diabetes
numonic for diabetes mellitus nursing assessment
S: Slow wound healing U: blUring vision G: Glycosuria A: Acetone breath R: Rashes on the skin and repeated yeast infections
guidlines for dietary recommendations
-combining starchy foods with protein and fat containing foods tend to slow absorption and low glycemic index -eating foods that are raw and whole results in a lower glycemic index than eating chopped, pureed, or cooked foods (except meat) -whole fruit instead of juice because fiber slows absorption
important objectives in the dietary and nutritional management of diabetes
-control of total caloric intake to attain or maintain reasonable body weight -control of blood glucose levels -normalization of lipids and blood pressure to prevent heart disease
alcohol consumption
-don't need to give up entirely but large amounts can be converted to fats, increasing the risk for DKA -major danger is hypoglycemia especially for patients who take insulin and drink on an empty stomach -may decrease gluconeogenesis -eat a meal with alcohol but carbs consumed with alcohol may raise blood glucose
gestational diabetes
-due to hormones secreted by the placenta, which inhibit the action of insulin -abnormal risk for perinatal complications, especially macrosomia (large babies) -treated with diet, and if needed insulin -risk factors include obesity age >30, family history of diabetes, previous large babies -should be screened for diabetes every 3 years
Type 1 clinical manifestations and implications
-onset any age, but usually young (<30) -usually thin at diagnosis; recent weight loss -often have islet cell antibodies -little or no endogenous insulin -need exogenous insulin to preserve life -ketosis prone when insulin absent
Type 2 clinical characteristics and implications
-onset any age, usually > or equal to years -usually obesity is present at diagnosis -no islet cell antibodies - decrease in endogenous insulin, or increased with insulin resistance -most patients can control blood glucose through weight loss if they have obesity - oral antidiabetic agents may improve blood glucose levels if dietary modification and exercise are unsuccessful -may need insulin on a short-or long term basis to prevent hyperglycemia -ketosis uncommon; except in stress or infection
prediabetes
-previous history of hyperglycemia (during pregnancy or illness) -current normal glucose metabolism -IGT or IFG screening after age 40 if there is a family history of diabetes or if symptomatic -encourage ideal body weight
what does insulin do in muscle, liver, and fat cells
-transports and metabolizes glucose for energy -stimulates storage of glucose in the liver and muscle (in the form of glycogen) -signals the liver to stop the release of glucose -enhances storage of dietary fat in adipose tissue -accelerates transport of amino acids into cells -inhibits breakdown of stored glucose, protein, and fat
once food is digested, what % of carbs are converted to glucose
100% -approx. 50% of protein (meat, fish, and poultry) are also converted to glucose and has minimal effect on blood glucose
Type 1 diabetes
5-10% of all patients with diabetes; formerly juvenile diabetes, or insulin-dependent diabetes
recommended caloric intake
50-60% of calories of carbs (majority should come from whole grains) 20-30% from fat and 10-20% from protein
Type 2 diabetes percentages
90-95% of all diabetes; patients with obesity 80% without obesity 20% formerly adult-onset or non-insulin dependent
Classic clinical manifestations of diabetes
Three Ps polyuria, polydipsia, and polyphagia -other symptoms include fatigue, weakness, sudden vision changes, tingling or numbness in hands or feet, dry skin, skin lesions or wounds that are slow to heal, and recurrent infections
diabetes risk factors
age >30 for type 2 -age <30 for type 1 -history of gestational diabetes -hypertension -family history of diabetes (parents or siblings) -obesity -race/ethnicity -previously identified IFG and IGT -HDL cholesterol level < or equal to 35 and/or triglyceride levels > or equal to 250
patients with LADA have at least two of these:
age of onset less than 50 years, BMI less than 25 kg, history of autoimmune disease, acute symptoms prior to diagnosis, or positive family history of autoimmune disease
why isn't DKA an issue for type 2 diabetes
although insulin secretion is impaired, there is enough insulin present to prevent the breakdown of fat and the accompanying production of ketone bodies
meds that cause hypoglycemia
beta blockers: mask symptoms of hypo ETOH: blocks liver from making new glucose aspirin: decreased basal rates of hepatic glucose production, enhanced tissue insulin sensitivity sulfonylureas MOA inhibitors used to treat depression bactrim: Hypoglycemia can be induced by the sulfa component of Bactrim, which binds receptors in the pancreas causing insulin to be secreted
exercise precautions
blood glucose exceeding 250 and who have ketones in urine should not begin exercising until urine tests are negative for ketones and levels are closer to normal
impaired glucose tolerance
blood glucose levels higher than normal but not high enough to be diagnosed as diabetes
six main exchange lists
bread/starch vegetable milk meat fruit
S/S of hypoglycemia
Blood glucose less than 60 sweaty, cold, clammy, confused, lightheaded, dizzy, double vision "Im sweaty, cold, and clammy... give me some hard candy"
prediabetes
classified as impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) -refers to a condition in which blood glucose concentrations fall between normal levels and those considered diagnostic for diabetes
what is a metabolic derangement?
