Ch. 37 care of patients with diabetes and hypoglycemia

Factors associated with type 1 diabetes

1. Family history 2. Previous infectious disease 3. More common in whites, American Indians, Alaska natives. 4. Presence of islet cell antibodies in the blood

Older adults are at greater risk for HHS because

They become dehydrated more quickly than do younger patients.

Hyperglycemia or hypoglycemia

When there is doubt as to whether a patient is experiencing hyperglycemia or hypoglycemia treatment is begun for hypoglycemia until a blood glucose determination is obtained.

Hypoglycemia

Low blood glucose

Glucose is a large enough molecule to have

Osmotic properties and pulls water with it when eliminated in the Urine.

Instructions for traveling

1. Carry twice the medication or insulin 2. Carry an emergency supply of fast acting sugar at all times in case of hypoglycemic episode 3. Check BG frequently 4. Best to travel with someone who is familiar with diabetes 5. Protect insulin from temperature extremes.

Type 1 diabetes S&S

1. Extreme thirst (polydipsia) 2. Frequent urination (polyuria) 3. Extreme hunger (polyphagia) 4. Rapid weight loss 5. Irritability 6. Weakness and fatigue 7. Nausea and vomiting

Foot care for diabetics

1. Inspect each foot daily for cuts, cracks, blisters, abrasions or discoloration of the toes report abnormalities. 2. Wash feet with warm NOT HOT water using mild soap and DO NOT soak the feet away it can cause cracking of the skin. 3. Thoroughly dry feet after washing - in between the toes don't put cream between toes but apply lotion if skin is too dry. 4. Cut nails along the shape of the toe and file to remove sharp edges. 5. Wear a clean pair of cotton socks each day 6. Wear fitted shoes that don't pinch or bind the foot NEVER walk barefoot 7. Break in new shoes gradually 8. Never wear open sandals or sandals with straps in between the toes 9. Use socks and blankets to warm the feet NO heating pad or hot water 10. Test temperature of bath with wrist or forearm before stepping in the tub 11. Elevate the feet whenever possible to improve circulation.

Key guidelines for safe exercise include

1. Knowing blood glucose before exercise 2. If blood sugar is low a carbohydrate snack (20-40 g based on body weight should be consumed before starting 3. Snacks during activity should be used to prevent hypoglycemia.

type 1 diabetes mellitus

1. Little or no exogenous insulin is produced. 2. Patients can be any age but are usually young 3. Patient must receive exogenous insulin and follow prescribed diet. 4. Renal, cardiovascular, retinal, and neurologic complications are likely if disease is not kept under right control.

Things that may precipitate HHS in a person with type 2 diabetes are ?

1. Medications that increase serum glucose levels or cause dehydration such as steroids, beta blockers. 2. Acute illnesses such as infection, myocardial infarction and stroke. 3. Chronic illnesses such as congestive heart failure and renal dysfunction. 4. Treatments such as total parenteral nutrition and peritoneal dialysis.

Gestational diabetes

1. Occurs only during pregnancy 2. After pregnancy, women with gestational diabetes have a 35-60 percent chance of developing diabetes within 5-10 years.

Factors associated with type 2 diabetes

1. Older age 2. Obesity 3. Family history of type 2 4. History of gestational diabetes 5. Impaired glucose metabolism 6. Physical inactivity 7. More coming in African Americans, Hispanic/Latinos, American Indians some Asian Americans; native Hawaiian/Pacific Islanders.

Type 2 diabetes S&S

1. Possibly polydipsia, polyuria, and polyphagia 2. More commonly excessive weight gain 3. Family history of diabetes mellitus 4. Poor healing of scratches, abrasions, and wounds 5. Blurred vision 6. Itching 7. Drowsiness 8. Increased fatigue 9. Tingling or numbness in the feet.

type 2 diabetes

1. Rarely develops ketosis but may develop hyperglycemic hyperosmolar state HHS. 2. Patients vary in need for exogenous insulin 3. Oral medications are given to help regulate blood glucose level. 4. New patients are usually older than 30 years old and most are obese.

