Brunner Ch 41 - DIABETES
After teaching a client with type 1 diabetes, who is scheduled to undergo an islet cell transplant, which client statement indicates successful teaching?
"I might need insulin later on but probably not as much or as often."
A client with type 1 diabetes has a highly elevated glycosylated hemoglobin (Hb) test result. In discussing the result with the client, the nurse is most accurate in stating:
"It tells us about your sugar control for the last 3 months."
What are the 2 main types of sweeteners?
1. Nonnutritive 2. Nutritive
A client with type 1 diabetes is scheduled to receive 30 units of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client:
9 units regular insulin and 21 units neutral protamine Hagedorn (NPH).
Which of the following is true regarding gestational diabetes?
A glucose challenge test should be performed between 24 to 28 weeks.
Potassium levels during treatment of DKA
A patient's serum potassium level may drop quickly as a result of rehydration and insulin treatment, potassium replacement must begin once potassium levels drop to normal.
When administering insulin to a client with type 1 diabetes, which of the following would be most important for the nurse to keep in mind?
Accuracy of the dosage
Moderation is the key Type 1: Primary risk is Hypoglycemia Type 2: Calculate calories into meal plan. Choose light beers, dry wine
Alcohol
Acarbose (Precose) Miglitol (Glyset)
Alpha-Glucosidase Inhibitors
Delay absorption of complex carbohydrates in the intestine and slow entry of glucose into system circulation Do not increase insulin secretion Can be used alone or in combination with sulfonylureas, metformin, or insulin to improve glucose control
Alpha-Glucosidase Inhibitors
Onset: 5-15 minutes Peak: 40-50 minutes Duration: 2-4 hours
Aspart (Novolog)
When should people with diabetes not exercise and why?
BS > 250 and those who have ketones in their urine. Because exercising with elevated BS may cause their BS to elevate even higher
Inhibit production of glucose by the liver Increase body tissues' sensitivity to insulin Decrease hepatic synthesis or cholesterol
Biguanides
Metformin (Glucophage, Clucophage XL, Fortament) Metformin with glyburide (Glucovance)
Biguanides
A client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which laboratory finding should the nurse expect in this client?
Blood glucose level 1,100 mg/dl
The nurse is reviewing the initial laboratory test results of a client diagnosed with DKA. Which of the following would the nurse expect to find?
Blood pH of 6.9
Approved for treatment of type 2 Diabetes in combination with metformin or sulfonylureas Derived from a hormone found in the small intestine that is found deficient in type 2 diabetes. Shown to result in weight loss bc of the increases satiety produced Must be injected BID within 1 hour before breakfast and dinner
Byetta (Exenatide)
50-60%, emphasize whole grains
Carbohydrates
As any time of the day without regard to time since the last meal
Causal plasma glucose
Fatigue and weakness Sudden vision changes Tingling or numbness in hands or feet, Dry skin Skin lesions or wounds that are slow to heal Recurrent infections The onset of type 1 diabetes may be associated with sudden weight loss or nausea, vomiting, or abdominal pains, if DKA has developed.
Clinical manifestations of Diabetes
Polyuria, Polydipsia, and Polyphagia Polyuria and polydipsia occur as a result of the excess loss of fluid associated with osmotic diuresis. Polyphagia results from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats
Clinical manifestations of Diabetes
Hypotension Profound dehydration (dry mucous membranes, poor skin turgor) tachycardia variable neurologic signs (alteration of sensorium, seizures, hemiparesis)
Clinical manifestations of HHNS
Not enough blood Milking the finger Improper cleaning of machine Damage to strips
Common errors with SMBG
Local reaction Systemic allergic reaction Lipodystrophy Insulin resistance Morning hyperglycemia
Complications of Insulin Therapy
A nurse educates a group of clients with diabetes mellitus on the prevention of diabetic nephropathy. Which of the following suggestions would be most important?
Control blood glucose levels
Symptoms of diabetes plus causal plasma glucose concentration = or > than 200 mg/dL Fasting plasma glucose > or = to 126 mg/dL Two-hour postload glucose = or > than 200 mg/dL during an oral glucose tolerance test
Criteria for the Diagnosis of Diabetes Mellitus
Ketones Kussmaul respiration Acetone breath Dehydration
DKA
Metabolic Acidosis
DKA
More common in type 1 diabetes Caused by omission of insulin; physiologic stress (infection, surgery, CVA, MI) Onset is rapid (<24 hours) BS usually > 250 Arterial pH level <7.3 Ketones are present Serum osmolality 300-350 mOsm/L Bicarbonate <15 mEq/L Bum and creatine levels elevated Mortality rate < 5%
DKA
Sitagliptin (Januvia) Vildagliptin (Galvus)
DPP-4 Inhibitor
1. Nutritional therapy 2. Exercise 3. Monitoring 4. Pharmacologic therapy 5. Education
Diabetes Management
A group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both.
