Adams Pharm for Nurses : Ch 45 : Drugs for Diabetes Mellitus

Meglitinides

stimulates the release of insulin from pancreatic islet cells similarly to sulfonylureas, short duration of action ex: repaglinide (Prandin), nateglinide (Starlix)

Antidiabetic drugs

sulfonylureas biguanides alpha-glucosidase inhibitors thiazolidinediones meglitinides incretin mimetics

Bigunaide

Reduces fasting & postprandial glucose levels by decreasing the hepatic production of glucose & reducing insulin resistance. reduction of glucose by the liver ex: metformin (Glucophage)

Insulin Types

rapid acting - humalog short acting - regular intermediate acting - NPH long acting - lantus

Thiazolidinediones

reduce blood glucose by decreasing insulin resistance & inhibiting hepatic gluconeogenesis. improve insulin uptake, transport into tissues ex: pioglitazone (Actos), rosiglitazone(Avandia)

The patient is scheduled to receive 5 units of Humalog and 25 units of NPH (Isophane) insulin prior to breakfast. Which nursing intervention is most appropriate for this patient? 1. Make sure the patient's breakfast is available to eat before administering this insulin. 2. Offer the patient a high-carbohydrate snack in 6 hours. 3. Hold the insulin if the blood glucose level is greater than 100 mg/dL. 4. Administer the medications in two separate syringes.

1 Rationale: Humalog is a rapid-acting insulin that is administered for elevated glucose levels. It should be given within 15 minutes before meals. Hypoglycemic reactions may occur rapidly if Humalog insulin is not supported by sufficient food intake. Options 2, 3, and 4 are incorrect. The administration of a snack 6 hours later should be based on blood glucose levels at that time. If hypoglycemia occurs, a carbohydrate and protein snack may be given. Insulin should not be held if the blood glucose is above 100 mg/dL or further hyperglycemia may occur. The Humalog and NPH insulins may be mixed in one syringe and the injection given immediately.

A 63-year-old patient with type 2 diabetes is admitted to the nursing unit with an infected foot ulcer. Despite previous good control on glyburide (DiaBeta), his blood glucose has been elevated the past several days and he requires sliding-scale insulin. What is the most likely reason for the elevated glucose levels? 1. It is a temporary condition related to the stress response with increased glucose release. 2. He is converting to a type 1 diabetic. 3. The oral antidiabetic drug is no longer working for him. 4. Patients with diabetes who are admitted to the hospital are switched

1 Rationale: The release of glucose may be in response to a stressful situation, such as hospitalization and infection. Blood glucose levels will continue to be monitored, and control may improve as the infection clears and the patient is discharged. Options 2, 3, and 4 are incorrect. The pathogenesis of type 1 and type 2 diabetes are different. Patients with type 2 diabetes may eventually need insulin, but patients with type 1 diabetes cannot take oral antidiabetic drugs and will consistently require insulin to replace what the body cannot produce. Immediate changes in response to an oral antidiabetic drug are not known to occur, and patients may continue to take all oral medications while in the hospital.

What patient education should the nurse provide to the patient with diabetes who is planning an exercise program? (Select all that apply.) 1. Monitor blood glucose levels before and after exercise. 2. Eat a complex carbohydrate prior to strenuous exercise. 3. Exercise may increase insulin needs. 4. Withhold insulin prior to engaging in strenuous exercise. 5. Take extra insulin prior to exercise.

1, 2 Rationale: Blood glucose levels should be monitored prior to starting and after ending exercise and should be addressed appropriately. A complex carbohydrate should be consumed prior to strenuous exercise. Options 3, 4, and 5 are incorrect. Regular exercise may assist the body to use glucose more effectively, and insulin needs may decrease. Insulin dose should not be withheld or increased prior to exercise. If symptoms suggest that hypo- or hyperglycemia are occurring during exercise, the patient should consult the healthcare provider about changing the insulin regimen.

