Brunner Ch 41 - DIABETES

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After teaching a client with type 1 diabetes, who is scheduled to undergo an islet cell transplant, which client statement indicates successful teaching?

"I might need insulin later on but probably not as much or as often."

A client with type 1 diabetes has a highly elevated glycosylated hemoglobin (Hb) test result. In discussing the result with the client, the nurse is most accurate in stating:

"It tells us about your sugar control for the last 3 months."

What are the 2 main types of sweeteners?

1. Nonnutritive 2. Nutritive

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:

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

Which of the following is true regarding gestational diabetes?

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

Potassium levels during treatment of DKA

A patient's serum potassium level may drop quickly as a result of rehydration and insulin treatment, potassium replacement must begin once potassium levels drop to normal.

When administering insulin to a client with type 1 diabetes, which of the following would be most important for the nurse to keep in mind?

Accuracy of the dosage

Moderation is the key Type 1: Primary risk is Hypoglycemia Type 2: Calculate calories into meal plan. Choose light beers, dry wine

Alcohol

Acarbose (Precose) Miglitol (Glyset)

Alpha-Glucosidase Inhibitors

Delay absorption of complex carbohydrates in the intestine and slow entry of glucose into system circulation Do not increase insulin secretion Can be used alone or in combination with sulfonylureas, metformin, or insulin to improve glucose control

Alpha-Glucosidase Inhibitors

Onset: 5-15 minutes Peak: 40-50 minutes Duration: 2-4 hours

Aspart (Novolog)

When should people with diabetes not exercise and why?

BS > 250 and those who have ketones in their urine. Because exercising with elevated BS may cause their BS to elevate even higher

Inhibit production of glucose by the liver Increase body tissues' sensitivity to insulin Decrease hepatic synthesis or cholesterol

Biguanides

Metformin (Glucophage, Clucophage XL, Fortament) Metformin with glyburide (Glucovance)

Biguanides

A client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which laboratory finding should the nurse expect in this client?

Blood glucose level 1,100 mg/dl

The nurse is reviewing the initial laboratory test results of a client diagnosed with DKA. Which of the following would the nurse expect to find?

Blood pH of 6.9

Approved for treatment of type 2 Diabetes in combination with metformin or sulfonylureas Derived from a hormone found in the small intestine that is found deficient in type 2 diabetes. Shown to result in weight loss bc of the increases satiety produced Must be injected BID within 1 hour before breakfast and dinner

Byetta (Exenatide)

50-60%, emphasize whole grains

Carbohydrates

As any time of the day without regard to time since the last meal

Causal plasma glucose

Fatigue and weakness Sudden vision changes Tingling or numbness in hands or feet, Dry skin Skin lesions or wounds that are slow to heal Recurrent infections The onset of type 1 diabetes may be associated with sudden weight loss or nausea, vomiting, or abdominal pains, if DKA has developed.

Clinical manifestations of Diabetes

Polyuria, Polydipsia, and Polyphagia Polyuria and polydipsia occur as a result of the excess loss of fluid associated with osmotic diuresis. Polyphagia results from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats

Clinical manifestations of Diabetes

Hypotension Profound dehydration (dry mucous membranes, poor skin turgor) tachycardia variable neurologic signs (alteration of sensorium, seizures, hemiparesis)

Clinical manifestations of HHNS

Not enough blood Milking the finger Improper cleaning of machine Damage to strips

Common errors with SMBG

Local reaction Systemic allergic reaction Lipodystrophy Insulin resistance Morning hyperglycemia

Complications of Insulin Therapy

A nurse educates a group of clients with diabetes mellitus on the prevention of diabetic nephropathy. Which of the following suggestions would be most important?

Control blood glucose levels

Symptoms of diabetes plus causal plasma glucose concentration = or > than 200 mg/dL Fasting plasma glucose > or = to 126 mg/dL Two-hour postload glucose = or > than 200 mg/dL during an oral glucose tolerance test

Criteria for the Diagnosis of Diabetes Mellitus

Ketones Kussmaul respiration Acetone breath Dehydration

DKA

Metabolic Acidosis

DKA

More common in type 1 diabetes Caused by omission of insulin; physiologic stress (infection, surgery, CVA, MI) Onset is rapid (<24 hours) BS usually > 250 Arterial pH level <7.3 Ketones are present Serum osmolality 300-350 mOsm/L Bicarbonate <15 mEq/L Bum and creatine levels elevated Mortality rate < 5%

DKA

Sitagliptin (Januvia) Vildagliptin (Galvus)

DPP-4 Inhibitor

1. Nutritional therapy 2. Exercise 3. Monitoring 4. Pharmacologic therapy 5. Education

Diabetes Management

A group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both.