Diabetes Mellitus
The main goal is to normalize insulin activity and blood glucose levels to reduce the development of vascular and neuropathic complications
Diabetes Treatment
Ketones are acids that disturb the acid-base balance of the body when they accumulate in excessive amounts. This results in _____________.
Diabetic Ketoacidosis (DKA)
May cause S/S such as abdominal pain, N/V, hyperventilation, a fruity breath odor, and, if left untreated, altered level of consciousness, coma, and death. Initiation of insulin treatment, along with fluid and electrolytes as needed.
Diabetic Ketoacidosis (DKA)
A metabolic derangements in type 1 diabetes that results from a deficiency of insulin; highly acidic ketone bodies are formed, resulting in acidosis; usually requires hospitalization for treatment and is usually caused by non adherence to the insulin regimen, concurrent illness, or infection.
Diabetic Ketoaidosis (DKA)
Increase and prolongs the action of incretin, a hormone that increases insulin release and decreases glucagon levels, with the result of improved glucose control
Dipeptidyl Peptidase-4 (DPP-4) Inhibitor
Dislodgment of needle Infection Hypoglycemia Inconvenience of wearing is 24 hrs/day Most common: ketoacidosis b/c of dislodgment of needle
Disadvantages of Insulin Pump
It is not very important to read labels.
FALSE
Blood glucose determination obtained in the laboratory after fasting more than 8 hours.
Fasting Plasma Glucose (FPG)
No caloric intake for at least 8 hours
Fasting plasma glucose
20-30%, with >10% from saturated and < 300 mg cholesterol
Fat
Acetohexamide (Dymelor) Chlorpropamide (Diabinese) Tolazamide (Tolinase) Tolbutamide (Orinase)
First-Generation Sulfonylureas
Used infrequently in US today Used in type 2 Diabetes to control blood glucose levels Stimulate beta cells of the pancreas to secrete insulin; may improve binding between insulin and insulin receptors or increase the number of insulin receptors
First-Generation Sulfonylureas
Use proper footwear and, if appropriate, other protective equipment Avoid exercise in extreme heat or cold Inspect feet daily after exercise Avoid exercise during periods of poor metabolic control
General Precautions for Exercise in People with Diabetes
Any degree of glucose intolerance with its onset during pregnancy
Gestational diabetes mellitus (GDM)
Onset: 1 hour Peak: No peak Duration: 24 hours
Glargine (Lantus) Detemir (Levemir)
Another pancreatic hormone secreted by the alpha cells of the islets of Langerhans which is released when blood glucose levels decreased and stimulates the liver to release stored glucose.
Glucagon
Together maintain a constant level of glucose in the blood by stimulating the release of glucose from the liver.
Glucagon & Insulin
After 8 to 12 hours without food, the livery forms glucose from the breakdown of noncarbohydrate substances, including amino acids.
Gluconeogenesis
If concentrations of glucose exceeds the renal threshold for glucose (180-200), the kidneys may not reabsorb all of the filtered glucose; the glucose appears in the urine
Glucosuria
Onset: 5-15 minutes Peak: 30-60 minutes Duration: 2 hours
Glulisine (Apridra)
A long-term measure of glucose control that is a result of glucose attaching to hemoglobin for the life of the red blood cell (120 days). The goal of diabetes therapy is a normal to near-normal level of glycated hemoglobin, the same as in the non diabetic population.
Glycated hemoglobin (glycosylated hemoglobin, HgB A1C, or A1C)
Used to describe how much a given food raises the blood sugar level compared with an equivalent amount of glucose
Glycemic Index
Initally, the liver produces glucose through the breakdown of glycogen.
Glycogenolysis
Blood test that reflects the average blood sugar over approx 2-3 months Normal range is 4-6%
Glycosylated Hemoglobin/A1C
Can occur is type 1 and type 2 Diabetes More common in type 2 diabetes, especially elderly patients Caused by physiologic stress (infection, surgery, CVA, MI) Onset slower (over several days) BS usually >600 Arterial pH normal No ketones Serum osmolality >350 mOsm/L Bicarbonate Normal Bun and creatine levels elevated Morality rate 10-40%
HHNS
No ketones
HHNS
You have high BS which causes polyuria (so high that it causes dehydration)
HHNS DKA
A client with type 1 diabetes asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are effective only if the client:
Has Type 2 Diabetes
Which of the following is the most rapid acting insulin?
