Chapter 48 Diabetes Mellitus STUDY GUIDE

Individualized nutrition therapy for patients using conventional, fixed insulin regimens should include teaching the patient to

Eat regular meals at regular times The body requires food at regularly spaced intervals throughout the day, and omission or delay of meals can result in hypoglycemia, especially for the patient using conventional insulin therapy or OAs. Weight loss may be recommended in type 2 diabetes if the individual is overweight, by many patients with type 1 diabetes are thin and do not requires a decease in caloric intake. Fewer than 7% of total calories should be from saturated fats and simple sugar should be limited, but moderate amounts can be used if counted as a part of total carbohydrate intake.

Which class of oral glucose-lowering agents (OA) is *most* commonly used for people with type 2 diabetes because it reduces hepatic glucose production and enhances tissue uptake of glucose?

Biguanide Biguanides (e.g., metformin [Glucophage]) are most commonly used with type 2 diabetes. They reduce glucose production by the liver and incrase insulin sensitivity at the tissue level that improves glucose transport into the cells. Insulin is not taken orally, as it is ineffective. Meglitinides and sulfonylureas increase insulin production from the pancreas.

What are manifestations of diabetic ketoacidosis (DKA) (select all that apply)?

- Thirst - Ketonuria - Dehydration - Metabolic acidosis - Kussmaul respirations - Sweet, fruity breath In DKA, thirst occurs to replace fluid used to eliminate ketones in the urine in trying to decrease the blood glucose and ketonemia. The metabolic acidosis leads to the Kussmaul respirations trying to decrease the acid in the system. The sweet, fruity breath odor is from acetone. Thirst and dehydration are found with both DKA and HHS.

When teaching the patient with diabetes about insulin administration, the nurse should include which instruction for the patient?

Consistently use the same size of insulin syringe to avoid dosing errors U100 insulin must be used with a U100 syringe but for those using low doses of insulin, syringes that have increments of 1 unit instead of 2 units are available. Errors can be made in dosing if patients switch back and forth between different sizes of syringes. Aspiration before injection of the insulin is no longer recommended, nor is the use of alcohol to clean the skin. Because the rate of peak serum concentration varies with the site selected for injection, injections should be rotated within a particular area, such as the abdomen, before changing to another area.

A nurse working in an outpatient clinic plans a screening program for diabetes. What recommendations for screening should be included?

FPG for all individuals at age 45 and then every 3 years The American Diabetes Association recommends that testing for type-2 diabetes with a FPG, A1C, or 2-hour OGTT should be considered for all individuals at the age of 45 and above and, if normal, repeated every 3 years. Testing for immune markers of type 1 diabetes is not recommended. Testing at a younger age or more frequently should be done for members of a high-risk ethnic population, including African Americans, Hispanics, Native Americans, Asian Americans, and Pacific Islanders. Overweight adults with additional risk factors should be tested.

A 72-year-old woman is diagnosed with diabetes. What does the nurse recognize about the management of diabetes in the older adult?

It is more difficult to achieve strict glucose control than in younger patients Older adults have more conditions that may be treated with medications that impair insulin action. Hypoglycemic unawareness is more common, so these patients are more likely to suffer adverse consequences from blood glucose-lowering therapy. Clinical manifestations of long-term complications of diabetes take 10 to 20 years to develop, so the goals for glycemic control are not as rigid as in the younger population. Treatment is indicated and insulin may be used if the patient does not respond to oral agents. The patient's needs rather than age determine the responsibility of others in care.

The nurse is assessing a newly admitted patient with diabetes. Which observation should be addressed as the *priority* by the nurse?

Rapid respirations with deep inspiration Rapid deep respirations are symptoms of diabetic ketoacidosis (DKA), so this is the priority of care. Stage II pressure ulcers and bilateral numbness are chronic complications of diabetes. The lumps and dents on the abdomen indicate the patient has lipodystrophy and may need to learn about site rotation of insulin injections.

A patient with diabetes is learning to mix regular insulin and NPH insulin in the same syringe. The nurse determines that additional teaching is needed when the patient does what?

Withdraws the NPH dose into the syringe first When mixing regular and intermediate-acting insulin, regular insulin should always be drawn into the syringe first to prevent contamination of the regular insulin vial with intermediate-acting additives. Air is added to the NPH vile first. Then air is added to the regular vial and the regular insulin is withdrawn, bubbles are removed, and then the dose of NPH is withdrawn.

What characterizes type 2 diabetes (select all that apply)?

