Care of Patients with Diabetes and Hypoglycemia

What is diabetic ketoacidosis, and how is it treated?

Diabetic ketoacidosis is a serious condition caused by incomplete metabolism of fats due to the absence or an insufficient supply of insulin. Treatment consists of fluids, insulin, and correction of electrolyte imbalances. Electrolytes, especially potassium, and serum glucose are monitored closely.

How is the diagnosis of hypoglycemia achieved?

Diagnosis of hypoglycemia is done with measurement of blood sugar values. The patient's insulin levels and C-peptide levels can also be measured. The diagnosis of reactive hypoglycemia may be made using a glucose tolerance test. To diagnose spontaneous hypoglycemia, a medically supervised fast may be used. Computed tomography scanning, ultrasound, and other diagnostics may be utilized if an insulinoma (insulin-secreting tumor) is suspected.

How can people with type 2 diabetes control their blood glucose?

In most cases, people with type 2 diabetes can control their blood glucose by reducing caloric intake and increasing physical exercise. In addition, oral hypoglycemic agents or antidiabetic agents may be prescribed for patients with type 2 diabetes to manage their blood glucose level. If control is difficult to maintain, then insulin may be added to the treatment plan.

How are insulin pumps helpful in managing diabetes?

Insulin pumps are helpful in managing diabetes because they allow for improved blood glucose control. Also, people using pumps tend to have fewer episodes and less severe hypoglycemia when compared with those taking multiple daily injections.

Describe the signs and symptoms of hypoglycemia.

Signs and symptoms of hypoglycemia include rapid heartbeat, tremulousness, weakness, anxiety, nervousness, and hunger. In reactive hypoglycemia, the signs and symptoms occur rather suddenly, within 4 hours after a meal is eaten. Some physiologic symptoms may be mistaken for indications of a psychiatric illness. These symptoms include irritability, personality change, temper tantrums, and other psychoneurotic manifestations.

When developing an exercise program for a patient with diabetes, what specific strategies must you incorporate?

The exercise program should be designed for the individual patient. The plan should consider the age and overall physical condition of the patient, his ability to carry out the exercises regularly, and how well controlled the diabetes is. All exercise programs should begin with milder forms of exercise and gradually increase until the patient's level of tolerance or the desired therapeutic effect is reached. A program should not be started until the blood glucose is under control. The exercise program should be planned so that the exercises are performed at the same time every day, preferably after a meal, when the blood glucose is highest. Blood glucose should be checked before beginning to exercise. The patient is encouraged to wear a MedicAlert bracelet and to exercise with a friend who knows the signs and symptoms of hypoglycemia and how to treat it. Every person with diabetes should have emergency supplies for treatment of hypoglycemia available when exercising. Physical limitations may discourage older adults with diabetes from exercising. Exercise should begin slowly and build up to 30 to 45 minutes three or four times a week.

Name the four sets of factors that influence the development of diabetes mellitus.

The four sets of factors that influence the development of diabetes mellitus are: (1) genetic, (2) metabolic, (3) microbiologic, and (4) immunologic.

Explain the mnemonic "clear to cloudy" as an easy way to remember which insulin to draw first when mixing regular insulin and a long-acting insulin.

The mnemonic "clear to cloudy" is an easy way to remember which insulin to draw up first. The clear (regular) insulin is drawn up first, followed by the cloudy (longer acting) insulin. The way to remember that clear comes first is that alphabetically, the word clear comes before the word cloudy.

Compare the symptoms of type 1 diabetes with the symptoms of type 2 diabetes.

The symptoms of type 1 diabetes are extreme thirst (polydipsia), frequent urination (polyuria), extreme hunger (polyphagia), rapid loss of weight, irritability, and weakness and fatigue. A patient with type 2 diabetes may experience polydipsia, polyuria, and polyphagia, and often has a family history of diabetes mellitus. Type 2 diabetics more commonly experience excessive weight gain; poor healing of scratches, abrasions, and wounds; blurred vision; itching; drowsiness; increased fatigue; and tingling or numbness in the feet.

Explain what happens when a person becomes hypoglycemic.

When hypoglycemia occurs, the body secretes glucagon, epinephrine, growth hormone, and cortisol to counteract the effects of low blood sugar. This increase in circulating hormones with falling insulin levels and the rise in glucose production from the liver raises blood glucose excessively. Insulin resistance also may occur for 12 to 48 hours because of the action of the released hormones. Often the Somogyi effect occurs when unrecognized hypoglycemia occurs during sleep. By morning, when the patient checks the blood glucose, the released hormones have caused elevated serum glucose. The patient thus increases the insulin dose, worsening the problem. The patient may report nightmares and night sweats, along with morning elevated serum glucose and ketones in the urine.