NURS 334, exam 3, metabolism

Somogyi effect

Rebound effect in which an overdose of insulin causes hypoglycemia. Release of counterregulatory hormones causes rebound hyperglycemia between 2-4 am but the rebound will not be present until they wake up in the morning and have their blood sugar taken. if their blood sugar is taken during 2-4 in the morning, will read as hypoglycemic.

onset of long acting insulin

0.8-4 hours

duration of rapid acting insulin

3-5 hours

OmniPad Insulin Management System

A, OmniPod Insulin Management System. The Pod holds and delivers insulin. B, The Personal Diabetes Manager (PDM) wirelessly programs insulin delivery via the Pod. The PDM has a built-in glucose meter.

1. The home care nurse is visiting a child newly diagnosed with DM. The nurse is instructing the child and parents regarding actions to take if hypoglycemic reactions occur. The nurse tells the child to: A. Drink 8 ounces of diet cola at the first sign of weakness B. Report to the ER if the blood glucose is 60mg/dL C. Carry hard candies whenever leaving home in case of hypoglycemic reaction occurs D. Administer glucagon immediately if shakiness is felt

C. Carry hard candies whenever leaving home in case of hypoglycemic reaction occurs

Dawn phenomenon

Early morning glucose elevation produced by the release of growth hormone and cortisol, which decreases peripheral uptake of glucose resulting in hyperglycemic levels in the morning. **if taking BG during 2-4 Am, would be normal of high, but mostly NORMAL.

regular insulin can be mixed with glargine (lantus) True False

False

examples of long acting insulin

Glargine (Lantus) Detemir (Levemir) Degludec (Tresiba)

examples of intermediate acting insulin

NPH (Humulin N, Novolin N)

patient teaching to prevent foot ulcers

Proper footwear Avoidance of foot injury (especially in elderly and youth) Skin and nail care Daily inspection of feet Prompt treatment of small problems diligent wound care for foot ulcers: out patient wound care (encourage an out-patient wound care clinic) consider neuropathic arthropathy

1. A client is scheduled for a preprandial blood sugar check. The blood sugar is 224 mg/dl. According to the sliding scale insulin schedule, the client is to receive 4 units of Regular insulin for a blood sugar from 201-250 mg/dl. You, the nurse prepare the insulin as ordered. Upon taking the insulin into the client's room, the client is vomiting and refuses to eat lunch. What would be an appropriate nursing action? a. Give the 4 units of Regular insulin and recheck the blood sugar in 30 minutes b. Give only 2 units of the Regular insulin because the client is vomiting c. Hold the 4 units of Regular insulin and notify the physician of client vomiting d. Hold the 4 units of Regular insulin and wait until the client is able to eat and drink and then give the insulin

c. Hold the 4 units of Regular insulin and notify the physician of client vomiting

nurse walks into a room to check pt BG. the pt is alert and orientated. the diabetic client is hypoglycemic with a BG of 60, what would be the best nursing intervention for this patient? give insulin give oral diabetic medication give orange juice

give orange juice

pt experiencing an episode of hypoglycemia. the nurse plans care for this patient knowing that which physiological mechanism that should take place combat the decline in the BG is what? decrease EPI release decrease cortisol release increase insulin secretion increased glucagon secretion

increased glucagon secretion

the following are all types of insulin except for which option? regular (Humulin R) NPH (Novolin R) Detremir (levemir) metformin (glocophage)

metformin (glucophage)

diabetic retinopathy

microvascular damage to the retina and is the leading cause of new cases of adult blindness. initially there are no changes in vision. annual eye examinations with dilation to monitor and at time of diagnosis prevention: maintain healthy blood glucose levels and manage HTN. treatment: laser photocoagulation, vitrectomy, medications

ambulatory care

overall goal: to enable pt or caregiver to reach an optimal level of independence in self-care activities. -->increased risk for other chronic conditions. want to decrease risk for complications by maintaining as normal of a glucose level as possible. Assess pts ability to preform SMBG and insulin injection. use assistive devices as needed. **use teach-back** assess patient/caregiver knowledge and ability to manage diet, medication, and exercise teach manifestations and how to treat hyper/hypo-glycemia. early recognition can help prevent a situation. providing emotional support and comfort to verbalize concerns.

