Nursing II Exam 3 Part 3

Assessment of Autonomic Neuropathy.

- Bowel and bladder incontinence. - Hypoglycemic unawareness. - Delayed gastric emptying (gastroparesis)- presents as anorexia, nausea and vomiting, feelings of fullness, and gastroesophageal reflux. The delay of absorption of food that occurs with gastroparesis can lead to the development of hypoglycemia. - Postural hypotension. - Asymptomatic myocardial infarction. - Resting tachycardia. - Sexual dysfunction.

Therapeutic Management of DKA.

- Consists of IV fluids, electrolytes, and regular insulin to correct hyperglycemia and dehydration; supportive care as indicated such as NPO status, vasopressors, and respiratory support. - Intravenous (IV) fluids of 0.9% normal saline (NS) or 0.45% NS are used to reestablish an adequate urine output of 30 to 60 mL/hour and reverse the hypotension. - Fluid therapy is needed for excessive dehydration that accompanies DKA: a. As much as 1 to 2 L normal saline solution may be given during first hour, then IV rate is decreased to 500 mL/hr as tolerated by cardiac and respiratory systems. b. When BG reaches 250-300 mg/dL, a 5% glucose solution (such as D51⁄2NS) is added to prevent hypoglycemia and cerebral edema. c. Central venous pressure or hemodynamic monitoring may be needed to evaluate effectiveness of therapy. _____________________________________________________________________ - Insulin: a. A bolus of IV regular insulin is given followed by a continuous IV drip (0.1 unit/kg body weight) until BG level drops to 250 mg/dL or pH is 7.30. b. Once this blood level is reached, regular insulin is given on a sliding scale per BG results. c. Bed side BG monitoring is done every 1-2 hours to evaluate effectiveness of therapy. - When the blood glucose level is down to 250 mg/dL, 5% dextrose is added to the IV fluids to prevent hypoglycemia. _____________________________________________________________________ - Potassium replacement is generally necessary in DKA: - At the onset, the potassium levels may be high or normal, but these levels will fall with the administration of IV insulin. Insulin will move the potassium from the circulation into the cells, and hypokalemia develops. This is a potentially lethal complication of DKA. Potassium replacement will be administered to prevent hypokalemia. The potassium replacement will be started when the serum potassium level falls below 5.5 mEq/L. a. The initial serum (K+) level is usually elevated. b. With reversal of acidosis and administration of insulin, K+ shifts into cells and serum level can drop rapidly. c. Institute replacement therapy based on serum K+ level and urine output. d. Institute cardiac monitoring to detect cardiac changes due to hyper- and hypokalemia and to monitor effects of therapy on serum K+ level. e. Replace other electrolytes such as phosphate based on laboratory results; bicarbonate is not given routinely in DKA because rapid correction of acidosis can cause severe hypokalemia. _____________________________________________________________________ - Analyze I&O, BG, urine ketones, VS, oxygenation, and breathing pattern. - Maintain skin integrity; promote healing of impaired skin; prevent infection by repositioning client every 2 hours; provide pressure relief as indicated; manage incontinence and perspiration with skin protective barriers and cleansing; provide appropriate nutrition and oxygen support. - Promote safety by analyzing VS, client communication, LOC and emotional response, and activity tolerance; implement measures to prevent falls. - Assist client to verbalize concerns and cope effectively with illness and fears. - Assist client to update Medic-Alert bracelet information as appropriate.

Clinical Manifestations of Hypoglycemia.

- Cool, moist skin - Pallor - Headache - Nausea - Sweating - Tremors - Hunger - Lethargy - Confusion - Slurred speech - Anxiety

Treatment of Retinal Detachment.

- Cryopexy. - Laser photocoagulation. - Scleral buckling surgery. - Pneumatic retinopexy. - Vitrectomy.

Clinical Manifestations of Keratoconus.

- Decreasing vision with distortion, glare, and diplopia. - Difficulty in achieving satisfactory optimum vision with corrective lenses. Eyeglasses and soft contact lenses may be effective initially; however, as vision deteriorates rigid contact lenses may provide better vision.

A client has just been admitted to the emergency department after being found disoriented at the grocery store. His medical alert bracelet indicates that he has type 1 diabetes. Which of the following clinical signs do you anticipate finding upon assessment? Check all that apply. 1. Hyperglycemia 2. Fruity odor of breath 3. Tachycardia 4. Hypertension

1, 2, and 3. Rationale: Clinical manifestations of type 1 diabetes are hyperglycemia, fruity odor of breath, and tachycardia.

Extracapsular Surgery.

A slightly larger incision is made, and the lens is removed as a whole. An artificial intraocular lens (IOL) with corrective power is placed in the remaining posterior capsule of the eye.

Phacoemulsification (phaco) Surgery.

An incision is made in the cornea, and a small probe is inserted into the eye. The device attached to the probe emits ultrasound waves that break up the lens, allowing for suction removal.

Nystagmus.

An involuntary rhythmic movement of the eyes in a back and forth, or cyclical, movement. Can be caused by lesions in the labyrinth, vestibular nerve, cerebellum, and brainstem. Drug toxicities (e.g., phenytoin [Dilantin] or alcohol), retinal disease, and diseases involving the cervical cord may also produce nystagmus.

Somatostatin.

Has an extremely short half-life of 3 minutes. Is secreted upon ingestion of food. Extends the period of time over which food nutrients are assimilated into the bloodstream by simultaneously depressing both insulin and glucagon secretion to decrease utilization of nutrients by the tissues. This process helps prevent rapid exhaustion of nutrients, therefore making it available for a longer period of time.

Emmetropia.

In normal vision the light falls onto the retina without any distortion or abnormal bending of the light.

Trabeculoplasty.

Surgery for open angle glaucoma. An argon laser procedure where the laser causes some of the areas of the drainage system to shrink, allowing for stretch opening of adjacent areas for increased outflow. This procedure often allows patients to reduce medications and avoid or delay further surgery.

Trabeculectomy.

Surgery for open angle glaucoma. Creation of a fistula. A small area of the trabecular meshwork is removed to allow the aqueous humor to drain. This procedure is done under local anesthetic, often with sedation. Follow-up includes an annual gonioscopy to inspect the anterior chamber of eye and for determining ocular motility and rotation. A gonioscopy is where a special lens with a mirror-like effect is placed on the eye to evaluate the trabecular meshwork through the slit lamp.

Assessment of Cataracts.

Symptoms of cataracts include cloudiness or blurriness, reduced night vision, and color distortion or faded colors. A visual acuity test (snellen chart) is part of the assessment for vision impairment related to cataracts. A dilated eye examination will be performed to assist with diagnosis. Patients with cataracts usually notice no pain or discomfort.

Insulin Injection Sites.

The rate of absorption of insulin varies with the anatomic location of the injection site. Insulin is absorbed fastest from the abdomen, followed by the arm, thighs, and buttocks. Exercise of the thigh or arm will increase the absorption time and rate of onset of action. The abdomen remains the preferred site of injection because of the convenience and its good absorption rates.

Vitrectomy.

The surgeon removes the vitreous fluid from the middle of the eye. The physician may then treat the retina with photocoagulation. At the end of surgery silicone oil or gas is injected into the eye to replace the vitreous fluid. This surgery may require an overnight hospital stay. The postoperative care includes assessment for bleeding into the vitreous area, further retinal detachment, fluid buildup in the clear cover of the eye (corneal edema), and increased IOP.

Hordeolum.

The sweat glands in and around the eyelid are at risk of inflammation or infection. When these inflamed sweat glands are reddened, swollen, and tender to touch they are called a hordeolum or stye. Management of inflammatory and infectious eye conditions includes the use of warm moist compresses and antibiotic ointment. In addition, the practice of good medical asepsis and avoiding touching the eye area are highly recommended.

Entropia (cross eyes).

An eye that deviates inward.

Exotropia (wall eyes).

An eye that deviates outward.

Peripheral Vascular Dysfunction (PVD).

- Diminished or absent pedal pulses. - Cool feet. - Pain at rest. - Intermittent claudication. - Hair loss on the extremity. - Rubor of the skin (i.e., redness) when the extremity is dependent, and slower capillary filling. Doppler studies or angiography will confirm the diagnosis. Loss of sensation from peripheral neuropathy is another major risk factor for the development of foot ulcers in patients with diabetes. Loss of sensation removes the protective function of pain, and the patient is unable to sense pressure, discomfort, or even injury. Pain sensation is assessed by use of a monofilament on the plantar aspect (sole) of the patient's foot. Management of PVD includes reduction or control of risk factors, especially smoking, hypertension, and elevated cholesterol levels. Patients may require surgery, including a bypass graft or amputation.

Assessment of Peripheral Neuropathy (Sensory Neuropathy).

- Generalized tingling or a prickly sensation (paresthesia) and burning sensations, particularly at night. - The patient may experience hyperesthesia (increased sensitivity of the skin) and may report that even light pressure from bedcovers is intolerable. - As the neuropathy advances, sensation in the feet decreases markedly, leaving the feet numb. This decreased sensation makes the patient susceptible to injury, as he or she is unaware of pain or pressure sensations. - Deformities of the feet, such as Charcot's joints. - Causes atrophy of the muscles in the foot. - Foot assumes an abnormal weight distribution on the joints and the motion of the foot is altered. - The patient may have decreased deep tendon reflexes on exam.

Treatment of Nephropathy.

- Glycemic control. - Prevention of urinary tract infections. - Management of hypertension. - Monitor medications. - Nutritional changes - low-protein, low-sodium diet diet. Patients with microalbuminuria in excess of 30 mg in 24 hours on two consecutive tests will be started on an angiotensin-converting enzyme (ACE) inhibitor to lower blood pressure and reduce microalbuminuria. Another option is the use of angiotensin-receptor blocking agents and a low-protein diet. Patients in ESRD are often placed on hemodialysis - ambulatory peritoneal dialysis for patients with diabetes, and ESRD. This type of dialysis allows the patient more freedom in their lifestyle. Insulin can be added to the dialysate to achieve better glycemic control. Some patients may need to increase their insulin requirements because of the glucose in the dialysate. Infection is a complication of peritoneal dialysis.

Assessment of Hypoglycemia.

- Irritability. - Increasing confusion. - Tremors. - Hunger. - Sweating. - Weakness. - Visual disturbances. The patient presentation is similar to alcohol intoxication, and if not treated rapidly, coma and death may occur. Patients may not be able to recognize the symptoms of hypoglycemia (hypoglycemia unawareness). This can occur because of neuropathy in the autonomic nervous system of the diabetic. - Unawareness is common in elderly patients and also in patients who take beta blockers. - Patients with hypoglycemic unawareness will usually be allowed to have higher blood glucose levels to prevent undetected episodes of hypoglycemia. * A patient may exhibit symptoms of hypoglycemia in the presence of blood glucose levels that are above normal. This can occur when the blood glucose level has been extremely high and decreases rapidly. Patients may experience the symptoms of hypoglycemia when hyperglycemia was treated aggressively.

Preventing Diabetes (Primary Prevention).

- Lifestyle changes - 150 minutes of physical activity per week. - Weight loss - 7-10% of body weight. - Improved nutrition - Reduced calorie and fat intake, and increased fiber intake to 14 grams/1,000 kcal. The ADA does not recommend eating based on the glycemic index, as there are not sufficient studies to support this.

Assessment of Ocular Cancer.

- Ocular hypotension or hypertension - Cataract if the tumor grows anteriorly. - Blurred visual acuity and floaters. - Severe ocular pain rarely occurs and is related to the melanoma impinging on the posterior ciliary nerves or from increased intraocular pressure. - Sunlight exposure is a likely contributor to the development of choroidal melanoma.

Foot Care for PVD.

- Patients should be instructed to wash their feet daily with warm water and mild soap. Decreased sensation increases the risk of burn injuries; therefore, the patient should first test the water temperature with his or her hands. - The feet should be patted dry, particularly between the toes. - Feet should be examined daily for cuts, blisters, and reddened areas. - Patients are advised not to use over-the-counter (OTC) preparations to treat calluses and corns. - The nails should be cut straight across to avoid ingrown toe nails, they are easier to trim following a bath or shower. - Shoes should fit properly and not be open-toed styles or high heels. - Socks are to be clean cotton and colorfast. Cotton socks are more absorbent and are therefore preferable. - Cuts are to be cleansed with warm water and mild soap. - The use of alcohol or iodine is to be avoided. Injuries to the skin or infections are to be reported immediately to the health care provider.

Assessment of Type 1 DM.

- Polyuria - The increased concentration of glucose in the circulation causes an osmotic diuresis, causing large amounts of urine to be produced (polyuria). - Polydipsia (excess fluid intake) - Increased blood sugar levels will cause water to be drawn from the cells by osmosis, resulting in cellular dehydration. This triggers the thirst center in the hypothalamus, and the patient drinks large volumes of water (polydipsia). - Polyphagia (increased food intake) and Weight loss - Type 1 diabetes is a disorder of metabolism of fat, protein, and carbohydrates. Without the presence of insulin, glucose is unable to enter the cells and remains in the bloodstream. As a result, the cells are starving, and the patient experiences hunger (polyphagia) with weight loss. The patient will experience weight loss as the body uses proteins and fats for energy and loses fluids from the osmotic diuresis. - Malaise. - Fatigue. - Elevated random and/or fasting blood glucose (BG). - Abnormal oral glucose tolerance test; elevated glycosylated hemoglobin (HgbA1c). - Positive serum ketones and possible urine ketones or acetone with ketoacidosis.

Nursing Assessment of Type 2 DM.