- β-cell exhaustion - Insulin resistance - Genetic predisposition - Altered production of adipokines - Inherited defect in insulin receptors - Inappropriate glucose production by the liver Type 2 diabetes is characterized by β-cell exhaustion, insulin resistance, genetic predisposition, altered production of adipokines, inherited defect in insulin receptors, and inappropriate glucose production by the liver. The roles of the brain, kidneys, and gut in type 2 diabetes development are being studied.

Which patient should the nurse plan to teach how to prevent or delay the development of diabetes?

A 34-year-old woman whose parents both have type 2 diabetes Type 2 diabetes has a strong genetic influence (8%-14% risk for offspring) and offspring of parents who both have type 2 diabetes have an increased chance of developing it. In contrast, type 1 diabetes is associated with a genetic susceptibility that is related to human leukocyte antigens (HLAs). Offspring of a mother with type 1 diabetes have a 1%-4% chance of developing the disease, while offspring of a father with diabetes have 5%-6% risk. Other risk factors for type 2 diabetes include obesity; Native American, Hispanic, of African American descent; and age of 55 years or older. Although 50% of people with a parent with maturity-onset diabetes of the young (MODY) will develop MODY, it is autosomal dominant, and treatment depends on which genetic mutation caused it. It is not associated with obesity or hypertension and is not currently considered preventable.

To prevent hyperglycemia of hypoglycemia related to exercise, what should the nurse teach the patient using glucose-lowering agents about the *best* time for exercise?

Plan activity and food intake related to blood glucose levels To plan for exercise, a person with diabetes must monitor blood glucose and make adjustments to insulin dose (if taken) and food intake to prevent exercise-induced hypoglycemia. Exercise is delayed if blood glucose is ≥ 250 mg/dL with ketones. Before exercise if blood glucose is ≤ 100 mg/dL a 15-g carbohydrate snack is eaten. Blood glucose levels should be monitored before, during, and after exercise to determine the effect of exercise on the levels.

Which tissues require insulin to enable movement of glucose into the tissue cells (select all that apply)?

- Adipose - Skeletal muscle Adipose tissue and skeletal muscle require insulin to allow the transport of glucose into the cells. Brain, liver, and blood cells require adequate glucose supply for normal function but do not depend directly on insulin for glucose transport.

Lispro insulin (Humalog) with NPH (Humulin N) insulin is ordered for a patient with newly diagnosed type 1 diabetes. The nurse knows that when lispro insulin is used, when should it be administered?

At mealtime or within 15 minutes of meals Lispro is a rapid-acting insulin that has an onset of action of approximately 15 minutes and should be injected at the time of the meal to within 15 minutes of eating. Regular insulin is short acting with an onset of action in 30 to 60 minutes following administration and should be given 30 to 45 minutes before meals.

The home care nurse should intervene to correct a patient whose insulin administration includes

Mixing an evening dose of regular insulin with insulin glargine in one syringe for administration Insulin glargine (Lantus), a long-acting insulin that is continuously released with no peak of action, cannot be diluted or mixed with any other insulin or solution. Mixed insulins should be stored needle-up in the refrigerator and warmed before administration. Currently used bottles of insulin may be kept at room temperature out of sunlight for 4 weeks.

In type 1 diabetes there is an osmotic effect of glucose when insulin deficiency prevents the use of glucose for energy. Which classic symptom is caused by the osmotic effect of glucose?

Polydipsia Polydipsia is caused by fluid loss from polyuria when high glucose levels cause osmotic diuresis. Cellular starvation from lack of glucose and the use of body fat and protein for energy contribute to fatigue, weight loss, and polyphagia in type 1 diabetes.

Why are the hormones cortisol, glucagon, epinephrine, and growth hormone referred to as counter regulatory hormones?

Stimulate glucose output by the liver The counter regulatory hormones have the opposite effect of insulin by stimulating glucose production and output by the liver and by decreasing glucose transport into the cells. The counter regulatory hormones and insulin together regulate the blood glucose level.

Following the teaching of foot care to a patient with diabetes, the nurse determines that additional instruction is needed when the patient makes which statement?

"I'll know if I have sores or lesions on my feet because they will be painful" Complete or partial loss of protective sensation of the feet is common with peripheral neuropathy of diabetes, and patients with diabetes may suffer foot injury and ulceration without every having pain. Feet must be inspected during daily care for any cuts, blisters, swelling, or reddened areas.

The patient with diabetes has a blood glucose level of 248 mg/dL. Which manifestations in the patient would the nurse understand as being related to this blood glucose level (select all that apply)?

- Headache - Abdominal cramps - Increase in urination - Weakness and fatigue Manifestations of hyperglycemia include abdominal cramps, polyuria, weakness, fatigue, and headache.

