Diabetes Mellitus ch. 48

microvascular complications

effect the tiny vessels of the eyes, kidneys, and nerves. They result from several pathways, all, in response to chronic hyperglycemia. - result from thickening of vessel membranes in capillaries and arterioles - retinopathy, neuropathy, nephropathy

s/s of hyperglycemia

polyuria polydipsia weakness, fatigue blurred vision HA glycosuria n/v abdominal cramps progression to DKA or HHS mood swings

basal insulin

used to maintain a background level of insulin throughout the day. Used to prevent DKA. No peak action- risk for hypoglycemia - degludec (tresiba), detemir (Levemir), glargine (langurs, toupee, basaglar)

hypoglycemia treatment if not able to swallow

- Administer 1 mg of glucagon IM or subcutaneously - Side effect: Rebound hypoglycemia - Have patient ingest a complex carbohydrate after recovery (starchy veg, whole grain bread) - In acute care settings - 20 to 50 mL of 50% dextrose IV push - Followed by a continuous infusion D5W

hypoglycemia treatment "rule of 15"

- If alert enough to swallow - Give 15-20 g of simple carb (juice followed by bread/crackers/peanut butter) - Recheck blood sugar 15 minutes after treatment - Repeat until blood sugar >70 mg/dL. - Patient should eat regularly scheduled meal/snack to prevent rebound hypoglycemia - Check blood sugar again 45 minutes after treatment

diabetic keto acidosis treatment

- Manage Airway - Correct fluid/electrolyte imbalance - IV infusion 0.45% or 0.9% NaCl - Restore urine output - Raise blood pressure - When blood glucose levels approach 250 mg/dL add 5% dextrose added to regimen to prevent hypoglycemia - Potassium replacement (know K level before starting insulin gtt) - Insulin therapy started after fluids have been started - Usually begin with a bolus of insulin followed by insulin drip - Monitor hourly

treatment of HHS

- Treatment similar to DKA - Manage Airway - Correct fluid/electrolyte imbalance - IV infusion 0.45% or 0.9% NaCl SLOWLY (patients are typically older with comorbidities) - Restore urine output - Raise blood pressure - When blood glucose levels approach 250 mg/dL add 5 -10 % dextrose added to regimen to prevent hypoglycemia • Potassium replacement (know K level before starting insulin gtt) • Insulin infusion therapy started after fluids have been started • Usually begin with a bolus of insulin followed by insulin drip • Monitor blood glucose hourly

why chronic hyperglycemia damages cells and tissues

- accumulation of damaging by-products of glucose metabolism, such as sorbitol, which is associated with damage to nerve cells - formation of abnormal glucose molecules in basement membrane of small blood vessels, such as those that circulate to eyes and kidneys - derangement in RBC function that leads to decrease in oxygenation to tissues

chronic complications of diabetes

1.) Angiopathy 2.) CAD 3.) HTN 4.) CVA 5.) Diabetic retinopathy 6.) Nephropathy 7.) Complications of feet and lower extremities 8.) Infection

bariatric surgery

Bariatric surgery may be considered for patients with type 2 diabetes who have a BMI greater than 35 kg/m2, especially if the diabetes or associated co-morbidities are difficult to manage with lifestyle and drug therapy.

acute complications of diabetes

Diabetic ketoacidosis (DKA) is a life-threatening condition caused by a profound deficiency of insulin. It is characterized by hyperglycemia, ketosis, acidosis, and dehydration. It is most likely to occur in people with type 1 diabetes as compared to type 2. Diagnosed by: Blood glucose >250mg/dL, pH < 7.3, HCO3 <16 mEg/L, Moderate to large ketones in urine. - kussmaul respirations, dehydration, tachycardia, orthostatic hypotension, fruity breath hyperosmolar hyperglycemic syndrome

somogyi effect

Elevated morning glucose levels may be due to the Somogyi effect. This is a rebound caused by hypoglycemia during the night that stimulates a counterregulatory response - Treat with bedtime snack

Drug Therapy: Oral and Noninsulin Injectable Agents

These agents primarily work on the defects of type 2 diabetes: (1) insulin resistance (2) decreased insulin production (3) increased hepatic glucose production.

