DIABETES

How do we monitor our DKA patients as we're treating them?

Hourly blood sugar, monitor renal function and electrolytes (BMP q 4h), Urine output, ECG, vital signs, signs of fluid overload *especially in heart patients/renal.

Long term complications with diabetics (nerve-related)

peripheral neuropathy. extremities. Parasthethias and numbness, pain. decrease in sensation for temp and pain. very dangerous. Decrease in deep tendon reflexes. Lyrica, neurontin and cymbalta.

So there's 3 different body systems involved in hypoglycemia symptoms

-Adrenergic (adrenalin) MILD S/S: sweating, tremors, tachycardia, palpitations, nervousness, hunger. -CNS (MODERATE s/s) h/a, confusion, inability to concentrate, slurred speach, drowsiness -SEVERE HYPOGLYCEMIA: seizure, disorientation, difficult to arouse, coma/loss of conciousness, death. patients that have been diabetic for a long time don't always recognize signs of low blood sugar. so be aware.

Sick Day Management for Diabetics

-During times of physical/emotional stress, more glycogen is broken down, increasing blood glucose levels -Take insulin/oral meds as usual, may need additional insulin -Test blood sugar/ketones q 3-4 h/report if up -Nausea, vomitting, diarrhea especially dangerous (DKA often associated w GI illness) -ingest frequent small portions of carbs... including foods usually not consumed (juices, sodas, gelatin)

What are the guidelines for diagnosing diabetes.

-Fasting blood glucose 126 or more -Random Glucose >200 with symptoms -Hemoglobin A1C (amount of hgn in blood attached to glucose. (3-4 mo/life of rbc) -Normal <6% -Diabetic goal <7%

What is insulin

-Insulin is a hormone secreted by beta cells in the Pancreas. -It's the key that unlocks the door so to speak, and allows glucose into the cell via insulin receptors and glucose channels. -It stimulates storage of glucose in the liver and muscle (stored as glycogen). -It tells the liver to stop releasing glucose -Helps storage of fat in adipose tissue -Accelerates transport of amino acids into cell. -It inhibits the breakdown of stored glucose, protein and fat.

exercise goals in managing diabetes

-Lowers blood glucose -reduces cardiovascular risk factors -Improves cholesterol -Blood Glucose >250 & Ketones in urine; don't exercise. -Monitor blood glucose before/after exercise and during if symptomatic -May need 15 extra carbs for exercise

What are some factors affecting diabetic foot care?

-Neuropathy (sensory loss of pain/sensation) -autonomic (dryness/fissuring) -motor (muscular atrophy) -Peripheral vascular disease (poor circulation, poor wound healing, gangrene) -Immunocompromise (high blood glucose so leukocytes cant destroy bacteria as well) -Foot ulcers usually start w soft tissue injury -Injury may go unnoticed-serious ulcer result

Considerations for a diabetic on enteral/perenteral feeds

-Plan for discontinuation -check glucose regularly

When a diabetic is on a clear liquid diet

-Simple carb heavy -Give insulin to match peaks in glucose levels -

S/S that someone is developing diabetes

-Three Ps: Polydipsia, Polyuria, Polyphasia. -Type 1 may have sudden weight loss. -Fatigue, weakness, vision changes, neuropathy, dry skin, slow-healing wounds,recurrent infections

Type II diabetes is characterized by

-insulin resistance and impaired insulin secretion. a lack of response by target cells to insulin--so even if there is insulin, the cells aren't opening up those glucose channels.

What do we monitor for in HHS?

1) Blood Sugar 2) Electrolytes (BMP) 3) Urine output 4) ECG 5) Vital Signs 6) Signs of fluid overload

A nurse is teaching a client with diabetes mellitus about self-management of his condition. The nurse should instruct the client to administer 1 unit of insulin for every:

15 g carbohydrates

Hypoglycemia tx

15 g of fast-acting concentrated carb (3-4 glucose tablets -4-6 oz juice or regular soda EMERGENCY: subcut or IM glucagon (note glucagon NOT GLUCOSE) followed by a snack when pt is able. Notify provider Close monitoring for at least 24 h In hospital setting 25-50ml dextrose 50% in water can be given IV--ITS A VEIN IRRITANT tho. Thick so have a solid IV

What happens in a hyperglycemic state?