foot care

patient are at an increased risk for neuropathy due to DM which can result in ulcers, sores, and open wounds. inspect daily avoid going barefoot wear proper footwear treat cuts (let HCP know if no improvement within 24 hours or if S/S of infection/inflammation.

pt with T1DM produce little or no insulin and always require daily insulin injections to control BG levels. True False

True

oral agents for diabetes

*NOT ORAL insulin -Work to improve mechanism by which the body makes and uses insulin and glucose work on three defects of type 2 diabetes: 1. insulin resistance 2. decreased insulin production 3. increased hepatic glucose production

acute illness and surgery

-Emotional and physical stress can increase blood glucose levels!!! -check levels Q4. TEST KETONES IF bg>240 mg/dL -report if glucose levels exceed 300 mg/dL twice and there are moderate to high ketone levels. -increase insulin for type 1 diabetic that is already on insulin. -type 2 may necessitate insulin -maintain normal diet and increase noncaloric calories. if normal diet isnt possible supplement with CHO-containing fluids while continuing medications. -continue to take antidiabetic medications as the counterregulatory hormone release will still occur.

Neuropathic arthropathy (Charcot's foot)

Weakening of bones in foot-foot changes shape can eventually lead to foot drop

continuous glucose monitoring (CGM)

Wearable technology that measures blood glucose automatically; may be linked to an insulin pump could update every 5 minutes. requires an insertion device-->monitor the area for inflammation consider the correct application by the patient.

exercise

-begin slowly after medical clearance while closely monitoring the BG levels for hypoglycemia. -glucose lowering effect up to 48 hours after exercise. dependent on how active the patient was. especially prevalent in the evening. -if to strenuous of exercise, counterregulatory hormone release will occur. -exercise 1 hour after a meal. -snack to prevent hypoglycemia if exercise doesnt occur 1 hour after a meal. ***DO NOT EXERCSE IF BG> 300 ng/dL and if ketones are present in the urine.

alcohol considerations

-limit moderate amount ( 1 drink/day for women, 2 drinks/day for men.) -it inhibits gluconeogenesis by the liver which can cause SEVERE hypoglycemia -blood glucose levels must be monitored closely especially if they are drinking throughout the night. DONT confuse hypoglycemic episode with overconsumption of ETOH. -encourage CHO when drinking, focus on CHO and glucose content of the alcohol drinks. -encourage sugar free mixes or a dry wine. important teaching for adolescent and young adults.

Foot complications of diabetes

-micro and macrovascular disease increase risk for injury and infection. --clotting abnormalities, impaired immune function, autonomic neuropathy are also risk factors. --sensory neuropathy and PAD are major risk factors for amputation. **smoking increases the risk greatly!!!

hypoglycemia

a problem associated with insulin therapy. #1 tissue you will run into with insulin. absorbs quicker than expecting. there are often issues timing of the meal or the patient absorbs insulin quicker or differently than expecting.

duration of intermediate acting insulin

12-18 hours

1. After a thorough evaluation, a nurse concludes that the efforts of a client with type 2 diabetes mellitus (DM) to control blood glucose levels have been highly effective over the last 3 months. Which finding supports the nurse's conclusion? a. Hemoglobin A1C level of 5% b. No incidence of diabetic ketoacidosis (DKA) c. No ketones in the urine d. Negative oral glucose tolerance test (OGTT)

a. Hemoglobin A1C level of 5%

vitrectomy

aspiration of blood, membrane, and fibers inside the eye through a small incision just behind the cornea. used to treat diabetic retinopathy

lipodystrophy and insulin therapy

atrophy or hypertrophy of the subcutaneous tissue often limited to one site. can often be avoided by rotating sites. makes insulin absorption erratic and unpredictable.

