Diabetes/Insulin Therapy

Management of Hypoglycemia in hospital or ER for patients who are unconscious or can't swallow

- 25-50 cc of Dextrose 50% water - (D50, D50W) IVP

Ketones should be checked in Type 1 diabetic:

- BG > 240 2x in a row - During illness

Microvascular Complication

- Capillary basement membrane thickening affects: ~ retina ~ kidney

Macrovascular Complication

- Changes to medium to large blood vessels - Happen at an earlier age -Blood vessels: thicken, sclerose-harden, become occluded by plaque - 3 main types; ~ Coronary artery disease - MI, silent MI ~ Cerebrovascular disease - TIA, strokes ~ Peripheral vascular disease - Occlusive peripheral arterial disease causes poor wound healing - Severe form: gangrene & amputation

Severe Hypoglycemia Symptoms

- Disoriented behavior - Seizures - Difficulty arousing from sleep - Loss of consciousness

Risk Factors for Type 1

- Early onset - Familial - Genetic predisposition - Possible immunologic or environmental (viral or toxins) factors

Hyperglycemic Hyperosmolar Syndrome (HHS) Clinical Manifestations

- Hyperglycemia, glycosuria, EXTREME dehydration, hypernatremia, increase serum osmolarity, and altered consciousness; no significant ketosis - BUN and serum creatinine levels are markedly increased

Management of Hypoglycemia in unconscious patients

- Injection of 1 mg of glucagon IM - May take up to 20 minutes for patient to regain consciousness - Follow with 15 grams of concentrated carbs & a snack

Risk Factors for Type 2

- Obesity - Age - Previous identified impaired fasting glucose or impaired glucose tolerance - Hypertension ≥ 140/90 mm Hg - HDL ≤ 35 mg/dL - Triglycerides ≥ 250 mg/dL - History of gestational diabetes or babies over 9 lbs

Moderate Hypoglycemia Symptoms

- Poor concentration - Headache - Lightheadedness - Confusion - Memory lapses - Slurred speech - Impaired coordination - Double vision - Drowsiness

DKA Management

- Rehydration to replace fluid lost - NS, 1/2 NS, Dextrose when BG reaches 300 to prevent precipitous drop in BG * Monitor lung sounds for fluid overload during rapid IV fluid administration - Restoring electrolytes * Potassium primary concern; tends to be high but rehydration causes it to be low - Potassium replacements - every 2-4 hours have ECGs & frequent lab checks - Insulin Drip * Must check BG on hourly basis

Mild Hypoglycemia Symptoms

- Sweating - Tremor - Tachycardia - Palpitations - Nervousness - Hunger

Extra Information About Intermediate Acting Insulin

-NPH Insulin -they are white or cloudy -are expected to cover subsequent meals -can be given 1-2 times a day -if given 2 times a day, must give 12 hours apart

Very Long Acting Insulin: Glargine (Lantus)

-Onset: 1 hour -Peak: No peak -Duration: Used for basal dose -Notes: Clear, NEVER MIX

Short-Acting Insulin: Regular

-Onset: 1-1.5 hours -Peak: 2-3 hours -Duration: 4-6 hours -Notes: Clear, draw 1st when mixing

Rapid-Acting Insulin: Lispro (Humalog)

-Onset: 10-15 minutes -Peak: 1 hour -Duration: 2-4 hours -Notes: Feed right after injection, draw 1st

Intermediate Acting Insulin: NPH

-Onset: 2-4 hours -Peak: 4-12 hours -Duration: 16-20 hours -if a pt takes 2 doses of NPH, they should take them at the same time every 12 hrs bc if given without the proper duration bw doses, then the med could peak at the same time the other one does -Notes: Cloudy, "roll", draw 2nd when mixing

Rapid-Acting Insulin: Aspart (Novalog)

-Onset: 5-15 minutes -Peak: 40-50 minutes -Duration: 2-4 hours -Notes: Feed right after injection, draw 1st

Insulin Therapy for Diabetes

-Type 1 diabetic will always REQUIRE insulin -Type 2, gestational & diabetes from other conditions may require insulin therapy -insulins may be grouped into several categories based on the onset, peak, and duration of action