3 Ps: Polyuria, Polydipsia, and Polyphasia. -all this circulating glucose in the blood circulating can't get into the cells. Glucose is normally reabsorbed by the kidneys. When the glucose levels get too high, the kidneys get overwhelmed, and can't absorb anymore glucose. So it spills over into the urine. Usually this happens at about 200.

What is the carb goal for diabetics?

45-60 daily

A client is receiving insulin lispro at 7:30 AM. The nurse ensures that the client has breakfast by which time?

7:45 am

NPH insulin (Humulin N)

> intermediate acting > onset 1-2hr > peak 4-12 hr > duration 18-24hr

Factors in SMBG (self-monitor blood glucose)

Affected by: -visual acuity -fine motor coordination -cognitive ability -cost -Usually recommended 2-4X daily (before meals and at bedtime)

What are some nursing considerations in pediatric diabetes?

Can be either type 1 or type 2 Children need to be monitored for the same complications as adults with the disease (hypertension, dyslipidemia, retinopathy, nephropathy). Celiac disease and hypothyroidism is also associated with Type 1 diabetes.

A client with type 1 diabetes reports waking up in the middle of the night feeling nervous and confused, with tremors, sweating, and a feeling of hunger. Morning fasting blood glucose readings have been 110 to 140 mg/dL. The client admits to exercising excessively and skipping meals over the past several weeks. Based on these symptoms, the nurse plans to instruct the client to

Check blood glucose at 0300 Rationale: In the Somogyi effect, the client has a normal or elevated blood glucose concentration at bedtime, which decreases to hypoglycemic levels at 2 to 3 a.m., and subsequently increases as a result of the production of counter-regulatory hormones. It is important to check blood glucose in the early morning hours to detect the initial hypoglycemia.

When a diabetic is NPO

Consider the length of time Still likely to need insulin May need dextrose fluids

what's the difference between HHS and DKA?

DKA has ketosis and acidosis. HHS has enough insulin present so that is doesnt have to break down fat and proteins. Will severely dehydrate though.

The client who is managing diabetes through diet and insulin control asks the nurse why exercise is important. Which is the best response by the nurse to support adding exercise to the daily routine?

Exercise Increases ability for glucose to get into the cell and lowers blood sugar. Exercise increases trans membrane glucose transporter levels in the skeletal muscles. This allows the glucose to leave the blood and enter into the cells where it can be used as fuel. Exercise can provide an overall feeling of well-being but is not the primary purpose of including in the daily routine of diabetic clients. Exercise does not stimulate the pancreas to produce more cells. Exercise can promote weight loss and decrease risk of insulin resistance but not the primary reason for adding to daily routine.

Long acting insulin

Glargine (Lantus), Detimir, basil insulin No peak-not food dependent lasts 24

Unconcious w blood sugar <40

Glucagon IM, IV: gi upset and may interfere w coagulation

What are the hallmark signs of DKA?

Hyperglycemia, dehydration, acidosis Glucose can't get into cells--> hyperglycemia Liver releases glucose-->gluconeogenesis -->hyperglycemia Kidneys excrete glucose-->Leads to dehydration and electrolyte loss Fat & Muscle breakdown--> ketones-->Metabolic Acidosis (ketones are highly acidic) May occur due to missed/incorrect dose of insulin, illness, undiagnosed diabetes.

Which combination of adverse effects should a nurse monitor for when administering IV insulin to a client with diabetic ketoacidosis?

