diabetes

numonic for diabetes mellitus nursing assessment

S: Slow wound healing U: blUring vision G: Glycosuria A: Acetone breath R: Rashes on the skin and repeated yeast infections

guidlines for dietary recommendations

-combining starchy foods with protein and fat containing foods tend to slow absorption and low glycemic index -eating foods that are raw and whole results in a lower glycemic index than eating chopped, pureed, or cooked foods (except meat) -whole fruit instead of juice because fiber slows absorption

important objectives in the dietary and nutritional management of diabetes

-control of total caloric intake to attain or maintain reasonable body weight -control of blood glucose levels -normalization of lipids and blood pressure to prevent heart disease

alcohol consumption

-don't need to give up entirely but large amounts can be converted to fats, increasing the risk for DKA -major danger is hypoglycemia especially for patients who take insulin and drink on an empty stomach -may decrease gluconeogenesis -eat a meal with alcohol but carbs consumed with alcohol may raise blood glucose

gestational diabetes

-due to hormones secreted by the placenta, which inhibit the action of insulin -abnormal risk for perinatal complications, especially macrosomia (large babies) -treated with diet, and if needed insulin -risk factors include obesity age >30, family history of diabetes, previous large babies -should be screened for diabetes every 3 years

Type 1 clinical manifestations and implications

-onset any age, but usually young (<30) -usually thin at diagnosis; recent weight loss -often have islet cell antibodies -little or no endogenous insulin -need exogenous insulin to preserve life -ketosis prone when insulin absent

Type 2 clinical characteristics and implications

-onset any age, usually > or equal to years -usually obesity is present at diagnosis -no islet cell antibodies - decrease in endogenous insulin, or increased with insulin resistance -most patients can control blood glucose through weight loss if they have obesity - oral antidiabetic agents may improve blood glucose levels if dietary modification and exercise are unsuccessful -may need insulin on a short-or long term basis to prevent hyperglycemia -ketosis uncommon; except in stress or infection

prediabetes

-previous history of hyperglycemia (during pregnancy or illness) -current normal glucose metabolism -IGT or IFG screening after age 40 if there is a family history of diabetes or if symptomatic -encourage ideal body weight

what does insulin do in muscle, liver, and fat cells

-transports and metabolizes glucose for energy -stimulates storage of glucose in the liver and muscle (in the form of glycogen) -signals the liver to stop the release of glucose -enhances storage of dietary fat in adipose tissue -accelerates transport of amino acids into cells -inhibits breakdown of stored glucose, protein, and fat

once food is digested, what % of carbs are converted to glucose

100% -approx. 50% of protein (meat, fish, and poultry) are also converted to glucose and has minimal effect on blood glucose

Type 1 diabetes

5-10% of all patients with diabetes; formerly juvenile diabetes, or insulin-dependent diabetes

recommended caloric intake

50-60% of calories of carbs (majority should come from whole grains) 20-30% from fat and 10-20% from protein

Type 2 diabetes percentages

90-95% of all diabetes; patients with obesity 80% without obesity 20% formerly adult-onset or non-insulin dependent

Classic clinical manifestations of diabetes

Three Ps polyuria, polydipsia, and polyphagia -other symptoms include fatigue, weakness, sudden vision changes, tingling or numbness in hands or feet, dry skin, skin lesions or wounds that are slow to heal, and recurrent infections

diabetes risk factors

age >30 for type 2 -age <30 for type 1 -history of gestational diabetes -hypertension -family history of diabetes (parents or siblings) -obesity -race/ethnicity -previously identified IFG and IGT -HDL cholesterol level < or equal to 35 and/or triglyceride levels > or equal to 250

patients with LADA have at least two of these:

age of onset less than 50 years, BMI less than 25 kg, history of autoimmune disease, acute symptoms prior to diagnosis, or positive family history of autoimmune disease

why isn't DKA an issue for type 2 diabetes

although insulin secretion is impaired, there is enough insulin present to prevent the breakdown of fat and the accompanying production of ketone bodies

meds that cause hypoglycemia

beta blockers: mask symptoms of hypo ETOH: blocks liver from making new glucose aspirin: decreased basal rates of hepatic glucose production, enhanced tissue insulin sensitivity sulfonylureas MOA inhibitors used to treat depression bactrim: Hypoglycemia can be induced by the sulfa component of Bactrim, which binds receptors in the pancreas causing insulin to be secreted

exercise precautions

blood glucose exceeding 250 and who have ketones in urine should not begin exercising until urine tests are negative for ketones and levels are closer to normal

impaired glucose tolerance

blood glucose levels higher than normal but not high enough to be diagnosed as diabetes

six main exchange lists

bread/starch vegetable milk meat fruit

S/S of hypoglycemia

Blood glucose less than 60 sweaty, cold, clammy, confused, lightheaded, dizzy, double vision "Im sweaty, cold, and clammy... give me some hard candy"

prediabetes

classified as impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) -refers to a condition in which blood glucose concentrations fall between normal levels and those considered diagnostic for diabetes

what is a metabolic derangement?