The nurse is teaching the patient with prediabetes ways to prevent or delay the development of type 2 diabetes. What information should be included (select all that apply)?

- Maintain a healthy weight - Monitor for polyuria, polyphagia, and polydipsia To reduce the risk of developing diabetes, the patient with prediabetes should maintain a healthy weight, learn to monitor for symptoms of diabetes, have blood glucose and glycosylated hemoglobin (A1C) tested regularly, exercise regularly, and eat a healthy diet.

A patient with newly diagnosed type 2 diabetes has been given a prescription to start an oral hypoglycemic medication. The patient tells the nurse she would rather control her blood sugar with herbal therapy. Which action should the nurse take?

Advise the patient to discuss using herbal therapy with her HCP before using it Advise the patient to seek the guidance of the HCP regarding the safety, efficacy, and specifics of using herbal therapy rather than or with the medication prescribed. Not all herbal therapy is unsafe, but dosages are not universal.

The nurse should observe the patient for symptoms of ketoacidosis when

An insulin deficit causes the body to metabolize large amounts of fatty acids rather than glucose for energy When insulin is insufficient and glucose cannot be used for cellular energy, the body uses stored fats to meet energy needs. Free fatty acids from stored triglycerides are metabolized in the liver in such large quantities that ketones are formed. Ketones are acidic and alter the pH of the blood, causing acidosis. Osmotic diuresis from the elimination of both glucose and ketones in the urine causes dehydration, not ketosis. The loss of bicarbonate and skipping a meal after insulin administration do not cause ketosis.

Two days following a self-managed hypoglycemic episode at home, the patient tells the nurse that his blood glucose levels since the episode have been between 80 and 90 mg/dL. Which is the *best* response by the nurse?

"That is a good range for your glucose levels" Blood glucose levels of 80 to 90 mg/dL are within the normal range and are desired in the patient with diabetes, even following a recent hypoglycemic episode. Hypoglycemia is often caused by a single event, such as skipping a meal, taking too much insulin, or vigorous exercise. Once corrected, normal glucose control should be maintained.

During routine health screening, a patient is found to have fasting plasma glucose (FPG) of 132 mg/dL (7.33 mmol/L). At a follow-up visit, a diagnosis of diabetes would be made based on which laboratory results (select all that apply)?

- A1C of 7.5% - FPG ≥ 127 mg/dL (7.0 mmol/L) The patient has one prior test result of fasting plasma glucose (FPG) greater than or equal to 126 mg/dL (7.0 mmol/L) that meets criteria for a diagnosis of diabetes, and the result is confirmed on this follow-up visit. The A1C is 7.5% or greater than diagnostic criteria of 6/5% or higher. The other diagnostic criteria include a 2-hour OGTT level ≥200 mg/dL (11.1 mmol/L), or a patient with classic symptoms of hyperglycemia (polyuria, polydipsia, polyphagia, unexplained weight loss) or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (11.1 mmol/L).

What disorders and diseases are related to macrovascular complications of diabetes (select all that apply)?

- Coronary artery disease - Ulceration and amputation of the lower extremities Macrovascular disease causes coronary arter disease and ulceration and results in amputation of the lower extremities However, neuropathy may also contribute to not feeling ulcerations.

The patient with diabetes has been diagnosed with autonomic neuropathy. What problems should the nurse expect to find in this patient (select all that apply)?

- Erectile dysfunction - Vomiting undigested food - Painless myocardial infarction Autonomic neuropathy affects most body systems. Manifestations of autonomic neuropathy include erectile dysfunction in men and decreased libido, gastroparesis (nausea, vomiting, gastroesophageal reflux and feeling full), painless myocardial infarction, postural hypotension, and resting tachycardia.

The patient with type 2 diabetes is being put on acarbose (Precose) and wants to know about taking it. What should the nurse include in this patient's teaching (select all that apply)?

- Take it with the first bit of each meal - Effectiveness is measured by 2-hour postprandial glucose - It delays glucose absorption from the GI tract Acarbose (Precose) is an α-glucosidase inhibitor that is taken with the first bite of each meal. The effectiveness is measured with 2-hour postprandial blood glucose testing, as it delays glucose absorption from the GI tract.

The patient with diabetes is brought to the ER by his family members, who say that he has had an infection, is not acting like himself, and he is more tired than usual. Number the nursing actions in the order of priority for this patient. A. Establish IV access B. Check blood glucose C. Ensure patent airway D. Begin continuous regular insulin drip E. Administer 0.9% NaCl solution at 1 L/hr F. Establish time of last food and medication(s)

1. Ensure patent airway 2. Check blood glucose 3. Establish IV access 4. Administer 0.9% NaCl solution at 1 L/hr 5. Begin continuous regular insulin drip 6. Establish time of last food and medication(s) As with all patients, first establish an airway. With a patient with diabetes and abnormal behavior, the blood glucose must then be checked to determine if the patient's symptoms are related to the diabetes. In this case, it is hyperglycemia, so an IV must be started for fluid resuscitation and insulin administration. The last food intake and times at which medications were recently taken may establish a cause for the hyperglycemia and aid in determining further treatment.

