4- INP ch 46 Diabetes mellitus and Hypoglycemia

Whipple's triad

> The presence of symptoms > Documentation of low blood glucose when symptoms occur > Improvement of symptoms when blood glucose rises

Diabetic Ketoacidosis (DKA): Late signs

- Air hunger (Kussmaul respirations), coma, and shock - Death can result without prompt medical care

Pathophysiology: Diabetes Mellitus

- Chronic disorder of impaired metabolism with vascular and neurologic complications - Key feature is elevated blood glucose, called hyperglycemia *The ingestion of carbohydrates triggers the secretion of a larger volume of insulin.*

Physical examination

- Level of consciousness, posture and gait, and apparent well-being - Vital signs, height, and weight - Skin colour, warmth, turgor, and lesions noted - Inspect eye grounds for evidence of diabetic retinopathy or cataracts - Be alert for a sweet, fruity odor to the patient's breath that is common with ketoacidosis - Carefully assess the feet - Test gait, balance, and motor coordination

* Microvascular Complications*

- Nephropathy - Retinopathy *Among people 25 to 74 years of age, DM is the leading cause of blindness. *

Risk Factors: DM

- Obesity - Sedentary lifestyle - Family history of diabetes - Age 40 years and older - History of gestational DM - History of delivering infant weighing more than 10 lb - African American (33% higher risk for type 2 DM) - Latin American/Hispanic (>300% higher risk for type 2 DM) - American Indians (33% to 50% higher risk for type 2 DM)

Possible immunologic cause of diabetes mellitus.

1) Virus 2) Macrophage activity 3) T cells and T helper cells 4) Chemicals that form 5) Gamma interferon 6) Interleukin-1 that kills 7) Insulin-producing beta cells 8) Tumor necrosis factor 9) Human leukocyte antigen

The causes of hypoglycemia may be divided into three categories

1) exogenous 2) endogenous, 3) and functional

What are the two types of diabetic retinopathy?

1) nonproliferative 2) proliferative Both types may be present at the same time.

Assessment: Hypoglycemic patient

: expect to find tachycardia, anxiety, trembling, and decreasing level of consciousness

Signs and symptoms: Acute Hypoglycemia

> *Adrenergic:* shakiness, nervousness, irritability, tachycardia, anxiety, lightheadedness, hunger, tingling or numbness of the lips or tongue, and diaphoresis > *Neuroglucopenia:* drowsiness, irritability, impaired judgment, blurred vision, slurred speech, headaches, and mood swings progressing to disorientation, seizures, and unconsciousness

Intranasal route

> Only 10% of the drug is absorbed through the nasal mucosa, making it relatively expensive to use > Nasal irritation is a frequent side effect > Only Regular insulin is given intranasally

Neuropathy

pathologic changes in nerve tissue

Why can intravenous solutions that contain high amounts of glucose cause HHNS?

total parenteral nutrition (TPN) or dialysis. In both of these procedures, intravenous solutions that contain large amounts of glucose are administered to the patient. Because the digestive system is bypassed, no stimulus triggers the pancreas to release insulin.

Insulin Therapy: Dosing schedules

*Conventional therapy* Typically uses a combination of a short-acting and an intermediate- or long-acting insulin *Intensive therapy * To achieve tight control; may require 3 or 4 injections daily *Continuous subcutaneous insulin infusion * Patient has indwelling subcutaneous catheter connected to an external portable infusion pump; pump delivers Regular insulin continuously *Exogenous insulin is administered in an effort to mimic the action of a normal pancreas.* *The preprandial (before meal) doses are adjusted for the caloric content of the meal with intensive therapy.*

Nephropathy

*Kidney damage* Diabetes is the most common cause of end-stage renal disease (ESRD) in the United States. Factors that contribute to the development of nephropathy (kidney damage) include poor control of blood glucose, hypertension, long-standing diabetes, and genetic susceptibility.

Retinopathy

*Pathological changes in the retina that are associated with DM * Signs and symptoms that suggest impending eye problems are the presence of spots "floaters" in the field of vision, seeing "cobwebs," or sudden visual changes.