Hypoglycemia and hypokalemia Rationale: Blood glucose needs to be monitored in clients receiving IV insulin because of the risk of hyperglycemia or hypoglycemia. Hypoglycemia might occur if too much insulin is administered. Hypokalemia, not hyperkalemia, might occur because I.V. insulin forces potassium into cells, thereby lowering the plasma level of potassium.

What is the job of insulin?

Insulin carries glucose into body cells as their preferred source of energy. Besides, it promotes the liver's storage of glucose as glycogen and inhibits the breakdown of glycogen back into glucose. Insulin does not aid in gluconeogenesis but inhibits the breakdown of glycogen back into glucose.

how is insulin stored?

Insulin should be kept at room temperature for administration. Insulin is refrigerated if it needs to be stored for up to three months for later use.

A nurse is teaching a client recovering from diabetic ketoacidosis (DKA) about management of "sick days." The client asks the nurse why it is important to monitor the urine for ketones. Which statement is the nurse's best response?

Ketones accumulate in the blood and urine when fat breaks down in the absence of insulin. Rationale: Ketones signal an insulin deficiency that will cause the body to start breaking down stored fat for energy."

diabetic ketoacidosis

Lack of insulin causes hyperglycemia out of control leading to the breakdown of muscle and fats that create ketone bodies. Fluids, insulin, K+

Rapid acting insulins

Lispro (Humalog) Aspart (Novolog) Onset (5-15) Peak: 45 min-1 hr Duration: 2-4h PT MUST EAT 5-15 MIN after

What are the macrovascular complications of diabetes?

MACROANGIOPATHY: More common in type 2, its changes to the medium to large blood vessels. These are atherosclerotic changes. Vessels thicken, become sclerosed--->occlusions occur. Atherosclerosis leads to coronary artery disease, cholesterol levels, cerebravascular disease, peripheral vascular disease, poor wound healing---> risk of gangrene and amputation, claudication (Claudication is pain caused by too little blood flow, usually during exercise. Sometimes called intermittent claudication, this condition generally affects the blood vessels in the legs and buttocks.

DKA treatment

MAIN GOAL IS REHYDRATION> We're going to correct the 3 underlyers: Dehydration/hyperglycemia/metabolic acidosis -Rehydration w IV fluids (Normal Saline) or in heart failure we might use ( 0.45% NS) -As blood sugar drops and gets to 250-300 we switch to D5W to prevent a fast drop. -Continuous IV solution of regular insulin so we monitor blood sugar -Reverse acidosis and replenish electrolytes.

Diazoxide

Oral glucose-raising agent Not for pregnant Thiazide diuretics interaction Vascular effects

What does DKA look like?

Polyurea, Polydipsia, Polyphasia, low bp, weak, rapid pulse, N/V, abdominal pain, fruity breath, kussmaul respiration (trying to take deep breaths to blow off CO2 and compensate). Blood sugar may be 300-1000. LOC changes. Severity isn't necessarily how high the blood sugar is, it's severity depends on how bad the acidosis is. Ketones in blood and urine. Electrolyte abnormalities. K+ high. Elevated BUN/ CREAT.

Lispro (Humalog) is an example of which type of insulin?

Rapid Acting.

What type of insulin will most likely be administered intravenously to a client with a blood glucose level over 600 mg/dL (33.33 mmol/L)?

Reg. Insulin -Regular insulin has rapid onset of action and can be given via IV. It is the drug of choice for acute situations, such as diabetic ketoacidosis.

Short acting insulin

Regular (Humulin R, Novolin R); 30 to 60 before meals, given on sliding scale and given on continuous IV infusion Clear Onset: 30-1h Peak: 2-3h Duration: 4-6h Also used w other insulins

Hyperglycemic Hyperosmolar State

Related to type 2 and has high mortality rate. It often occurs in elderly who can't tolerate the dehydration that occurs. Illness increases the body's demand for insulin and leads to insulin deficiency Hyperglycemia occurs--->osmotic diuresis (kidneys pee it all out w electrolytes)-->loss of fluids and electrolytes--->water shifts FROM inside of cell to outside of cell to maintain osmotic equilibrium. Dehydration---> hypernatremia and increased osmolarity. There's still ENOUGH insulin in the body to prevent fat breakdown ---> KETOSIS and ACIDOSIS is minimal or absent.

