NUR 221 - Ch 30 Diabetes Mellitus
Explain why IV insulin is administered to treat the acidosis found in DKA.
Accumulation of Ketone bodies occurs as a result of fat breakdown. The acidosis that occurs in dka is reversed with insulin.
Regular insulin is added to a saline solution and given IV at a slow, continuous rate.
Hourly blood glucose levels must be measured. The goal is to decrease the serum glucose level by 500 to 100 mg DL to prevent complications.
5 describe the rationale behind exercise precautions for those with hyperglycemia
patients with blood glucose levels exceeding 250 mg/dL and ketonuria should not begin exercising until two criteria are reached:
the major electrolyte of concern during treatment of diabetic ketoacidosis
potassium
match the insulin drug with its associated onset, duration or indication for use.
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the lowest fasting plasma glucose level suggestive of a diagnosis of diabetes is:
115 mg/dL The normal serum glucose level is approximately 80 to 110 mg/dL. Laboratory reports usually list the normal range for each test so that abnormalities are readily seen
a 6-month pregnant patient was evaluated for gestational diabetes mellitus. The doctor considered prescribing insulin based on the serum glucose result of:
138 mg/dL 2 hours postprandial The goal for a 2-hour, postprandial glucose level is less than 120 mg/dL in a patient who might develop gestational diabetes.
a nurse knows to assess a patient with type 1 diabetes for postprandial hyperglycemia. The nurse knows that glycosuria is present when the serum glucose level exceeds:
180 mg/dL Glycosuria occurs when the renal threshold for sugar exceeds 180 mg/dL. Glycosuria leads to an excessive loss of water and electrolytes osmotic diuresis.
A patient with type 2 diabetes is scheduled for surgery. During the preoperative period, the patient's dose of insulin will be adjusted. Select the dose of NPH that the nurse should expect to give based on the patient's normal morning dose of 40 units.
20 units The preoperative dosage of insulin may be reduced by 50 to 60%. Therefore, 20 units is 50% less than 40 units.
Diabetes mellitus affects approximately _____ million people which is about _____ percent of the population
24 million, 8%
A female patient with diabetes who weighs 150 pounds has an ideal body weight of 118 pounds. She can lose one pound per week and drop her extra 32 lb in approximately 8 months. To meet this goal, the nurse advises the patient to decrease her calories by:
3500 per week A person needs to decrease caloric intake by 3500 for each pound of weight that is lost. To lose one pound per week a person would decrease his or her daily caloric intake by 500 calories. 500 calories times 7 days equals 3500 calories which equals 1 pound.
A health care provider prescribes short-acting insulin for a patient, instructing the patient to take the insulin 20 to 30 minutes before a meal. The nurse explains to the patient that Humulin are taken at 6:30 a.m. will reach Peak Effectiveness by:
8:30 a.m. Short-acting insulin reaches its peak Effectiveness 2 to 3 hours after Administration. See table 30-3 in the text.
a u-100 concentration of insulin means
A u-100 concentration of insulin means that there are 100 units of insulin per milliliter
pancreas - decreased glucose secretion, increased insulin secretion
Amylin analogs, Incretins; insulin secretagogues incretins {major effect}
action peaks in less than one hour
Aspart
liver - decreased hepatic glucose ouput
Biguanides {major effect} & Thiazolidinediones {minor effect}
{Second sequence of events}
Breakdown of fat into fatty acids and glycerol
3 explain why diabetic ketoacidosis does not typically occur in type 2 diabetes
Despite the impaired insulin secretion that is characteristic of type 2 diabetes, there is enough insulin present to prevent the breakdown of fat and the accompanying production of Ketone acids.
Describe the laboratory results that the nurse would expect to find with this patient.
Diagnostic laboratory findings would include: blood glucose levels greater than 250 mg/dL, a low serum pH of 6.8 to 7.3, a low serum bicarbonate of 0 to 15 mEq/L, accumulation of serum and urine ketones, the presence of glycosuria, abnormal serum electrolyte levels {sodium, potassium, and chloride}
the urine test negative for ketones and the blood glucose level is close to normal.