A patient with type 1 diabetes uses 20 U of Novolin 70/30 (NPH/regular) in the morning and at 6:00 PM. When teaching the patient about this regimen, what should the nurse emphasize?

A set meal pattern with a bedtime snack in necessary to prevent hypoglycemia A split-mixed dose of insulin requires that the patient adhere to a set meal pattern to provide glucose for the peak action of the insulin, and a bedtime snack is usually required when patients take an intermediate-acting insulin late in the day to prevent nocturnal hypoglycemia. Hypoglycemia is most likely to occur with this dose late in the afternoon and during the night. When premixed formulas are used, flexible dosing based on glucose levels is not recommended.

When caring for a patient with metabolic syndrome, the nurse should give the *highest* priority to teaching the patient about which treatment plan?

Achieving a normal weight Metabolic syndrome is a cluster of abnormalities that include elevated glucose levels, abdominal obesity, elevated BP, high levels of triglycerides, and low levels of HDLs. Overweight individuals with metabolic syndrome can prevent or delay the onset of diabetes through a program of weight loss. Regular physical activity is also important, but normal weight is most important.

A patient with diabetes is found unconscious at home and a family member calls the clinic. After determining that a glucometer is not available, what should the nurse advise the family member to do?

Administer glucagon 1 mg intramuscularly (IM) or subcutabeously If a patient with diabetes is unconscious, immediate treatment for hypoglycemia must be given to prevent brain damage, and IM or SQ administration of 1 mg of glucagon should be done. If the unconsciousness has another cause, such as ketosis, the risk in glucose caused by the glucagon is not as dangerous as the low glucose level. Following administration of the glucagon, the patient should be transported to a medical facility for further treatment and evaluation. Oral carbohydrates cannot be given when the patients are unconscious, and insulin is contraindicated without knowledge of the patient's glucose level.

A patient with diabetes calls the clinic because she is experiencing nausea and flu-like symptoms. Which advice from the nurse will be the *best* for this patient?

Administer the usual insulin dose During minor illnesses, the patient with diabetes should continue drug therapy and fluid and food intake. Insulin is important because counter regulatory hormones may increase blood glucose during the stress of illness. Food or a carbohydrate liquid substitution is important because during illness the body requires extra energy to deal with the stress of the illness. Blood glucose monitoring should be done every 4 hours, and the HCP should be notified if the level is greater than 240 mg/dL or if fever, ketonuria, or nausea and vomiting occur.

The following interventions are planned for a patient with diabetes. Which intervention can the nurse delegate to unlicensed assistive personnel (UAP)?

Check that the bath water is not too hot Checking the temperature of the bath water is part of assisting with ADLs and within the scope of care for UAP. This is important for the patient with neuropathy. Discussion of complications, teaching, and assessing learning are appropriate for RNs.

The nurse assesses the technique of the patient with diabetes for self-monitoring of blood glucose (SMBG) 3 months after initial instructions. Which error in the performance of SMBG noted by the nurse requires intervention?

Cleaning the puncture site with alcohol before the puncture Cleaning the puncture site with alcohol is not necessary and may interfere with test results and lead to drying and splitting of the fingertips. Washing the hands with warm water is adequate cleaning and promotes blood flow to the fingers. Blood flow is also increased by holding the hand down. Punctures on the side of the finger pad are less painful. Self-monitored blood glucose (SMBG) should be preformed before and after exercise.

The nurse determines that a patient with a 2-hour OGTT of 152 mg/dL has

Impaired glucose tolerance Impaired glucose tolerance exists when a 2-hour OGTT level is higher than normal but lower than the level diagnostic for diabetes (i.e., >200 mg/dL). Impaired fasting glucose exists when fasting glucose levels are greater than the normal of 100 mg/dL but less than the 126 mg/dL diagnostic of diabetes. Both abnormal values indicate prediabetes.

Which laboratory results would indicate that the patient has prediabetes?

Fasting blood glucose result of 120 mg/dL (6.7mmol/L) Prediabetes is defined as impaired glucose tolerance and impaired fasting glucose or both. Fasting blood glucose results between 100 mg/dL (5.56 mmol/L) and 125 mg/dL (6.9 mmol/L) indicate prediabetes. A diagnosis of impaired glucose tolerance is made if the 2-hour-oral glucose tolerance test (OGTT) results are between 140 mg/dL (7.8 mmol/L) and 199 mg/dL (11.0 mmol/L).