Humalog
Onset: 3-4 hours Peak: 4-12 hours Duration: 16-20 hours
Humulin N Iletin II Lente Iletin II NPH Novolin L [Lente] Novolin N [NPH]
Elevated blood glucose level; fasting level greater than 110 mg/dL; 2-hour postprandial level greater than 140 mg/dL.
Hyperglycemia
A serious condition in which hyperosmolarity and hyperglycemia predominate, with alterations of the sensorium (sense of awareness). Ketones absent. Lack of effective insulin (ie. insulin resistance)
Hyperglycemic hyperosmolar nonketotic syndrome
A metabolic disorder of type 2 diabetes resulting for a relative insulin deficiency initiated by an intercurrent illness that raises the demand for insulin; associated with polyuria and severe dehydration
Hyperglycemic hyperosmolar nonketotic syndrome (HHNS)
Low blood glucose level (less than 60 mg/dL)
Hypoglycemia
Which combination of adverse effects should a nurse monitor for when administering I.V. insulin to a client with diabetic ketoacidosis?
Hypokalemia and hypoglycemia
A metabolic stage intermediate between normal glucose homeostasis and diabetes; now referred to a prediabetes
Impaired fasting glucose (IFG), impaired glucose tolerance (IGT)
Prevents constipation
Insoluble Fiber
*Transports and metabolizes glucose for energy *Stimulates storage of glucose in the liver and muscle (in the form of glycogen) *Signals the liver to stop the release of glucose *Enhances storage of dietary fat in adipose tissue *Accelerates transport of amino acids (derived from dietary protein) into cells
Insulin
A hormone secreted by the beta cells of the islets of Langerhans of the pancreas that is necessary for the metabolism of carbohydrates, proteins, and fats; a deficiency of this results in diabetes mellitus
Insulin
Inhibits the breakdown of stored glucose, protein, and fat
Insulin
Secreted by beta cells, which are one of the 4 types of cells in the islets of Langerhans in the pancreas. It is an anabolic, or storage, hormone. When a person eats a meal, secretion increases and moves glucose from the blood into muscle, liver, and fat cells.
Insulin
May be given SQ or IM Not given PO b/c it is destroyed by digestive insulins Should have another nurse verify dosage prior to giving Concentration: 100 units/ mL 1/2 cc & 1 cc syringes
Insulin Therapy
The progressive increase in blood glucose from bedtime to morning
Insulin Warning
Appear white and cloudy Onset varies slightly: 2-4 or 3-4 hours Peaks: 4-12 hours Duration: 16-20 hours Examples are Humulin NPH, Novolog N, NPH
Intermediate Acting Insulins
NPH is an example of which type of insulin?
Intermediate-acting
An investigational procedure in which purified islet cells from cadaver donors are injected into the portal vein of the liver, with the goal of having these cells secrete insulin and cure type 1 diabetes
Islet cells transplantation
When administering Insulin it is very important to read the label carefully and to be sure that the correct type of insulin is administered.
It is also important to avoid mistaking Lantus insulin for Lente insulin and vice versa.
A 53-year-old client is brought to the ED, via squad, where you practice nursing. He is demonstrating fast, deep, labored breathing and has a fruity odor to his breath. He has a history of type 1 diabetes. What could be the cause of his current serious condition?
Ketoacidosis
A highly acidic substance formed when the liver breaks down free fatty acids in the absence of insulin; the result is diabetic ketoacidosis
Ketone
Onset: 10-15 minutes Peak: 1 hour Duration: 2-4 hours
Lispro (Humalog)
Insulin unlocks the door so glucose can travel into muscles, etc. so it isn't in the blood stream.
Lock & Key method
Lantus Very long acting Onset 1 hours Given once a day Mimics pancreas Peak-less insulin Cannot be mixed with another insulin- causes precipitation Used for basal dose
Long Acting Insulins
What does exercise do to your blood sugar?
Lowers blood glucose levels by increasing the uptake of glucose by body muscles and by improving insulin utilization
Consider food preferences, lifestyle, usual eating times, and cultural/ethnic background Review diet history and need for weight loss, gain, or maintenance Caloric requirements and calorie distribution throughout the day
Meal Planning
Nutritional therapy prescribed by the physician for management of diabetes
Medical Nutrition Therapy (MNT)
Includes HTN, hypercholesterolemia, and abdominal obesity. To overcome insulin resistance and to prevent the buildup of glucose in the blood, increased amounts of insulin must be secreted to maintain the glucose level at a normal or slightly elevated level.