S/S of hypoglycemia

1. Tremulousness 2. Hunger 3. Headache 4. Pallor 5. Sweating 6. Palpitations 7. Blurred vision 8. Weakness

Signs of hyperglycemia

1.Polydipsia 2. polyuria 3. polyphagia

At least 4 sets of factors influence the development of diabetes mellitus and they are

1.genetic 2. Metabolic 3. Microbiological 4. Immunologic

The ADA recommends screening all adults, especially those who are ?

Overweight and have 1 more additional risk factors for díabetes.

Gastrectomy and surgical bypass procedures may restrict

Adequate glucose absorption. Tumors of the pancreas, liver disease and disorders of the adrenal cortex and pituitary gland can also produce abnormally low blood glucose levels.

Finger sticks for blood glucose testing should be performed

30 mins before breakfast. If 1 hour has elapsed without insulin being given after the reading was obtain the test must be repeated before insulin administration.

Research has demonstrated that lowering A1C levels to

6.5% is associated with decreased microvascular complications.

Type 2 diabetes makes up

90-95% of all known cases, it is believed to begin with insulin resistance. More insulin is produced by the pancreas to maintain cellular metabolism.

Type 1 diabetes accounts for

About 5-10% of all cases. It occurs when the body's immune system destroys insulin-producing beta cells. It requires injections of exogenous (from outside the body) insulin to maintain life because they produce little or no endogenous (inside the body) insulin on their own. They are more prone to a serious complication such as excess production of ketones leading to Ketoacidosis (metabolic acidosis)

Insulin and exercise

Advise patients to avoid injecting insulin to an area that will soon receive extra exercise. The abdomen is a good site for insulin injection because absorption is steady, rapid and not affected by exercise.

Rebound hyperglycemia

Also known as somogyi effect follows a period of hypoglycemia often during sleep.

Oral hypoglycemic agents OHAs or

Anti diabetic agents may be prescribed for patients with type 2 diabetes to manage their blood glucose level.

Diabetic neuropathy

Approximately 60-70% of people with diabetes have mild to severe.

Some patients are alert with a glucose level of 40mg/dL whereas others

Are comatose at this level

The classic symptoms of diabetes mellitus, regardless of type , are related to an elevated

Blood glucose level or hyperglycemia

When insulin is not present in adequate amounts to meet metabolic needs the body

Breaks down protein & fat for energy. Which produces abundant by products of fat metabolism which are potent organic acids called ketones.

The somogyi effect is diagnosed by

Checking blood sugars during the night.

Long term consequences of diabetes mellitus are

Chiefly the result of damage to the large and small blood vessels.

Vascular changes typically cause very poor

Circulation in the feet and lower extremities. Healing of wounds in these areas is difficult because of poor blood supply.

Patients who have had diabetes for more than 10 years are likely to

Develop 1 or more complications of the disease.

The less closely the blood glucose has been controlled the more likely is the

Development of cardiovascular, eye and renal complications.

Diet is typically managed by reducing

Concentrated sugars and by adhering to a meal schedule.

Glucose levels of 20-40 mg/dL respond best to

Concentrated sugars, such as honey, table sugar or juice.

Piogitazone (actos)

Contraindicated in people with congestive heart failure - black box warning for cardiac risk

In most cases people who have type 2 diabetes can

Control their blood glucose by deducting caloric intake and increasing physical exercise.

Patients receiving OHAs should know that these medications

DO NOT eliminate the need for following their diet and exercise program.

Because ketosis and acidosis are absent the gastrointestinal symptoms

DO NOT occur and the patient does not seek medical care early in the course of illness.

Diabetes is the 7th leading cause of

Death in the United States for all age groups

Another contributing factor to infection and delayed healing may be

Decreased supply of blood to the tissues because of atherosclerotic changes in the blood vessels.

Diet is the cornerstone of

Diabetic treatment

Ethnicity and type 2 diabetes

Diagnosed more frequently in children and adolescents, particularly African Indians, African Americans, and Hispanic/Latino Americans.