Diabetes Mellitus

The main goal is to normalize insulin activity and blood glucose levels to reduce the development of vascular and neuropathic complications

Diabetes Treatment

Ketones are acids that disturb the acid-base balance of the body when they accumulate in excessive amounts. This results in _____________.

Diabetic Ketoacidosis (DKA)

May cause S/S such as abdominal pain, N/V, hyperventilation, a fruity breath odor, and, if left untreated, altered level of consciousness, coma, and death. Initiation of insulin treatment, along with fluid and electrolytes as needed.

Diabetic Ketoacidosis (DKA)

A metabolic derangements in type 1 diabetes that results from a deficiency of insulin; highly acidic ketone bodies are formed, resulting in acidosis; usually requires hospitalization for treatment and is usually caused by non adherence to the insulin regimen, concurrent illness, or infection.

Diabetic Ketoaidosis (DKA)

Increase and prolongs the action of incretin, a hormone that increases insulin release and decreases glucagon levels, with the result of improved glucose control

Dipeptidyl Peptidase-4 (DPP-4) Inhibitor

Dislodgment of needle Infection Hypoglycemia Inconvenience of wearing is 24 hrs/day Most common: ketoacidosis b/c of dislodgment of needle

Disadvantages of Insulin Pump

It is not very important to read labels.

FALSE

Blood glucose determination obtained in the laboratory after fasting more than 8 hours.

Fasting Plasma Glucose (FPG)

No caloric intake for at least 8 hours

Fasting plasma glucose

20-30%, with >10% from saturated and < 300 mg cholesterol

Fat

Acetohexamide (Dymelor) Chlorpropamide (Diabinese) Tolazamide (Tolinase) Tolbutamide (Orinase)

First-Generation Sulfonylureas

Used infrequently in US today Used in type 2 Diabetes to control blood glucose levels Stimulate beta cells of the pancreas to secrete insulin; may improve binding between insulin and insulin receptors or increase the number of insulin receptors

First-Generation Sulfonylureas

Use proper footwear and, if appropriate, other protective equipment Avoid exercise in extreme heat or cold Inspect feet daily after exercise Avoid exercise during periods of poor metabolic control

General Precautions for Exercise in People with Diabetes

Any degree of glucose intolerance with its onset during pregnancy

Gestational diabetes mellitus (GDM)

Onset: 1 hour Peak: No peak Duration: 24 hours

Glargine (Lantus) Detemir (Levemir)

Another pancreatic hormone secreted by the alpha cells of the islets of Langerhans which is released when blood glucose levels decreased and stimulates the liver to release stored glucose.

Glucagon

Together maintain a constant level of glucose in the blood by stimulating the release of glucose from the liver.

Glucagon & Insulin

After 8 to 12 hours without food, the livery forms glucose from the breakdown of noncarbohydrate substances, including amino acids.

Gluconeogenesis

If concentrations of glucose exceeds the renal threshold for glucose (180-200), the kidneys may not reabsorb all of the filtered glucose; the glucose appears in the urine

Glucosuria

Onset: 5-15 minutes Peak: 30-60 minutes Duration: 2 hours

Glulisine (Apridra)

A long-term measure of glucose control that is a result of glucose attaching to hemoglobin for the life of the red blood cell (120 days). The goal of diabetes therapy is a normal to near-normal level of glycated hemoglobin, the same as in the non diabetic population.

Glycated hemoglobin (glycosylated hemoglobin, HgB A1C, or A1C)

Used to describe how much a given food raises the blood sugar level compared with an equivalent amount of glucose

Glycemic Index

Initally, the liver produces glucose through the breakdown of glycogen.

Glycogenolysis

Blood test that reflects the average blood sugar over approx 2-3 months Normal range is 4-6%

Glycosylated Hemoglobin/A1C

Can occur is type 1 and type 2 Diabetes More common in type 2 diabetes, especially elderly patients Caused by physiologic stress (infection, surgery, CVA, MI) Onset slower (over several days) BS usually >600 Arterial pH normal No ketones Serum osmolality >350 mOsm/L Bicarbonate Normal Bun and creatine levels elevated Morality rate 10-40%

HHNS

No ketones

HHNS

You have high BS which causes polyuria (so high that it causes dehydration)

HHNS DKA

A client with type 1 diabetes asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are effective only if the client:

Has Type 2 Diabetes

Which of the following is the most rapid acting insulin?