1. A pt screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL. Which statement by the nurse is best? a. You will develop T2DM within 5 years b. You are at an increased risk for developing diabetes c. The test is normal, and diabetes is not a problem d. The lab result is positive for T2DM

b. You are at an increased risk for developing diabetes prediabetes: fasting glucose 100-125mg/dL

1. A client is having their blood sugar checked in the clinic where you work. The client states their fasting blood sugar is 118 mg/dl. The client wants to know why the physician instructed them to watch their diet and exercise to prevent diabetes. Your explanation to the client is based on the knowledge that prediabetes: a. will always lead to a diagnosis of diabetes. b. can be prevented or delayed with proper diet and exercise. c. have fasting blood sugar levels between 130 and 150 d. have less incidence of developing complications of diabetes

b. can be prevented or delayed with proper diet and exercise.

1. A client is scheduled for surgery the following morning and calls you, the nurse, who works for the client's primary care physician. The client wonders if he should take his scheduled insulin dosage before surgery the next morning. Your response is: a. "Yes, you may take your scheduled dose of insulin before surgery and we will check your blood sugar when you arrive at the ambulatory care center." b. "No, do not take any insulin before surgery because you will not eat or drink anything after midnight to prepare you for surgery." c. "I will check with your physician about if or how much insulin he/she would like you to take before surgery." d. "Check your blood sugar tomorrow morning before surgery and if it is >120mg/dl, take one half of the prescribed dose of your insulin

c. "I will check with your physician about if or how much insulin he/she would like you to take before surgery."

1. A clinic nurse is evaluating a client with type 1 diabetes who intends to enroll in a tennis class. Which statement made by the client indicates that the client understands the effects of exercise on insulin demand? a. "I will carry a high-fat, high-calorie food, such as a cookie." b. "I will administer 1 unit of lispro insulin prior to playing tennis." c. "I will eat a 15-gram carbohydrate snack before playing tennis." d. "I will decrease the meal prior to the class by 15-grams of carbohydrates."

c. "I will eat a 15-gram carbohydrate snack before playing tennis."

a pt with T1Dm calls the clinic complaining of N/V, diarrhea. it is important the nurse advises the patient to: -withhold the regular dose of insulin -drink cool fluids with high glucose content -check BG level every 2-4 hours -use a less strenuous form of exercise than usual until the illness resolves.

check BG level every 2-4 hours

nutritional therapy for diabetes (general)

counseling, education, ongoing monitoring, interprofessional team (nurses often initiate consults or assessments)

duration of short acting insulin

5-8 hours

what would the results of a fasting plasma glucose level be to indicate a diagnosis of diabetes mellitus? <90 90-100 >126 110-120

>126

peak of long acting insulin

less defined or no pronounced peak

which lab result for a glycosylated hgb or A1C shows that blood sugar has been well-controlled for the past 2-3 months? less than 7% between 12-15% less than 180 mg/dL between 90 -130 mg/dL

less than 7%

allergic reaction to insulin therapy

local inflammatory reaction. erythema, puritis, burning sensation. antihistamine and avoidance of the sight are recommended to prevent this. localized reaction and often self-limiting. very rare to have a true insulin allergy, if there is one, it would be a systemic, anaphylactic reaction.

nutritional therapy for T1DM

meal planning (based on usual food intake and preferences; is balanced with insulin and exercise patterns as these two are often coordinated) -daily consistency makes it easier to manage BG levels. -more flexibility with rapid-acting insulin, multiple daily injections, and an insulin pump

why is it important to reach and maintain glycemic goals? maximize insulin use minimize diabetes-related complications decrease weight increase self-confidence

minimize diabetes-related complications

the nurse is teaching a patient with t1DM about disease management. which statement made by the pt indicates an understanding of the teaching? i will always take my BS reading after meals insulin allows me to eat ice cream at bedtime a weigh reduction program will make my hypoglycemic my body does not produce insulin

my body does not produce insulin

travel needs

need to consider medication, supplies, food, and activity. -not to be sedentary for greater than 2 hours. -if on a plane, wear compression socks and flex/extend if sitting for a while. -use a satellite pharmacy for necessary medications. -encourage planning ahead when considering food. **pack ALL necessary medication in the carry-on in case the luggage were to be misplaced/lost. **wear a medical ID bracelet to explain the patient is diabetic. aphasia presents during hypoglycemic episodes.