Metabolic Syndrome
Humulin 70/30 Novolog 70/30 Humalog 75/25 Cloudy
Mixed Insulin
An elevated blood glucose level in the morning caused by an insufficient amount of insulin. May be caused by: The dawn phenomenon the Somogyi effect Insulin warning
Morning Hyperglycemia
Onset: 2-4 hours Peak: 4-12 hours Duration: 16-20 hours
NPH (neutral protamine Hagedorn)
A long-term complication of diabetes in which the kidney cells are damaged; characterized by microalbuminuria in early stages and progressing to end-stage renal disease
Nephropathy
A nurse expects to find which signs and symptoms in a client experiencing hypoglycemia?
Nervousness, diaphoresis, and confusion
A long-term complication of diabetes resulting from damage to the nerve cell
Neuropathy
Repaglinide (Prandin) categorized as a meglitinide Nateglinide (Starlix) categorized as d D-phenylalanine derivative
Non-Sulfonylurea Insulin Secretagogues
Stimulate pancreas to secrete insulin Can be used alone on in combination with metofrmin or thiazolidinediones to improve glucose control
Non-Sulfonylurea Insulin Secretagogues
Have minimal or no calories Produce minimal or no elevation in BS Have been approved by the FDA as safe for people with diabetes Include saccharin, aspartame (NutraSweet), acesulfame-K (Sunnette), and sucralose (Splenda)
Nonnutritive sweeteners
Individualized Calorie distribution Exchange list Food guide pyramid Work with dietian
Nutritional Management
Include fructose (fruit sugar), sorbitol, and xylitol, all of which provide calories in amounts similar to those in sucrose (table sugar). Cause less elevation in BS than sucrose does and are often used in "sugar-free" foods
Nutritive Sweeteners
When excessive glucose is excreted in the urine, it is accompanied by excessive loss of fluid/electrolytes
Osmotic diuresis
Impaired glucose metabolism in which blood glucose concentrations fall between normal levels and those considered diagnostic for diabetes; includes IFG and IGT, not clinical entities in their own right by risk factors for future diabetes and cardiovascular disease
Prediabetes
Give right before a meal Humalog: 10-15 mins Novolog: 5-15 minutes
Rapid Acting Insulins
Used for rapid reduction of glucose level, to treat postprandial hyperglycemia, and/or to prevent nocturnal hypoglycemia
Rapid-acting insulins
Onset: 1/2 to 1 hour Peak: 2-3 hours Duration: 4-6 hours
Regular (Humalog R, Novolin R, Iletin II Regular)
A long-term complication of diabetes in which the microvascular system of the eye is damaged
Retinopathy
Glipizide (Glucotrol, Clucotrol XL) Glyburide (Micronase, Glynase, Dia-Beta) Glimepiride (Amaryl)
Second-Generation Sulfonylureas
Stimulate beta cells of the pancreas to secrete insulin; may improve binding between insulin and insulin receptors or increase the number of insulin receptors Have more potent effects than first-generation May be used in combination with metformin or insulin to improve glucose control
Second-Generation Sulfonylureas
A method of capillary blood glucose testing in which the patient pricks his or her finger and applies a drop of blood to a test strip that is read by a meter.
Self-monitoring of blood glucose (SMBG)
Clear 20-30 mins before a meal Commonly used for coverage Peaks: 2-3 hours Examples are Humulin R, Novolog R May be given in combination with longer acting insulins
Short Acting Insulins
Because illness, especially infections, can cause increased blood glucose levels, the patient does not need to decrease the insulin dose to compensate for decreased food intake when ill and may even need to increase the insulin dose.
Sick day rules
Lowers blood sugar and lipid levels
Soluble Fiber
Nocturnal hypoglycemia followed by rebound hyperglycemia
Somogyi effect
A classification of oral antidiabetic medication for treating type 2 diabetes; stimulates insulin secretion and insulin action
Sulfonylurea
100% of carbohydrates go into glucose
TRUE
50% of Protein is converted into Glucose
TRUE
Use of artificial sweeteners is acceptable, especially if it assists in overall dietary adherence.
TRUE
A male client, aged 42, is diagnosed with diabetes mellitus. He visits the gym regularly and is a vegetarian. Which of the following factors is important when assessing the client? `
The clients consumption of carbohydrates
Characterized by relatively normal blood glucose level until approx 3AM, when blood glucose levels begin to rise.