Exercising with an elevated blood glucose level increases the secretion of glucagon, growth hormone, and catecholamines. The liver then releases more glucose, resulting in a further increase in the blood glucose level.
6 explain the significance of measuring glycated hemoglobin as an assessment for the diagnosis of prediabetes
Glycated hemoglobin {also referred to as glycosylated hemoglobin HgbA1c or A1C} is a blood test that reflects average blood glucose levels over a period of approximately two to three months.
Christine, a 54 year old woman, is admitted to the clinical area with a diagnosis of diabetic ketoacidosis {DKA}. On admission she is drowsy yet responsive.
Her skin is warm and dry, with decreased skin turgor. She is also hypotensive and tachycardic.
Therefore, diabetic ketoacidosis does not typically occur in type 2 diabetes.
However, uncontrolled type 2 diabetes may lead to hyperglycemic hyperosmolar nonketotic syndrome, another acute complication of diabetes.
expected duration is 12 to 16 hours
Humulin N
has an onset of action from two to four hours
Humulin N
2 explain why insulin resistance leads to hyperglycemia
Insulin resistance refers to decreased tissue sensitivity to insulin. Normally, insulin binds to special receptors on Cell surfaces and initiates a series of reactions involved in glucose metabolism.
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It is believed that the immune system destruction of the beta cells is initiated by environmental factors, such as viruses or toxins.
can be used as a basal dose
Lantus
is continuously effective for 24 hours
Lantus
name an insulin that can be effective up to 24 hours
Lantus
a rapid onset within 15 minutes
Lispro
Hyperosmolality causes poly dipsea with fluid shifts from the intracellular to the extracellular space.
Low to normal serum sodium levels are referred to as pseudo - hyponatremia.
Blood vessels in the vitreous form scar tissue that can pull and detach the retina.
Neovascularization into the vitreous humor is considered a diagnostic sign.
has an expected duration of 4 to 6 hours
Novolin R
has an onset of action from 30 to 60 minutes
Novolin R
reaches Peak Effectiveness in 2 to 3 hours
Novolin R
identify the five major components that are essential for the management of diabetes mellitus
Nutrition, exercise, monitoring medication and education
What indicators of fluid overload should the nurse assess?
Signs of fluid overload would include crackles, full neck things, edema, weight gain, shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, hypertension, moist mucous membranes, and a full and bounding pulse.
In type 2 diabetes, these intra-cellular reactions are diminished, making insulin less effective in stimulating glucose uptake by the cells and at regulating glucose released by the liver. {see figure 30-1 in the text.}
The exact mechanisms that lead to insulin resistance and impaired insulin secretion in type 2 diabetes are unknown, although genetic factors are thought to play a role.
muscles - increased peripheral glucose uptake
Thiazolidinediones {major effect} & Biguanides {minor effect}
The potential glucose-lowering effect of fiber may be caused by a slower rate of glucose absorption from foods that contain soluble fiber. Insoluble fiber is found in whole grain Breads and cereals and in some vegetables.
This type of fiber is important in increasing stool bulk and preventing constipation. Both insoluble and soluble fibers increase satiety which is helpful for weight loss.
When the blood glucose level reaches 250 mg DL or less, prevention of hypo glycemia requires changing IV solutions to those containing glucose.
Typically the insulin dose for continuous IV infusion is 4 - 10 units per hour.
Describe how IV insulin and blood glucose should be monitored.