Humalog

Onset: 3-4 hours Peak: 4-12 hours Duration: 16-20 hours

Humulin N Iletin II Lente Iletin II NPH Novolin L [Lente] Novolin N [NPH]

Elevated blood glucose level; fasting level greater than 110 mg/dL; 2-hour postprandial level greater than 140 mg/dL.

Hyperglycemia

A serious condition in which hyperosmolarity and hyperglycemia predominate, with alterations of the sensorium (sense of awareness). Ketones absent. Lack of effective insulin (ie. insulin resistance)

Hyperglycemic hyperosmolar nonketotic syndrome

A metabolic disorder of type 2 diabetes resulting for a relative insulin deficiency initiated by an intercurrent illness that raises the demand for insulin; associated with polyuria and severe dehydration

Hyperglycemic hyperosmolar nonketotic syndrome (HHNS)

Low blood glucose level (less than 60 mg/dL)

Hypoglycemia

Which combination of adverse effects should a nurse monitor for when administering I.V. insulin to a client with diabetic ketoacidosis?

Hypokalemia and hypoglycemia

A metabolic stage intermediate between normal glucose homeostasis and diabetes; now referred to a prediabetes

Impaired fasting glucose (IFG), impaired glucose tolerance (IGT)

Prevents constipation

Insoluble Fiber

*Transports and metabolizes glucose for energy *Stimulates storage of glucose in the liver and muscle (in the form of glycogen) *Signals the liver to stop the release of glucose *Enhances storage of dietary fat in adipose tissue *Accelerates transport of amino acids (derived from dietary protein) into cells

Insulin

A hormone secreted by the beta cells of the islets of Langerhans of the pancreas that is necessary for the metabolism of carbohydrates, proteins, and fats; a deficiency of this results in diabetes mellitus

Insulin

Inhibits the breakdown of stored glucose, protein, and fat

Insulin

Secreted by beta cells, which are one of the 4 types of cells in the islets of Langerhans in the pancreas. It is an anabolic, or storage, hormone. When a person eats a meal, secretion increases and moves glucose from the blood into muscle, liver, and fat cells.

Insulin

May be given SQ or IM Not given PO b/c it is destroyed by digestive insulins Should have another nurse verify dosage prior to giving Concentration: 100 units/ mL 1/2 cc & 1 cc syringes

Insulin Therapy

The progressive increase in blood glucose from bedtime to morning

Insulin Warning

Appear white and cloudy Onset varies slightly: 2-4 or 3-4 hours Peaks: 4-12 hours Duration: 16-20 hours Examples are Humulin NPH, Novolog N, NPH

Intermediate Acting Insulins

NPH is an example of which type of insulin?

Intermediate-acting

An investigational procedure in which purified islet cells from cadaver donors are injected into the portal vein of the liver, with the goal of having these cells secrete insulin and cure type 1 diabetes

Islet cells transplantation

When administering Insulin it is very important to read the label carefully and to be sure that the correct type of insulin is administered.

It is also important to avoid mistaking Lantus insulin for Lente insulin and vice versa.

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?

Ketoacidosis

A highly acidic substance formed when the liver breaks down free fatty acids in the absence of insulin; the result is diabetic ketoacidosis

Ketone

Onset: 10-15 minutes Peak: 1 hour Duration: 2-4 hours

Lispro (Humalog)

Insulin unlocks the door so glucose can travel into muscles, etc. so it isn't in the blood stream.

Lock & Key method

Lantus Very long acting Onset 1 hours Given once a day Mimics pancreas Peak-less insulin Cannot be mixed with another insulin- causes precipitation Used for basal dose

Long Acting Insulins

What does exercise do to your blood sugar?

Lowers blood glucose levels by increasing the uptake of glucose by body muscles and by improving insulin utilization

Consider food preferences, lifestyle, usual eating times, and cultural/ethnic background Review diet history and need for weight loss, gain, or maintenance Caloric requirements and calorie distribution throughout the day

Meal Planning

Nutritional therapy prescribed by the physician for management of diabetes

Medical Nutrition Therapy (MNT)

Includes HTN, hypercholesterolemia, and abdominal obesity. To overcome insulin resistance and to prevent the buildup of glucose in the blood, increased amounts of insulin must be secreted to maintain the glucose level at a normal or slightly elevated level.