- Polyuria. - Polydipsia. - Blurred vision. - Fatigue. - Paresthesia (numbness, tingling, sensitivity). - Skin infections. - Elevated random and/or fasting blood glucose (BG). - Abnormal oral glucose tolerance test; elevated glycosylated hemoglobin (HgbA1c). - Positive serum ketones and possible urine ketones or acetone with ketoacidosis.

Nursing Assessment of DKA.

- Thirst. - Nausea and vomiting. - Malaise and lethargy. - Change in LOC. - Polyuria. - Warm dry skin, flushed face. - Acetone (fruity) odor to breath. - Dehydration - fluid and electrolyte depletion, pts will have hypotension and tachycardia. - Kussmaul respirations (deep, nonlabored, rapid respirations) - associated with server later stages of DKA. The respiratory rate increases as dose the depth of respirations in an attempt to blow off the carbon dioxide accumulating with the acidosis state. Lab findings: - Serum glucose above 250 mg/dL. - pH under 7.35. - Bicarbonate (HCO3-) under 15 mEq/L. - Serum ketones present. - Urine positive for glucose and ketones. - May have abnormal serum sodium and chloride levels. - Potassium levels may also be near normal or low. This represents a severe total body depletion of potassium and requires careful monitoring as the treatment of DKA will further lower the potassium levels. The patient is typically slightly hypothermic, and an infection should be suspected if an elevation in temperature is present. Hypothermia occurs because of peripheral vasodilatation and is considered a poor prognostic sign. The patient will experience fatigue, polydipsia, and polyuria prior to the development of ketoacidosis. Physical examination reveals dehydration from the hyperglycemia and the characteristic acetone or fruity odor of the breath.

Risk Factors for Hypoglycemia.

- Trauma - Illness - Exercise - Renal failure - Alcohol intake - Surgery

Client Teaching for DM.

- Type of DM, symptoms to report, self-administration of medication, fingerstick glucose monitoring, plan for regular exam by practitioner, need to wear Medic-Alert bracelet indicating DM and medication prescription, need for lifelong medication management and lifestyle adjustments. - Foot care: keep feet clean and dry; inspect feet daily using mirror to see soles; protect feet by wearing shoes (allow 1⁄2- to 3⁄4-inch toe room) or slippers at all times; avoid snug fitting socks or stockings; use cotton socks because they wick perspiration away from skin. - Sick-day management: maintain food and fluid intake, continue to take insulin; BG monitoring (up to q4h; report > 250 mg/dL); monitor urine for ketones. - Diet plan, including considerations for traveling, sports, attendance at parties, and other alterations in daily routine. - Provide these instructions to clients receiving insulin: a. Storage: store insulin in use at room temperature, away from direct sunlight, and replace after 4 weeks; administration of cold insulin causes subQ atrophy (lipoatrophy) or hypertrophy (lipodystrophy), which alters insulin absorption; store extra vials of insulin not being used in refrigeraton. b. Preparation: note date of expiration; discard vial and use new one if regular insulin appears cloudy; do not shake—may inactivate insulin and/or form bubbles that lead to dosage errors; roll nonregular insulin gently between hands to evenly disperse suspended particles; draw regular (clear) insulin first when mixing it with other types of insulin; only mix insulins of same concentration (e.g., U100 regular and U100 NPH) and from same source. c. Injection: rotate injection sites to prevent lipoatrophy and lipodystrophy; do not inject insulin in an area that will be involved in exercise, as it will increase rate of absorption, onset, and peak action. d. Monitor for signs of hypoglycemia; have candy or foods with simple carbohydrates available. e. Avoid alcohol while taking insulin because it lowers BG levels and can cause hypoglycemia. - Teach signs of hypoglycemia (restlessness, irritability, weakness, hunger, nausea, pale diaphoretic skin, shakiness or trembling, headache, confusion, inability to concentrate, deteriorating LOC to coma, seizures), actions to take, causes of hypoglycemia, and methods to prevent. - Instruct how to prevent and manage acute complications of DM (hyperglycemia, hypoglycemia, diabetic ketoacidosis, and HHNK; and chronic complications of DM (diabetic retinopathy, nephropathy, and neuropathy). - Develop with client a plan for wellness, including exercise: a. Daily cardiovascular exercise decreases risk for insulin resistance, reduces risk for complications, and improves glucose management. b. Check BG before exercise; check for urine ketones if fasting BG is 250 mg/dL; call practitioner if ketones are present and avoid exercis. c. Monitor for signs of hypoglycemia for up to 24 hours after extensive exercise.

Treatment of Peripheral Neuropathy (Sensory Neuropathy).

-Glycemic control. - Topical anesthetics (e.g., capsaicin). - Tricyclic antidepressants (e.g., amitriptyline). - Antiseizure drugs (e.g., gabapentin). Capsaicin is produced from chili peppers. As a topical medication, it acts locally to decrease the chemicals that mediate pain. It is used with a fair amount of success when applied three to four times daily. The patient may initially experience an increase in symptoms. Within two weeks of therapy, the patients will begin to have pain relief. Tricyclic antidepressants decrease the pain sensation by inhibiting the reuptake of serotonin and norepinephrine and decrease the transmission of pain sensation at the spinal level. The exact mechanism of action of gabapentin is not understood, but it has been shown to relieve the pain of peripheral neuropathy.

Criteria for Diagnosis of Diabetes.

1. A1C ≥ 6.5%. The test is performed in a laboratory using the National Glycohemoglobin Standardization Program (NGSP) method or Diabetes Control and Complications Trail (DCCT) assay standardized. OR 2. Fasting Plasma Glucose (FPG) ≥ 126 mg/dL. Fasting is having no caloric intake for ≥ 8 hours. OR 3. 2-hour plasma glucose ≥ 200 mg/dL during an Oral Glucose Tolerance Test (OGTT) using a 75 g glucose load. OR 4. When a patient has symptoms of a hyperglycemic crisis, a random plasma glucose of ≥ 200 mg/dL. * In the absence of unequivocal hyperglycemia, tests 1-3 should be confirmed by repeat testing before a final diagnosis of diabetes is made.

A client has an abnormality of the eye in which both eyes are affected, yet the problem is often more acute in one eye than the other. This is most likely which condition? 1. Cataract 2. Keratoconus 3. Glaucoma 4. Retinal detachment

1. Rationale: Cataract describes the condition asked for in the question.

Which of the following lab tests offers the best information about glycemic control? 1. HgbA1C 2. Fasting plasma glucose 3. Glucose tolerance test 4. Capillary glucose measurement

1. Rationale: HgbA1C is the lab test that offers the best information about glycemic control.

A client has a visual problem that is correct with convex corrective lenses. The problem is most likely what? 1. Hyperopia 2. Myopia 3. Astigmatism 4. Corneal abrasion

1. Rationale: Hyperopia is the condition corrected with convex corrective lens.

What is the most common cause of ocular cancer? 1. Melanoma 2. Diabetes mellitus 3. Intracranial pressure problems 4. Hypertension

1. Rationale: Melanoma is the most common cause of ocular cancer.

Which of the following types of insulin can be administered intravenously? 1. Regular 2. Lente 3. Semi-Lente 4. NPH

1. Rationale: Regular insulin can be administered intravenously.

What is the primary difference between DKA and HHNS? 1. The absence of ketosis is the distinguishing feature. 2. HHNS has much higher blood glucose levels. 3. DKA has associated hyperkalemia. 4. HHNS is usually a reaction to previous conditions of hypoglycemia.

1. Rationale: The primary difference between DKA and HHNS is the absence of ketosis.

Treatment of Hypoglycemia.

15 g of fast acting carbohydrate, e.g., 3-4 glucose tablets, 4-6 ounces of fruit juice or regular soda pop. Glucagon 1 mg subcutaneously or intramuscularly followed by a concentrated source of carbohydrate when the patient is fully alert.

Keratoconus.

A progressive, noninflammatory bilateral disease of the cornea characterized by thinning of the cornea layers that leads to corneal surface distortion. The resulting visual loss is from irregular astigmatism, myopia, and secondarily from scarring. Risk factors for developing keratoconus include ocular allergies, rigid contact lens wear, and vigorous eye rubbing. It usually presents at puberty and progresses until the third or fourth decade of life; however, it can occur at any time.

Exercise.

150 minutes/week of physical activity of moderate to severe intensity. Resistance training three times per week if there are no contraindications. Exercise increases the body's uptake of glucose by the muscles and therefore lowers blood sugar levels. Strength or resistance training will increase lean muscle mass and increase the metabolic rate. This is helpful in weight reduction. Exercise will aid in the reduction of cardiovascular risks by increasing HDLs and lowering cholesterol and triglyceride levels. There are additional exercise benefits resulting in decreased stress, decreased depression, and increased self-esteem. Patients should work toward a goal of 30 minutes of exercise daily. The intensity of exercise should allow both breathing and talking with ease during the exercise. Patients can be taught to gauge the intensity of exercise by determining their desired heart range and checking the pulse to see if their heart rate falls in the target range. Target range is estimated by: - Patient's age - 220 = ? then x 60% to determine the lower limit and by 80% to obtain the upper limit. * Patients just beginning an exercise program should use the lower limit as their target heart rate initially. * Those patients who have pacemakers, take beta blockers, have arrhythmias, or have autonomic neuropathies should use this heart rate formula with caution. The lower limit of 60% may overtax the heart.

A client is found after an accident with an impaled object in an eye. The nurse remembers to first do what? 1. Place a cup over the impaled object and tape in place 2. Assess the client for priority injuries 3. Pull out the object and observe for bleeding 4. Turn the client on his or her side, to prevent aspiration

2. Rationale: Assessment of the client with an impaled object is the priority.

A client has been rubbing her eye frequently for the past several weeks. Which complication results from the rubbing action? 1. Hyperopia 2. Keratoconus 3. Corneal ulceration 4. Refraction

2. Rationale: Keratoconus is caused by rubbing the eyes profusely.

Which of the following is true of the dawn phenomena? 1. It manifests itself as morning hypoglycemia. 2. The corresponding hyperglycemia results from predawn release of counter-regulatory hormones. 3. It is best managed by decreasing the administered amounts of insulin. 4. The client is not allowed to take insulin in any form when diagnosed with the dawn phenomena.

2. Rationale: The corresponding hyperglycemia seen in the dawn phenomena results from predawn release of counter-regulatory hormones.

A client with diabetes has just finished the teaching session on mixing insulins. The nurse knows that more teaching is needed when the client: 1. Injects air into the NPH insulin first followed by injecting air into the regular insulin vial 2. Withdraws too much NPH insulin and injects the extra back into the Lente vial 3. Withdraws too much regular insulin and injects the extra back into the regular insulin vial 4. Uses separate syringes to draw up 5 units of regular insulin and 4 units of NPH

2. Rationale: The nurse knows that more teaching is needed when the client who is mixing insulin withdraws too much NPH insulin and injects the extra back into the Lente vial.

A client has an eye disorder with inflamed sweat glands that are reddened, swollen, and tender to touch. This is: 1. Uveitis 2. Iritis 3. Hordeolum 4. Conjunctivitis

3. Rationale: Hordeolum is the label for the condition described in the question.

Which of the following is true regarding the autonomic neuropathy conditions associated with diabetic complications? 1. They result in bradycardia and profuse diaphoresis. 2. They are seldom seen in adult-onset diabetic conditions. 3. They lead to bowel and bladder incontinence and delayed gastric emptying. 4. They result in foot ulcers due to a lack of adequate circulation.

3. Rationale: The autonomic neuropathy conditions associated with diabetic complications lead to bowel and bladder incontinence and delayed gastric emptying.

A client has blurred vision and states it is better in bright light. In addition, she sees wavy lines on the Amsler grid (diagnostic test). This is most likely which condition? 1. Glaucoma 2. Diabetic retinopathy 3. Age-related macular degeneration 4. Strabismus

3. Rationale: The condition described in the question is age-related macular degeneration.

A client has glaucoma, which was determined by testing the pressure within his eye. The diagnostic test revealing the presence of this eye pressure is: 1. Intracranial pressure 2. Ballottement 3. Tonometry 4. Trabeculectomy

3. Rationale: Tonometry is the diagnostic test used to reveal the presence of eye pressure.

A client is admitted to the hospital with DKA. The nurse can anticipate which of the following solutions will be administered initially intravenously? 1. 5% dextrose in water 2. Ringer's lactate 3. 0.9% NS 4. 5% dextrose in 0.45% NS

3. Rationale: When a client is admitted to the hospital with DKA, the nurse can anticipate that 0.9% NS will be administered.

Lipohypertrophy.

A buildup of subcutaneous fat tissue at a site where insulin has been injected continuously. Insulin absorption can be inconsistent or delayed if the medicine is injected in an area of lipohypertrophy. To prevent lipohypertrophy, insulin injection site rotation is highly recommended .

What are clinical manifestations of hypoglycemia? 1. Severe abdominal pain, accompanied by nausea 2. Cardiac arrhythmias 3. Neurological responses of the parasympathetic nervous system 4. Irritability, increasing confusion, tremors, hunger, sweating, weakness, and visual disturbances

4. Rationale: Clinical manifestations of hypoglycemia are irritability, increasing confusion, tremors, hunger, sweating, weakness, and visual disturbances.

A client has an inflammation of the cornea and conjunctiva known as keratoconjunctivitis sicca or dry eye syndrome. Which is not an appropriate nursing intervention for this condition? 1. Make a conscious effort to blink more frequently 2. Avoid rubbing the eyes 3. Inform the client that high altitude, dry, or winter climates may make the condition worse 4. Decrease daily intake of water

4. Rationale: Decreasing daily intake of water is not an appropriate nursing intervention for keratoconjunctivitis sicca.