Diabetic Ketoacidosis (DKA): Early signs and symptoms

- Anorexia, - headache, and fatigue As condition progresses, classic symptoms of polydipsia, polyuria, and polyphagia develop

ADA recommends

- Blood pressure: <130 systolic, <80 diastolic - Total cholesterol: <200 mg/dL - LDL: <100 mg/dL - HDL: >45 mg/dL for men (>55 mg/dL for women) - Triglyceride: <150 mg/dL

Review of systems

- Description of the patient's general health - Changes in skin moisture or turgor - Inquire whether the patient has had floaters, diplopia (double vision), or blurred vision, or has seen white halos around objects - Abdominal symptoms: diarrhea, abdominal bloating, and gas - Problems passing or holding urine - If any pain in the legs, note when it occurs - Numbness, tingling, or burning in the extremities - Changes in mental alertness or seizures

Interventions: Impaired Adjustment

- Emotional support for the patient with hypoglycemia is necessary during diagnosis and treatment. - Prepare the patient for diagnostic tests, and tell the patient what to expect. - Once the diagnosis is made, explore the patient's feelings and concerns. - Support the patient in learning to incorporate the management of hypoglycemia into his or her lifestyle. - Guide the patient to anticipate problem situations and possible solutions

Medical Treatment

- In an unconscious patient who has diabetes, hypoglycemia should be suspected until it is ruled out - The patient with a milder form of hypoglycemia - Prevention of hypoglycemia by proper food intake *-In an unconscious patient who has diabetes, hypoglycemia should be suspected until it is ruled out. *

Prediabetes

- Individuals with impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT) - Individuals should receive education on weight reduction and increasing physical activity

Interventions

- Ineffective Health Maintenance - Ineffective Therapeutic Regimen Management - Risk for Deficient Fluid Volume - Risk for Injury - Activity Intolerance - Chronic Pain - Disturbed Sensory Perception or Impaired Skin Integrity - Disturbed Thought Processes - Ineffective Coping

Endogenous hypoglycemia

- Occurs when internal factors cause an excessive secretion of insulin or an increase in glucose metabolism - These conditions may be related to tumors or genetics

Interventions: Deficient Knowledge

- Patient education is priority to prevent future occurrences - Teach patients to recognize the signs and symptoms and to treat them promptly. - teach what may trigger episodes *such as foods, medications, alcohol, fasting, and exercise.* -Basic concepts of diet described earlier need to be stressed and reinforced - A referral for a consultation with a registered dietitian may be helpful for the patient. - As a patient educator, you are very influential in promoting self-monitoring and treatment of hypoglycemia.

Medical diagnosis: *One or more of the following criteria on two separate occasions is considered DM*

- Polyuria, polydipsia, polyphagia, unexplained weight loss plus random glucose level >200 mg/dLl - Fasting serum glucose level >126 mg/dl (after at least an 8-hour fast) - Two-hour postprandial glucose level >200 mg/dl during oral glucose tolerance test (OGTT) under specific guidelines. Test must use a glucose load of 75 g of anhydrous glucose dissolved in water

Exogenous hypoglycemia

- Results from outside factors acting on the body to produce a low blood glucose - Include insulin, oral hypoglycemic agents, alcohol, or exercise

Interventions: Risk for injury

- The hypoglycemic patient is at risk for injury as a result of weakness and dizziness. - Be alert for signs and symptoms of hypoglycemia. - Monitor serum glucose levels. Administer carbohydrates as prescribed by the physician. - Until the episode passes, keep the patient in bed with the side rails up and the call bell nearby. - Advise the patient not to get up unassisted

Hypoglycemic Unawareness

- The usual symptoms of tachycardia, palpitations, tremor, sweating, and nervousness may be absent - Patient may suddenly have changes in mental status as the first sign of hypoglycemia

Patient goes into a coma from extremely high glucose levels (>600 mg/dl)

- There is no evidence of elevated ketones - Pancreas produces enough insulin to prevent breakdown of fatty acids and formation of ketones, but not enough to prevent hyperglycemia

Risk Factors: Metabolic syndrome

- Thought to be a precursor to diabetes - Impaired glucose tolerance, high serum insulin, hypertension, elevated triglycerides, low HDL cholesterol, altered size and density of LDL cholesterol - Believed that metabolic syndrome is a chronic low-grade inflammatory process affecting endothelial tissue - Long-term effects: atherosclerosis, ischemic heart disease, left ventricular hypertrophy, type 2 DM - Research directed at learning how to detect this syndrome early and what interventions might slow or arrest the progress

> Past medical history

- Type and duration of DM - Name and dosage of prescribed medications and when they were last taken - If patient monitors blood glucose, record type of equipment used, testing schedule, recent test results

What are the goals of medical nutrition therapy?