Metabolic Syndrome

Humulin 70/30 Novolog 70/30 Humalog 75/25 Cloudy

Mixed Insulin

An elevated blood glucose level in the morning caused by an insufficient amount of insulin. May be caused by: The dawn phenomenon the Somogyi effect Insulin warning

Morning Hyperglycemia

Onset: 2-4 hours Peak: 4-12 hours Duration: 16-20 hours

NPH (neutral protamine Hagedorn)

A long-term complication of diabetes in which the kidney cells are damaged; characterized by microalbuminuria in early stages and progressing to end-stage renal disease

Nephropathy

A nurse expects to find which signs and symptoms in a client experiencing hypoglycemia?

Nervousness, diaphoresis, and confusion

A long-term complication of diabetes resulting from damage to the nerve cell

Neuropathy

Repaglinide (Prandin) categorized as a meglitinide Nateglinide (Starlix) categorized as d D-phenylalanine derivative

Non-Sulfonylurea Insulin Secretagogues

Stimulate pancreas to secrete insulin Can be used alone on in combination with metofrmin or thiazolidinediones to improve glucose control

Non-Sulfonylurea Insulin Secretagogues

Have minimal or no calories Produce minimal or no elevation in BS Have been approved by the FDA as safe for people with diabetes Include saccharin, aspartame (NutraSweet), acesulfame-K (Sunnette), and sucralose (Splenda)

Nonnutritive sweeteners

Individualized Calorie distribution Exchange list Food guide pyramid Work with dietian

Nutritional Management

Include fructose (fruit sugar), sorbitol, and xylitol, all of which provide calories in amounts similar to those in sucrose (table sugar). Cause less elevation in BS than sucrose does and are often used in "sugar-free" foods

Nutritive Sweeteners

When excessive glucose is excreted in the urine, it is accompanied by excessive loss of fluid/electrolytes

Osmotic diuresis

Impaired glucose metabolism in which blood glucose concentrations fall between normal levels and those considered diagnostic for diabetes; includes IFG and IGT, not clinical entities in their own right by risk factors for future diabetes and cardiovascular disease

Prediabetes

Give right before a meal Humalog: 10-15 mins Novolog: 5-15 minutes

Rapid Acting Insulins

Used for rapid reduction of glucose level, to treat postprandial hyperglycemia, and/or to prevent nocturnal hypoglycemia

Rapid-acting insulins

Onset: 1/2 to 1 hour Peak: 2-3 hours Duration: 4-6 hours

Regular (Humalog R, Novolin R, Iletin II Regular)

A long-term complication of diabetes in which the microvascular system of the eye is damaged

Retinopathy

Glipizide (Glucotrol, Clucotrol XL) Glyburide (Micronase, Glynase, Dia-Beta) Glimepiride (Amaryl)

Second-Generation Sulfonylureas

Stimulate beta cells of the pancreas to secrete insulin; may improve binding between insulin and insulin receptors or increase the number of insulin receptors Have more potent effects than first-generation May be used in combination with metformin or insulin to improve glucose control

Second-Generation Sulfonylureas

A method of capillary blood glucose testing in which the patient pricks his or her finger and applies a drop of blood to a test strip that is read by a meter.

Self-monitoring of blood glucose (SMBG)

Clear 20-30 mins before a meal Commonly used for coverage Peaks: 2-3 hours Examples are Humulin R, Novolog R May be given in combination with longer acting insulins

Short Acting Insulins

Because illness, especially infections, can cause increased blood glucose levels, the patient does not need to decrease the insulin dose to compensate for decreased food intake when ill and may even need to increase the insulin dose.

Sick day rules

Lowers blood sugar and lipid levels

Soluble Fiber

Nocturnal hypoglycemia followed by rebound hyperglycemia

Somogyi effect

A classification of oral antidiabetic medication for treating type 2 diabetes; stimulates insulin secretion and insulin action

Sulfonylurea

100% of carbohydrates go into glucose

TRUE

50% of Protein is converted into Glucose

TRUE

Use of artificial sweeteners is acceptable, especially if it assists in overall dietary adherence.

TRUE

A male client, aged 42, 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? `

The clients consumption of carbohydrates

Characterized by relatively normal blood glucose level until approx 3AM, when blood glucose levels begin to rise.