clinically significant complication due to major trauma caused by things such as obesity or inactivity
meal planning and related education
consistency in the approx. time intervals between meals, with the addition of snacks if necessary, helps prevent hypoglycemic reactions and maintain glucose control
metabolic syndrome
constellation of symptoms including hypertension, hypercholesterolemia, abdominal obesity, and other abnormalities
nutritive sweeteners
contain calories -fructose (fruit sugar), sorbitol (may have laxative effect), and xylitol -cause less elevation in blood sugar than sucrose does
medicine induced diabetes
corticosteroids thiazide diuretics beta blockers statinswhen the number of infection-fighting white blood cells in the blood decreases and cause the patient to be more likely to get an infection8 hour
diabetes is the seventh leading cause of
death and blindness in adults aged 18-64 years
destruction of beta cells results in
decreased insulin production, increased glucose production by the liver, and fasting hyperglycemia -in addition glucose derived from food cannot be stored in the liver but instead remains in the bloodstream and contributes to postprandial (after meals) hyperglycemia
glycemic index
describes how much a given food increases the blood glucose levels compared with an equivalent amount of glucose -monitoring BG levels after ingestion of certain foods can help patients determine their glycemic index
gerontologic considerations for diabetes
diabetes is prevalent in older adults and affects approx. 20% of older adults -there is a high prevalence among African Americans and those who are 65-74 years
manangement
dietary modifications and blood glucose monitoring -if hyperglycemia persists, insulin is prescribed
why is a glucose tolerance test more effective in diagnosis of diabetes than urine testing in older patients
due to the high renal threshold for glucose
when is type 2 usually detected?
during routine lab tests or ophthalmoscopic exams
Somogyi effect
early-morning hyperglycemia that occurs as a result of nighttime hypoglycemic episodes when the hypoglycemic episodes occur, cortisol and/or catacolamines and growth hormone are released to increase blood sugar -can counteract by eating a bedtime snack or decreasing bedtime insulin
participants in the diabetes prevention research group received (3 things) -these proved that type 2 can be prevented
either 1. standard lifestyle recommendations plus metformin 2. standard lifestyle recommendations plus placebo 3. intensive program with lifestyle modifications
impaired fasting glucose
fasting blood glucose levels that are higher than normal but not high enough to lead to a diagnosis of type 2 diabetes -body isn't able to use glucose as it should
basic criterion for the diagnosis of diabetes
fasting plasma glucose random plasma glucose glucose level 2 hours after receiving glucose
symptoms that are experienced as a result of the slow onset of type 2 (mild symptoms if any at all detected over many years)
fatigue, irritability, polyuria, polydipsia, poorly healing skin wounds, vaginal infections, or blurred vision
my plate food guide
foods are categorized into 5 groups: fruits, grains, vegetables, proteins, dairy plus fats and oils -foods (grains, fruits and veggies) are lowest in calories and fat and highest in fiber and should make up the basis of diet -great tool when teaching patients about how to control portions and how to identify carbohydrates, proteins, and fats
what is the exchange list
foods with similar amount of carbohydrates per serving size are grouped together -foods within one group contain equal numbers of calories and are approx. equal in grams of proteins, fat, and carbs -foods may be interchanged with one food from the list allowing a variety of options
insoluble fiber
found in whole-grain breads and cereals and in some veggies
what to do if someone has hypoglycemia
give them a simple carb or if unconscious IV D50 hard candies, life savers, fruit juice, graham crackers, honey
diagnosis for diabetes for two hour postload
glucose equal to or greater than 200 during an oral glucose tolerance test
diagnosis for diabetes for fasting plasma
glucose greater than or equal to 126
nonnutritive sweeteners
have few or no calories. Minimal or no elevation in blood glucose. Better to use these sweeteners. -sweet and low, equal, splenda
high risk ethnic groups for gestational diabetes
hispanic americans, native americans, asian americans, african americans, and pacific islanders
assessing a patient with diabetes
history physical exam lab findings need for referrals
insulin
hormone secreted by beta cells -insulin is an anabolic, or storage, hormone
type 2 acute complication
hyperglycemia hyperosmolar syndrome -very dehydrated, thirsty, increased BP, mental status changes
what are the three different metabolic derrangements
hyperglycemia, ketosis, and metabolic acidosis
nutrition labels