1) Attain and maintain optimal metabolic outcomes (glucose, lipids, blood pressure [BP]). 2) Prevent and treat the chronic complications of diabetes (obesity, dyslipidemia, cardiovascular disease, hypertension, nephropathy). 3) Improve health through healthy food choices and physical activity. 4) Address individual nutritional needs while considering lifestyle, personal, and cultural preferences. 5) Attaining or maintaining a realistic weight

*Diabetic Ketoacidosis (DKA): Treatment aimed at correction of three main problems*

1) Dehydration 2) Electrolyte imbalance 3) Acidosis

What sequence of events occurs with DKA?

1) Tissues cannot use glucose without insulin, resulting in an increase in serum glucose levels. 2) Excess glucose entering the renal tubules increases osmotic pressure. This results in the reabsorption of water, increasing urine output (i.e., osmotic diuresis). As glucose is eliminated in the kidneys, so are large amounts of water and electrolytes. 3) The patient voids large amounts of dilute urine (i.e., polyuria). 4) To make matters worse, the sympathetic nervous system responds to the cellular need for fuel by converting glycogen to glucose and manufacturing additional glucose. 5) As glycogen stores are depleted, the body begins to burn fat and protein for energy. 6) The breakdown of fat and protein for energy produces acidic substances called ketone bodies. As the ketones accumulate, the pH of the blood decreases and results in severe acidosis, which can be fatal. 7) Protein metabolism results in the loss of lean muscle mass and a negative nitrogen balance (the amount of nitrogen being excreted is greater than the amount of nitrogen ingested).

What are the three "Ps" related to symptoms of DM?

1) polyphagia 2) polidipsia 3) polyuria

Assessment : Ketoacidosis:

: ketonuria, Kussmaul respirations, orthostatic hypotension, hypertension, nausea, vomiting, lethargy, or change in level of consciousness

> Combination oral medications

> ACTOplus met (pioglitazone and metformin), > Avandamet (rosiglitazone and metformin), > Avandaryl (rosiglitazone and glimepiride), > Glucovance (glyburide and metformin), > Metaglip (glipizide and metformin)

Type 1: DM

> Absence of endogenous insulin *Formerly called juvenile-onset diabetes because it most commonly occurs in juveniles and young adults * > An autoimmune process, possibly triggered by a viral infection, destroys beta cells, the development of insulin antibodies, and the production of islet cell antibodies (ICAs) > Affected people require exogenous insulin for the rest of their lives

* Macrovascular Complications*

> Accelerated atherosclerotic changes in the person with diabetes > Associated with coronary artery disease (CAD), cerebral vascular accidents (CVA or stroke), and peripheral vascular disease (PVD) > Individuals with diabetes have a 2- to 4-fold increased risk for heart disease and stroke, which accounts for 65% of the deaths in people with diabetes. > Treatment for macrovascular disease is directed toward weight loss and exercise.

Insulin Therapy

> All patients with type 1 disease need insulin injections; some patients with type 2 disease may eventually need insulin > Insulins classified by source and course of action - Source: human, pork, or beef (beef is being phased out) - Course of action: rapid acting, short acting, intermediate acting, and long acting *All rapid-acting and short-acting insulins are clear The other insulins are cloudy* *"Human" insulin causes fewer problems than that from animal sources. *

Self-Monitoring of Blood Glucose

> Allows patients to monitor blood glucose levels to regulate their diet, exercise, and medication regimens to remain euglycemic > Portable electronic glucose meters have largely replaced other methods of self-monitoring *The self-monitoring of blood glucose levels is seen as the greatest breakthrough in managing diabetes since the advent of insulin. *

Cause

> An autoimmune malfunction may cause complete destruction of the islets of Langerhans in the pancreas, creating type 1 diabetes > Islet cell antibodies are identified in more than 80% of all people with type 1 diabetes at the time of diagnosis