S/S of hypoglycemia

blood glucose <70 cold, clammy skin numbness of fingers, toes, mouth tachycardia emotional changes HA nervousness, tremors faintness, dizzy unsteady gait, slurred speech hunger changes in vision seizures, coma

dawn phenomenon

characterized by hyperglycemia that is present on awakening in the morning, resulting from the release of counterregulatory hormones in the predawn hours. Treat by increasing or adjusting insulin

basal-bolus plan

consists of multiple daily insulin injections together with frequent self-monitoring of BG

macrovascular complications

diseases of the large and medium-sized blood vessels (heart, peripheral vascular system, and brain) that occur with greater frequency and with an earlier onset in people with diabetes. - CVD - optimizing BP control is significant in prevention - increased lipid abnormalities, smoking, obesity, and sedentary lifestyle increase risk

angiopathy

damage to blood vessels

insulin

hormone made by beta cells in islets of langerhans of pancreas - lowers BG by promoting transport from bloodstream into cell - anabolic- storage hormone - counter regulatory hormones to insulin (glucagon, epic, GH, cortisol) increase BG by stimulating glucose production by liver and decreasing movement of glucose into cells

Hyperosmolar hyperglycemic syndrome (HHS)

life-threatening syndrome that can occur in the patient with diabetes who is able to produce enough insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion. Diagnosed by: Blood glucose > 600mg/dL and increase in serum osmolality. Ketones are absent or minimal in blood serum and urine.

hypoglycemia

low blood glucose, occurs when there is too much insulin in proportion to available glucose in the blood. - Hypoglycemia is often related to a mismatch in the timing of food intake and the peak action of insulin or oral hypoglycemic agents that increase endogenous insulin secretion. - A critical role of the nurse is the prompt recognition of hypoglycemia and the initiation of appropriate treatment dependent on the patient's status.

lipodystrophy

may occur if the same injection sites are used frequently. The incidence has decreased with the use of human insulin derived from common bacteria or yeast cells using recombinant DNA technology

diabetic nephropathy

microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidneys. Teach patients to get screened annually for albuminuria. A measurement of albumin-creatinine ratio from a urine specimen may also be done to assess renal function. - ACE-Is or ARBs

diabetic neuropathy

nerve damage that occurs because of the metabolic derangements associated with diabetes mellitus. The two major categories of diabetic neuropathy are sensory neuropathy, which affects the peripheral nervous system, and autonomic neuropathy. - The most common form of sensory neuropathy is distal symmetric neuropathy, which affects the hands and/or feet bilaterally. - loss of sensation, abnormal sensations, pain, paresthesias - usually worse at night - must manage BG, some drugs for symptoms - Autonomic neuropathy can affect nearly all body systems and lead to hypoglycemic unawareness, delayed gastric emptying (gastroparesis), constipation, diarrhea, urinary retention, and sexual dysfunction.

diabetic retinopathy

refers to the process of microvascular damage in the retina because of chronic hyperglycemia. Because the earliest and most treatable stages produce no vision changes, teach persons with diabetes to have an annual dilated eye examination. - nonproliferation is most common- particle occlusion of small blood vessels in retina causes microaneuysms to develop in capillary walls - proliferative retinopathy- most severe, involves retina and vitreous - new blood vessels formed via neovascularization- extremely fragile and hemorrhage easily to produce vitreous contraction - many treatments

bolus insulin

used at mealtimes to combat postprandial hyperglycemia. - aspart (Novolog), glulisine (apidra), lisper (Humalog)

diagnostic studies

• A diagnosis of diabetes is based on one of four methods: - AIC ≥ 6.5% - Fasting plasma glucose level >126 mg/dL - Two-hour OGTT level ≥200 mg/dL when a glucose load of 75 g is used - Random or casual plasma glucose measurement ≥200 mg/dL plus symptoms

infection

• A patient with diabetes is more susceptible to infections due to a defect in the mobilization of inflammatory cells and impaired phagocytosis by neutrophils and monocytes. • Antibiotic therapy for infections, which must be prompt and vigorous, has prevented infection from being a major cause of death in patients with diabetes.