includes info about how many grams of carbs are in a serving of food which is needed to determine how much medication is needed -although carb counting is important, reading labels is the most important *** -must include serving size, total calories, total fat, saturated fat, trans fat, cholesterol, sodium, total carb, dietary fiber, total sugars, any added sugars, protein, vitamin D, calcium, iron, and potassium
polyphagia
increased appetite that results from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats
fiber meal plan
increased intake may improve blood glucose levels, decrease the need for exogenous insulin, and lower total cholesterol and low-density lipoprotein levels in the blood
polydipsia
increased thirst occur as a result of the excess loss of fluid associated with osmotic diuresis
what happens when you exercise with elevated glucose levels
increases the secretion of glucagon, growth hormone, and catecholamines -the liver then releases more glucose resulting in an increase in blood glucose
what are the two main problems related to type 2 diabetes
insulin resistance and impaired insulin secretion
what happens with insulin after a meal
insulin secretion increases and moves glucose from the blood into muscle, liver, and fat cells
ketone bodies
ketone bodies are produced by the liver and used for energy when glucose is not readily available due to fats being broken down and there becomes free fatty acids. this increases acid production in the blood causing ketoacidosis (diabetic ketoacidosis)
soluble fiber
legumes, oats, and fruits -plays more of a role in lowering glucose and lipid levels than insoluble fiber -slows stomach emptying and movement of food through upper-digestive tract
risks in increasing fiber
may require adjusting the dosage of insulin or oral agents to prevent hypoglycemia -abdominal fullness -nausea -diarrhea -increased flatulence -constipation if fluid intake is inadequate
healthy food choices
measures servings
insulin resistance may lead to
metabolic syndrome
Sulfonylureas
most common oral antidiabetic -glyburide, glipizide, diabinese, amaryl -"ide" "ride" "zides" "mides" -stimulate beta cells to make insulin AVOID ETOH-severe hypoglycemia
type 2 diabetes
most commonly seen in adults older than 30 and who have obesity, although its increasing in younger people due to the growing epidemic of obesity in children, adolescents, and young adults -intracellular reactions that insulin initiates is diminished making insulin less effective at stimulating glucose uptake by the tissues and at regulating glucose release by the liver
do people inherit type 1 diabetes?
no but rather a genetic predisposition, or tendency, toward the development of it -this genetic tendency has been found in people with certain human leukocyte antigen types
protein meal plan
nonanimal sources such as legumes and whole grains to help reduce sat fat and cholesterol intake -protein intake may be reduced in those with early signs of kidney disease
Diabetes is the leading cause of
nontraumatic amputations and end-stage kidney disease
five components of diabetes management
nutritional therapy exercise (if BS over 250 with ketones present avoid this due to the breakdown of more fats) monitoring pharmacologic therapy education
Type 2 diabetes causes
obesity, heredity, and environmental factors
Rapid acting insulin
onset 15 minutes Peak: 1 hour duration 3-5 hours when to take: 0-15 minutes before meal "15 min feels like an hour during 3-5 rapid responses"
Intermediate acting insulin
onset: 2 hours Peak: 8 hours duration: 16 hours "nurses play hero 2 (to) 8 16 year olds
Short acting insulin
onset: 30 min peak: 2 hours duration: 8 hours "short staffed nurses when from 30 patients 2 (to) 8 patients
complications with diabetes mellitus
organ problems: glucose sticks to protein in vessels. they become hard a form plaques (atherosclerosis) (heart disease, strokes, neuropathy, decreased wound healing, eye trouble, infections, HTN)
Diabetes associated with other conditions or syndromes (previously classified as secondary diabetes)
pancreatic diseases, hormonal abnormalities, medications -depending on the ability of the pancreas to produce insulin, the patient may require treatment with oral antidiabetic agents or insulin
DKA
preceded by a day or more of polyuria, polydipsia, nausea, vomiting, and fatigue with eventual stupor and coma if not treated -fruity breath odor due to the presence of keto acids and Kussumal breathing
what is an acute complication of hyperglycemia
DKA
different types of insulin
rapid acting short acting intermediate acting long acting
Meglitinides
repiglinide stimulate beta cells to make insulin take with first bite of food
glucose control can decrease the progression of what complications
retinopathy (damage to blood vessels that nourish the retina), nephropathy (damage to kidney cells), and neuropathy (damage to nerve cells)
what do both soluble and insoluble fiber increase
satiety or increased fullness which is helpful for weight loss
Latent autoimmune diabetes in adults (LADA)