Assessment

> Be alert for indications of hyperosmolar nonketotic coma > Hypoglycemic patient: >Ketoacidosis: > Attempt to determine: - Type of diabetes - Hypoglycemic agents: name, dosage, when last dose was taken - Food and fluid intake for the past 3 days - Relevant laboratory values: blood glucose, blood pH, bicarbonate levels, electrolytes, and osmolality and urine osmolality

hyperglycemia

> Blood glucose level normally regulated by insulin, a hormone produced by beta cells in the islets of Langerhans located in the pancreas

Health History:

> Chief complaint and history of present illness > Past medical history > Family history > Review of systems > Functional assessment > Physical examination

Insulin Therapy: Premixed insulin products

> Contain both Regular and NPH insulin > 70% NPH and 30% Regular insulin > 50% NPH and 50% Regular insulin > 75% NPH and 25% Lispro

Learning Objectives

> Describe the role of insulin in the body. > Explain the pathophysiology of diabetes mellitus and hypoglycemia. > Describe the signs and symptoms of diabetes mellitus and hypoglycemia. > Explain tests and procedures used to diagnose diabetes mellitus and hypoglycemia. > Discuss treatment of diabetes mellitus and hypoglycemia. > Explain the difference between type 1 and type 2 diabetes mellitus. > *Differentiate between acute hypoglycemia and diabetic ketoacidosis.* > Describe the treatment of a patient experiencing acute hypoglycemia or diabetic ketoacidosis. > Describe the complications of diabetes mellitus. > Identify nursing interventions for a patient diagnosed with diabetes mellitus or hypoglycemia. > Identify nursing interventions for a patient diagnosed with ketoacidosis.

*Hypoglycemia: Pathophysiology*

> Develops when the blood glucose level falls to less than 45 to 50 mg/dl > Symptoms occur at different blood levels according to individual tolerances and how rapidly the level falls > Hypoglycemia may result from causes other than the pharmacologic treatment for diabetes. > *The causes of hypoglycemia may be divided into three categories: exogenous, endogenous, and functional *

Long-Term Complications: Prevention

> Diabetes Control and Complications Trial (DCCT): intensive treatment of type 1 DM delayed the onset or slowed the progress of diabetic retinopathy, nephropathy, and neuropathy > Outcome of United Kingdom Prospective Diabetes Study (UKPDS): similar benefits of tight control with type 2 DM *Tight control means that the blood glucose is maintained in the normal range with carefully balanced drugs, diet, and exercise.*

Oral glucose tolerance test

> Diet of 150 to 300 g carbohydrate for 3 days before test > Night before test, patient fasts after midnight > Morning of test, blood drawn for fasting serum glucose > Patient then given a drink (Glucola) containing 75 g of carbohydrates and instructed to remain quiet > Blood drawn at 30 minutes and 1 hour after the ingestion of glucose. After these two samples, blood is drawn at hourly intervals until the test is completed

Exercise

> Effective adjunct for people with diabetes > Aids in weight loss, improves cardiovascular conditioning, improves insulin sensitivity, and promotes a sense of well-being > Exercising muscle uses glucose at 20 times the rate of a muscle at rest and does not require insulin *Exercise is known to improve low-density lipoproteins, serum glucose, blood pressure, some blood coagulation parameters, and triglycerides. * *It is important for individuals with diabetes to monitor blood glucose levels before and after exercise.*

*Role of Insulin:* Protein

> Enhances protein synthesis in tissues and inhibits the conversion of protein into glucose > Amino acids are admitted into cells; enhances rate of protein formation while preventing protein degradation > Without adequate insulin, protein storage halts; large amounts of amino acids dumped into the bloodstream > High levels of plasma amino acids place people with diabetes at risk for development of gout > Changes in protein metabolism lead to extreme weakness and poor organ functioning

Causes

> Exogenous hypoglycemia > Endogenous hypoglycemia > Functional hypoglycemia

Acute Hypoglycemia: *treatment*

> Give patient 10 to 15 g of quick-acting carbohydrates > Repeat every 15 to 30 minutes until blood glucose is >70 mg/dl for adults, 80 to 100 mg/dl for older adults and children >If patient is unable to swallow, an IM or subcutaneous injection of 1 mg of glucagon or an IV dose of 50 ml of 50% dextrose should be given as ordered or per protocol