frequent oral care

need to inform dentists about and chronic illness such as DM

diabetic neuropathy

nerve damage due to metabolic derangements of diabetes. -60-70% of patients with diabetes have some degree of neuropathy. -reduced nerve conduction and nerve demyelination often are major contributors to severe wounds. both sensory and peripheral nerves are included. often leads to neurotrophic ulceration that will affect the hands and feet causing deformity or impaired hand or foot movement. **notes on autonomic neuropathy to be considered.

insulin pump

portable, battery-powered device that delivers insulin through the abdominal wall in measured amounts. a continuous subcutaneous infusion. the pump is connected to a catheter inserted into subq tissue not first-line therapy, they are very expensive and the pt needs to prove competency in maintaining it. program BASAL and BOLUS doses that can vary throughout the day potential for keeping blood glucose levels in a tighter range

examples of short acting insulin

regular (Novolin R) regular (Humulin R)

microvascular angiopathy

thickening of vessel membranes in capillaries and arterioles. specific to diabetes and includes: retinopathy, nephropathy, and dermopathy. usually appears 10-20 years after diagnosis

laser photocoagulation

use of a laser beam to seal leaking or hemorrhaging retinal blood vessels to treat diabetic retinopathy most common treatment.

angiopathy

damage to blood vessels secondary to chronic hyperglycemia. -leading cause of diabetes-related death -micro and macrovascular -tight glucose levels can prevent or minimize complications (long-term effects are extensive)

diabetic nephropathy

damage to small blood vessels that supply the glomeruli of the kidney. is the leading cause of end-stage renal disease risk factors: HTN, smoking, genetics, chronic hyperglycemia, abnormal blood glucose levels

infection and diabetes

defect in mobilization and inflammatory cells and impaired phagocytosis recurring or persistent infections (often yeast infection) treat right away and aggressively patient teaching for prevention: hand hygiene; flu and pneumonia vaccine

dietary teaching

dietitian and nurse provide instruction, coordinating their efforts to avoid repeating one another. CHO COUNTING: -serving size is 15 g -typically 45-60 g/meal, dependent on the diet of the patient. -insulin dose is based on number of CHOs consumed. -in hospital, BG are going to determine how much insulin per the sliding scale. -dont overtreat the CHO count.

macrovascular angiopathy

disease of large and medium-sized blood vessels. **greater frequency and earlier onset in patients with diabetes. **can lead to cerebrovascular, cardiovascular, and peripheral vascular disease. **decrease risk factors for prevention (obesity, smoking, HTN, high fat intake, sedentary lifestyle) --> screen and treat hyperlipidemia.

medication for retinopathy

drugs that block action of vascular endothelial growth factor (VEGF) for diabetic retinopathy

nutritional therapy for T2DM

emphasis on achieving glucose, lipid, and BP goals weight loss: -->even a decrease of 5-7% total weight can help to avoid insulin therapy. -->nutritionally adequate meal plan with decreased fat and CHO -->space three small meals with small snacks in between. patients are often on a unique eating schedule. it can be difficult for the body to regulate late-night meals. --> regular exercise is imperative. set realistic goals and dont become hyper-focused so to avoid becoming hypoglycemic.

self-monitoring of BG

enables the patient to make decisions for themselves in maintaining glycemic goals. accurate record of glucose fluctuations are kept. insulin users MUST monitor BG levels. if new dx, consistency is necessary. if sliding scale, will need to checked before each meal. frequency of testing varies. it a patient has only oral anti-diabetic medications, they will rarely monitor. alternate blood sampling sites to avoid calloused areas. blood glucose monitors are recalibrated every 24 hours and utilize single-use lancets.

which of the following are CM of T2DM? select all that apply. frequent yeast infections polydipsia shaking frequent urination polyphagia

frequent yeast infections polydipsia frequent urination polyphagia

1. A diabetic client who is taking insulin lispro (Humalog) injections would be advised to eat: A. Within 30 minutes after the injection B. 1 hour after the injection C. At anytime, because timing of meals with lispro injections is unnecessary D. 2 hours before the injection

A. Within 30 minutes after the injection

goals of nutritional therapy

ADA healthy food choices -maintain BG levels as close to normal as safely possible - maintain normal lipid levels and BP (consider future complications of abnormal levels) -prevent or slow complications -consider individual and cultural preferences with diet -maintain pleasure of eating (patients often feel restricted with their diet, encourage them to explore what they can eat.)