Diabetes is a chronic condition that requires effective long-term management. This management includes: 1. Initial treatment of all types of diabetes with dietary modifications for a three-month time period 2. Initial treatment of all diabetics with insulin administration to prevent complications 3. Initial treatment of all diabetics with an oral glucose lowering agent and an exercise program 4. Use of a glucose lowering agent, diet, and activity.

4. Rationale: The long term management of diabetes includes the use of a glucose lowering agent, diet, and activity.

Chalazion.

A chalazion is a small benign tumor similar to a sebaceous cyst, hordeolum, or even a sebaceous carcinoma. To obtain a definitive diagnosis a biopsy is often necessary. Clinical manifestations include an initial redness and tenderness that progresses to a swollen area without signs or symptoms of infection. Management of chalazion includes teaching good handwashing and avoiding touching the eye area with unclean hands. Antibiotic ointments may be applied, with warm moist compresses. Drainage and crusts are moistened with a wet cloth prior to removal. Surgical intervention may be indicated for chalazions that interfere with vision or are cosmetically displeasing.

Ulcerations.

A corneal ulceration is considered an ophthalmologic emergency. Bacterial corneal ulcers usually occur from a traumatic break in the corneal epithelium, allowing bacteria to enter. Other bacterial causes can include tear insufficiency, malnutrition, and contact lens use. Herpes simplex virus (HSV) is one of the most common causes of corneal ulceration. Visual acuity is affected based on location of the ulcer and whether inflammation is present in the cornea. Clinical manifestations include blurred vision, photophobia, pain, redness, and mucopurulent drainage. Emergent treatment includes an ophthalmologic consultation, cultures, and treatment with an antibiotic ointment to prevent vision loss.

Laceration and Penetrating Injuries.

A full-thickness injury may occur to the cornea in the form of a puncture, or it may occur as a linear or irregular corneal laceration. The initial injury can cause complete or partial vision loss and put the patient at risk for a secondary infection. Diagnosis is determined through the use of the standard Snellen chart and use of the slit lamp. Pressure on the globe should be avoided, the eye should be patched, and a patient with this condition should be referred to an ophthalmologist for a thorough examination. Every effort should be made to avoid any further injury by shielding the eye and elevating the head of the bed. The patient should be instructed not to touch the eye area and to rest until seen by the ophthalmologist. If there is a protruding body, do not remove it; the ophthalmologist should remove it. If the patient develops nausea and vomiting, antiemetics and NPO (nothing oral) status may be initiated. Broad-spectrum antibiotics should be started intravenously or orally after nausea and vomiting subside. Frequent eye examinations on follow-up are recommended for patients with lacerations or penetrating injuries because of an increased risk of traumatic cataracts and secondary glaucoma.

Low Vision.

A general term used to describe a permanent functional vision loss that is not correctable by medication, surgery, or corrective lenses. Patients classified with low vision may have any one of a wide range of diseases. These individuals may find that their ability to perform activities of daily living, work, and pleasure are impaired. In addition to the traditional assessment for vision and visual acuity, consideration should be given to the individual's ability to cope with their limitations.

Glaucoma.

A group of diseases related to the amount of intraocular pressure in the eye occurring as a result of neurodegenerative processes. Increasing intraocular pressure can rapidly result in optic nerve damage, causing a decrease in vision and even blindness. There are two primary forms of glaucoma: - Closed angle. - Open angle. In addition, there are congenital, normal tension, and secondary forms, such as pigmentary and neovascular glaucoma. After cataracts, glaucoma is the second leading cause of blindness worldwide.

Retinitis Rigmentosa (RP).

A group of inherited diseases affecting the retina. Are progressive diseases with a progressive loss of vision due to the loss of viable photoreceptors. In these progressive diseases, central vision is spared the longest, with peripheral vision affected first. The individual may have either the rods or the cones affected. When the rods are primarily affected, it results in symptoms of night blindness and slow loss of peripheral vision, whereas the individual with cones primarily affected has decreasing visual acuity, development of color blindness, and day vision problems. No medical treatment.

Hyperosmolar Hyperglycemic Nonketotic Sydrome (HHNS).

A life-threatening emergency associated with severe hyperglycemia, an osmotic diuresis, and a profound fluid volume deficit. The absence of ketosis is the distinguishing feature between DKA and HHNS. Patients with diabetes who produce sufficient insulin to prevent protein breakdown and ketoacidosis may not produce sufficient insulin to prevent or reverse severe hyperglycemia.

Lipodystrophy.

A localized complication of insulin administration characterized by changes in the subcutaneous fat at the site of the injection.] Encompasses both Lipohypertrophy and Lipoatrophy.

Self-monitoring of blood glucose (SMBG).

A method whereby a patient tests his or her own blood glucose levels. Allows patients who take insulin the ability to detect and treat asymptomatic hypoglycemia. SMBG is required three times a day but the frequency may vary by individual. There are no data to suggest the optimal number of times type 2 diabetics should monitor their blood sugar, but the frequency should be enough to facilitate reaching the glycemic goals. Whenever diet, exercise, or medications are modified, patients with both type 1 and type 2 diabetes should increase the frequency of monitoring.

Euglycemia.

A normal concentration of glucose in the blood.

Amblyopia (lazy eye).

A reduction in visual acuity caused by cerebral blockage of visual stimuli, which can develop in the eye affected by strabismus. * Failure to correct amblyopia, especially in children, can result in permanent loss of vision in the affected eye.

Keratoconjunctivitis Sicca.

AKA dry eye syndrome. Development of inflammation of the cornea and conjunctiva. Occurs when the individual produces fewer tears and is more common in women, especially after menopause. Aging is also a risk factor; as people grow older they produce fewer lipids, which affects the tear film. With less oil to seal the water layer, the tears evaporate more quickly or run down the cheek instead of staying in the eye to moisten it. Clinical manifestations include a scratchy or sandy feeling as though something were in the eye, irritation, burning, redness, and blurred vision that improves with blinking. Treatment: - Artificial Tears. - Closing the eye's drainage ducts with punctual plugs. One risk group is patients that are critically ill and in an intensive care unit. This is because they often blink less often, there is greater potential for dehydration, and there are dry conditions within the unit. These patients require additional proactive care.

Conjunctivitis.

AKA pink eye. Can be the result of exposure to allergens or irritants - Not contagious. There is a bacterial or viral form known as infectious conjunctivitis that is easily transmitted to others. * Viral conjunctivitis may be caused by adenovirus, HSV, or rubella. * In bacterial conjunctivitis the offending organisms include pneumococcus, streptococcus, staphylococcus, and gonococcus. Parasitic infections can also occur, such as Chlamydia trachoma or Onchocerca volvos. These infections, while rarely occurring in the western hemisphere, are a leading cause of blindness in the world. Diagnosis is obtained through use of cultures and antigen detection assays. Clinical manifestations are watery eyes, reddened appearance, itching, and burning-like pain. Good handwashing technique prior to touching the eye area and avoiding touching the eye and then handling other objects are good techniques for prevention. Health care workers should wear gloves when treating the eye. Allergen causes are treated with removal of the allergen if possible, rinsing with artificial tears, and use of topical medications, such as antihistamines and corticosteroids. Eye drops that treat the reddened appearance, such as vasoconstrictors, may be cosmetically beneficial. Care for bacterial or viral infections includes application of appropriate antibiotic ointments after a culture of the eye drainage is obtained. Oral antiviral agents, such as acyclovir or ganciclovir, may also be used. During the healing time makeup should be avoided and all old makeup replaced to prevent reinfection. Patients with parasitic infections are treated with topical antibiotics or oral antibiotics (tetracycline or sulfonamides), depending on their exposure and recurrence.

Diagnostic Test for Rental Disease.

Albumin in the urine is a hallmark of renal disease. Albumin in the urine may be detected with a urine dipstick or 24-hour urine collection. If significant amounts of albumin are present, blood urea nitrogen (BUN) and creatinine levels are obtained.

A1C.

Also called Glycated hemoglobin, hemoglobin A1c, HbA1c, A1C, Hb1c, or sometimes HbA1c. Measures the average blood glucose control for a period of up to three months. It is determined by measuring the percentage of glycated hemoglobin, or HbA1c, in the blood. The A1C percentage is usually measured at least twice a year, or more frequently when necessary. It does not replace daily self-testing of blood glucose. The A1C test has to be done in a laboratory setting using the standardized method certified by the National Glycohemoglobin Standardization Program (NGSP), or it must be standardized or traceable to the Diabetes Control and Complications Trial (DCCT) reference assay

Retinal Detachment.

Also called detached retina or retinal tear. Medical emergency! Should be seen by an eye specialist immediately. Occurs when the retina detaches by lifting or pulling away from its normal position. If not treated promptly, this can cause permanent vision loss. Retinal detachment can occur at any age, but it is more common in individuals over age 40. Other risk factors include extreme nearsightedness, previous history or family history of retinal detachment, previous cataract surgery, or a past eye injury. The retina is composed of two layers; these layers can separate from each other or the wall of the eye. The more inner layer detects light, and the outer layer provides the support and nutrients to the retina. The nerve cells that detect light entering the eye then translate the information into nerve signals about what the eye sees. When the detachment occurs the retina no longer can process what it sees, which results in vision loss in that area. This vision loss can be minimal or severe depending on the size and location of the tear or detachment. There is always some vision loss after a retinal detachment.

The mother of an adolescent with diabetes mellitus tells the nurse that her son likes to eat cheeseburgers and french fries when he goes out with his friends. The son is aware he is exceeding the allowable carbohydrate exchanges on the diabetic diet. How could the nurse best explain why adolescents sometimes make choices that place their health at risk? 1. They want to be like their peers. 2. They have a self-destructive wish. 3. They eat foods with friends that they can't eat at home. 4. They want to show risk-taking behavior.

Answer: 1 Rationale: As part of normal psychosocial development, adolescents need to feel like part of their group, even if it means impairing their health. There is no information to support a self-destructive wish. Although some foods may not be allowed at home, it is not likely to be the motivating factor. Displaying risk-taking behaviors is not likely the primary motivation, but rather a secondary event.

The client with diabetes mellitus (DM) is going home following angioplasty. The nurse observes that the client walks to the restroom barefoot, although slippers are in reach. What is the priority nursing diagnosis for this client? 1. Risk for Injury related to potential for falls while walking barefoot 2. Risk for Infection related to impaired tissue perfusion and walking barefoot 3. Deficient Knowledge related to post angioplasty care 4. Risk for Impaired Cerebral Perfusion related to potential for hypoglycemia

Answer: 2 Rationale: Clients with either diabetic mellitus or other conditions that have arterial insufficiency as a component of the disorder must constantly protect their feet from injury; assess the skin condition daily; prevent dry, cracked skin; and avoid crossing the legs in order to maintain tissue perfusion and prevent infection. These clients have delayed wound healing and poor sensation in their feet, increasing risk for injury and undetected injury with infection. The client is not at especially high risk for falls. There is no client information that supports deficient knowledge post-angioplasty. Hypoglycemia is an ongoing potential complication with diabetes mellitus but is not the highest priority at this time.

The client with diabetes mellitus requests a medication for headache soon after returning from an early morning x-ray procedure. The nurse observes the client is upset about the headache, angry at missing breakfast, and has moist hands. What priority action should he nurse take at this time? 1. Administer the medication for headache and arrange for a breakfast tray. 2. Check the blood glucose level and be prepared to give 4 ounces of juice immediately. 3. Acknowledge his dissatisfaction, offer to obtain a snack, and give the medication. 4. Administer the headache medication and review the day's lab test results.

Answer: 2 Rationale: Headache, restlessness, anxiety, sweating, and increased pulse are signs of hypoglycemia. Resolution of symptoms should occur after the client drinks the juice. Treating the headache and obtaining a breakfast tray fail to recognize the client's actual problem. Acknowledging dissat- isfaction, obtaining a snack and giving medication address the client's concerns but do not verify the client's blood glu- cose as a possible etiology for the symptoms. Treating the headache and checking labs fails to address the immediate risk of hypoglycemia, which can be addressed by checking blood glucose.

A 15-year-old weighing 250 pounds has started to experience increased thirst, increased appetite, and frequent urination. After being diagnosed with diabetes mellitus (DM), he is started on oral drug therapy. What information should the nurse give the adolescent about medications as a treatment option? 1. "You might receive a pill now, but you'll get insulin in the future if you don't comply with diet and medication therapy." 2. "Overweight teenagers may develop type 2 diabetes, which can be treated with an oral medication. You may or may not need insulin in the future." 3. "Insulin is used when people with diabetes won't take oral pills, so you can avoid this by taking your medication as ordered." 4. "Your diabetes is mild, so you won't need to take medication for long. You will probably only need to restrict sweets."

Answer: 2 Rationale: Some teens develop type 2 diabetes, especially those who are overweight. They might need to take an oral hypoglycemic with or without accompanying insulin. Warning the client about compliance does not provide the information needed about medication therapy. Insulin is not used for those who won't take oral medication. Sweets and complex carbohydrates will need to be restricted regardless of medication therapy.

A 70-year-old client admitted a few hours ago with a blood glucose (BG) of 750 mg/dL is being treated for hyperos- molar hyperglycemic nonketotic coma (HHNK) with intravenous regular insulin at 10 units/hour, normal saline with 20 mEq of potassium per liter infusing at 250 mL/hr, and oxygen at 2 L/min. The client has been oriented when stimulated, and BG has dropped to 400 mg/dL. The client now demands to get out of bed and his skin feels cool and moist. What should the nurse do at this time? 1. Interpret this as a sign of hypoglycemia and check his blood glucose. 2. Recognize the client is feeling better and is seeks control of his situation. 3. Auscultate breath sounds and assess oxygen saturation. 4. Assess the client for bladder distention or signs of imbalanced body temperature.