Signs and Symptoms

> Glucose level falls rapidly, causes epinephrine, cortisol, glucagon, and growth hormone to be secreted in an attempt to increase glucose levels Symptoms: - weakness, - hunger, - diaphoresis, - tremors, - anxiety, - irritability, - headache, - pallor, and - tachycardia > A blood glucose level that falls over several hours: symptoms attributed to lack of essential glucose to brain tissue Symptoms: - confusion, - weakness, - dizziness, - blurred or double vision, - seizure, and in severe cases, coma

Glycosylated Glucose Levels

> Glycosylated hemoglobin (HbA1c) reflects glucose levels over the past few months > Fructosamine levels reflect those over several weeks

Oral Hypoglycemic Agents

> If patients with type 2 DM unable to control blood glucose with nutrition and exercise, physician may prescribe oral hypoglycemics > Sulfonylureas (three generations), alpha-glucosidase inhibitors, biguanides, thiazolidinediones, D-phenylalanines, meglitinides > Combination oral medications

Type 2: DM

> Inadequate endogenous insulin and body's inability to properly use insulin > Beta cells respond inadequately to hyperglycemia; results in chronically elevated blood glucose > Continuous high glucose level in the blood desensitizes the beta cells; they become less responsive to the elevated glucose > More common in adults; increasing in children > Controlled by diet and exercise; may require oral hypoglycemic agents or exogenous insulin

*Role of Insulin:* Glucose

> Insulin stimulates active transport of glucose into cells > If insulin absent, glucose remains in the bloodstream > Blood becomes thick, which increases its osmolality > Increased osmolality stimulates the thirst center > Increased fluid does not pass into body tissues; high serum osmolality retains fluid in the bloodstream > As blood passes through the kidneys, some glucose eliminated > Osmotic force created by glucose draws extra fluid and electrolytes with it, causing abnormally increased urine volume

Diabetic Ketoacidosis (DKA)

> Life-threatening emergency caused by a relative or absolute deficiency of insulin > If untreated, patient becomes: - Dehydrated - weak - lethargic with abdominal pain - Nausea/ vomiting - Fruity breath - increased respirations - Tachycardia - blurred vision - Hypothermia *The patient with ketoacidosis has hyperglycemia (300 mg/dl); ketonuria; and acidosis, with a pH of less than 7.3 or a bicarbonate level of less than 15 mEq/L.* 300= 16.7 mmol/L

Foot Complications of Diabetes

> May have foot problems associated with neuropathy, inadequate blood supply, or a combination > Mechanical irritation > Thermal injury > Chemical irritation *The patient may have a foot injury but fail to recognize it in the absence of pain.*

Insulin pump

> Needle is inserted subcutaneously in an appropriate part of the anatomy > Pump is programmed to deliver a steady trickle of insulin throughout the day and can provide a bolus of insulin at mealtimes >*Consists of a battery-driven syringe with a long piece of tubing (usually made of Teflon) that is attached to a small needle. * > *One advantage of the external insulin pump is that patients do not have to use intermediate- or long-acting insulins, with their uncertain peaks and valleys. * A, MiniMED 507 external insulin pump with Quick-Release Infusion Set. B, MiniMED 2001 implantable insulin pump and handheld programmer.

* Neuropathic Complications* :

> Neuropathy > Mononeuropathy affects a single nerve or group of nerves > Polyneuropathy involves both sensory and autonomic nerves > Autonomic neuropathy affects the sympathetic and parasympathetic nervous systems > *Almost 30% of individuals older than age 40 with diabetes have impaired sensation in as least one area of the foot. *

Insulin Therapy: Route

> Oral: insulin cannot be given orally because it is rendered useless in the gastrointestinal tract > Subcutaneously: all insulins can be given subcutaneously > Intravenously: ONLY regular insulin can be given intravenously > Inhalation: a form of insulin that can be taken by inhalation has recently been approved, but it is not yet widely used

Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)

> Patient goes into a coma from extremely high glucose levels (>600 mg/dl) > Persistent hyperglycemia causes osmotic diuresis, resulting in loss of fluid and electrolytes > Dehydration and hypernatremia develop > May be caused by the same factors that trigger ketoacidosis - *Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) may be caused by the same factors that trigger ketoacidosis.* - It also can be brought about by total parenteral nutrition or dialysis.