inhaled insulin

(afrezza) -onset: 12-15 min -peak: 60 min -duration: 2.5-3 hr rapid-acting. administered at beginning of each meal or within 20 minutes after starting a meal not a substitute for long-acting insulin, is only a short-acting! poor candidates include those with chronic lung disease as bronchospasm would be a primary concern with these patients. side effects: throat irritation, cough

insulin pen

-->dial up 2 units, prime the pen once the NEW needle is on -->draw up units on MAR for the patient, clicking while drawing up could be useful for patients who have vision issues. -->make sure to inject all the way down for full, effective administration for ordered dose. --> don't throw away insulin pen. throw away the sharps --> used for rapid, short, and long-acting insulin.

autonomic neuropathy (part of the peripheral NS)

1. gastroparesis: delayed gastric emptying; anorexia, N/V, hyperglycemia due to reduced emptying. 2. cardiovascular abnormalities: postural hypotension, resting tachycardia, painless MI, 3. sexual function: ED is often one of the first signs of AN in males; decreased libido; vaginal infections 4. neurogenic bladder (decreased inner wall sensation): leads to urinary retention. TO TREAT: Crede's maneuver (messaging downwards on the abdominal/bladder wall to help with emptying. is a less-invasive option; medications; self-catheterization)

onset of intermediate acting insulin

1.5-4 hours

onset of action of rapid acting insulin

10-30 min

duration of long-acting insulin

16-24 hours

peak of short acting insulin

2-5 hours

peak of rapid acting insulin

30 min to 3 hour

onset of short acting insulin

30 minutes to 1 hour

peak of intermediate acting insulin

4-12 hours

examples of rapid acting insulin

Lispro (Humalog) Aspart (Novolog) Glulisine (Apidra)

1. A nurse administers 15 units of glargine (Lantus) insulin at 2100 hours to a Hispanic client when the client's fingerstick blood glucose reading was 110mg/dL. At 2300 hours, a nursing assistant reports to the nurse that an evening snack was not given because the client was sleeping. Which instruction by the nurse is most appropriate? a. "You will need to wake he client to check he blood glucose and then give a snack. All diabetics get a snack at bedtime." a. "It is not necessary for this client to have a snack because glargine is absorbed very slowly over 24 hours and doesn't have a peak." c. "The next time the client wakes up, check a blood glucose level and then give a snack." d. "I will need to notify the physician because a snack at this time will affect the client's blood glucose level and he next dose of glargine insulin."

a. "It is not necessary for this client to have a snack because glargine is absorbed very slowly over 24 hours and doesn't have a peak."

1. A home-health nurse is planning the first home visit for a 60-year-old client newly diagnosed with type 2 diabetes mellitus. The client has been instructed to take 70/30 combination insulin in the morning and at suppertime. Which interventions should be included in the client's plan of care for diabetics? SELECT ALL THAT APPLY. a. Instruct the client to inspect the feet daily b. Ensure that the client eats a bedtime snack c. Assess the clients ability to read small print d. Teach the client to perform a hemoglobin A1c test daily

a. Instruct the client to inspect the feet daily b. Ensure that the client eats a bedtime snack c. Assess the clients ability to read small print

1. A nurse is teaching a client who has been newly diagnosed with type 2 diabetes mellitus (DM). Which teaching point should the nurse emphasize? a. Use the arm when self-administering NPH insulin b. Exercise for 30 minutes daily, preferably after a meal c. Consume 30% of the daily calorie intake from protein foods d. Eat a 30-gram carbohydrate snack prior to strenuous activity

b. Exercise for 30 minutes daily, preferably after a meal

1. The nurse plans a class for patients who have newly diagnosed T2DM. which goal is most appropriate? a. Make all patients responsible for the management of their disease b. Involve the family and significant others in the care of these patients c. Enable the patients to become active participants in the management of the disease d. Provide the patients with as much information as soon as possible to prevent complications.

c. Enable the patients to become active participants in the management of the disease

1. The nurse is caring for a pt with T1Dm who is admitted for DKA. The nurse would expect which lab result? a. Hypokalemia b. Fluid overload c. Hypoglycemia d. Hyperphosphatemia

hypokalemia