Answer: 3 Rationale: Increased preload caused by the intravenous infusion at 250 mL/hr may exceed the myocardium's workload capacity, leading to signs of decreased cardiac output and congestive heart failure. There is no risk for hypoglycemia while the BG is still elevated to 400 mg/dL. The nurse should seek a physiological basis for the change in client's status rather than seeking control, especially since the skin is cool and moist. Checking for bladder distention or fever represents a failure to directly assess for signs of possible fluid overload.

The client who has a long history of type 1 diabetes melli- tus is being treated for bronchitis and sinusitis. The nurse observes deep, rapid, unlabored respirations, fruity odor on the client's clothes, and dry skin. Which action should the nurse take next? 1. Assess breath sounds for additional signs of response to treatment of the infection. 2. Assess blood glucose level for signs of hypoglycemia. 3. Encourage the client to rest frequently and to drink 8 to 10 glasses of fluids daily. 4. Assess blood glucose level for hyperglycemia and check urine for ketones.

Answer: 4 Rationale: Diabetic ketoacidosis can occur in diabetic clients with infection and is characterized by elevated blood glucose and ketonuria. Deep, rapid, unlabored respirations are called Kussmaul respirations. Kussmaul respirations, fruity odor, and dry skin are signs of hyperglycemia. Assessing breath sounds does not address hyperglycemia and ketoacidosis, which is the client's current problem. Hypoglycemia is the opposite problem of the one the client is experiencing. Rest periods will not help treat hyperglycemia and ketoacidosis, and although fluids are needed, 8-10 glasses daily will not be enough to reverse the dehydration that accompanies diabetic ketoacidosis.

Autonomic Neuropathies.

Are widespread, and they affect nearly every body system. Breakdown of the autonomic nervous system.

Insulin Storage.

As a protein, insulin is affected by heat and freezing. An insulin vial that is currently in use can be stored at room temperature as long as four weeks if the temperature of the room remains between 37 and 86 degrees. The vials should be protected from direct sunlight. Insulin not in use should be stored in the refrigerator. Insulin that is kept at room temperature is less likely to irritate the injection site than insulin that is cold.

Cataracts.

As the opacity of the lens becomes cloudy or turns a yellowish brown color, distorting the light passing through to the retina. The lens is made of water and protein; when the protein clumps together this produces the cloudiness. When the lens develops the yellowish brown color it often results in color distortion. Cataracts can also form after traumatic eye injury or secondary to other eye problems, such as diabetes or surgery for glaucoma. Occurs as a part of the aging process for many individuals. Occur simultaneously in both eyes, yet the problem is often more acute in one eye than the other. Risk for the development of cataracts is seen in conjunction with disease (e.g., diabetes), personal behavior (e.g., smoking, alcohol use), medical treatment (e.g., side effect from use of steroids), and environment (e.g., exposure to sunlight).

Therapeutic Management of HHNS.

As with DKA, fluid resuscitation is of utmost importance to the nurse when treating a patient with HHNS. IV therapy is initiated with 0.9% NS if oliguria and hypotension are present. If hypotension and oliguria are not present, fluid therapy is initiated with 0.45% NS, because the patient is hyperosmolar. It is common to deliver large volumes of fluid, as much as 6 to 8 liters in the first 8 to 10 hours of therapy. When the blood glucose level reaches 250 mg/dL, 5% dextrose will be added to the IV solution. A goal of therapy is maintenance of the blood glucose levels between 250 and 300 mg/dL to decrease the risk of cerebral edema. Urine output of 50 mL/hour is a goal of fluid therapy. The patient will be given IV regular insulin, but HHNS may require less insulin than DKA. If the fluid volume deficit is corrected, the hyperglycemia lessens. Correction of the hypovolemia will increase the functioning of the kidneys and the excretion of glucose in the urine. Potassium imbalances occur with HHNS as insulin drives the glucose and potassium in to the cells. The patient with HHNS will have fewer problems with potassium than the patient with DKA because of the absence of acidosis. As with any administration of potassium, adequate renal function must be established.

Medical Nutrition Therapy (MNT).

Based on a well-balanced diet and is one of the mainstays in the treatment of diabetes. A registered dietitian familiar with the components of diabetes MNT best provides the therapy. Prediabetes: - Decrease the risk of diabetes and cardiovascular disease and promote healthy food choices, physical activity, and weight control. Diabetes: - Maintain blood glucose levels at normal or near normal range. - Maintain a lipid profile that reduces the risk for vascular disease. - Maintain a blood pressure levels at the normal or near normal range. - Prevent or slow the onset of diabetes complications with diet and life style modifications. Specific Situations: - Youth with type 1 or type 2 diabetes, pregnant/lactating mothers, and older adults with diabetes need nutrition plans that are customized to their specific needs. - Individuals treated with insulin need self-management training for safe exercise, including prevention and treatment of hypoglycemia, and diabetes treatment during acute illness

Prediabetes.

Blood glucose levels that are higher than normal but not yet high enough to be diagnosed as diabetes. Prediabetes may be able to delay or prevent the development of diabetes through intensive lifestyle change, such as exercise, improved nutrition intake, and weight reduction. People with prediabetes have a higher risk for developing type 2 diabetes, heart disease, and a stroke. People with prediabetes have either impaired glucose tolerance (IGT) or impaired fasting glucose (IFG). Usually associated with a condition called metabolic syndrome.

Colorblindness.

Can be an acquired abnormality of color vision, such as with aging, when normal sensitivity to color gradually diminishes. It is thought to result from the progressive yellowing of the lens occurring with aging. While all colors become less intense, the ability to discriminate between blue and green is greatly affected. In patients with DM, color vision deteriorates more rapidly than in the general population. The genetically linked colorblindness results in the inability to distinguish red from green. Testing for colorblindness is done with an Ishihara chart. There is currently no treatment for this visual dysfunction.

Foreign Body Eye Injury.

Can be the result of dust, dirt, eyelashes, or a fingernail. Because the cornea is an extremely sensitive area, a corneal abrasion may result. Corneal abrasions are often painful even when the scratch is relatively minor. It is important to seek health care immediately for any foreign body that is not removed by blinking. Fast-acting anesthetic agents can numb the area and allow a qualified health care professional to remove the object. Irrigation with normal saline can be used to rinse out loose particles of dust or dirt. Afterward, antibiotic ointment may be used to prevent infection, and anti-inflammatory drops may be used to reduce discomfort until the cornea heals. An eye patch may be used to minimize movement of the eyelids during the healing process.

Treatment for Glaucoma.

Cannot be cured. Damage is irreversible. The progression of the disease can be controlled with eye drops, oral medications, laser procedures, or surgery. All medications used to lower the IOP do so by either reducing aqueous inflow or increasing aqueous outflow with the goal of keeping the pressure in the mid to lower range (12-16 mmHg) of normal IOP. These drugs fall in the following categories: - Sympathomimetics. - Parasympathomimetics. - Beta-adrenergic antagonists. - Carbonic anhydrase inhibitors. - Prostaglandin analogues. Each category has advantages and disadvantages. Primary open-angle glaucoma was treated with beta-blocker type miotics, such as timolol (Timoptic). Now prostaglandin analogues, such as latanoprost (Xalatan), have become the gold standard. For best effect beta-blockers are often used in combination with the prostaglandin analogues. In closed-angle glaucoma the same medications are used to treat the condition temporarily until surgery can be done. Surgery for open angle glaucoma: - Popular choice of treatment for primary open-angle glaucoma is a trabeculoplasty. - Conventional surgery of choice is a trabeculectomy (creation of a fistula). Surgery for closed angle glaucoma: - Laser peripheral iridectomy.

Controlling Diabetes (Secondary Prevention).

Carbohydrate intake: - From fruits, vegetables, whole grains, legumes, and low-fat milk, a minimum of 130 grams of carbohydrates/day is essential for energy needs. - Sucrose-containing food should be limited but may be incorporated into a meal plan if there is proper coverage with insulin or oral diabetes medications to avoid excessive energy intake and high blood glucose levels. - Sugar alcohols and noncaloric sweeteners may be used in moderation and within the established FDA recommendations. Fat: - Saturated fat should be limited to < 7% of total calories; trans fats should be minimized; dietary cholesterol intake should not exceed 200 mg/day; and fish intake is recommended two or more times a week. Protein: - 20-30% of daily energy consumption for an average individual with diabetes without a history of renal disease is sufficient. * Foods with protein increase insulin response but do not increase blood glucose concentration; therefore, protein-rich foods should not be used to treat acute hypoglycemia. * The ADA does not recommend high protein diets because although they promote acute weight loss, their long-term safety has not been established. Alcohol: - Should be avoided or limited to one drink or less per day for women and two drinks or less a day for men. - Should be taken with food to avoid nocturnal hypoglycemia when using insulin or insulin secretagogues. * When alcohol is consumed in moderation by itself, it has no effect on insulin or glucose concentrations. * Alcohol with another carbohydrate source in mixed drinks induces hyperglycemia. Vitamin/mineral substances: - Has not been shown to have additional benefits for people with diabetes compared to the general population. Type 1 Diabetes: - Integrating insulin therapy into the individual's dietary and physical activity patterns. - Rapid acting insulin either by insulin pump or injection should be adjusted for the amount of carbohydrate content in meals and snacks. If the individual is taking a fixed daily insulin regimen, the carbohydrate intake should be kept consistent with respect to the time and amount. - For a planned exercise session, insulin doses may be adjusted; for unplanned exercise, additional carbohydrates may be needed. Type 2 Diabetes: - Lifestyle modifications to include increased physical activity; and reduced energy consumption, saturated and trans fats, cholesterol, and sodium to improve weight, glycemia, dyslipidemia, and blood pressure. - Blood glucose monitoring is also an essential tool in achieving good glycemic control. Pregnancy: - Need adequate nutrition for weight maintenance or modest weight gain. - Although weight loss is not recommended during pregnancy, women who are overweight or obese with GDM need to restrict carbohydrates to maintain normoglycemia. - Ketonemia and ketoacidosis should be prevented. - MNT for GDM focuses on food choices for appropriate weight gain, normoglycemia, and absence of ketones. Older Adults: - Reduced caloric intake, weight loss, and increased physical activity, but the benefits may be less than those enjoyed by their younger adult counterparts. - Older adults may also benefit from daily vitamin and mineral supplementation, especially if they have reduced energy intake.

Preoperative Care for Cataract Surgery.

Cataract surgery is done almost exclusively as an outpatient procedure. The patient will arrive in the morning and plan to be discharged by the afternoon. Preoperative nursing care includes preoperative history and physical, including medication usage, administration of eye drops to dilate the pupil and cause vasoconstriction, and patient education. Oral medications may be given in the preoperative phase to reduce intraocular pressure, such as acetazolamide (Diamox, Acetazolam). During the intraoperative procedure, the cataract is removed, and an IOL is placed in most patients.

Legal Blindness.

Defined as vision of 20/200 on a Snellen chart or less in the better eye with correction. Of those who are legally blind, about 10% are fully sightless. The rest have some vision, from light perception alone to relatively good acuity. Those who are not legally blind but have serious visual impairment are said to possess low vision.

Diagnosis of Keratoconus.

Determined through refraction, keratometry (measurement of the cornea), and use of the slit lamp.

Oral Medications for Treatment of Diabetes.

Commonly used for treatment of type 2 diabetes. They are not insulin but affect the manner in which glucose and insulin are made and used by the body. It is necessary for the patient to have some endogenous (produced or originating from within a cell or organism) insulin for the oral hypoglycemics to take effect. _____________________________________________________________________ First Generation Sulfonylureas: - Tolinase (tolazamide). - Dymelor (acetohexamide). - Orinase (Tolbutamide). * First generation because they have been used to longest. * Cause a high incidence of hypoglycemia and have been prescribed sparingly in the United States since the advent of second-generation sulfonylureas and other newer, more novel medications for diabetes. Second Generation Sulfonylureas: - Glucotrol and Glucotrol XL (glipizide). - Micronase. - DiaBeta. - Glynase (glyburide). - Amaryl (glimepiride). * Have a longer duration of action and fewer side effects. Sulfonylureas act to increase the production of insulin by the pancreas, and therefore, a functioning pancreas is necessary. They also improve the action of insulin at the cellular level and are thought to decrease glucose production in the liver. They tend to have better effectiveness early in the course of the disease. _____________________________________________________________________ Alpha glucosidase inhibitors: * Delay the absorption and digestion of carbohydrates in the small intestine, resulting in a smaller increase in blood glucose after eating. * Does not alter insulin production and does not produce hypoglycemia. * They can be used as monotherapy or in combination with sulfonylureas, thiazolidinediones, or meglitinide. * The patient may experience hypoglycemia when used in combination with sulfonylureas and thiazolidinediones. * The most common side effect of meglitinide is flatulence, which may cause the patient some minor discomfort. _____________________________________________________________________ Biguanides: * Act by decreasing absorption from the intestines and glucose production in the liver. * Peripheral insulin sensitivity is increased. * Because they do not act on the beta cells in the pancreas, there is no change in the secretion of insulin and no hypoglycemia. _____________________________________________________________________ Meglitinide: * Used to lower blood glucose by stimulation of the beta cells of the pancreas. * It is shorter acting than the sulfonylureas. * There must be some functioning of the pancreas for this drug to be effective. * It is to be taken before meals to stimulate the body to secrete insulin in response to the meal. * Hypoglycemia is a side effect of meglitinide. _____________________________________________________________________ Thiazolidinediones: * Lower insulin resistance by resensitization of the body to its own insulin and are most effective in patients with insulin resistance. * They will not cause hypoglycemia when used as monotherapy, because they do not increase the production of insulin. _____________________________________________________________________ Incretins: * Help lower blood glucose by acting in the gut, increasing insulin secretion from the pancreas, suppressing glucose production in the liver, and increasing satiety to help control blood glucose postprandially.