Assessment: hypoglycemia

> Present illness: shakiness, nervousness, irritability, tachycardia, anxiety, lightheadedness, hunger, tingling or numbness of the lips or tongue, nightmares, and crying out during sleep > Note when episodes occur in relation to meals and particular food intake > The past medical history documents diabetes, previous gastric surgery, abdominal cancer, or adrenal insufficiency > Medications, paying particular attention to hypoglycemic agents > Note hypoglycemic agents, prescribed dose, and the time last dose taken > Functional assessment: information about current diet, exercise, alcohol intake, and the effects of symptoms on daily activities > Important aspects of the physical examination include general behavior, appearance, pulse, and blood pressure

*Role of Insulin:* Fatty acids

> Promotes fatty acid synthesis and conversion of fatty acids into fat, which is stored as adipose tissue > Also spares fat by inhibiting breakdown of adipose tissue and mobilization of fat and by inhibiting the conversion of fats to glucose > Without adequate insulin, fat stores break down and increased triglycerides are stored in the liver > Increased fatty acids in the liver can triple the production of lipoproteins; promotes atherosclerosis

Insulin injection

> Site rotation helps prevent lipohypertrophy or lipoatrophy > Absorption rate varies with different body sites > American Diabetes Association recommends rotating sites within one anatomic area rather than moving among all areas > See Figure 46-3 > *The rate of absorption from the abdomen is approximately 50% faster than from the thighs. *

Causes of acute hypoglycemia

> Taking too much insulin, not eating enough food or not eating at the right time, an inconsistent pattern of exercise > Gastroparesis, renal insufficiency, and certain drugs including aspirin and beta-adrenergic blockers

Medical Diagnosis

> The diagnosis of hypoglycemia not associated with diabetes can be based on fasting blood glucose, OGTT, intravenous glucose tolerance test, and 72-hour inpatient fasting > Whipple's triad

Prevention of hypoglycemia by proper food intake

> The diet is directed by the underlying cause > If overproduction of insulin after carbohydrate ingestion, a low-carbohydrate, high-protein diet > Restriction of carbohydrates to no more than 100 g/day is recommended > Simple sugars avoided; complex carbohydrates encouraged > Patients may tolerate smaller, more frequent meals. Alcohol should be avoided

Insulin Therapy: Concentrations

> U-100 insulin has 100 units/ml Most commonly used > U-500 insulin has 500 units/ml Used only in emergencies and for patients who are extremely insulin resistant > U-40 insulin has 40 units/ml Not available in the United States

The patient with a milder form of hypoglycemia

>* Treated with 15 g carbohydrate If the patient's condition does not improve, another > 15 g of carbohydrate should be given after 10 minutes*

In an unconscious patient who has diabetes, hypoglycemia should be suspected until it is ruled out

>*50 ml of 50% glucose solution should be administered immediately *

Nutritional management

Medical nutrition therapy (MNT) is an important part of diabetes management; should be included in diabetes self-management education - *Because of complexity of nutritional management, a registered dietitian should be part of the diabetes management team, and the individual with diabetes should be included in decision making* > To maintain weight, a caloric intake of 28 calories/kg of body weight is required. > To reduce weight, the caloric intake is calculated based on 15 to 20 calories/kg body weight. > Patient teaching should include sample menus that include as many favorite foods as possible.

What is syndrome X?

Metabolic syndrome is a group of five risk factors that can increase your chance of developing heart disease, diabetes, and stroke. The five risk factors include: > increased blood pressure (greater than 130/85) > high blood sugar levels (insulin resistance) > excess fat around the waist > high triglyceride levels > low levels of good cholesterol, or HDL

What percentage of people who have had DM for more than 25 years experience neuropathies?

Neuropathy affects approximately 13% of all people with diabetes. *Patients who have had diabetes for more than 25 years have a 50% chance of experiencing neuropathies. Neuropathy can be classified as mononeuropathy, polyneuropathy, or autonomic neuropathy.*

What are examples of quick-acting carbohydrates?