clinically significant complication due to major trauma caused by things such as obesity or inactivity

meal planning and related education

consistency in the approx. time intervals between meals, with the addition of snacks if necessary, helps prevent hypoglycemic reactions and maintain glucose control

metabolic syndrome

constellation of symptoms including hypertension, hypercholesterolemia, abdominal obesity, and other abnormalities

nutritive sweeteners

contain calories -fructose (fruit sugar), sorbitol (may have laxative effect), and xylitol -cause less elevation in blood sugar than sucrose does

medicine induced diabetes

corticosteroids thiazide diuretics beta blockers statinswhen the number of infection-fighting white blood cells in the blood decreases and cause the patient to be more likely to get an infection8 hour

diabetes is the seventh leading cause of

death and blindness in adults aged 18-64 years

destruction of beta cells results in

decreased insulin production, increased glucose production by the liver, and fasting hyperglycemia -in addition glucose derived from food cannot be stored in the liver but instead remains in the bloodstream and contributes to postprandial (after meals) hyperglycemia

glycemic index

describes how much a given food increases the blood glucose levels compared with an equivalent amount of glucose -monitoring BG levels after ingestion of certain foods can help patients determine their glycemic index

gerontologic considerations for diabetes

diabetes is prevalent in older adults and affects approx. 20% of older adults -there is a high prevalence among African Americans and those who are 65-74 years

manangement

dietary modifications and blood glucose monitoring -if hyperglycemia persists, insulin is prescribed

why is a glucose tolerance test more effective in diagnosis of diabetes than urine testing in older patients

due to the high renal threshold for glucose

when is type 2 usually detected?

during routine lab tests or ophthalmoscopic exams

Somogyi effect

early-morning hyperglycemia that occurs as a result of nighttime hypoglycemic episodes when the hypoglycemic episodes occur, cortisol and/or catacolamines and growth hormone are released to increase blood sugar -can counteract by eating a bedtime snack or decreasing bedtime insulin

participants in the diabetes prevention research group received (3 things) -these proved that type 2 can be prevented

either 1. standard lifestyle recommendations plus metformin 2. standard lifestyle recommendations plus placebo 3. intensive program with lifestyle modifications

impaired fasting glucose

fasting blood glucose levels that are higher than normal but not high enough to lead to a diagnosis of type 2 diabetes -body isn't able to use glucose as it should

basic criterion for the diagnosis of diabetes

fasting plasma glucose random plasma glucose glucose level 2 hours after receiving glucose

symptoms that are experienced as a result of the slow onset of type 2 (mild symptoms if any at all detected over many years)

fatigue, irritability, polyuria, polydipsia, poorly healing skin wounds, vaginal infections, or blurred vision

my plate food guide

foods are categorized into 5 groups: fruits, grains, vegetables, proteins, dairy plus fats and oils -foods (grains, fruits and veggies) are lowest in calories and fat and highest in fiber and should make up the basis of diet -great tool when teaching patients about how to control portions and how to identify carbohydrates, proteins, and fats

what is the exchange list

foods with similar amount of carbohydrates per serving size are grouped together -foods within one group contain equal numbers of calories and are approx. equal in grams of proteins, fat, and carbs -foods may be interchanged with one food from the list allowing a variety of options

insoluble fiber

found in whole-grain breads and cereals and in some veggies

what to do if someone has hypoglycemia

give them a simple carb or if unconscious IV D50 hard candies, life savers, fruit juice, graham crackers, honey

diagnosis for diabetes for two hour postload

glucose equal to or greater than 200 during an oral glucose tolerance test

diagnosis for diabetes for fasting plasma

glucose greater than or equal to 126

nonnutritive sweeteners

have few or no calories. Minimal or no elevation in blood glucose. Better to use these sweeteners. -sweet and low, equal, splenda

high risk ethnic groups for gestational diabetes

hispanic americans, native americans, asian americans, african americans, and pacific islanders

assessing a patient with diabetes

history physical exam lab findings need for referrals

insulin

hormone secreted by beta cells -insulin is an anabolic, or storage, hormone

type 2 acute complication

hyperglycemia hyperosmolar syndrome -very dehydrated, thirsty, increased BP, mental status changes

