Med surg Diabetes mellitus
OGTT
*oral glucose tolerance test* Overnight fasting, avoid caffeine, no smoking for 12 hours prior to test, fasting glucose is obtained, 100 g glucose load is given, and serum glucose levels are determined at 1, 2, and 3 hours following ingestion
infection in diabetes
- Diabetics are more susceptible to infections because of a defect in mobilization of WBCs and impaired phagocytosis by neutrophils and monocytes - Neuropathy (loss of sensation) may delay the detection of infection - Persistent glycosuria may predispose patient to bladder infection
Macrovascular complications of diabetes
-*cerebral vascular disease* (CVD): 2 or 4 fold increase in CV mortality and stroke -*coronary artery disease* (CAD): 8/10 will die from a CV event -*peripheral vascular disease* (PVD): abnormal narrowing of arteries other than those that supply the heart or brain. -*foot problems*
Microvascular complications of diabetes
-*retinopathy* -nephropathy -ED -*peripheral neuropathy*
lab values seen in HHS
-Blood glucose >600 mg/dl -Increase in serum osmolality -Absent/minimal ketone bodies
metformin
-Glucophage -reduces glucose production by the liver and enhances the tissue's insulin sensitivity
nursing dx for type 2 diabetes
-Ineffective therapeutic regimen management -Risk for injury -Risk for infection -Powerlessness -Imbalanced nutrition: More than body requirements
Acanthosis nigricans
-Skin lesions appear red/brown round/oval patches. Seen frequently on front of the legs -Most common sites are seen on flexures, axillae, and neck
prevention for diabetic nephropathy
-Tight glucose control- minimize high and low BG levels -Blood pressure management (Angiotensin-converting enzyme (ACE) inhibitors Used even when not hypertensive) -Yearly screening: Microalbuminuria in urine, Serum creatinine
how insulin is normally metabolized
-comes from beta cells in pancreas -releases continuously into bloodstream in small incraments with larger amounts releasing after food intake -secretes
manifestations of hypoglycemia
-confusion -irritability -diaphoresis -tremors -hunger -weakness -visual disturbances (can mimic alcohol intoxication)
sensory diabetic neuropathy
-distal symmetric most common form, this affects hands/feet b/l -loss of sensation, abnormal sensation, pain, paresthesia, LOPS (typically worse at night, can cause atrophy)
diabetes causes the leading causes of:
-end stage renal disease -adult blindness -non traumatic lower limb amputation
A1C levels
Normal: below 5.7% Prediabetes: 5.7 to 6.4% Diabetes: 6.5% or above : really effects the periodontium and overall health negatively
diabetes mellitus broad definition
a chronic multisystem disease related to abnormal/impaired insulin production
prediabetes
a condition in which the blood sugar level is higher than normal, but not high enough to be classified as type 2 diabetes -impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)
secondary diabetes
a type of diabetes caused by another disease or certain drugs or chemicals ex.) crushing's syndrome, parenteral nutrition( getting fed through IV), corticosteroids usually resolves when underlying condition treated
diabetic ketoacidosis
acidity of the blood caused by the presence of ketone bodies produced when the body is unable to burn sugar; thus, it must burn fat for energy
what is insulin produced by?
beta cells of islets of Langerhans in pancreas
seventh leading cause of death
diabetes mellitus
if prediabetes doesn't get controlled what happens
diabetes will develop typically in 10 years
diabetic retinopathy
disease of the retina in diabetics characterized by capillary leakage, bleeding, and new vessel formation (neovascularization) leading to scarring and loss of vision -microvascular damage to retina -eye dilation annually is important
A1C test
for diabetes by checking sugar on red blood cells to get an average glucose level over 90-120 days
what is 2-4 times more likely to develop with diabetes?
heart disease HTN (hypertension)
when should ketone testing be done on diabetes pt?
if blood glucose is >240mg/dl
IFG (prediabetes)
impaired fasting glucose (8-12) hour fast >100 and <125mg/dl
IGT (prediabetes)
impaired glucose tolerance 2 hour plasma glucose higher than normal between 140 and 199mg/dl
what damage occurs in prediabetes?
long-term damage occurs to hear and blood vessels
type 2 diabetes
progressive disorder in which body cells become less responsive to insulin -gradual onset -greater in ethnic populations -most prevalent type of diabetes -Person may go many years with undetected hyperglycemia
normal A1C tests help
reduces risk of retinopathy, nephropathy, and neuropathy
kinds of diabetes
type 1 type 2 gestational prediabetes
treatment for sensory diabetic neuropathy
•Tight blood glucose control •Drug therapy •Topical creams •Tricyclic antidepressants •Selective serotonin and norepinephrine reuptake inhibitors •Antiseizure medications
Potassium range
3.5-5.0 mEq/L
stable glucose range
74-106mg/dl
causes of hypoglycemia
>blood sugar, too much insulin, not enough food, overexterts (exercise)
what should be monitored in prediabetes?