When regular insulin is administered IV, it's half life is about 9 minutes and a steady state is reached in about 45 minutes.
intestine - decreased glucose absorption
alpha glucosidase inhibitors, Amylin analogs {major effect}
elevated levels of glucose in the blood
hyperglycemia
They are hypoglycemia, diabetic ketoacidosis DKA and...
hyperglycemic hyperosmolar nonketotic syndrome HHNS also called hyperglycemic hyperosmolar syndrome HHS
A nurse is caring for an elderly patient who has Type 2 diabetes mellitus. She suspects that the patient is exhibiting symptoms of diabetic ketoacidosis {DKA} instead of hyperglycemic hyperosmolar nonketotic syndrome {HHNS}. Which of the following are indicators of a diagnosis of DKA? Select all that apply.
blood glucose levels of 280 mg/dL arterial pH of 7, plasma bicarbonate level of 13 mEq/L Refer to table 30-7 in the text for this outline of the differences between DKA and HHNS
type 1 diabetes is characterized by _____ whereas type 2 diabetes is characterized by _____ and _____
destruction of the pancreatic beta cells, insulin resistance, and impaired insulin secretion
normal blood glucose levels
euglycemia
stimulates the liver to release stored glucose
glucagon
a term used for the breakdown of glycogen by the liver
glycogenolysis
Exercise lowers blood glucose levels. Which of the following are the physiological reasons that explain this statement. Select all that apply.
increase lean muscle mass, increase resting metabolic rate as muscle size increases, decrease total cholesterol, increases glucose uptake by body muscles All of the options are benefits of exercise except the effect of decreasing the levels of HDL. Exercise increases the levels of HDL.
exercise lowers blood glucose levels by
increasing the uptake of glucose by body muscles and by improving insulin utilization
A patient is prescribed glucophage, an oral anti-diabetic agent classified as a biguanide. The nurse knows that a primary action of this drug is its ability to:
inhibit the production of glucose by the liver The action of the bike when I can be found in table 30-6 in the text.
sites of action of oral anti-diabetic medications. fill in the unlabeled boxes with glucose or insulin actions.
insert the type of anti-diabetics near the arrows (p. 208 & 472)
loss of subcutaneous fat
lipoatrophy
Insulin is a hormone secreted by the islets of langerhans and is essential for the metabolism of carbohydrates fats and protein. the nurse understands the physiologic importance of gluconeogenesis which refers to the:
synthesis of glucose from noncarbohydrate sources Gluconeogenesis refers to the making of glucose from noncarbohydrate. This occurs mainly in the liver its purpose is to maintain the glucose level in the blood to meet the body's demands.
absent or inadequate amount of insulin...
{First sequence of events}
A nurse is aware that insulin secretion increases three to five minutes after a meal and then returns to baseline. If a patient ate breakfast at 7:30 a.m., the nurse would expect a baseline level by:
10:30 a.m. Serum insulin levels return to Baseline within 2 to 3 hours
Fatty acids are converted into Ketone bodies by the liver.
Accumulated ketones lead to metabolic acidosis.
peaks in 6 to 8 hours
Humulin N
1 explain the statement "diabetes mellitus is an autoimmune disease"
Immune destruction of the beta cells, caused by Auto antibodies against islet cells and insulin, is associated with certain human leukocyte antigen types.
When blood glucose levels are elevated, glucose molecules attached to hemoglobin in red blood cells.
The longer the amount of glucose in the blood remains above normal, the more glucose binds to hemoglobin and the higher the glycated hemoglobin level becomes.
a nurse is assigned to care for a patient who is suspected of having type 2 diabetes. Select all the clinical manifestations that the nurse knows could be consistent with this diagnosis.
blurred or deteriorating vision, fatigue and irritability, polyuria and polydipsia, wounds that heal slowly or respond poorly to treatment All the options are correct except for weight loss and anorexia. Obesity is almost always associated with type 2 diabetes.
the nurse practitioner worked with a registered dietitian to customize an 1800 calorie diabetic diet for a 53 year old man with special dietary needs. Which of the following percent distribution of calories should be provided?
carbohydrates 50% fat 25% and protein 20% The American dietetic Association currently recommends following distribution of caloric intake: 50% to 60% carbohydrates, 20% to 30% fat, and 10% to 20% protein.
a nurse practitioner ordered blood work for a 65 year old man who is hypertensive and obese. Which of the following results is consistent with a diagnosis of prediabetes?