• 4-6 oz of undiluted orange or apple juice, soft drink (not sugar free) • 8 oz skim milk • 1 tablespoon of sugar • 1 tablespoon of honey or syrup • 6-8 Life Savers • 3-4 glucose tablets or 15 g of glucose gel

What fasting glucose levels indicate IFG? IGT?

• IFG: fasting plasma glucose level from 100 to 125 mg/dl *5.6 -6.9* • IGT: 2-hour plasma glucose between 140 and 199 mg/dl during OGTT *7.8 - 11.1*

Complications of Therapy: Somogyi phenomenon

Rebound hyperglycemia in response to hypoglycemia *The Somogyi phenomenon should be suspected when a patient reports awakening with a headache, and complains of restless sleep, nightmares, enuresis (involuntary voiding during sleep), and nausea and vomiting. *

What is the recommended amount of carbohydrates per day?

Restriction of carbohydrates to no more than 100 g/day is recommended Simple sugars are avoided, and complex carbohydrates are encouraged. Because no significant increase in blood glucose is noted with protein ingestion, a high-protein diet is recommended. If the cause is related to an overproduction of insulin after carbohydrate ingestion, then a low-carbohydrate, high-protein diet is commonly ordered

> Chief complaint and history of present illness

Signs/symptoms that prompted patient to seek medical care

Proliferative disease is characterized

by the growth of abnormal capillaries on the retina and the optic disc. These fragile vessels can penetrate the vitreous humor and rupture. When hemorrhaging into the vitreous occurs, it becomes cloudy and vision is lost. The blood is eventually reabsorbed, but scars may remain, which places traction on the retina and may result in retinal detachment.

What vessels are affected by atherosclerosis?

mostly larger, high-pressure vessels such as the coronary, renal, femoral, cerebral, and carotid arteries.

Table 46-4 Exogenous, Endogenous, and Functional Causes of Hypoglycemia in Adults

CAUSES PREDISPOSING FACTORS OCCURRENCE Exogenous Causes Insulin: Intentional or accidental overdose; may be combined with inadequate food intake, usually increased exercise, decrease in insulin requirement, or potentiating medications Most frequent cause of hypoglycemia Oral hypoglycemic agents Intentional or accidental overdose; may be combined with inadequate food intake, increased exercise, or potentiating medications Frequent cause of hypoglycemia with sulfonylurea and meglitinide agents Alcohol Particularly likely in chronically malnourished or acutely food-deprived people Occurs within 6-36 hours of ingesting moderate to large amounts of alcohol Exercise Increased duration and intensity of exercise increases glucose uptake and normally decreases insulin secretion Occurs with both insulin sulfonylurea administration and intense exercise but may be unpredictable in onset Endogenous Causes Organic hypoglycemia Insulinoma (a tumor of the beta cells of the pancreatic islets of Langerhans) Uncommon neoplasm of beta cells of islets of Langerhans Extrapancreatic neoplasms May be mesenchymal tumors, hepatomas, adrenocortical carcinomas, gastrointestinal (GI) tumors, lymphomas, or leukemias Rare; most common in adults 40-70 years old Functional Causes Alimentary hypoglycemia Rapid dumping of carbohydrates into upper small intestine Postgastrectomy Drug-related (ethanol, haloperidol, pentamidine, salicylates) reactive hypoglycemia Syndrome with symptoms such as diaphoresis, tachycardia, tremulousness, headache, fatigue, drowsiness, and irritability Rarely diagnosed throughout the world; widely diagnosed in the United States, prompting American Diabetes Association and Endocrine Society to issue statement that entity is probably overdiagnosed Abrupt discontinuation of hyperalimentation Drinking alcohol on an empty stomach More common with drinks containing saccharin (e.g., beer, gin and tonic, rum and cola, whiskey and ginger ale) Rapid discontinuation of total parenteral alimentation Endocrine deficiency states (cortisol, growth hormone [GH], glucagons, epinephrine) Easily prevented Glucocorticoid deficiency Critical illness (cardiac, hepatic, and renal disease) A danger for any person with adrenal insufficiency Severe liver deficiency Insufficient glucose output by liver Fasting hypoglycemia Lack of body stores for protein, fat, and carbohydrates Profound malnutrition Common; also found with relative frequency in kwashiorkor Prolonged muscular exercise Metabolism of energy- producing substances Occurs if exercise is too prolonged or severe or if nutritional intake and carbohydrate stores are insufficient

Functional hypoglycemia

From a variety of causes, including gastric surgery, fasting, or malnutrition

Complications of Therapy: Hypoglycemia

A person injects too much insulin, does not eat enough, eats at the wrong time, or exercises inconsistently: glucose levels may suddenly drop

Why would a patient be asked for a 24-hour dietary history?