The patient with type 2 diabetes has had trouble controlling his blood glucose with several OA but wants to avoid the risks of insulin. The HCP told him a medication will be prescribed that will increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, and slow gastric emptying. The nurse knows this is which medication that will have to be injected?

Glucogon-like peptide-1 receptor agonist, exenatide extended release (Bydureon) This glucagon-like peptide-1 (GLP-1) receptor agonist stimulates GLP-1 to increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, slow gastric emptying, and must be injected subcutaneously once every 7 days. The other medications are oral agents (OAs). The mechanism of action for glycemic control for the dopamine receptor agonist is unknown. Dipeptidyl peptidase-4 (DPP-4) enzyme that inactivates incretin so there is increased insulin release, decreased glucagon secretion, and decreased hepatic glucose production. Sodium-glucose co-transporter 2 (SGLT-2_ inhibitors block the reabsorption of glucose by the kidney and increase urinary glucose excretion

What describes the primary difference in treatment for diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS)?

HHS requires greater fluid replacement to correct the dehydration The management of DKA is similar to that of HHS except that HHS requires greater fluid replacement because of the severe hyperosmolar state. Bicarbonate is not usually given in DKA to correct acidosis unless the pH is < 7.0 because administration of insulin will reverse the abnormal fat metabolism. Total body potassium deficit is possible in both conditions, requiring monitoring and possibly potassium administration , and in both conditions glucose is added to IV fluids when blood glucose levels fall to 250 mg/dL.

In addition to promoting the transport of glucose from the blood into the cell, what does insulin do?

Increases amino acid transport into cells and protein synthesis Insulin is an anabolic hormone that is responsible for growth, repair, and storage. It facilitates movement of amino acids into cells, synthesis of protein, storage of glucose as glycogen, and deposition of triglycerides and lipids as fat into adipose tissue. Fat is used for energy when glucose levels are depleted. Glucagon is responsible for hepatic glycogenolysis and gluconeogenesis.

Which statement *best* describes atherosclerotic disease affecting the cerebrovascular, cardiovascular, and peripheral vascular systems in patients with diabetes?

It occurs with a higher frequency and earlier onset than in the nondiabetic population The development of atherosclerotic vessel disease seems to be promoted by the altered lipid metabolism common in diabetes. Although tight glucose control may help to delay the process, it does not prevent it completely. Atherosclerosis in patients with diabetes does respond somewhat to a reduction in general risk factors, as it does in nondiabetics, and reduction in fat intake, control of hypertension, abstention from smoking, maintenance of normal weight, and regular exercise should be carried out by all patients.

A patient taking insulin has recorded fasting glucose levels above 200 mg/dL (11.1 mmol/L) on awakening for the last 5 mornings. What should the nurse advise the patient to do *first*?

Monitor the glucose level at bedtime, between 2:00 AM and 4:00 AM, and on arising The patient's elevated glucose on arising may be the result of either dawn phenomenon or Somogyi effect. The best way to determine whether the patient needs more or less insulin is be monitoring the glucose at bedtime, between 2:00 AM and 4:00 AM, and on arising. If the 2:00 AM to 4:00 AM blood glucose levels are below 60 mg/dL, the insulin dose should be reduced to prevent Somogyi effect; if it's high, the insulin should be increased to prevent dawn phenomenon.

What should the goals of nutrition therapy for the patient with type 2 diabetes include?

Normal serum glucose and lipid levels The specific goals of nutrition therapy for people with diabetes include maintaining near-normal blood glucose levels and achievement of optimal serum lipid levels and BP. Dietary modifications are believed to be important factors in preventing both short- and long-term complications of diabetes. Loss of weight, which may or may not be to ideal body weight, may improve insulin resistance. There is no longer a specific "diabetic diet," and use of dietetic foods is not necessary for glucose control. Most patients with diabetes eat 3 meals a day, and some require a bedtime snack for control of nighttime hypoglycemia. The other goals of nutrition therapy include prevention of chronic complications of diabetes, attention to individual nutritional needs, and maintenance of the pleasure of eating.

When teaching the patient with type 1 diabetes, what should the nurse emphasize as the major advantage of using an insulin pump?

Tight glycemic control can be maintained Insulin pumps provide tight glycemic control by continuous subcutaneous insulin infusion based on the patient's basal profile, with bolus doses at mealtime at the patient's discretion and related to blood glucose.