Hypoglycemia.

Condition characterized by a blood glucose level less than 70 mg/dL. Must be recognized and treated quickly, because the brain requires constant sufficient supplies of glucose to function. Can occur in both type 1 and type 2 diabetes.

Abrasions.

Corneal abrasions are one of the most common eye injuries and probably the most neglected. These injuries may result in permanent scarring and a loss of visual acuity and function. They occur as a disruption in the integrity of the corneal epithelium or because the corneal surface was denuded from physical external forces, such as contact lenses or sports injuries. Many of these injuries are minor, but they can lead to blindness. These same injuries can place economic burdens on otherwise healthy people, resulting in lost time at work or school. Abrasions usually heal in two to three days without treatment; however, they can result in bacterial keratitis if the epithelium integrity is damaged, or they can deteriorate into a corneal ulceration. Clinical manifestations include pain, watering, foreign body sensation, and photophobia. Treatment includes prophylactic antibiotics after trauma or surgery, cycloplegics for comfort, and an eye patch.

Gestational DM (GDM).

Defined as any degree of glucose intolerance that begins or is first recognized during pregnancy. Deterioration of glucose tolerance usually occurs during the third trimester of pregnancy. Most commonly occurs in overweight or obese women with a family history of diabetes. Other risk factors for developing GDM are marked obesity, previous history of GDM, glycosuria, and strong family history of diabetes.

Assessment of DM.

Diabetics who are obese will commonly display thin muscular extremities with increased deposits of fat in the abdomen, chest, neck, and face. A waist/hip ratio of greater than 0.9 in men and greater than 0.8 in women is associated with diabetes. Past health history should include childhood illnesses (rubella, mumps, or other viral illnesses), recent surgery, trauma, stress or infection, pregnancy history, birth weight of infants, and history of pancreatitis. The nurse should inquire about medications used, especially diuretics and corticosteroids, and use of insulin and oral agents. Nutritional: - Metabolic Assess for obesity, changes in weight, increased thirst and hunger, nausea, vomiting, delayed wound healing especially involving the feet, and daily food intake pattern. Elimination Inquire: - Constipation, diarrhea, frequency of urination, nocturia, urinary tract infections, and incontinence. Activity: - Exercise Assess for the presence of fatigue and muscle weakness. Cognitive Perceptual: - Assess for the presence of headaches, abdominal pain, pruritus, numbness and tingling in extremities, or blurred vision. Eyes: - Inspect for vitreal hemorrhages and cataracts. Skin: - Inspect for pigmentation on legs, ulcers on feet, and loss of hair on legs and feet. Respiratory: - Assess for Kussmaul breathing (rapid, deep respirations). Cardiovascular: - Assess for weak rapid pulse and hypotension. GI: - Assess for fruity breath, vomiting, and dry oral mucous membranes. Neurological: - Assess for restlessness, confusion, stupor, coma, and altered deep tendon reflexes.

Therapeutic Management of Diabetes Mellitus.

Diet: - Follow diet recommended in MyPyramid or exchange system diet from American Diabetes Association. - Caloric intake is based on individual needs, including possible weight loss needs for type 2 DM. - CHO in amounts tailored to individual need, avoiding simple sugars. - Protein at 10-20% of caloric intake. - Saturated fat less than 10% of calories with cholesterol intake equal to or less than 300 mg/day. - Sodium intake 2400 to 3000mg/day (same as for general population). - Dietary fiber 20 to 35 gm/day. - Tailor diet to individual and cultural preferences as possible to improve adherence. Oral antidiabetic medications: - Used in type 2 DM only and indicated when diet and exercise alone fail to control BG levels. - Consist of oral sulfonylureas, alpha-glucosidase inhibitors, meglitinides, thiazolidinediones, a biguanide, and combination agents. - Instruct clients taking oral sulfonylureas that concurrent use of alcohol can cause a disulfiram-type reaction (hypoglycemia, flushing, headache, nausea, and abdominal cramps). - Instruct client about risk of metabolic acidosis and to discuss with primary care provider about need to discontinue medicine if severe diarrhea, infection, or dehydration occur. - Instruct all clients about manifestations of both hyperglycemia and hypoglycemia, and appropriate corrective actions. Insulin therapy: - Is used in type 1 DM or when diet, exercise, and oral agents are insufficient to control type 2 DM. - Different insulin preparations are available to maintain near-normal blood glucose levels; insulin is classified according to source, onset, peak, and duration of action. - Source: human insulin has a faster onset of action, a shorter peak, and a shorter duration than animal derived insulin; it is preferred to pork or beef insulin (higher incidence of allergic reaction). - Preparations include: - Rapid-acting (e.g., Insulin lispro [Humalog], aspart [Novolog], and glulisine [Apidra]). - Short-acting (e.g., regular [Humulin R or Novolin R]). - Intermediate-acting, (e.g., isophane susp. NPH, Humulin N]). - Long-acting (e.g., zinc extended [Ultra lente], detemir [Levemir], glargine [Lantus]). - Mixtures of NPH and regular. - Buffered insulin (e.g., Humulin BR); buffered preparations are used for external insulin pumps. Insulin preparations can be combined to mimic pancreatic response to variations in BG levels; for example, rapid- and short- acting insulins are usually given to cover mealtimes, while intermediate- and long-acting insulins maintain basal insulin requirements between meals - Insulin regimens combine short- acting, intermediate-acting, and long-acting preparations to maintain target BG levels. - Only regular insulin may be given IV; insulin preparations are usually given via subcutaneous (Subq) route; a continuous Subq insulin infusion (insulin pump) is also available to deliver a basal rate of insulin and allow for additional bolus doses based on requirements (e.g., before a meal). - Encourage an exercise plan that meets needs of growing child or enhances fitness and euglycemia in adult. - Promote safety: use appropriate lighting; have client wear protective slippers, socks, and shoes that do not rub or impinge on skin; analyze symptoms, activity tolerance, and coping effectiveness; monitor BG levels; give medication and appropriate food and fluids. - Prevent infection through appropriate foot care, aseptic injection technique, and fingerstick glucose monitoring technique. - Identify appropriate glucose-monitoring protocol and medication administration process depending on client's vision, finances, finger dexterity, living environment, resources, literacy, lifestyle, personal values, work/school environment, and coping status. - Coordinate continuing care as appropriate for client's school, work, and other schedules, such as health club. - Promote acceptance and effective coping while living with DM. - Promote safety: explain early identification of hypoglycemia; check BG as scheduled; treat hypoglycemia with 15 gram CHO snack, such as 8 oz skim milk, 5 Lifesaver candies, 3 large marshmallows, 6 oz juice; and need to recheck BG after treatment of hypoglycemia. - Maintain hydration and avoid hyperglycemia; develop sick-day protocol and exercise protocol with client.

Treatment of Dry Eyes.

Drink 8-10 glasses of water daily. Make a conscious effort to blink more frequently. Avoid rubbing the eyes. Be aware that high altitude, dry, or winter climates may make the condition worse.

Treatment of Ocular Cancer.

Enucleation- surgical removal of the eye. This is done with choroidal melanomas or to help relieve intolerable pain in a blind eye. Plaque brachytherapy - used to treat medium size tumors using iodine 125. The plaque is temporarily sutured to the sclera and limbus underlying the melanoma. Radioactive plaques are left in place for three to seven days. The goal of treatment is arrest of tumor growth or regression in size of the tumor. Complications of plaque brachytherapy include cataract, scleral necrosis, radiation retinopathy, and optic nerve damage. External beam irradiation using charged particles, such as protons, is an alternative to the brachytherapy. Block incision- used to treat small tumors. used hoping to salvage the eye, and many of these patients retain some useful vision. A block incision removes the tumor surrounding choroid, retina, sclera, and a 3-mm margin of health tissue. Complications include vitreous hemorrhage, retinal detachment, residual tumor, and cataract.

Exposure to Sunlight.

Extended exposure to the sun's ultraviolet (UV) rays has been linked to eye damage, including cataracts, macular degeneration, and ocular cancer (basal and squamous cell). Wearing sunglasses may decrease this sun exposure and result in a decreased risk. Even if the risk is low, sunscreen, hats, and sunglasses are excellent for sun exposure protection. Look for sunglasses that block 100% of UV rays. To protect the skin around the eyes as much as possible, choose sunglasses with large lenses or a close-fitting wraparound style. The amount of UV protection is unrelated to the color or darkness of the lenses.

Hyperopia.

Farsightedness. Occurs when the light passing through the eye is focused behind the retina when looking at close objects. As a result, images up close are unclear, but images over 20 feet distant are clear. Hyperopia is treated with a convex corrective lens that redirects the light to the retina.

Diagnosis Criteria for Increased Risk of Diabetes or Prediabetes.

Fasting plasma glucose of 100-125 mg/dL. 2-hour postprandial glucose (PG) after 75 g oral glucose tolerance test (OGTT) 140-199 mg/dL. A1C of 5.7-6.4%.

Assessment of HHNS.

Has a slower onset, days to weeks, with polydipsia, polyuria, and weakness. Blood glucose levels can rise extremely high (e.g., above 400 mg/dL), which increases the osmolality of the blood. This leads to neurological changes that include seizures, aphasia, somnolence, and coma. Occurs more often in the older adult. Often these patients will have congestive heart failure and renal insufficiency. The presence of either of these will make the prognosis for the patient worse. Common precipitating factors include infection or recent surgery. The onset is frequently attributed to a decreased fluid intake. The patient will present with blood glucose levels greater than 400 mg/dL and the absence of ketones. The serum osmolality will be greater than 310 mOsm/kg, with no evidence of acidosis. The serum sodium level may be greater than 140 mEq/L.

Assessment of Retinal Detachment.

Floaters in the visual field and flashes of light or sparks when patients move their eyes or head. Floaters are similar to little cobwebs or specks that float in the visual field. The patient sees small dark shadowy shapes or crooked lines that move as his or her eye moves or drift when the eyes stop moving. They may be more annoying when looking at something bright, such as the sky or something white. Floaters are not usually treated unless they impair vision sufficiently to warrant treatment or cause retinal tears or detachment. While floaters and flashes can occur for other reasons and not signal retinal detachment, they may be a warning sign. The patient describes a shadow or curtain that has come down in the visual field and will not go away. Side vision is often affected and progresses over time (hours or days) as more of the retina separates from the wall. If the detachment involves the macula, vision loss can be severe or total in the affected eye. Retinal detachments rarely self-repair, and surgery is usually necessary.

Diagnostic Test for Diabetic Retinopathy.

Fluorescein angiograph: - This is a painless procedure. - There could be brief discomfort associated with the camera flash. - Venous injection of a dye that is carried throughout the body but accumulates in the vessels of the retina. - Nausea with the injection of the dye, a yellow fluorescent color of the urine and skin for 12 to 24 hours, and occasionally, an allergic reaction with hives and itching. Examination with an ophthalmoscope allows direct visualization of the retina.

Type 1 DM.

Formerly known as insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes. Results from autoimmune destruction of beta cells; has a genetic predisposition; is more common in males; can occur at any age but usually occurs in children and adolescents; is also characterized by hyperglycemia and ketosis (ketones in blood resulting from gluconeogenesis from fats). Results from cellular-mediated autoimmune destruction of the ß-cells of the pancreas in 90% of cases and is idiopathic in 10% of cases. Usually occurs in childhood or early adulthood, although the disease can occur at any age. Type 1 diabetes with a slower onset is called autoimmune diabetes of the adult latent autoimmune diabetes (LADA). It is a catabolic disorder wherein there is complete and utter destruction of insulin gradually over time or abruptly, plasma glucagon is elevated, and the plasma ß-cells fail to respond to insulinogenic stimuli. Type 1 diabetes is an immune-mediated disorder caused by genetics in one-third of all cases and environmental factors in two-thirds of all cases. - The genetic causes are usually related to the human leukocyte antigen associations (HLA).

Cryopexy.

Freezes the area around the tear, and scar formation connects the tissues.

Aging and Diabetes.

Geriatric patients with diabetes should be given a comprehensive geriatric history and physical in addition to a preexercise screening. Issues to be considered include an assessment of balance and gait, nutritional status, visual changes, cognitive level, and functional capacity. Elderly patients should avoid high-intensity exercise that can increase the risk of myocardial ischemia, which may be asymptomatic in diabetes. Strength training with low resistance for the legs, trunk, arms, and stomach will help to prevent functional decline and loss of muscle mass.

Assessment of Glaucoma.

Glaucoma is determined through a comprehensive eye exam including a visual acuity test, visual fields test, dilated eye exam, and tonometry. Tonometry measures the pressure within the eye. Once it becomes apparent that there is a significant increase in IOP, it is important to take more than one measure of it. Several readings need to be taken throughout the day to establish a diurnal curve with the highest reading to be the treated pressure. The thickness or thinness of the cornea may give a false higher or lower IOP.

Treatment of Type 2 DM.

Some patients with type 2 diabetes will be successful with weight control, diet modifications, and exercise; however, the majority of patients with type 2 diabetes will require medication to control their blood sugar.

Obesity.