The nurse is initiating discharge teaching with the newly diagnosed patient with diabetes. Which statement indicates that the patient needs additional teaching? 1. "If I am experiencing hypoglycemia, I should drink 1/2 cup of apple juice." 2. "My insulin needs may increase when I have an infection." 3. "I must draw the NPH insulin first if I am mixing it with regular insulin." 4. "If my blood glucose levels are less than 60 mg/ dL, I should notify my healthcare provider."

3 Rationale: Additional teaching is needed to ensure that the patient is mixing insulin correctly in the same syringe. The short-acting solution (regular insulin) should be drawn into the syringe first, followed by the longer-acting (intermediate) solution (NPH). Options 1, 2, and 4 are incorrect. Drinking a quick-acting carbohydrate such as apple juice is an appropriate treatment for hypoglycemia and it should be followed by a protein source if a meal is not immediately available. Due to the stress response in an infection, insulin needs may increase. Blood glucose levels less than 60 mg/dL should be reported to the healthcare provider if they are consistent or accompanied by symptoms of hypoglycemia.

A patient receives NPH and regular insulin every morning. The nurse is verifying that the patient understands that there are 2 different peak times to be aware of for this insulin regimen. Why is this an important concept for the nurse to stress? 1. The patient needs to plan the next insulin injection around the peak times. 2. Additional insulin may be needed at peak times to avoid hyperglycemia. 3. It is best to plan exercise or other activities around peak insulin activity. 4. The risk for hypoglycemia is greatest around the peak of insulin activity.

4 Rationale: Insulin peak times are the periods of maximum insulin utilization with the greatest risk of hypoglycemia. Options 1, 2, and 3 are incorrect. Because the risk of hypoglycemia is greatest around peak insulin activity, giving additional insulin or planning exercise or other activities may increase the risk further.

A patient with type 2 diabetes has been nothing by mouth (NPO) since midnight for surgery in the morning. He has been on a combination of oral type 2 antidiabetic drugs. What would be the best action for the nurse to take concerning the administration of his medications? 1. Hold all medications as per the NPO order. 2. Give him the medications with a sip of water. 3. Give him half the original dose. 4. Contact the healthcare provider for further orders.

4 Rationale: The healthcare provider should be contacted for further orders. The need for oral hypoglycemic medication may have been overlooked, or other measures, such as insulin, to treat hyperglycemia during the surgery may be planned. Contacting the healthcare provider ensures that the provider is aware that the patient has diabetes and that no medications for diabetes were ordered. Options 1, 2, and 3 are incorrect. Holding all medications as ordered will not address the patient's glucose needs during surgery. IV fluids during this time may contain glucose solutions, resulting in a hyperglycemic condition. It is not within the scope of a nurse's practice to independently change a medication dosage order or to give medications when an NPO order has been written. The provider should be contacted before these decisions are carried out.

Rapid-Acting Insulin (Humalog)

Onset: 15 minutes Peak: 1 hour Duration: 3 hours "15 minutes feels like an hour during 3 rapid responses."

Intermediate-Acting Insulin (NPH)

Onset: 2 hours Peak: 8 hours Duration: 16 hours "Nurses Play Hero to (2) eight 16 year olds."

Long-Acting Insulin (Lantus)

Onset: 2 hours Peak: NONE Duration: 24 hours "The two long nursing shifts never peaked but lasted 24 hours."

Short-Acting Insulin (regular)

Onset: 30 minutes Peak: 2 hours Duration: 8 hours "Short-staffed nurses went from 30 patient to (2) 8 patients."

Alpha-glucosidase inhibitors

Slows intestinal carbohydrate digestion/absorption by blocking the enzymes in the small intestine. delay glucose absorption from gut ex: acarbose (Precose), miglitol (Glyset)

Sulfonylureas

stimulate the release of insulin from pancreatic islet cells & by increasing sensitivity of insulin receptors on target cells ex: glimepiride (Amaryl), glipizide (Glucotrol), glyburide (DiaBeta)

Incretin mimetics

lowering blood glucose by increasing the secretion of insulin, slowing the absorption of glucose, reducing the action of glucagon. inhibits incretin from secreting and raising sugar levels ex: exenatide (Byetta), dulaglutide (Trulicity)