subtype of diabetes in which the progression of autoimmune beta cell destruction in the pancreas is slower than in type 1 and 2 -patients with LADA are at high risk of becoming insulin dependent
oral antidiabetics
sulfonylureas biguanides meglitinides alpha-glucoside inhibitors thiazolidineidlone
diagnosis for diabetes with casual plasma
symptoms of diabetes plus glucose concentration equal to or greater than 200
cystic fibrosis related to diabetes
the build up of sticky mucous caused by can lead to inflammation and scarring of the pancreas damaging the cells that produce insulin
what happens if glucose in the blood exceeds the renal threshold for glucose
the kidneys may not reabsorb all of the filtered glucose; glycosuria then occurs
what occurs during fasting periods (between meals and overnight)
the pancreas continuously releases a small amount of insulin (basil insulin) -another pancreatic hormone called glucagon (secreted by alpha cells) is released when blood glucose levels decrease stimulating the liver to release stored glucose - insulin and glucagon work together to maintain constant levels of glucose
consequence of undetected diabetes
these diagnosis's may have developed before the actual diagnosis of diabetes is made -eye disease, peripheral neuropathy and peripheral vascular disease
carbohydrates
these have the greatest effect on blood glucose levels because they are more quickly digested than other foods and are converted into glucose rapidly -consists of sugars (sucrose), and starches (rice, pasta, bread) and these should be eaten in moderation to avoid high postprandial blood glucose
meds that cause hyperglyemia
thiazides: impaired insulin sensitivity, increased hepatic glucose production glucocorticoids: inhibit glucose uptake by muscle and fat; they are also directly cytotoxic to pancreatic beta cells, causing destruction and decreased insulin production estrogen therapy:
women who are considered high risk for gestational diabetes are
those who are obese, a personal history of gestational diabetes, glycosuria, or a strong family history
how does the liver produce glucose
through glycogenolysis (breakdown of glycogen) -after 8-12 hours without food, the liver forms glucose from the breakdown of non-carbohydrate substances including amino acids, through gluconeogenesis
why is it important to limit total intake of cholesterol? what is the limit?
to reduce risk factors such as increased serum cholesterol levels associated with coronary artery disease (the leading cause of death and disability among diabetes patients) -300 mg/day
classifications of diabetes
type 1, type 2, gestational, latent autoimmune diabetes (LADA) of adults, and diabetes associated with other conditions or syndromes -each type vary in cause, clinical course, and treatment -except those who have type 1, patients many move from one category to another
dawn phenomenon
Early morning glucose elevation produced by the release of growth hormone, which decreases peripheral uptake of glucose resulting in elevated morning glucose levels. Admin of insulin at a later time in day will coordinate insulin peak with the hormone release. -can also administer NPH at night to help counteract
misleading food labels
Foods labeled "sugarless" or "sugar-free" may still provide calories equal to those of the equivalent sugar-containing products if they are made with nutritive sweeteners (can have fructose) Therefore, these foods should not be considered "free" foods to be eaten in unlimited quantity, because *they can elevate blood glucose levels.* Foods labeled "dietetic" are not necessarily reduced-calorie foods. Patients are advised that foods labeled dietetic may still contain significant amounts of sugar or fat.
etiology of type 1 diabetes
Genetic, environmental or immunological factors damage pancreatic beta cells resulting in insulin deficiency
osmotic diuresis
when excess glucose is excreted in urine, it is accompanied by excessive loss of fluids and electrolytes
lab examinations (findings) for diabetes
HgbA1c fasting lipid profile test for miroalbuminuria serum creatinine level urinalysis electrocardiogram
nmunomic "insulin"
I: rapId N: novalog and humalog S: short: regular (humalin R, Novalin R) U: humalin N (intermediate.. U is in the middle): NPH L: long acting I: levomIr N: laNtus
Biguanides
Metformin (Glucophage) decreases the liver stores of glucose dont take 48 hours prior to surgery watch renal function can cause diarrhea
which ethnic and racial groups are most at risk for diabetes, greater risk for complications, and have higher death rates
Native Americans and persons of Hispanic origin
long acting
Onset: 2 hours Peak: NONE Duration: 24 hours "the 2 long nursing shifts never peaked but lasted 24 hours
Thiazolidinediones
Pioglitazone Rosiglitazone decreases glucose production in the liver watch liver and heart function as an increased risk of MI
Alpha-glucoside inhibitors
Precose, Glyset lower blood sugar by slowing down the breakdown of starchy foods in the GI system which helps slowly rise the blood sugar instruct pts to take first bite with meal