fasting plasma glucose of 128 mg/dL A fasting plasma glucose greater than 126 mg DL is considered diagnostic for pre-diabetes. C box 30-2 in the text
name the two characteristics of hyperglycemic hyperosmolar non ketotic syndrome (HHNS)
hyperglycemic hyperosmolar nonketotic syndrome HHNS is a serious, life-threatening condition characterized by hyperosmolality > or = to 340 mOsm/L and hyperglycemia > or = to 600 with alterations in level of consciousness. Ketosis is minimal or absent.
a hormone produced by the pancreas that regulates glucose
insulin
a nurse understands that a major concern with type 2 diabetes is:
insulin resistance A major concern with type 2 diabetes is insulin resistance, which refers to decreased tissue sensitivity to insulin. Age and body weight contribute to the diagnosis.
byproducts of fat breakdown that accumulate in the blood and urine
ketones
Reduced cellular glucose and increased production of glucose by the liver lead to hyper glycemia.
kidneys excrete excess glucose, which leads to polyuria, osmotic diuresis, dehydration, and electrolyte loss.
name an Insulin that can be effective within 15 minutes
lispro
a patient who is diagnosed with type 1 diabetes would be expected to:
need exogenous insulin Type 1 diabetes is characterized by the destruction of pancreatic beta cells that require exogenous insulin.
The nurse suspects that a patient with diabetes has developed proliferative retinopathy. The nurse confirms this by the presence of which of the following diagnostic signs?
neovascularization into the vitreous Proliferative retinopathy, and ocular complication of diabetes, occurs because of the abnormal growth of new blood vessels on the retina that bleed into the vitreous and block light.
A hospitalized insulin-dependent patient with diabetes has been experiencing morning hyperglycemia the patient will be awakened once or twice during the night to test blood glucose levels the healthcare provider suspects that the cause is related to the Somogyi effect. Which of the following indicators support this diagnosis? Select all that apply.
normal bedtime blood glucose, increase in blood glucose from 3 a.m. until breakfast, decrease in blood sugar to a hypoglycemic level between 2 and 3 a.m., elevated blood glucose at bedtime. For an explanation of the diagnosis of the Somogyi effect, refer to table 30-5 in the text.
the pancreas continues to release a small amount of basal insulin overnight, while a person is sleeping. The nurse knows that, if the body needs more sugar:
the pancreatic hormone glucagon will stimulate the liver to release stored glucose. When sugar levels are low, glucagon promotes hyperglycemia by stimulating the release of stored glucose. Glycogenolysis and gluconeogenesis will both be increased. Insulin secretion would promote hypoglycemia.
premixed insulins are available in different ratios of NPH insulin to regular insulin and Insulin ratio that is 70/30 means
the ratio of 70/30 means that the insulin combination is available as 70% NPH and 30% regular in one vial
list the six laboratory tests that should be completed for a diagnosis of diabetes mellitus
the six laboratory tests that are used are: HgbA1c parentheses (A1c), the fasting lipid profile, the test for microalbuminuria, the serum creatinine level, a urinalysis, and an electrocardiogram
the three major acute complications of diabetes are...
the three major, acute complications of diabetes are caused by short-term imbalances in blood glucose levels.
4 distinguish between the two types of dietary fiber soluble and insoluble
there are two types of dietary fiber: soluble and insoluble. Soluble fiber in food such as legumes, oats, and some fruits appears to lower blood glucose and lipid levels more than does insoluble fiber.
Health teaching for a patient with diabetes who is prescribed Humulin N, an intermediate NPH insulin, would include which of the following advice?
you should take your insulin after you eat breakfast and dinner NPH Humulin n insulin is an intermediate acting insulin that has an onset of two to four hours, if Peak effectiveness of six to eight hours, and a generation of 12 to 16 hours. See table 30-3 in the text.
write the sequence of the pathophysiology of diabetic ketoacidosis
{see figure p. 208 & 472)