etiology and patho

• Diabetes mellitus is a chronic multisystem disorder of glucose metabolism related to absent or insufficient insulin, impaired utilization of insulin, or both. • Current theories link the causes of diabetes to genetic, autoimmune, and environmental factors. 4 types: type 1, type 2, gestational, other

drug therapy- insulin

• Exogenous (injected) insulin is needed when a patient has inadequate insulin to meet specific metabolic needs. • Insulin is divided into two main categories: short-acting (bolus) and long-acting (basal) insulin. • A variety of insulin regimens are recommended for patients depending on the needs of the patient and his or her preference. • Insulin is most often given by subcutaneous injection. IV administration of regular insulin can be given when immediate onset of action is desired. • The speed with which peak serum concentrations are reached varies with the anatomic site for injection. The fastest subcutaneous absorption is from the abdomen. Absorption is better when rotate sites • An insulin pump can be used to administer continuous short-acting insulin. It is programmed to deliver a continuous infusion 24 hours a day with boluses at mealtime and correction boluses to bring down elevated blood glucose levels. • Hypoglycemia, allergic reactions, lipodystrophy, the dawn phenomenon, and the Somogyi effect are problems associated with insulin therapy.

complications of feet and LE

• Foot complications are one of the most common causes of hospitalization in the person with diabetes. Sensory neuropathy is a major risk factor for lower extremity amputation. • Proper care of foot ulcers is critical to prevent infections. • Because of the loss of protective sensations, proper care of the feet in patients with diabetes is critical.

gestational diabetes

• Gestational diabetes develops during pregnancy and is usually screened for and detected at 24 to 28 weeks of gestation by an oral glucose tolerance test. • Although most women with gestational diabetes will have normal glucose levels within 6 weeks postpartum, their risk for developing type 2 diabetes is 63% within 16 years.

secondary diabetes

• Results from another medical condition - Cushing syndrome - Hyperthyroidism - Pancreatitis - Parenteral nutrition - Long term steroid treatments - Cystic fibrosis - Treatment of a medical condition that causes abnormal blood glucose level * Corticosteroids (Prednisone), Thiazides, Phenytoin (Dilantin), Atypical antipsychotics (clozapine) • Usually resolves when underlying condition treated • Usually treated with sliding scale insulin

oral agents

• Metformin (Glucophage) is a biguanide glucose-lowering agent. The primary action of metformin is to reduce glucose production by the liver. The ADA algorithm for the management of type 2 diabetes recommends the use of metformin combined with lifestyle interventions as the first-line therapy option. • Sulfonylureas increase insulin production from the pancreas. Since they can cause hypoglycemia, it is important to teach patients how to recognize and manage low blood glucose. Sulfonylureas are sometimes added if metformin and lifestyle interventions are not effective. • Meglitinides also increase insulin production from the pancreas. Because they are more rapidly absorbed and eliminated, they offer a reduced potential for hypoglycemia. They are taken before meals, usually resulting in dosing three times a day. • α-Glucosidase inhibitors, also known as "starch blockers," work by slowing down the absorption of carbohydrate in the small intestine. • Thiazolidinediones are most effective for people who have insulin resistance. Due to their severe adverse effects, the two drugs in this class are rarely used.

nursing management: diabetes

• Nursing responsibilities for the patient receiving insulin include proper administration, assessment of the patient's response to insulin therapy, and teaching of the patient regarding administration of, storage, adjustment to, and side effects of insulin, particularly recognition and management of hypoglycemia. • Proper administration and assessment of the patient's use of and response to oral and noninsulin injectable agents, as well as teaching the patient and family about these drugs, are all part of the nurse's role. • The goals of diabetes self-management education are to enable the patient to become the most active participant in his or her care, while matching the level of self-management to the ability of the individual patient.

pancreases transplantation

• Pancreas transplantation can be used as a treatment option for patients with type 1 diabetes mellitus. Transplants are done for patients with end-stage kidney disease and who had or are having a kidney transplant. - considered for those with a history of frequent, acute, and severe metabolic complications, clinical and emotional problems with use of insulin therapy, and consistent failure of insulin-based management to prevent acute complications

psychological considerations

• Patients with diabetes have increased rates of mental health disorders, particularly depression. Assess patients for the signs and symptoms of depression at each visit. • Individuals with type 1 diabetes, particularly young women, have an increased risk of developing an eating disorder in comparison to people without diabetes. Open and collaborative communication is critical for identifying these behaviors early.