In overweight or obese patients who have insulin resistance, moderate weight loss has been shown to improve insulin resistance. Weight loss is recommended for this population especially if they are at risk for diabetes. Decreasing carbohydrate and fat consumption by up to 30% of total daily caloric intake, or a reduction of 500-1,000 calories a day, will result in a modest weight loss of about 1-2 pounds per week. Provide information on physical activity and behavior modification. Some patients will also be prescribed weight loss medication, so it is important to provide them with information about the drug and its side effects. Bariatric surgery has been used.

Screening for Prediabetes.

Include risk factors such as: - Being overweight (BMI ≥ 25 kg/m2) or obese (BMI ≥ 30 kg/m2). - Prior history of GDM or large-for-gestational-age baby. - Presence of glycosuria. - Diagnosis of pylocystic ovarian syndrome (PCOS). - Family history, and other cardiovascular risk factors. - Lifestyle changes. - Weight loss. - Exercise. - Metformin (for very high risk individuals) have been demonstrated in some studies to prevent or delay the development of diabetes.

Postoperative Care for Cataract Surgery.

Includes use of eye drops, including a steroid and antibiotic placed subconjunctivally. The eye is usually left unpatched, and the patient is discharged home. Patient education is extremely important in preparation of the patient prior to surgery and in the aftercare. Because many patients having cataract surgery are older, there is a need to emphasize the postoperative care of eye drop instillation. The postoperative period should be relatively free of complications, and pain or swelling are generally not expected. If pain with nausea and vomiting should occur, notify the ophthalmologist.

Treating and Managing Diabetes Complications (Tertiary Prevention).

Individuals with diabetes who have microvascular complications, such as chronic kidney failure, should reduce their protein intake to 0.7-1 gm/kg of body weight. MNT that reduces cardiovascular risk may also be beneficial for retinopathy and nephropathy. Reduction of cardiovascular disease (CVD) risk includes targeting A1C as close to normal as possible without moving to hypoglycemia. Individuals with diabetes who are at risk for CVD and hypertension should include fruits, vegetables, whole grains, and nuts in their diet to reduce their CVD risk. Individuals with symptomatic heart failure are advised to limit their sodium intake to < 2,000 mg/day to reduce symptoms. Individuals with diabetes and hypertension may also benefit from reducing sodium to < 2,000 mg/day. Treatment of hypoglycemia includes ingesting 15-20 g of a glucose source. Effects of this treatment should be apparent 15-20 minutes after carbohydrate ingestion.

Developmental Care for Preschoolers hild with Type 1 Diabetes M School-Age Mellitus.

Infants and Toddlers: - Allow toddler to make choices in food selection while monitoring CHO levels. - Toddler may wish to help with fingerstick by cleaning his or her finger. - Monitor temper tantrums as a possible sign of hypoglycemia. Preschoolers: - Allow preschooler to make food choices while monitoring CHO levels. - Be prepared to substitute snacks at birthday parties and at daycare Encourage guided independence during blood glucose/fingerstick procedure. - Have appropriate snacks available if needed during sports that require a high energy expenditure. School-Age: - Encourage independence of school-age child in food selection, glucose monitoring, and insulin injections; assess level of knowledge. - Assure that school personnel are available and knowledgeable if hypoglycemia should occur during school hours. - Encourage exercise but have snacks available for child. - Discourage fast food or snack machine selections. Teen: - Assess teen's body image and sense of identity; assess adherence to other tasks. - Encourage independence with food selection, blood glucose monitoring, and insulin injections. - Supervise diabetic tasks if teen is nonadherent to plan. - Discuss future plans with teen Include diabetic issues, but promote a normal lifestyle.

Blepharitis.

Inflammation of the hair follicles (cilia) and glands along the edges of the eyelids is called blepharitis. The eyelids become sore, red, and tender, with sticky exudates. The patient may complain of itchiness, watering eyes, and loss of eyelashes. Photophobia may also be a complaint. This is the most common infection seen by ophthalmologists. Blepharitis is most often a result of a staphylococcal infection and is treated with antibiotic eye ointment. Treatment should be vigorous to prevent development of hordeolum. Eyelid areas should be cleansed gently and patted dry frequently to minimize exudate developing crusts and hardening.

Diagnosis of ADM.

Initial visual exam for specific signs of macular degeneration. Fluorescein angiography and indocyanine green angiography may be used to identify signs of macular degeneration.

Assessment of Wet ADM.

Instead of straight lines the patient sees wavy lines on the Amsler grid. As fluid leaks into the macular area from the increased blood vessels it lifts the macula causing a distorted vision. Central vision can also be lost as a small blind spot may also begin to develop into wet AMD.

Administration of Insulin.

Insulin is injected subcutaneously at a 90° angle. It is not necessary to aspirate with the injection. The needle should remain in the skin for five seconds after the injection to ensure that a complete dose of insulin has been administered. This is particularly true if an insulin pen is used. If blood or clear fluid is visible at the injection site after withdrawing the needle, pressure should be applied to the injection site for 5 to 10 seconds without rubbing. If this occurs, the patient should monitor their blood glucose more often that day. Pain with the insulin injection can be minimized by: - Injecting insulin at room temperature. - Ensuring no air bubbles are in the syringe prior to injection. - Allowing topical alcohol to evaporate prior to injection. - Using a quick wrist motion to puncture the skin quickly. - Avoiding reuse of needles.

Treatment of Keratoconus.

Primary treatment is rigid contact lenses. There is no direct pharmacological management of keratoconus; however, anti-inflammatory and antihistamine topical medications are sometimes helpful. Corneal transplants are possible through the donation of cadaver corneas; letting family know of a person's wish to be a donor may improve the availability to corneas for transplant. Corneal transplants are done most often to treat vision loss as a result of disease, swelling, scarring, infection, or chemical burns. This is an outpatient surgical procedure lasting about an hour. Follow-up care includes wearing an eye shield for the prevention of injury during the healing process and antirejection eye drops.

Iritis and Uveitis.

Iritis is inflammation of the iris. Uveitis is inflammation of one or all parts of the uveal tract. The uveal tract includes the iris, the ciliary body, and the choroid. Uveitis is divided into four components: (a) anterior (b) confined to the iris and the anterior chamber (iritis) (c) confined to the iris the anterior iris, the anterior chamber, and the ciliary body (iridocyclitis) (d) posterior uveitis (choroiditis). Posterior uveitis is uncommon except in patients with AIDS who may develop cytomegalovirus retinitis. Uveitis can be acute and chronic. Uveitis is caused by an immune reaction. Uveitis is often associated with infections, such as HSV, and autoimmune disorders, such as systemic lupus erythematosus and rheumatoid arthritis. Clinical manifestations include pain, eye redness, blurred vision, photophobia, and tearing. In posterior uveitis there may be floaters or occasional photophobia. The first line of treatment is cycloplegic and steroidal ophthalmic drops. Patients may also receive oral steroids and immunosuppressive agents. Follow-up with an ophthalmologist is imperative. If vitreous hemorrhage occurs a vitrectomy may be used in patients who cannot take immunosuppressive agents.

Age Related Macular Degeneration (ADM).

Is largely an age-related disease process whereby central vision gradually deteriorates. Family hx of smoking is a risk factor. Painless disease where the macula gradually breaks down from the development of fatty, yellow, metabolic waste products, which accumulate in the retina. There are two forms of AMD: - Dry (atrophic). - Wet (neovascular).

Diabetic Ketoacidosis (DKA)

It is a life-threatening medical emergency. Marked insulin deficiency and is manifested by hyperglycemia, ketosis, acidosis, and dehydration. Life-threatening metabolic acidosis resulting from persistent hyperglycemia and breakdown of fats into glucose, leading to presence of ketones in blood. Can be triggered by emotional stress, uncompensated exercise, infection, trauma, or insufficient or delayed insulin administration. Hyperglycemia causes uncompensated polyuria, hemoconcentration, dehydration, hyperosmolarity, and electrolyte imbalance; a significant accumulation of serum ketones leads to acidosis. In DKA, there is insufficient insulin to metabolize glucose, and the body begins to break down protein stores for energy. Ketones are by-products of protein breakdown and are acidic in nature. As the ketone level in the blood increases, the pH is altered, and metabolic acidosis develops. Type 1 diabetes is associated with ketoacidosis buy may also occur in Type 2! Factors contributing to the development of DKA include illness, infection, inadequate management of the disease, insufficient insulin, and undiagnosed type 1 diabetes. Noncompliance with the therapeutic regimen is the most common causes of recurrent ketoacidosis

Signs and Symptoms of Kidney Disease.

It is not uncommon for multiple body systems to fail as kidney disease progresses, including visual impairment, foot ulcerations, nocturnal diarrhea, and heart failure. Patients in the early stages of renal disease will frequently develop hypertension.

Lipoatrophy.

Local reaction at the site of insulin injection in older insulin preparations.

Hypotany.

Low intraocular pressure.

Angiopathy or Vessel Disease.

Macrovascular complications cause changes in the large vessels. These changes may occur in patients who do not have diabetes but are more frequent and earlier in patients who do have diabetes. As a disease of metabolism, diabetes affects the metabolism of lipids. Plaque formation from atherosclerosis is associated with diabetes. The incidence of vessel disease can be decreased with optimal glycemic control. The diseases of the larger vessels include cardiovascular, cerebral, and peripheral vascular diseases. Patients should understand the risk factors associated with macrovascular disease, because many of the risk factors are modifiable with lifestyle changes. Risk factors include: - Obesity. - Smoking. - Sedentary lifestyle. - High blood pressure. - Increased fat intake.

Treatment of Cataracts.

Management for patients with cataracts starts with adjusting the corrective lens as frequently as necessary to ensure optimal vision. Surgical treatment for cataracts begins when vision is sufficiently impaired to interfere with activities of daily living. There are two types of surgery: - Phacoemulsification (phaco) surgery. - Extracapsular surgery. Following either surgery a patient may need glasses only for reading. When an IOL cannot be inserted, the eye is unable to accommodate, resulting in aphakic vision (absence of the crystalline lens of the eye), which requires special corrective lenses.

Endogenous.

Produced or originating from within a cell or organism.

Diabetic Retinopathy.

Microvascular complication. Chronic hyperglycemia causes damage to the small vessels of the retina in patients with diabetes. Present in approximately 60 % of patients with type 2 diabetes and nearly every patient with type 1 diabetes for longer than 20 years. Most frequent cause of new blindness among adults ages 20 to 74. Risk of developing many different ophthalmic complications, including corneal abnormalities, glaucoma, cataracts, and neuropathies. The exact mechanism by which diabetes causes retinopathy is unknown; however, there are several hypotheses. The first hypothesis is that growth hormone may play a causative role. The second hypothesis is that hematologic abnormalities in diabetes, such as erythrocyte aggregation, increased platelet aggregation, and sluggish circulation, may be factors. The third hypothesis is related to abnormal glucose metabolism where high levels of blood glucose are thought to have an affect on the retinal capillaries, causing them to function poorly and eventually leading to retinal hypoxia.

Wet (neovascular) ADM.

More devastating, because it can result in severe sight loss within a few short months. This type of AMD is caused by an abnormal growth of blood vessels in the macula, leaving the surface of the retina uneven.

Dawn Phenomenon.

Morning hyperglycemia present on awakening. Results from predawn release of counter-regulatory hormones. It is likely that cortisol and growth hormones are factors in the occurrence of the dawn phenomenon. It is most common in adolescence and young adults. Treatment: - Increase in insulin or an adjustment in the administration.

Assessment of Diabetic Retinopathy.

Most common form of retinopathy is nonproliferative. This manifests itself as microaneurysms in the retinal capillaries. Capillary fluid leaks from the weakened aneurysms and retinal edema occurs. If the macular area of the eye is involved, the vision will be affected. Proliferative retinopathy is more severe, involving the vitreous humor and the retina. New blood vessels are formed in the retina as the smaller capillaries become occluded. This is called neovascularization. The new blood vessels are extremely friable (broken) and subject to hemorrhage. As the vessels tear and bleed in the vitreous, the patient's vision is changed. The patient will report the appearance of red or black lines or spots. There may be retinal detachment or involvement of the macula.

Errors of Visual Refraction.

Most common visual problems. Light passing through the layers of the eye to the retina is distorted. This can be caused by irregularities in the cornea, the focusing power of the lens, and the length of the eye. 3 types of refraction errors: - Myopia (nearsightedness). - Hyperopia (farsightedness). - Astigmatism.

Peripheral Neuropathy (Sensory Neuropathy).

Most often involves the nerves of the lower extremities, affecting the body symmetrically, and proceeding proximally. The most common type seen in diabetes are the polyneuropathies, or bilateral sensory disorders, that begin in the toes and feet and progress upward. These conditions can become serious and lead to complete tissue destruction, and gangrene, and they may even require limb amputations or lead to the development of septic shock.

Client Education on DKA.

Nature and causes of DKA (excess glucose intake, insufficient medications, physiological and/or psychological stressors) and any new medications.

Myopia.

Nearsightedness. Occurs when the light passing through the eye is overbent or overrefracted. As a result the light rays are focused in front of the retina when viewing a distant object. Objects that are viewed up close are clear, and distant objects are unclear. Myopia is treated with a corrective lens that redirects the light to the retina by changing the angle of the light. These corrective lenses are cut biconcave.

Complications for People with Diabetes while Traveling.

Need extra planning when they travel. Supplies for their disease management should be readily available in carry-on luggage, including blood glucose monitoring meters, insulin, and syringes. With the increase in homeland security, the patient should bring a letter from his or her health care provider explaining the medical necessity of the syringes. The patient should bring along fast-acting carbohydrate sources to reverse hypoglycemia. Extra medications and food should be included in the event of long delays, canceled flights, and closed restaurants. Patients with diabetes should wear identification stating that they are diabetic. It is also recommended that the patient carry identification with the names of their medications and health care providers.