A1C levels and glucose levels
exogenous insulin
Insulin from an outside source Required for type 1 diabetes Prescribed for patient with type 2 diabetes who cannot control blood glucose by other means
Hypoglycemic unawareness
No warning signs/symptoms until glucose level critically low Related to autonomic neuropathy and lack of counterregulatory hormones Patients at risk should keep blood glucose levels somewhat higher
HHS and DKA treatment
*administer:* -IV fluids -insulin therapy -electrolyte replacement *assess:* -renal/cardiopulmonary status -LOC -signs of potassium imbalance -cardiac monitoring -vital signs
autonomic diabetic neuropathy
*can affect nearly all body systems* *gastroparesis:* delayed gastric emptying (can trigger hypoglycemia) *CV abnormalities:* postural hypotension, resting tachycardia, and painless MI *ED/decreased libido* *neurogenic bladder:* urinary retention
hypoglycemia
*cold and clammy need some candy* occurs when: -too much insulin in proportion to glucose in blood -blood glucose level *less than 70* Untreated can progress to loss of consciousness, seizures, coma, and death
lab tests for type 2 diabetes
*fasting plasma glucose* >126 mg/dl *random plasma glucose* > or = 200mg/dl plus sx *2hr OGTT level* > or = 200mg/dl using glucose load of 75g *hemaglobin A1C test* >6.5%
Hyperosmolar Hyperglycemic Syndrome (HHS)
*hot and dry, sugar is high* -life threatening -less common than DKA -often in pt over 60 with type 2 -Patient has enough circulating insulin so ketoacidosis (DKA) does not occur -*Neurologic manifestations occur* due to ↑ serum osmolality -typically a hx of: Inadequate fluid intake, increasing mental depression, polyuria -will require fluid replacement
interventions for type 2 diabetes
*identify those at risk* -health screenings for overweight pt above age 45 (FPG) -diet education by registered dietician (ADA guidelines), carb counting, meal plan, no alcohol -exercise plans after medial clearance (Monitor blood glucose levels before, during, and after exercise) -exogenous insulin (Long-acting (basal) once a day Rapid/short-acting (bolus) before meals) -insulin pump -SMBG -metformin -personal hygiene -medical identification band
hypoglycemia treatment
-immediate ingestion of *15g* of a simple carbohydrate -avoid foods with fat (decrease absorption of sugar) -no overeating -*recheck blood sugar 15 minutes after eating* -repeat until blood sugar is above 70mg/dl -Patient should eat regularly scheduled meal/snack to prevent rebound hypoglycemia -Check blood sugar again *45 minutes after treatment* *IF THIS DOESN"T WORK:* -Administer 1 mg of glucagon IM or subcutaneously (may have rebound hypoglycemia) -Have patient ingest a complex carbohydrate after recovery -20 to 50 ml of 50% dextrose IV push if very low or acute care
acute interventions for diabetes pt
-increase blood glucose level -continue regular meal plan -increase intake of noncaloric fluids -continue oral agents/insulin -frequent blood glucose monitoring -Patients undergoing surgery or radiologic procedures requiring contrast medium should hold their metformin day of surgery and 48 hours
signs/symptoms of type 1 diabetes
-polyuria (increased urination) -polydipsia (increased thirst) -polyphagia (increased hunger) -weight loss -fatigue -high frequency of infections -rapid onset -insulin dependent -peak incidence from 10-15 years
signs/symptoms of type 2 diabetes
-sedentary lifestyle -hx of high blood pressure -familial tendency -fatigue -obesity -recurrent infections -recurrent yeast infections -prolonged wound healing -visual changes -polyuria -polydipsia -polyphagia -fasting blood sugar >126mg/dl
chronic complications of diabetes
-stroke -hypertension -retinopathy -cataracts, gluacoma, blindness -coronary artery disease -atherosclerosis -neuropathy -gastroparesis -peripheral vascular atherosclerosis -gangrene -ED -islet cell loss -nephropathy
non-proliferative diabetic retinopathy
1) microaneurysms (sacular outpouchings) 2) intraretinal hemorrhages (dots, flame shape, & cotton wool spots) 3) retinal vascular leakage (permeability) 4) CSME (clinically significant macular edema) - retinal thickening and/or hard exudates that either involve center of macula or threaten to infiltrate it 5) venous beading - signs of ischemia 6) retinal hemorrhages and exudation
proliferative diabetic retinopathy
1) neovascularization - growth of new blood vessels along the surface of the retina; fragile and rupture easily 2) vitreous hemorrhage 3) retinal detachment
4 major metabolic abnormalities in type 2 diabetes
1. insulin resistance 2. pancreas decreases ability to produce insulin 3. inappropriate glucose production from liver 4. alternation in production of hormones and adipokines