of insulin?

1. rapid-acting 2. short-acting 3. intermediate-acting 4. long-acting

-programmable delivery system -generally refilled every 3 months through direct injection

CCSI (Continuous subQ insulin infusion Implantable pump with refillable reservoir)

______can test glucose with a drop of blood-important in self-moinitoring-limited for health care practitioner in evaluating long-term compliance. Drop of blood on a chemically treated strip, read by machine. -For type 1, should be done ___ times a day. -Target value: ___ before meals and ____ at bedtime.

Capillary blood glucose levels -3 or more -80-120 mg/dl; 100-140 mg/dl

Disorder of energy metabolism

Diabetes Mellitus

synthesis of glucose from noncarbohydrate sources

Gluconeogenesis

glycogen synthesis

Glycogenesis

The liver regulates blood glucose through what three processes?

Glycogenesis, Glycogenolysis, and Gluconeogenesis

glycogen breakdown

Glycogenolysis

_____: an adverse effect of insulin therapy -Referred to as ___ or ____. -Caused by _____ (OR reduced intake of food, V/D, alcohol, increased exercise) -S/S: ______ -If severe, ___, ___, and ____ occur -In conscious, give ____ supplements (food or glucose tablets) -If gag reflex is suppressed or unconscious, give ____ or ___.

HYPOGLYCEMIA -"insulin reaction" or "insulin shock" -excess insulin -tachycardia, palpitations, sweating, and nevousness -brain damage, coma, and death -oral carbohydrate -IV glucagon or D50

_____: measures glucose for the past 3 months. (hemoglobin sticks to glucose and hemoglobin lives for up to 3 months) -now used for diagnosis -___=No Diabetes -__=Pre-Diabetes -___= Diabetes

Hb A1C -5% or less -5.7-6.4% -6.5% or more

Lab values to monitor for Glycemic Control-Glycosylated hemoglobin-____: -Glucose interacts with ____ to form glycosylated derivatives, the most prevalent of which is named _____. -Glucose entry into RBS is not ____. -Glucose attaches to the hemoglobin molecule. Once attached, it cannot dissociate. The higher the blood glucose levels have been the ____ the glycosylated hemoglobin. Since RBC live 120 days, the Hgb A1C reflects the average glucose levels over a ___ period of time.

Hgb A1C -hemoglobin; hemoglobin A1C -insulin dependent -higher; 3 month

Type 1 (also referred to as ___): -Type 1 diabetes is characterized by a ____ of insulin, a ___ in blood glucose, and a breakdown of ___ and ___. -In the absence of insulin, ___ develops when _____ are released from fat cells and converted to ___ in the liver. These individuals are prone to developing _____. -All persons with type 1 require ____ to control blood glucose levels and prevent ketosis.

IDDM -absolute lack; elevation; body fats and proteins -ketosis; fatty acids; ketones; ketosis -exogenous insulin replacement

____ are a hallmark of diabetes. ___ of all sizes are affected. The sclerosis and capillary basement membrane thickening are related to _____.

Vascular lesions; vessels; hyperglycemia

-leading cause of death in diabetics

macrovascular disease

earliest clinical sign of diabetic retinopathy

microaneurysm

Involvement of the autonomic nervous system may be accompanied by ___, ___, ____ (caused by nerve tissue damage)

nocturnal diarrhea, delayed gastric emptying, erectile dysfunction.

Hyperglycemia acts as a ___. This means that the amount of glucose filtered by the kidneys exceeds that which can be reabsorbed by the renal tubules (exceeds renal threshold). This leads to ____ in the urine. -Urine output___ -During the diuretic phase, sodium and potassium ___. -What is the management for Hyperglycemia/diabetes?

osmotic diuretic; "spilling sugar" -increases -decreases -med bracelet; need to know your diabetic

leading cause of blindness in the US.

retinopathy

Neuropathy: -Nerve degeneration results in _______.

tinging sensations in the fingers and toes, pain, loss of sensation.

CVA (stroke) is ___ as common in diabetics as nondiabetics.

twice