prediabetes

• Prediabetes is a condition in which blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes. Those with prediabetes will usually develop type 2 diabetes within 10 years if no preventive measures are taken. • Long-term damage to the body, especially the heart and blood vessels, may already be occurring in patients with prediabetes. • Fasting glucose levels are 100 to 125 mg/dL, 2-Hour plasma glucose levels are between 140 and 199 mg/dL, AIC is in range of 5.7% to 6.4%.

monitoring blood glucose

• Self-monitoring of blood glucose (SMBG) is a cornerstone of diabetes management. By providing a current blood glucose reading, SMBG enables the patient to make self-management decisions regarding food, exercise, and medication. • The frequency of monitoring depends on several factors, including the patient's glycemic goals, the type of diabetes that the patient has, the patient's ability to monitor independently, and the patient's willingness to perform SMBG. - continuous glucose monitoring (CGM) are another route - most ppl with type 1 use this and even some type 2 as well - updated every 1-5 minutes to help identify trends and alert - teaching is essential for monitoring since technology is not always consistent

interprofessional care

• The goals of diabetes management are to reduce symptoms, promote well-being, prevent acute complications of hyperglycemia and hypoglycemia, and prevent or delay the onset and progression of long-term complications. These goals are most likely to be met when the patient maintains blood glucose levels as near to normal as possible. - patient teaching, nutrition, exercise, drug therapy, self-monitoring

nutritional therapy

• The overall goal of nutritional therapy is to assist people with diabetes in making healthy food choices, eating a varied diet, and maintaining exercise habits that will lead to healthy blood glucose levels. • For those using conventional, fixed insulin doses, day-to-day consistency in timing and amount of food eaten is important. Patients using a basal-bolus approach with rapid-acting insulin can make adjustments in dosage before meals based on the premeal blood glucose level and the carbohydrate content of the meal. • The emphasis of nutrition management in diabetes is placed on achieving glucose, lipid, and BP goals as well as achieving weight loss if the patient is overweight or obese. • People with diabetes are encouraged to follow the same healthy eating guidelines as those without: eat whole grains, low-fat dairy, and lean protein; limit saturated and trans fats, and increase plant-based foods. • Encourage patients to frankly discuss the use of alcohol with their HCPs because its use can make blood glucose more difficult to manage. • Regular, consistent exercise is an essential part of diabetes and prediabetes management. Exercise increases insulin sensitivity and can have a direct effect on lowering blood glucose levels.

type 1

• Type 1 diabetes mellitus typically occurs in people who are under 40 years of age. It may occur at any age. • Type 1 diabetes is the result of a long-standing autoimmune process in which the body's own T cells attack and destroy pancreatic -cells, which are the source of the body's insulin. • Because the initial manifestation of type 1 diabetes is often rapid, the symptoms are usually acute. • The classic symptoms—polyuria, polydipsia, and polyphagia—are caused by hyperglycemia. • The individual with type 1 diabetes requires insulin therapy to sustain life. Without insulin, the patient will develop diabetic ketoacidosis (DKA), a life-threatening condition resulting in metabolic acidosis.

type 2

• Type 2 diabetes mellitus accounts for more than 90% of patients with diabetes. • In type 2 diabetes, the pancreas usually continues to produce some insulin. However, the insulin that is produced is either insufficient for the needs of the body and/or is poorly used by the tissues. • There are many factors and several genes involved in the development of type 2 diabetes causing insulin resistance- a condition in which body tissues do not respond to action of insulin because insulin receptors are unresponsive, insufficient in number, or both • The most important risk factor for developing type 2 diabetes is believed to be obesity, specifically abdominal and visceral adiposity. • The manifestations of type 2 diabetes are more nonspecific and include fatigue, recurrent infections, recurrent vaginal yeast infections, prolonged wound healing, and visual changes.

integumentary complications

• Up to two thirds of patients with type 1 and type 2 diabetes develop diabetes-related skin problems. Common skin complications include acanthosis nigricans (light brown to black skin thickening at flexions), dermatopathy , and necrobiosis lipoidica diabeticorum (red-yellow shiny lesions). • Because skin is prone to injury, special care must be taken to protect it from injury and ulceration.