Basal Insulin

-VERY LONG ACTING INSULIN -necessary to maintain glucose control (basal) -used to maintain BG levels irrespective of meals -a constant level of insulin is required at all times -provide a relatively constant level of insulin; aka "peakless" -NEVER MIX & NEVER HOLD WITHOUT AN ORDER -given once a day, at the same time each day to prevent overlap of action

Insulin: Effects on Ketone Metabolism

-a product of fat metabolism -if you don't have enough insulin, you break down fat for energy & produce ketone bodies (which are acids) -occurs in type 1 diabetes

Why can't you mix basal insulin?

-bc the insulin is in a suspension with a pH of 4, it cannot be mixed with other insulins bc this would cause precipitation

Diabetes Mellitus vs Diabetes Insipidus

-diabetes mellitus is characterized by disturbances in carbohydrate, fat, and protein metabolism; consists of Type 1 & 2 -diabetes insipidus results from a deficiency of circulating ADH or vasopressin

Insulin: Effects on Lipoprotein Metabolism

-enhances fat deposition -inhibits breakdown of triglycerides

What tests can confirm the diagnosis of diabetes mellitus?

-fasting plasma glucose test > or = 126 mg/dL - random blood glucose > or = 200 mg/dl

What would you assess the patient for when looking for diabetes mellitus?

-fatigue -polyuria r/t hyperglycemia -polydipsia -nocturia -dry mucous membranes -poor skin turgor -weight loss -blurred vision -polyphagia

Duration of Action of Insulin

-how long the insulin lasts -the length of time from administration that it keeps lowering your BG

Onset of Insulin

-how soon after the insulin starts to lower BG after it is administered

Insulin Injection Sites

-insulin shots can be given pretty much wherever there's enough fat under the skin -main areas: abdomen (used the most), thighs, and back of upper arm -site rotation is different for every person

Type 2 DM

-most commonly occurs in obese adults after age 40 -usually treated with exercise, meal planning & antidiabetic drugs -may result from impaired insulin secretion, peripheral insulin resistance, or increased basal hepatic glucose production

When giving a patient an injection of a rapid acting insulin such as Lispro or Aspart, how long after the injection is okay for the patient to consume food?

-patient should eat not more than 5-15 minutes after injection

Insulin Functions

-secreted by beta cells of the islets of Langerhans in the pancreas & lowers BG after meals -allows glucose to transport into cells for use as energy or storage as glycogen; facilitates the uptake & utilization of glucose by muscle, fat, and liver cells -stimulates protein synthesis & free fatty acid storage in adipose tissue

Insulin: Effects on Protein Metabolism

-stimulates amino acid uptake & protein synthesis -inhibits protein degradation

Insulin: Effects on Glucose Metabolism

-stimulates storage of glucose as glycogen in liver & muscle -inhibits hepatic glucose production

What is the most common site used to give insulin?

-the abdomen -bc it is easy to reach & the insulin is absorbed from the abdomen at a more consistent rate from shot to shot

Extra Information About Rapid & Short Acting Insulin

-the nurse should emphasize which meals & snacks are being "covered" by which insulin doses -these insulins cover the increase in glucose levels after meals, immediately after injection -PRANDIAL: the amount of insulin given to cover intake

Peak of Insulin

-the time after administration that the insulin is working the hardest to lower BG

Glycosylated Hemoglobin A1C Test

-used to assess long term diabetes control -amount of glycosylation directly correlates with BG levels -should measure no more than 1.5 times the normal level (3-6%) -a high HbA1C value with any BG level suggests hyperglycemia over several weeks -a low HbA1C value with a high BG level suggests recent onset of hyperglycemia

Insulin Regimens

-usually a combination of short acting insulin & intermediate or long acting insulin -normal functioning pancreas secretes small amounts of insulin during the day & night; the goal of insulin regimens is to mimic this normal pattern of insulin secretion in response to food intake & activity patterns -short acting insulin covers the glucose raising effect of food