A typical 24-hour dietary history is useful in evaluating how well the patient understands and adheres to the prescribed diet.

Complications of Therapy: Dawn phenomenon

An increase in fasting blood glucose levels between 5 and 9 AM that is not related to hypoglycemia

How can the need for multiple venipunctures be eliminated?

Because blood must be drawn several times, it may be best to insert a heparin lock into the vein at the time blood is obtained for the fasting blood sugar. This eliminates the need for multiple venipunctures.

Acute Hypoglycemia

Dangerous drop in blood glucose

> Family history

Diabetes, heart disease, stroke, hypertension, hyperlipidemia

What is the difference in endogenous and exogenous insulin?

Endogenous: insulin, that is internal and created by the person Exogenous: external insulin

Functional assessment

Explore factors that can affect patient's ability to perform self-care, including literacy, financial resources such as health insurance, and family support The impact of diabetes on the patient's life should be explored, including self-concept, social relationships, and employment.

What glucose levels are considered moderate hypoglycemia?

Glucose levels between 50 and 70 mg/dl are considered moderate hypoglycemia. However, some people with diabetes have been known to have serum glucose levels below 50 mg/dl without signs and symptoms of hypoglycemia 2.8 mmol/l - 3.9mmol/L

Insulin catheter

Indwelling subcutaneous catheters may be placed in the abdomen to permit repeated insulin injections without repeated needlesticks

Manifestations of nonproliferative disease

include small hemorrhages and aneurysms in the retina, hard lipid and protein exudates that leak from the blood vessels, infarcted nerve fibers (described as "cotton wool spots"), and changes in retinal veins.

Role of Insulin

The patient may take in more food but, unfortunately, cannot use the extra glucose without insulin. Weight loss occurs despite increased appetite and food ingestion.

What is hypoglycemic unawareness attributed to?

This phenomenon has been attributed to autonomic neuropathy, but that relationship has not been consistently demonstrated.

How can the Somogyi phenomenon be confirmed?

To confirm suspected Somogyi phenomenon, the patient's blood glucose needs to be measured between 2 and 4 AM and again at 7 AM. The 2 and 4 AM levels below 60 mg/dl *(3.3mmol)*and a 7 AM level above 180 mg/dl *(10 mmol)* support the diagnosis of Somogyi phenomenon. This vicious cycle can be broken by gradually decreasing the evening dose of exogenous insulin by 2 or 3 unitsevery 3 or 4 days until the rebound hyperglycemia is brought under control. A bedtime snack also may be helpful.

*What is the best treatment for foot complications?*

Treatment is difficult and not always effective, so the best treatment is prevention.

Insulin mixing

Two types can be mixed in one syringe to avoid two injections

What medications are recommended for patients with increased cardiovascular risks?

Use of aspirin and ACE inhibitors is recommended for those with increased cardiovascular and renal risk factors.

What is largely responsible for maintaining glucose levels during exercise?

exercise must be accompanied by appropriate nutrition to have long-term beneficial results. Exercising muscle uses glucose at 20 times the rate of a muscle at rest and does not require insulin. have a small snack before exercise *Before Exercise* • Patients should be careful about exercising after skipping a recent meal. • Patients who take insulin should ask their health care team whether they should change their dosage before engaging in physical activity. *During Exercise* • Patients should wear a medical identification bracelet or other form of identification . • Patients with type 2 DM should always carry food or glucose tablets so that they are prepared to treat hypoglycemia. If patients exercise for more than 1 hour, blood glucose should be checked at regular intervals. *After Exercise* • Patients should check to see how exercise affected their blood glucose level.