The loss of glucose(glucosuria) and water in the urine also causes

Electrolyte loss

Muscular activity improves glucose use for

Energy and improves circulation

Blood glucose should be checked before beginning

Exercise, the patient is encouraged to wear a medical alert bracelet.

The pancreas also produces

Extra insulin after meals (Postprandial)

After years of having to filter too much blood with elevated blood glucose the filtering mechanism of the kidneys begins to

Fail allowing large particles that normally would have been filtered out (such as protein) to exit through the Urine.

Treatment of HHS focuses on

Fluid replacement and correction of electrolyte imbalances.

If a patient is on a sliding scale of insulin based in finger sticks glucose for nutritional coverage and receives RAPID ACTING insulin before meals make sure the

Food tray is in front of the patient before giving the insulin to help prevent hypoglycemic events.

Emphasis should be placed on the positive aspects of the diet and on the

Foods allowed rather than those that are forbidden.

Peripheral vascular disease

Gangrene which often leads to amputation is far more common in people with diabetes.

When hypoglycemia occurs the body secretes

Glucagon, epinephrine, growth hormone and cortisol to counteract the effects of low blood sugar. The patient may report nightmares and night sweats along with morning elevated serum glucose

For patients with diabetes distribution of calories is important for ?

Glycemic control

Hyperglycemic hyperosmolar state

HHS- occurs primarily in people with type 2 diabetes who experience high Blood glucose levels because of illness or added stress such as infection glucose greater than 600mg/dL. In some cases the BG can reach 1000mg/dL.

Hyperglycemia mis be anticipated and assessed diringv

Hospitalization when the patient is undergoing the added stress of diagnostic testing, unknown diagnosis and unrelieved physical distress new medications or surgery.

Treating hypoglycemia includes

Hugh in proteins and low in carbohydrates and carbohydrates should be complex ones which as those found in whole fruits vegetables and whole grains.

Emotional and physical stress of surgery can

Increase the blood glucose level and alter the amounts of medication needed for glycemic control.

Hyperglycemia

Increases the concentration of the intravascular fluid, raising its osmotic pressure, and pulling water from the cells and tissues into the blood, causing cellular dehydration.

The protocol for control of diabetes mellitus is highly ?

Individualized and depends on the type of diabetes a person has, age, generals tate of health, ability to follow prescribed regimen, and acceptance of responsibility for managing the illness.

People with diabetes are prone to

Infection, delayed healing , and vascular disease.

The basal dose again would be

Intermediate, or long acting insulin, a bolus dose or correction dose or short or rapid acting insulin

Dawn phenomenon

Is characterized by elevated blood glucose in the morning. It is caused by release of growth hormone, glucagon, and epinephrine during the night ad part of the body's natural circadian rhythm.

Hunger (polyphagia) is the result of the body's effort to increase

It's supply of energy

Metformin (glucophage)

Keep liver from releasing excessive glucose

When the kidney is unable to handle accumulated ketones in the blood

Ketosis occurs which leads to a severe and potentially fatal acidosis

Long acting insulin

Lantus, Levemir peak - none duration 24 hours.

Signs and symptoms of DKA diabetic keto acidosis can be

Life threatening

There is no cure for diabetes mellitus the goal is to

Maintain blood glucose and lipid levels within normal limits.

What to do on sick days

Medication- take insulin as prescribed If taking oral hypoglycemic take usual dose do not increase dose unless ordered to do so monitoring- test BG at least every 4 hrs and record results, If severe ill check BG q2hrs Test Urine for ketones if BG level is higher than 300mg/dL.

Increase levels of glucose in the blood provide a good

Medium for bacterial growth and decrease immune response it is harder to eradicate infection.

Intermediate acting insulin

NPH (Humulin N, Novolin N) onset 1.5 Hours

Gradual increase in activities and consultation with the health care provider are

Necessary for safe implementation of an exercise program.

Improperly or untreated diabetes is the leading cause of

New blindness, renal failure leading to dialysis, and non-traumatic lower limp amputations.