Type 1 DM

-usually occurs before age 30 (although it may occur at any age) -no insulin produced -autoimmune disease strongly associated with human leukocyte antigens DR 3 & 4 -pt is usually thin & will require exogenous insulin & dietary management to achieve control -must take insulin daily bc of their absolute insulin deficiency

Categories of Insulin

1. Rapid-Acting: Lispro (Humalog), Aspart (Novalog), Glulisine (Apidra) 2. Short-Acting: Regular (Humalog R, Novolin R, Iletin II Regular) 3. Intermediate-Acting: NPH (neutral protamine Hagedorn) (Humulin N, Iletin II Lente, Iletin II NPH, Novolin L [Lente], Novolin N [NPH]) 4. Very Long-Acting: Glargine (Lantus), Detemir (Levemir)

Classification of Diabetes

1. Type 1 Diabetes (juvenile diabetes, insulin dependent diabetes) 2. Type 2 Diabetes (non-insulin dependent diabetes, adult onset diabetes) 3. Gestational Diabetes (diabetes during pregnancy) 4. Diabetes associated with other conditions or syndromes (ex. high dose prednisone=high BG levels can develop)

Insulin Sliding Scale

1. for a BG >180: BG-100/30 = # of units of Regular insulin or Aspart insulin per orders 2. for a BG >150: BG-100/40 = # of units of Regular insulin *there is not one specific formula; these differ among patients* -only 100 was subtracted from the BG bc you don't want to bring it down to 0

Hypoglycemia occurs when BG falls to less than _____ mg/dL

70

HHS Treatment

Fluid replacement, correction of electrolyte imbalances, insulin administration, administration of 0.9% or 0.45% NS until BG reaches 300

Management of Hypoglycemia in alert patients

Give 15 grams of fast acting concentrated carbohydrates: - 2-3 glucose tablets - 4 ounces of juice/soda - 1 tablespoon sugar, honey, or corn syrup - 8 ounces of nonfat or 1% milk Then follow with snack-starch and protein

Diabetic ketoacidosis (DKA) causes

Nausea, vomiting, and abdominal pain and can progress to cerebral edema, coma, and death

DKA Clinical Manifestations

Polyuria, polydipsia, fatigue, blurred vision, headaches weakness, orthostatic BP, frank hypotension, weak rapid pulse, fruity smelling breath, kussmaul respirations, altered mental status

Urine dipstick ketone test

Turns purple in the presence of ketones

A client with type 1 diabetes is scheduled to receive 30 units of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client: a. 9 units regular insulin and 21 units neutral protamine Hagedorn (NPH). b. 21 units regular insulin and 9 units NPH. c. 10 units regular insulin and 20 units NPH. d. 20 units regular insulin and 10 units NPH.

a. 9 units regular insulin and 21 units neutral protamine Hagedorn (NPH).

Matt Thompson, a 37-year-old farmer, has been diagnosed with pre diabetes. Following his visit with his primary care provider, you begin your client education session to discuss treatment strategies. What can be the consequences of untreated pre diabetes? a. All options are correct. b. Type 2 diabetes c. Cardiac disease d. CVA

a. All options are correct.

A 53-year-old client is brought to the ED, via squad, where you practice nursing. He is demonstrating fast, deep, labored breathing and has a fruity odor to his breath. He has a history of type 1 diabetes. What could be the cause of his current serious condition? a. Ketoacidosis b. Hyperosmolar hyperglycemic nonketotic syndrome c. Hepatic disorder d. All options are correct

a. Ketoacidosis

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 health care provider suspects that the cause is related to the Somogyi effect. Which of the following indicators support this diagnosis? Select all that apply. a. Normal bedtime blood glucose b. Rise in blood glucose about 3:00 AM c. Increase in blood glucose from 3:00 AM until breakfast d. Decrease in blood sugar to a hypoglycemic level between 2:00 to 3:00 AM e. Elevated blood glucose at bedtime

a. Normal bedtime blood glucose c. Increase in blood glucose from 3:00 AM until breakfast d. Decrease in blood sugar to a hypoglycemic level between 2:00 to 3:00 AM e. Elevated blood glucose at bedtime