The dawn phenomenon

A class of oral antidiabetic medications that reduce insulin resistance in target tissues, enhancing insulin action without directly stimulating insulin secretion.

Thiazolidinedione

Pioglitazone (Actos) Rosiglitazone (Avandia)

Thiazolidinediones

Sensitize body tissue to insulin; stimulate insulin receptor sites to lower blood glucose and improve action of insulin May be used alone or in combination with sulfonylurea, metformin, or insulin

Thiazolidinediones (or glitazones)

Rehydration Restoring electrolytes Reversing Acidosis

Treatment for DKA

Change time of injection of evening intermediate-acting insulin from dinnertime to bedtime

Treatment for Dawn Phenomenon

Increase evening (Predinner or bedtime) dose of intermediate-acting or long-acting insulin, or institute a dose of insulin before the evening meal if one is not already part of the treatment regimen

Treatment for Insulin warning

Decrease evening (predinner or bedtime) dose of intermediate-acting insulin, or increase bedtime snack

Treatment for Somogyi Effect

Fluid replacement Correction of electrolyte imbalances Insulin administration

Treatment of HHNS

Peak of insulin is where hypoglycemia reactions occurs.

True

Sweeteners containing sorbitol may have a laxative effect.

True

The renal threshold for glucose is 180 to 200 mg/dL.

True

This test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.

Two hour post load glucose test

5-10% of all people Results from destruction of pancreatic beta cells Etiology: genetic, immunologic, and environmental (viruses) Onset at any age, usually <30 Usually thin with recent weight loss at diagnosis Have little or no endogenous insulin Often have antibodies to insulin Ketosis prone when insulin absent Tx: insulin to preserve life Acute complications of hyperglycemia=DKA

Type 1 Diabetes

Glucose derived from food cannot be stored in the liver, but instead remains in the blood stream and contributes to postprandial hyperglycemia

Type 1 Diabetes

Regardless of specific etiology, destruction of the beta cells results in unchecked glucose production by the liver and fasting hyperglycemia

Type 1 Diabetes

A metabolic disorder characterized by an absence of insulin production and secretion from autoimmune destruction of the beta cells of the islets of Langerhans in the pancreas; formerly called insulin-dependant, juvenile

Type 1 diabetes

Fat breakdown occurs resulting in increased production of ketone bodies (by product of fat breakdown)

Type 1 diabetes

Acute complications: Hyperglycemic Hyperosmolar Nonketotic Syndrome: HHNS

Type 2 DIabetes

Because its associated with a slow, progressive glucose intolerance, its onset may go undetected for many years. If the PT experiences symptoms, they are frequently mild and may include fatigue, irritability, polyuria, polydipsia, poorly healing skin wounds, vaginal infections, or blurred vision (if glucose levels are very high)

Type 2 Diabetes

Causes: obesity, heredity, & environmental factors Onset at any age, but usually > 30 Usually obese on diagnosis Slow progression.. may go undetected for years No islet cell antibodies Ketosis rare except in stress or infection

Type 2 Diabetes

Normally, insulin binds to special receptors on cell surfaces and initiates a series of reactions involved in glucose metabolism. These intracellular reactions are diminished = insulin less effective at stimulating glucose uptake by tissues

Type 2 Diabetes

Results from: decreased in endogenous insulin and/or decreased sensitivity to insulin (insulin resistance)

Type 2 Diabetes

There is enough insulin present to prevent the breakdown of fat and production of ketone bodies. Therefore, DKA does not occur.

Type 2 Diabetes

To overcome insulin resistance and to prevent the increase glucose causes increased secretion of insulin; however beta cells cannot keep up with increased demand for insulin, glucose rises

Type 2 Diabetes

Two main problems related to insulin are insulin resistance (decreased sensitivity of the tissues to insulin) and impaired insulin secretion

Type 2 Diabetes

Tx: first with diet & exercise to lose weight Then.. oral hypoglycemic Some may require insulin Some may need insulin during periods of acute physiologic stress

Type 2 Diabetes

A metabolic disorder characterized by the relative deficiency of insulin production and a decreased insulin action and increased insulin resistance; Formerly called non-insulin-dependant, adult-onset.

Type 2 diabetes

Not done as much bc of SMBG Renal threshold 180-200 mg/dL Hypoglycemia can not be detected Some medications may interfere

Urine Testing for Glucose

What is the goal of insulin regimen?

to mimic the pattern of insulin secretion as closely as possible


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