The dawn phenomenon
A class of oral antidiabetic medications that reduce insulin resistance in target tissues, enhancing insulin action without directly stimulating insulin secretion.
Thiazolidinedione
Pioglitazone (Actos) Rosiglitazone (Avandia)
Thiazolidinediones
Sensitize body tissue to insulin; stimulate insulin receptor sites to lower blood glucose and improve action of insulin May be used alone or in combination with sulfonylurea, metformin, or insulin
Thiazolidinediones (or glitazones)
Rehydration Restoring electrolytes Reversing Acidosis
Treatment for DKA
Change time of injection of evening intermediate-acting insulin from dinnertime to bedtime
Treatment for Dawn Phenomenon
Increase evening (Predinner or bedtime) dose of intermediate-acting or long-acting insulin, or institute a dose of insulin before the evening meal if one is not already part of the treatment regimen
Treatment for Insulin warning
Decrease evening (predinner or bedtime) dose of intermediate-acting insulin, or increase bedtime snack
Treatment for Somogyi Effect
Fluid replacement Correction of electrolyte imbalances Insulin administration
Treatment of HHNS
Peak of insulin is where hypoglycemia reactions occurs.
True
Sweeteners containing sorbitol may have a laxative effect.
True
The renal threshold for glucose is 180 to 200 mg/dL.
True
This test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.
Two hour post load glucose test
5-10% of all people Results from destruction of pancreatic beta cells Etiology: genetic, immunologic, and environmental (viruses) Onset at any age, usually <30 Usually thin with recent weight loss at diagnosis Have little or no endogenous insulin Often have antibodies to insulin Ketosis prone when insulin absent Tx: insulin to preserve life Acute complications of hyperglycemia=DKA
Type 1 Diabetes
Glucose derived from food cannot be stored in the liver, but instead remains in the blood stream and contributes to postprandial hyperglycemia
Type 1 Diabetes
Regardless of specific etiology, destruction of the beta cells results in unchecked glucose production by the liver and fasting hyperglycemia
Type 1 Diabetes
A metabolic disorder characterized by an absence of insulin production and secretion from autoimmune destruction of the beta cells of the islets of Langerhans in the pancreas; formerly called insulin-dependant, juvenile
Type 1 diabetes
Fat breakdown occurs resulting in increased production of ketone bodies (by product of fat breakdown)
Type 1 diabetes
Acute complications: Hyperglycemic Hyperosmolar Nonketotic Syndrome: HHNS
Type 2 DIabetes
Because its associated with a slow, progressive glucose intolerance, its onset may go undetected for many years. If the PT experiences symptoms, they are frequently mild and may include fatigue, irritability, polyuria, polydipsia, poorly healing skin wounds, vaginal infections, or blurred vision (if glucose levels are very high)
Type 2 Diabetes
Causes: obesity, heredity, & environmental factors Onset at any age, but usually > 30 Usually obese on diagnosis Slow progression.. may go undetected for years No islet cell antibodies Ketosis rare except in stress or infection
Type 2 Diabetes
Normally, insulin binds to special receptors on cell surfaces and initiates a series of reactions involved in glucose metabolism. These intracellular reactions are diminished = insulin less effective at stimulating glucose uptake by tissues
Type 2 Diabetes
Results from: decreased in endogenous insulin and/or decreased sensitivity to insulin (insulin resistance)
Type 2 Diabetes
There is enough insulin present to prevent the breakdown of fat and production of ketone bodies. Therefore, DKA does not occur.
Type 2 Diabetes
To overcome insulin resistance and to prevent the increase glucose causes increased secretion of insulin; however beta cells cannot keep up with increased demand for insulin, glucose rises
Type 2 Diabetes
Two main problems related to insulin are insulin resistance (decreased sensitivity of the tissues to insulin) and impaired insulin secretion
Type 2 Diabetes
Tx: first with diet & exercise to lose weight Then.. oral hypoglycemic Some may require insulin Some may need insulin during periods of acute physiologic stress
Type 2 Diabetes
A metabolic disorder characterized by the relative deficiency of insulin production and a decreased insulin action and increased insulin resistance; Formerly called non-insulin-dependant, adult-onset.
Type 2 diabetes
Not done as much bc of SMBG Renal threshold 180-200 mg/dL Hypoglycemia can not be detected Some medications may interfere
Urine Testing for Glucose
What is the goal of insulin regimen?
to mimic the pattern of insulin secretion as closely as possible