what are the three different metabolic derrangements

hyperglycemia, ketosis, and metabolic acidosis

nutrition labels

includes info about how many grams of carbs are in a serving of food which is needed to determine how much medication is needed -although carb counting is important, reading labels is the most important *** -must include serving size, total calories, total fat, saturated fat, trans fat, cholesterol, sodium, total carb, dietary fiber, total sugars, any added sugars, protein, vitamin D, calcium, iron, and potassium

polyphagia

increased appetite that results from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats

fiber meal plan

increased intake may improve blood glucose levels, decrease the need for exogenous insulin, and lower total cholesterol and low-density lipoprotein levels in the blood

polydipsia

increased thirst occur as a result of the excess loss of fluid associated with osmotic diuresis

what happens when you exercise with elevated glucose levels

increases the secretion of glucagon, growth hormone, and catecholamines -the liver then releases more glucose resulting in an increase in blood glucose

what are the two main problems related to type 2 diabetes

insulin resistance and impaired insulin secretion

what happens with insulin after a meal

insulin secretion increases and moves glucose from the blood into muscle, liver, and fat cells

ketone bodies

ketone bodies are produced by the liver and used for energy when glucose is not readily available due to fats being broken down and there becomes free fatty acids. this increases acid production in the blood causing ketoacidosis (diabetic ketoacidosis)

soluble fiber

legumes, oats, and fruits -plays more of a role in lowering glucose and lipid levels than insoluble fiber -slows stomach emptying and movement of food through upper-digestive tract

risks in increasing fiber

may require adjusting the dosage of insulin or oral agents to prevent hypoglycemia -abdominal fullness -nausea -diarrhea -increased flatulence -constipation if fluid intake is inadequate

healthy food choices

measures servings

insulin resistance may lead to

metabolic syndrome

Sulfonylureas

most common oral antidiabetic -glyburide, glipizide, diabinese, amaryl -"ide" "ride" "zides" "mides" -stimulate beta cells to make insulin AVOID ETOH-severe hypoglycemia

type 2 diabetes

most commonly seen in adults older than 30 and who have obesity, although its increasing in younger people due to the growing epidemic of obesity in children, adolescents, and young adults -intracellular reactions that insulin initiates is diminished making insulin less effective at stimulating glucose uptake by the tissues and at regulating glucose release by the liver

do people inherit type 1 diabetes?

no but rather a genetic predisposition, or tendency, toward the development of it -this genetic tendency has been found in people with certain human leukocyte antigen types

protein meal plan

nonanimal sources such as legumes and whole grains to help reduce sat fat and cholesterol intake -protein intake may be reduced in those with early signs of kidney disease

Diabetes is the leading cause of

nontraumatic amputations and end-stage kidney disease

five components of diabetes management

nutritional therapy exercise (if BS over 250 with ketones present avoid this due to the breakdown of more fats) monitoring pharmacologic therapy education

Type 2 diabetes causes

obesity, heredity, and environmental factors

Rapid acting insulin

onset 15 minutes Peak: 1 hour duration 3-5 hours when to take: 0-15 minutes before meal "15 min feels like an hour during 3-5 rapid responses"

Intermediate acting insulin

onset: 2 hours Peak: 8 hours duration: 16 hours "nurses play hero 2 (to) 8 16 year olds

Short acting insulin

onset: 30 min peak: 2 hours duration: 8 hours "short staffed nurses when from 30 patients 2 (to) 8 patients

complications with diabetes mellitus

organ problems: glucose sticks to protein in vessels. they become hard a form plaques (atherosclerosis) (heart disease, strokes, neuropathy, decreased wound healing, eye trouble, infections, HTN)

Diabetes associated with other conditions or syndromes (previously classified as secondary diabetes)

pancreatic diseases, hormonal abnormalities, medications -depending on the ability of the pancreas to produce insulin, the patient may require treatment with oral antidiabetic agents or insulin