A client with diabetes mellitus is receiving an oral antidiabetic agent. Which of the following aspects should the nurse observe when caring for this client? a. Signs of hypoglycemia b. Polyuria c. Blurred vision d. Polydipsia

a. Signs of hypoglycemia

The nurse is teaching an older client how to self-administer insulin. Which of the following would be most helpful to the client who is having difficulty drawing up the correct dosage of insulin in the syringe? a. Syringe magnifier b. Insulin pen c. Jet injector d. Insulin pump

a. Syringe magnifier

A male client, aged 42 years, is diagnosed with diabetes mellitus. He visits the gym regularly and is a vegetarian. Which of the following factors is important when assessing the client? a. The client's consumption of carbohydrates b. History of radiographic contrast studies that used iodine c. The client's mental and emotional status d. The client's exercise routine

a. The client's consumption of carbohydrates

How long are insulin pens good for when you take them out of the fridge? a. at least 30 days b. at least 24 hours c. at least 1 week d. at least 90 days

a. at least 30 days

A 35-year old insulin-dependent diabetic patient was admitted to your unit with a diagnosis of pneumonia. This patient has been febrile since admission. It's 7:30 a.m. and time to administer his 24 units of NPH insulin. You understand that NPH insulin will reach its maximum effect (peak) between the hours of: a. 9:30 a.m. - 11:30 a.m. b. 11:30 a.m. - 7:30 p.m.

b. 11:30 a.m. - 7:30 p.m.

A child is brought into the emergency department with vomiting, drowsiness, and blowing respirations. The father reports that the symptoms have been progressing throughout the day. The nurse suspects diabetic ketoacidosis (DKA). Which action should the nurse take first in the management of DKA? a. Give prescribed antiemetics. b. Begin fluid replacements. c. Administer prescribed dose of insulin. d. Administer bicarbonate to correct acidosis.

b. Begin fluid replacements.

What is the time period in which a patient taking insulin is most likely to have a hypoglycemic event? a. Onset b. Peak c. Duration of Action d. Before eating

b. Peak Rationale: The peak is the time after administration that the insulin is working the hardest to lower BG.

The nurse understands that a client with diabetes mellitus is at greater risk for developing which of the following complications? a. High blood pressure b. Urinary tract infections c. Lifelong obesity d. Elevated triglycerides

b. Urinary tract infections

A nurse is caring for a client with type 1 diabetes who exhibits confusion, light-headedness, and aberrant behavior. The client is conscious. The nurse should first administer: a. I.M. or subcutaneous glucagon. b. I.V. bolus of dextrose 50%. c. 15 to 20 g of a fast-acting carbohydrate such as orange juice. d. 10 units of fast-acting insulin.

c. 15 to 20 g of a fast-acting carbohydrate such as orange juice.

Which of the following statements is true regarding gestational diabetes? a. It occurs in most pregnancies. b. Its onset is usually in the first trimester. c. A glucose challenge test should be performed between 24 and 28 weeks. d. There is a low risk for perinatal complications.

c. A glucose challenge test should be performed between 24 and 28 weeks.

What is the only insulin approved for IV use? a. Lispro b. Aspart c. Regular d. NPH

c. Regular (Short-Acting Insulin)

A client with type 2 diabetes asks the nurse why he can't have a pancreatic transplant. Which of the following would the nurse include as a possible reason? a. Increased risk for urologic complications b. Need for exocrine enzymatic drainage c. Underlying problem of insulin resistance d. Need for lifelong immunosuppressive therapy

c. Underlying problem of insulin resistance

Which of the following categories of oral antidiabetic agents exert their primary action by directly stimulating the pancreas to secrete insulin? a. Thiazolidinediones b. Biguanides c. Alpha glucosidase inhibitors d. Sulfonylureas

d. Sulfonylureas

When is short acting insulin (Regular) given to a patient with diabetes? a. administered 5-10 minutes before a meal b. administered 10-15 minutes before a meal c. administered 15-20 minutes before a meal d. administered 20-30 minutes before a meal

d. administered 20-30 minutes before a meal

When a person eats a meal, insulin secretion _______________ to move glucose from the blood into muscle, liver, and fat cells.

increases