Diabetic Nephropathy

Occurs directly from changes in the renal blood circulation.

Rapid acting insulin

Novolog, Humalog onset .25 hours

About 80% of patients with type 2 diabetes are ?

Obese

Insulin therapy can be prescribed for

Patients with either type 1 or 2 diabetes the goal of insulin therapy is to closely mimic basal insulin.

In an attempt to rid itself of acidosis produced by ketones the body increases

Respiratory rate and depth (kussmaul respiration's) characteristics is fruity odor to the breath.

Metformin is the

Preferred drug for type 2 diabetes

Tight glycemic control is the best strategy to

Prevent the vascular changes that cause myocardial infarction and stroke.

Betic neuropathy

Primarily affects the peripheral nerves. Causing sexual impotence in men, constipation, neurogenic bladder and pain or anesthesia(lack of feeling) in the lower extremities.

Short acting insulin

Regular (Humulin R, Novolin R) onset 0.5 hours

The goals of treatment for DKA is to

Restore the normal pH of the blood and other fluids, correct the fluid & electrolyte imbalance, lower the blood glucose level gradually , and provide life support measure as necessary.

With weight reduction and increased physical activity blood glucose can be ?

Restored to normal levels and maintained there. Hence the importance of diet and exercise in the management of type 2 diabetes.

Studies have demonstrated that there are benefits of

Right glycemic control ( control of glucose in the blood)

Exercise makes the insulin receptors on cells more

Sensitive to the hormone and thus improve use of the available glucose.

Exercise can rapidly lower blood glucose and cause

Serious hypoglycemia

Extreme high level of glucose in the blood causes

Severe dehydration and circulating fluid volume depletion secondary to osmotic diuresis.

Untreated fasting hypoglycemia can lead to

Severe neuroglycopenia(shortage of glucose in the brain) and possibly death.

Semaglutide (Ozempic)

Site of action: gut, liver, pancreas Slow gastric emptying and stimulate insulin release. Increase liver gluconeogenesis. Requires injection, contraindicated in patients with chronic renal failure in dialysis.

Insulin enter the bloodstream at different

Speeds when given at different sites

Glimepiride (Amaryl) & Glipizide (glucotrol)

Stimulate pancreas to secrete more insulin Quick action can cause hypoglycemia contraindicated in advanced kidney or liver disease or for those with sulfa allergies

Metformin should be held before

Surgery or a procedure requiring contrast media and for 48hrs afterward until renal function is verified.

Treatment for hypoglycemia depends on

The degree of it or the level of consciousness

Fatigue and muscular weakness occur because

The glucose needed for energy is not metabolized properly

The thighs and buttocks have slowest absorption unless

The injection is given before exercise when blood flow to those areas will be increased.

Gestational diabetes may occur as a result of ?

The stress of pregnancy, it may be treated with diet, oral hypoglycemia agents or insulin.

The abdomen has the quickest absorption rate followed by

The upper arms

Diabetic Ketoacidosis (DKA)

Type 1 diabetes Is a serious condition caused by incomplete metabolism of fats resulting from absence or insufficient insulin supply.

Weight gain is common in persons with

Type 2 diabetes - this gain can make a patient with this type of diabetes more insulin resistant:

Weight loss is seldom goal for older adults with

Type 2 diabetes, unless weight is more than 1 1/2 times normal height and frame.

Emotional or physical stress can ?

Unmask an inherited predisposition to the diabetes disease.

The kidneys try to get rid of the extra glucose in the

Urine

Retinopathy

Visual impairment and blindness are common sequelae of diabetes mellitus.

ketoacidosis

What causes it - Illness or infection Symptoms 1. Increase thirst (polydipsia) 2. Increased urination(polyuria) 3. Acetone breath odor (fruity) 4.Deep respiration's( kussmaul respiration's) Treatment- IV fluid and insulin

Sugars accumulate in the

blood and urine, and the by products of alternative fat metabolism (ketones)

Diabetes Mellitus results in the body's failure to

metabolize sugars and starch.