Chronic Effects or Complications of Diabetes Mellitus.

Neurological: - Somatic neuropathies (paresthesias, pain, and loss of sensation and motor control). - Visceral neuropathies (pupil constriction, fixed heart rate, constipation or diarrhea, dysfunction of sweat glands, incomplete voiding, and sexual dysfunction). Sensory: - Cataracts. - Glaucoma. - Diabetic retinopathy. Cardiovascular: - Orthostatic hypotension. - Accelerated atherosclerosis leading to stroke. - Myocardial infarction (MI). - Peripheral vascular disease (PVD). - Increased blood viscosity, and platelet disorders. Renal: - Hypertension. - Edema. - Albuminuria. - Chronic renal failure Integumentary: - Atrophic changes. - Foot ulcers. - Gangrene. Immune: - Poor healing. - Periodontal disease. - Lung infections. - Chronic skin infections. - Urinary tract infections. - Vaginitis.

Occular Cancer.

Occur in nearly any anatomical structure of the eye, including the eyelid, the orbit, and the conjunctiva. The most common ocular cancer is melanoma. A melanoma can develop in the ciliary body, conjunctiva, choroid, iris, and eyelid. A choroidal melanoma is the most common primary intraocular tumor. Choroidal melanoma arises from melanocytes within the choroid. They may range from darkly pigmented to no coloration. As they grow choroidal melanomas can push against the retinal epithelium, causing atrophy and decrease in normal choroidal circulation. These melanomas may progress silently until they produce noticeable vision loss. If the melanoma erodes into the blood vessels in adjacent areas, it can lead to vitreous hemorrhage. Metastases to distant locations are generally the ultimate cause of death, rather than local spread. The most common site of choroidal melanoma metastasis is the liver.

Strabismus.

Occurs when one muscle is weak and results in one eye deviating from the other when the eyes are focused on an object. Depending on the muscle or muscles involved the eye may deviate in an inward, upward, outward, or downward pattern. Causes of strabismus include weak ocular muscle tone, reduced visual acuity, or an oculomotor nerve lesion.

Closed-Angle Glaucoma.

Occurs when there is a similar increase in IOP, but the onset is sudden, causing headaches, blurred vision, and pain in the eye.

Keratitis.

Occurs when there is an inflammation and ulceration of the cornea. Because of the involvement of the cornea there is often a loss in visual acuity. The clinical manifestations include watery eyes, pain, and photophobia. Keratitis can be caused by drugs, vitamin A deficiency, sun exposure, trauma, immune-mediated response, or microorganisms. The most common viral cause is HSV, and bacterial causes are Staphylococcus aureus, Streptococcus pneumoniae, pseudomonas, mycobacterium, and serratia. Patients wearing contact lenses, particularly those using extended wear contact lens, are at risk for bacterial infections.

Presbyopia.

Older adults begin to experience a loss of near acuity (near vision) as the lens loses its elasticity and accommodation of the lens fails. Patient begins to hold reading material at a further and further distance from the eyes to establish focus. Treatment consists of using reading glasses or making adjustments to glasses with a bifocal (two foci) or trifocal (three foci) in which the reading correction is in the lower portion of the lens.

Treatment of ADM.

Ongoing self-monitoring of vision is important in this disease. Patients can place an Amsler grid on the refrigerator and every morning assess for changes to vision. Diet supplements with vitamins, antioxidants, and zinc can have significant benefit in preventing disease progression. Patients may find the use of low vision aids, such as magnifiers for reading, telescopes to see into the distance, and talking watches, supportive in maintaining quality of life. Wet AMD treatment: - Treated with use of a laser, which may stop or lessen vision loss in the early stages. - The laser destroys existing blood vessels, and the scar formation afterward may result in some permanent vision loss in the area of the retina affected. - It is effective in about 50% of cases. - Photodynamic therapy using a light-activated drug given intravenously and a laser beam can close the abnormal vessels while leaving the retina intact. - Repeat treatment may be needed because closed vessels can reopen. - Vitamins, antioxidants, and zinc are useful in prevention as well as use of sunglasses that block ultraviolet sunrays from sun exposure. There is no treatment for dry AMD.

Exogenous.

Originating outside an organ. Because of the insulin deficiency of beta cells, patients with type 1 diabetes require administration of exogenous (originating outside an organ) insulin to maintain blood glucose control. Patients with type 2 diabetes produce insulin and have functioning beta cells. Individuals with type 2 diabetes may require insulin supplementation after years of prolonged hyperglycemia and ß-cell failure and loss that cause inadequate insulin production. They may also need insulin, if diet, exercise, weight reduction, and oral antidiabetes medications do not maintain blood glucose control.

Ocular Muscle Paralysis.

Paralysis of ocular muscles may occur as a result of trauma or pressure on cranial nerves or diseases, such as diabetes mellitus (DM) or myasthenia gravis. This can result in limited abduction, abnormal closure of the lid, ptosis (drooping of the eyelid) or diplopia from unopposed muscle movement.

Laser Photocoagulation.

Performed in an outpatient surgery center or health care provider's office. The laser makes small burns around the tear to weld the retina back into place.

Insulin Pumps.

Provide a continuous administration of short-acting insulin subcutaneously. Pumps are small battery operated devices that can be worn on a belt. Pump is connected to a catheter inserted in the subcutaneous tissue in the patient's abdomen. The patient will change the insertion site every 48 to 72 hours and refill the pump with insulin. The pump delivers a basal rate of insulin 24 hours a day. The user programs the pump to deliver boluses at mealtime based on the amount of carbohydrates ingested. Because the insulin pump closely mimics normal insulin secretion and uses either a short-acting or rapid-acting insulin, which have the least variable absorption rate, tighter glycemic control is possible. Because the insulin is absorbed more efficiently, patients often require 25% less insulin with a pump than with multiple daily injections. Patients who use the pump must be knowledgeable about carbohydrate counting, because the pump delivers boluses based on carbohydrates eaten at a meal. Use of a pump offers the advantage of more flexibility with mealtimes and a more normal lifestyle

Contusion.

Periorbital contusion, or black eye, is a relatively common result of a traumatic injury to the face or head. Bleeding occurs in the area surrounding the eye; however, this may not be the extent of the injury. Often the eye globe is pushed back into the socket, stretching the surrounding muscles and soft tissues. This can result in oculomotor dysfunctions and even rupture the globe. Pain and swelling are the most common clinical manifestations. Double vision, loss of vision, loss of consciousness, inability to move the eye (look in different directions), and blood on the surface of the eye are signs of a more serious injury. Immediate health care attention should be sought for the previously maintained clinical manifestations. Initial treatment includes testing visual acuity and ophthalmoscopy. Additional testing may be performed depending on what was found, including X-rays to rule out orbital fractures. Rest and ice are the first aid interventions. The ice should be wrapped in a cloth and applied to the affected area for 20 minutes an hour for every hour while awake for the first 24 hours. Avoid potential causes of injury until the eye has healed. Assessment by an ophthalmologist is necessary for injuries to the eye itself.

Exercise and BG.

Physical exercise lowers insulin resistance and can cause hypoglycemia for up to 48 hours after. Commonly, blood glucose levels will drop between 6 and 15 hours after exercise as insulin resistance is decreased, and the muscles and liver replace the glycogen stores. The patient can reduce the risk of hypoglycemia during exercise by checking the blood sugar level before exercise and eating a carbohydrate snack for a blood sugar reading less than 100 mg/dL. It is safe to start exercise if the blood sugar level is between 100 and 200 mg/dL and should not exercise if the blood sugar level is greater than 400 mg/dL. The patient should be taught to monitor blood glucose levels before, during, and after exercise and to eat a carbohydrate snack if the exercise session lasts longer than 60 minutes. If the patient becomes hypoglycemic during exercise, they should immediately stop and monitor their blood sugar every 15 minutes until the level is higher than 89 mg/dL. - Always have a ready supply of glucose sugars and carbohydrates on hand. - Exercise-induced hypoglycemia should be treated with such substances as 15 grams of carbohydrate, one half cup of fruit juice, 8 ounces of low fat milk, 6 ounces of sweetened carbonated beverage, or 4 glucose tablets. Exercise can also cause hyperglycemia in diabetics. This typically happens when the circulating level of insulin is low and occurs more commonly in type 1 diabetes. - Check BG before exercise. If > 250 mg/dL, the urine should be checked for ketones. If the ketone level in the urine is moderate to high, the patient should not exercise until the blood sugar and ketone levels are lower. * Patients with type 1 diabetes can exercise with an elevated blood glucose level (250 to 300 mg/dL) as long as there are no ketones present. * The blood sugar level should decrease within 15 minutes of exercise.

Insulin.

Plays a large role in carbohydrate metabolism, but it also contribute to both protein and fat metabolism. In the presence of a carbohydrate load from a meal, the glucose that is absorbed into the bloodstream immediately causes the release of insulin for rapid uptake, storage, and use of glucose by the different tissues in the body, especially the muscles, adipose tissue, and the liver. In cases of acute or chronic lack of insulin, the body becomes prone to ketosis, muscle wasting, weakness, heart attacks, stroke, and many other deranged functions of the organs. The pancreas secretes insulin along with glucagon in steady, small amounts throughout the day to regulate blood glucose in the absence of a carbohydrate load. Insulin preparations in the past were from cows (bovine) and pigs (porcine). These insulins worked effectively, but some individuals were allergic to these preparations. The majority of the insulins available in the market currently are analog and human insulins. Human insulin is produced using strands of Escherichia coli and DNA technology. Human insulin has fewer incidences of allergic reactions than animal insulins. Classified according to onset, peak action, and duration. Measured in units. Usually administered by injection using an insulin syringe. Preparations usually comes in 100 units per milliliter, or U-100. A more concentrated form of regular insulin, U-500, is available in the market for individuals who are severely insulin resistant and who require > 200 units/day. - Regular U-500 insulin is very potent. A 1-unit preparation in a standard insulin syringe of regular insulin U-500 is equivalent to 5 units of regular insulin U-100. Additives of protamine, zinc, and acetate buffers alter the onset, peak, and duration of insulin action. NPH insulin contains zinc and protamine. The additives in the insulin may cause allergic reactions at the injection site. The additives alter the appearance of the insulin, making it cloudy, rather than the clear appearance of analog or regular insulin.

Three Ps of Diabetes.

Polydipsia. Polyphagia. Polyuria.

Treatment of Diabetic Retinopathy.

Prevention by glycemic control. Laser photocoagulation to destroy the areas of revascularization and leaking vessels. This procedure may have a profound impact on slowing the progression of vision loss. These treatments are done on an outpatient basis, with most patients returning to usual activities of daily living the next day.

Type 2 DM.

Previously known as non-insulin dependent diabetes mellitus (NIDDM) or adult-onset diabetes. *These names are no longer appropriate because type 2 diabetes patients may need insulin as the disease progresses due to loss of pancreatic ß-cell function, and in the past few decades, an increasing number of children have been diagnosed with type 2 diabetes related to obesity. Caused by ß-cell dysfunction and insulin resistance. Several proposed causes include compromised ability of beta cells to respond to hyperglycemia, abnormal insulin receptors on cells, and peripheral insulin resistance; it has a genetic predisposition, can occur at any age, and is more common in obesity, older adults, African Americans, Hispanic Americans, and Native Americans Acute complications include hypoglycemia, diabetic ketoacidosis, and hyperglycemic hyperosmolar nonketotic (HHNK) coma, also called hyperosmolar coma (HOC) in type 2 Long-term or chronic complications. The major pathophysiologic conditions that occur in patients with type 2 diabetes are: (1) defective beta-cell secretion with early loss of first phase insulin production. (2) insulin resistance in the peripheral tissues, especially the muscles and liver. (3) increased production of glucose from the liver as the disease progresses. First phase insulin secretion is regulated with the balance of the production and output of glucose by the liver. When there are defects in the ß-cell function, inhibitory effects are lost, resulting in uninhibited production of glucose by the liver even during a carbohydrate load from a meal, when glucose production in the body is not required. Consequently, there is more glucose circulating in the blood, or hyperglycemia, in the early prediabetes state most commonly seen 2 hours postprandially and a higher fasting blood glucose years later during the development of diabetes. The body compensates by increasing second phase insulin secretion, which results in increased insulin production, or hyperinsulinemia, to regulate blood glucose and to counteract the tissues' resistance to insulin. The ß-cells will continue to secrete high levels of insulin for years to regulate blood glucose levels. Eventually, ß-cell failure occurs and insulin production diminishes. These slow and insidious pathophysiologic changes in type 2 diabetes occur over time, taking up to 20 years to develop. Risk factors for the development of type 2 diabetes are older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, insulin resistance, less than optimum intrauterine environment, physical inactivity, and race/ethnicity.

Glucagon.

Primary function is to increase the glucose concentration in the blood by breaking down liver glycogen (glycogenolysis) and increasing glucose production in the liver (glycogneogenesis).

Laser Peripheral Iridectomy.

Surgery for closed angle glaucoma. Yttrium-aluminum-garnet (YAG) laser is used. Forms a permanent connection between the anterior and posterior chambers, thus preventing recurrence.

Surgical Treatment for Refractive Errors.