HHS treatment

Very similar to DKA. 1) Rehydrate slowly 2) Administer insulin 3) Determine underlying cause

The diabetic client asks the nurse why shoes and socks are removed at each office visit. Which assessment finding is most significant in determining the protocol for inspection of feet? Autonomic neuropathy Retinopathy Sensory neuropathy Nephropathy

Sensory Neuropathy. Rationale: Neuropathy results from poor glucose control and decreased circulation to nerve tissues. Neuropathy involving sensory nerves located in the periphery can lead to lack of sensitivity, which increases the potential for soft tissue injury without client awareness. The feet are inspected on each visit to insure no injury or pressure has occurred. Autonomic neuropathy, retinopathy, and nephropathy affect nerves to organs other than feet.

What s/s would you expect to see in hypoglycemia?

Sweating, light-headedness, nervousness, confustion. -Rationale: Signs and symptoms associated with hypoglycemia include nervousness, diaphoresis, weakness, light-headedness, confusion, paresthesia, irritability, headache, hunger, tachycardia, and changes in speech, hearing, or vision. If untreated, signs and symptoms may progress to unconsciousness, seizures, coma, and death. Polydipsia, polyuria, and polyphagia are symptoms associated with hyperglycemia.

What are the long term autonomic s/s in diabetes

The autonomic nervous system doesnt detect changes as well. So possibly a silent MI, delayed gastric emptying, bladder retention... all of these things these aren't communicating with the brain to express danger signal.

What are the long term microangiopathic complications of diabetes?

Thickening of the capillaries (tiny vessels) that leads to weakening and leaking that slows the flow of blood throughout the body. Occurs in eyes and kidneys. Retinopathy and nephropathy (ESKD)

Classifications of Diabetes

Type I Type II Prediabetes (Impaired Fasting Glucose/or Glucose Tolerance) Gestational Caused by other conditions or syndromes (endocrine/etc).

Should blood sugars be assessed if neurological symptoms present?

Yes. We need to figure out if the symptoms are r/t blood sugar or if they're actually having a stroke.

hypoglycemia

blood sugar less than 70. Considered severe is less than 40. -not enough to eat, skipped meals -too much insulin -excessive physical activity -gerontologic considerations-may not recognize symptoms/poor renal function/longer to excrete orals/vision loss and make mistakes on insulin

NPH is what type of insulin?

intermediate acting

Glargine (Lantus) is what type of insulin?

long acting

gestational diabetes

diabetes that develops during pregnancy. Increases the risk of hypertensive disorders. Should be screened: hx, obesity, or glycosurea (glucose in urine) management is diet and exercise and insulin if necessary. Never any oral types of meds.... just insulin . Typically will go away after birth, but are at ahigher risk of developing type 2 at some point in their life.

For diabetics, what is a nursing consideration during physical stress or routine changes?

hyperglycemia

too much insulin or delays in eating...

hypoglycemia

treatment of type 2 diabetes

i. Losing weight ii. Healthful eating patterns iii. Exercising regularly iv. Medications - improve sensitivity of body cells to insulin or reduce the amount of glucose the liver produces

Humulin R is a what kind of insulin

short acting insulin

Causes of Diabetes

type 1: beta cells in pancreas are destroyed type 2: overweight, body becomes insulin resistant gestational: hormones during pregnancy cause glucose levels to rise

Assessment of HHS

we want to spot the acute illness. Check the level of dehydration--can mimic a stroke. 600-1200 blood sugar. Normal serum osmolality (>320), Elevated BUN and Creatinine. Electrolyte abnormalties.