DKA

preceded by a day or more of polyuria, polydipsia, nausea, vomiting, and fatigue with eventual stupor and coma if not treated -fruity breath odor due to the presence of keto acids and Kussumal breathing

what is an acute complication of hyperglycemia

DKA

different types of insulin

rapid acting short acting intermediate acting long acting

Meglitinides

repiglinide stimulate beta cells to make insulin take with first bite of food

glucose control can decrease the progression of what complications

retinopathy (damage to blood vessels that nourish the retina), nephropathy (damage to kidney cells), and neuropathy (damage to nerve cells)

what do both soluble and insoluble fiber increase

satiety or increased fullness which is helpful for weight loss

Latent autoimmune diabetes in adults (LADA)

subtype of diabetes in which the progression of autoimmune beta cell destruction in the pancreas is slower than in type 1 and 2 -patients with LADA are at high risk of becoming insulin dependent

oral antidiabetics

sulfonylureas biguanides meglitinides alpha-glucoside inhibitors thiazolidineidlone

diagnosis for diabetes with casual plasma

symptoms of diabetes plus glucose concentration equal to or greater than 200

cystic fibrosis related to diabetes

the build up of sticky mucous caused by can lead to inflammation and scarring of the pancreas damaging the cells that produce insulin

what happens if glucose in the blood exceeds the renal threshold for glucose

the kidneys may not reabsorb all of the filtered glucose; glycosuria then occurs

what occurs during fasting periods (between meals and overnight)

the pancreas continuously releases a small amount of insulin (basil insulin) -another pancreatic hormone called glucagon (secreted by alpha cells) is released when blood glucose levels decrease stimulating the liver to release stored glucose - insulin and glucagon work together to maintain constant levels of glucose

consequence of undetected diabetes

these diagnosis's may have developed before the actual diagnosis of diabetes is made -eye disease, peripheral neuropathy and peripheral vascular disease

carbohydrates

these have the greatest effect on blood glucose levels because they are more quickly digested than other foods and are converted into glucose rapidly -consists of sugars (sucrose), and starches (rice, pasta, bread) and these should be eaten in moderation to avoid high postprandial blood glucose

meds that cause hyperglyemia

thiazides: impaired insulin sensitivity, increased hepatic glucose production glucocorticoids: inhibit glucose uptake by muscle and fat; they are also directly cytotoxic to pancreatic beta cells, causing destruction and decreased insulin production estrogen therapy:

women who are considered high risk for gestational diabetes are

those who are obese, a personal history of gestational diabetes, glycosuria, or a strong family history

how does the liver produce glucose

through glycogenolysis (breakdown of glycogen) -after 8-12 hours without food, the liver forms glucose from the breakdown of non-carbohydrate substances including amino acids, through gluconeogenesis

why is it important to limit total intake of cholesterol? what is the limit?

to reduce risk factors such as increased serum cholesterol levels associated with coronary artery disease (the leading cause of death and disability among diabetes patients) -300 mg/day

classifications of diabetes

type 1, type 2, gestational, latent autoimmune diabetes (LADA) of adults, and diabetes associated with other conditions or syndromes -each type vary in cause, clinical course, and treatment -except those who have type 1, patients many move from one category to another

dawn phenomenon

Early morning glucose elevation produced by the release of growth hormone, which decreases peripheral uptake of glucose resulting in elevated morning glucose levels. Admin of insulin at a later time in day will coordinate insulin peak with the hormone release. -can also administer NPH at night to help counteract

misleading food labels

Foods labeled "sugarless" or "sugar-free" may still provide calories equal to those of the equivalent sugar-containing products if they are made with nutritive sweeteners (can have fructose) Therefore, these foods should not be considered "free" foods to be eaten in unlimited quantity, because *they can elevate blood glucose levels.* Foods labeled "dietetic" are not necessarily reduced-calorie foods. Patients are advised that foods labeled dietetic may still contain significant amounts of sugar or fat.

etiology of type 1 diabetes

Genetic, environmental or immunological factors damage pancreatic beta cells resulting in insulin deficiency

osmotic diuresis

when excess glucose is excreted in urine, it is accompanied by excessive loss of fluids and electrolytes

lab examinations (findings) for diabetes

HgbA1c fasting lipid profile test for miroalbuminuria serum creatinine level urinalysis electrocardiogram

nmunomic "insulin"

I: rapId N: novalog and humalog S: short: regular (humalin R, Novalin R) U: humalin N (intermediate.. U is in the middle): NPH L: long acting I: levomIr N: laNtus

Biguanides

Metformin (Glucophage) decreases the liver stores of glucose dont take 48 hours prior to surgery watch renal function can cause diarrhea

which ethnic and racial groups are most at risk for diabetes, greater risk for complications, and have higher death rates

Native Americans and persons of Hispanic origin

long acting

Onset: 2 hours Peak: NONE Duration: 24 hours "the 2 long nursing shifts never peaked but lasted 24 hours

Thiazolidinediones

Pioglitazone Rosiglitazone decreases glucose production in the liver watch liver and heart function as an increased risk of MI

Alpha-glucoside inhibitors

Precose, Glyset lower blood sugar by slowing down the breakdown of starchy foods in the GI system which helps slowly rise the blood sugar instruct pts to take first bite with meal