Radial keratotomy (RK) - uses a diamond knife to make several incisions into the cornea in a circular rotation. This alters the mechanical structure of the cornea and changes its shape to correct nearsightedness. Results are rapid and patients see quite well within one to two days. Laser vision correction - done with photorefractive keratotomy (PRK) and laser in situ keratomileusis (LASIK). In PRK an excimer laser is used to reshape the surface of the cornea after the surface epithelial cells are removed. This differs from LASIK, in which a corneal flap is created and the laser is applied beneath. Rapid recovery is expected with PRK and LASIX procedures, along with a return to near normal vision without further correction. Intacs - a nonlaser procedure in which an intracorneal ring segment is placed under the cornea, which may be helpful for patients with low-level myopia. The benefits are the ring segments are removable and adjustable as eye changes occur. Postoperative care includes use of antibiotic drops and steroid drops immediately after the procedure. Verification of flap placement, smoothness, and absence of debris are assessed. Patients may complain of scratchiness, tearing, burning, and sensitivity to light, which wane as time progresses. Makeup and swimming are contraindicated for the first one to two weeks postoperatively. Complications associated with these surgeries include dislodged flaps and flap folds; infection; refractive complications, such as overcorrection or undercorrection; and dry eye syndrome.

Types of Insulin.

Rapid acting insulin: - Aspart (Novolog) - injection! - Lispro (Humalog) - injection! - Glulisine (Apida) * All have an onset of 5-15 minutes, with peak action of 50-90 minutes and a duration of approximately 4 hours or <5 h. * Food intake must occur within 15 minutes of administering a rapid-acting insulin analog to prevent hypoglycemia. Short acting insulin: - Regular insulin * Has an onset of 30-60 minutes, with peak action of 2-3 hours and a duration of 5-8 hours. * Regular insulin is best given 30 to 45 minutes prior to food intake. * Regular insulin may be used intravenously in hyperglycemic emergencies. Intermediate acting insulin: - NPH * Onset is at 2-4 hours, with peak action at 4-10 hours and effective duration of 10-16 hours. * Due to its sharp peak action curves, teach the patient to observe for signs and symptoms of hypoglycemia. * It is usually given twice daily and mixed with regular insulin to mimic the body's own insulin pattern. Long acting insulin: - Glargin (Lantus) - Injection! * Onset is at 2-4 hours, with no peak and effective duration of 20-24 hours. * usually administered once a day at any time, but is preferably given at bedtime. - Detemir (Levemir) - Injection! * Onset is at 3-8 hours, with no peak and effective duration of 5.7-23.2 hours. * Majority of its effects occurring in 14 hours. * Given either once or twice a day, depending on the person's insulin requirements. However, it is important to note that because detemir does not last quite 24 hours, it is advisable to take this insulin twice a day like NPH insulin. Premixed insulin: All Injections! - 75% insulin lispro protamine suspension/25% insulin lispro injection (Humalog mix 75/25). - 50% insulin lispro protamine suspension/50% insulin lispro injection (Humalog mix 50/50) - 70% insulin aspart protamine suspension/30% insulin aspart injection (Novolog Mix 70/30) * All have an onset at 5-15 min, with dual peak and effective duration of 10-16 hours. * Available for patients who may have difficulty mixing insulins.

Causes of Hypoglycemia.

Rapid onset! - Too little food. - Too much insulin. - Increased exercise. - Delay in eating.

Nephropathy.

Renal disease, secondary to microvascular changes associated with diabetes. Symptoms of renal disease will manifest within 10 to 15 years for type 1 diabetics and within 10 years for type 2 diabetics. Because of the slow development of type 2 diabetes, frequently, patients will also develop evidence of renal disease at the time of diagnosis of type 2 diabetes. When glycemic control is not adequate, allowing elevated levels of blood glucose, the kidneys' filtration will decrease, and protein from the blood is excreted in the urine. Protein has fluid attracting properties, and the pressure in the blood vessels of the kidneys increases. This increased blood pressure is thought to be the mechanism for nephropathy.

Metabolic Syndrome.

Syndrome X, term coined to describe a host of metabolic abnormalities associated with insulin resistance. *There was another Syndrome X documented in cardiology at the time, hence insulin resistance syndrome or Reaven syndrome were more frequently used names. Diagnosed when three or more factors such as high blood pressure, abdominal obesity, high triglyceride levels, low high-density lipoprotein (HDL) cholesterol and high fasting blood glucose levels are present. Was initially associated with clustering atherogenic abnormalities, such as high triglycerides (hypertriglyceridemia), increased proportion of sense density LDL cholesterol particles, reduced concentration of HDL cholesterol hypertension, and dysglycemia. Obesity was not a part of the cluster of abnormalities identified in earlier studies, but more recent studies indicate a strong relationship between abdominal or visceral adiposity and metabolic syndrome. People with metabolic syndrome are at an increased risk for developing cardiovascular complications and diabetes. The importance of clustering these abnormalities as metabolic syndrome is to remind clinicians that treatment should address all of these abnormalities

Diabetes Melllitus (DM).

The American Diabetic Association (ADA) describes diabetes mellitus as a group of diseases characterized by hyperglycemia primarily resulting from defects in insulin action, insulin secretion, or both. A group of chronic disorders of metabolism characterized by elevated blood glucose levels and disturbances in metabolism of carbohydrate, fats, and protein. Disorder of pancreas characterized by insufficient or absolute lack of insulin production, causing hyperglycemia (elevated blood glucose) and resulting in multisystem changes in health status. Uncontrolled diabetes causes many acute and chronic complications. Chronic and prolonged hyperglycemia, not the diagnosis of diabetes, is associated with long-term complications and damage of various organs, such as the eyes, kidneys, nerves, heart, and blood vessels. There are several types of diabetes. The most common types of diabetes are: (1) type 1 DM. (2) type 2 DM. (3) gestational DM.

Color Perception.

The ability to distinguish color is composed of two stages; the first is through the light-sensitive receptors, and the second is through the neural components of processing, partitioning, and encoding information about the wavelength that the photoreceptors collect. Hue is determined by the wavelength of content of colors that allows us to perceive colors. There are two separate and remarkably different systems for determining colors: the blue-yellow system and the red-green system. The blue-yellow system is more likely to be injured through toxic exposure, eye disease, or trauma, whereas the red-green system is more likely to be impaired because of congenital defects. These congenital defects rarely affect the blue-yellow system.

Open-Angle Glaucoma.

The channels (trabecular meshwork or canal of Schlemm) that drain fluid within the eye become blocked, causing pressure to rise. This increased pressure pushes back on to the vitreous humor, causing damage to the retina. Normal intraocular pressures (IOP) ranges from 10 to 21 mm Hg, and as the pressure begins to rise it causes a gradual loss of vision. Because there are few symptoms, and vision loss is gradual, individuals may not notice for a long time that they are losing their sight.

Impaled Object in the Eye.

The health care provider must treat the impaled object found in an eye by doing the following: (a) assess the patient for priority injuries first. (b) leave the object in place and stabilize the patient's head. (c) place a cup over the impaled object and tape in place. (d) transport the patient in a safe and efficient manner, remembering to not allow the impaled object to move.

Astigmatism.

The light is spread over a diffuse area. Occurs when there is an unequal curve of the cornea, and the light rays are bent unevenly. The exact cause of astigmatism is unknown, although there is some familial pattern. Astigmatism is treated with a corrective lens in a cylindrical shape. It is not uncommon for refractive errors of myopia or hyperopia to coexist with astigmatism.

Dry (atrophic) ADM.

The most common cause type, accounting for 90 percent of all people with AMD. This occurs because of a gradual deterioration of the macula from waste product buildup and lack of proper nutrition. The progress is slow and usually results in mild to moderate loss of sight; this usually does not cause a total loss of reading vision.

Assessment of Dry ADM.

The most common early sign of dry AMD is blurred vision. As time progresses and fewer macular cells function, details become less clear with some improvement in brighter light. Continued degeneration can result in a small but growing blind spot in the middle of the visual field. As dry AMD worsens it can deteriorate into wet AMD because of the increased development of blood vessels in the area.

Scleral Buckling Surgery.

The most common method of treatment. Requires that a piece of silicone, rubber, or semi-hard plastic be placed against the outer surface of the eye and sutured into place. The piece pushes the sclera toward the middle of the eye, allowing the retina to settle back against the wall of the eye. The buckle may encircle the eye or just cover the area around the detachment. This surgery is usually performed in a hospital or outpatient surgical center under local or general anesthesia. Postoperative care includes monitoring for swelling, redness, tenderness, and pain management. This procedure has an 80-90% success rate. The scleral buckle can cause an increase in IOP, and the changes in the eye shape from buckle can result in a refractive error, affecting vision.

Diplopia (double vision).

The primary symptom of strabismus.

Gluconeogenesis.

The process of the liver converting predominant amino acids to glucose in the fasting state.

Other Types of Diabetes.

There are many other forms of diabetes, which are more rare. They are: (1) genetic defects of ß-cell function. (2) genetic defects in insulin action. (3) diseases of the exocrine pancreas (e.g., pancreatitis, trauma/pancreatectomy, neoplasia, cystic fibrosis, hemochromocytosis, fibrocalculous, pancreatopathy). (4) endocrinopathies (e.g., acromegaly, cushing's syndrome, glucagonoma, pheochromocytoma, hyperthyroidism, somatostatinoma, aldosteronama). (5) drug or chemical-induced (drugs such as vacor, pentamidine, nicotinic acid, glucocorticoids, thyroid hormones, diazoxide, thiazide, ß-adrenergic agonists, phenytoin, and certain psychotropic drugs). (6) infections. (7) uncommon forms of immune-mediated diabetes. (8) genetic syndromes associated with diabetes (e.g., Down syndrome, Klinefelter syndrome, Turner syndrome, Wolfram syndrome, Friedreich ataxia, Huntington's chorea, Laurence-Moon-Biedl syndrome, Myotonic dystrophy, Porphyria, Prader-Willi syndrome).

Diagnosis of Type 1 DM.

There are several markers of immune destruction. Circulating antibodies are commonly found in people with type1 diabetes. For example: The islet cell (ICA), insulin (IAA), glutamic acid decarboxylase (GAD65), and tyrosine phosphatases (IA-2 and IA2-ß). These antibodies can be easily detected allowing for better identification of the disease.

Visual Acuity Test.

To check visual acuity, one eye is covered at a time and the vision is recorded from each eye and both eyes together. 20/20 means that the patient can read at a 20 feet distance from the chart the letters of a certain line (8) of the chart. If a person sees 20/40 at 20 feet from the chart, the person can read letters that a person with 20/40 can read from 40 feet away. The 20/40 letters are twice the size of 20/20 letters; however, this does not indicate 50% vision because 20/20 sounds like one half of 20/40. If 20/20 is considered 100% visual efficiency, 20/40 visual acuity is 85% efficient.

Diagnostic Test for Ocular Cancer.

Ultrasound of the globe and orbit areas is useful in detecting tumors more than 2-3 mm thick. Computed tomograph (CT) scans and magnetic resonance imaging (MRIs) are less sensitive than ultrasound and more expensive. Other tests may be used to rule out metastases, such as chest radiograph and liver enzymes. Biopsy may be used only in cases in which it is difficult to distinguish whether the tumor is primary or metastatic.

Pneumatic Retinopexy.

Used to reattach the retina. The health care provider uses a bubble of gas to push the two layers back together again. This is usually done as an outpatient procedure under local anesthesia. Cryopexy or photocoagulation may be used to then seal the tear. The bubble is gradually absorbed over a week and keeps the tear closed and the retina flattened until a seal forms between the retina and the wall of the eye. This surgery takes about three weeks to achieve optimal healing. The patient may be expected to lie in a specific position for 16-21 hours per day to keep the bubble in the right location. Patients with confusion or attention problems would not be candidates for this type of procedure.

Papilledema.

When there is an increase in intracranial pressure as a result of trauma or other disease process a swelling of the optic disc (papilledema) may occur. Other causes include any tumors occupying space in the central nervous system, meningitis, and encephalitis. Papilledema usually occurs bilaterally and can develop rapidly or slowly over time depending on the underlying cause. Because the subarachnoid space of the brain is continuous with the optic nerve sheath, as the cerebrospinal fluid pressure increases, the pressure is transmitted to the optic nerve. This results in swelling and inflammation of the optic nerve at the entrance to the retina. Clinical manifestations include headache, nausea, and vomiting. While visual symptoms may not occur, some patients develop graying of vision or transient flickering, blurry vision, and diplopia. Visual acuity is usually unaffected until the condition is quite advanced. In severe cases blindness can occur rapidly, unless the pressure is relieved and the swelling decreases. Treatment: Efforts to reduce papilledema include carbonic anhydrase inhibitor diuretics, weight reduction in idiopathic intracranial hypertension, and corticosteroids for inflammatory causes. Surgical treatment may include removing the tumor, a ventriculoperitoneal shunt, or optic nerve sheath decompression.

Somogyi Effect.

Wide variations in early morning or fasting blood glucose levels (measurement of BG after not eating after 8 hours). It is a result of too much insulin and occurs during sleep. Too much insulin activates the counter-regulatory hormones, and gluconeogenesis and glycogenolysis occur, resulting in hyperglycemia and ketosis. When the blood sugar is measured in the morning and hyperglycemia is present, the patient or the health care worker may increase the dose of insulin. This action is incorrect because the Somogyi effect is a result of too much insulin. It causes headaches on awakening, nightmares, and night sweats. When the Somogyi effect is suspected, the patient's blood sugar should be monitored between 2 and 4 a.m. to check for the presence of hypoglycemia at that time. If the patient is hypoglycemic then, the insulin dose affecting the morning blood sugar level should be reduced. Treatment: - Less insulin.

Treatment of Type 1 DM.

Will require insulin therapy in addition to diet and exercise.