Chapter 48 Diabetes Mellitus (Test 1)

Insulin Regimens- Mealtime Insulin (Bolus)

-To manage postprandial blood glucose levels, the timing of rapid- and short-acting insulin in relation to meals is crucial (post prandial = Levels after a meal) -Rapid-acting synthetic insulin analogs, which include aspart (NovoLog), glulisine (Apidra), and lispro (Humalog), have an onset of action of about 15 minutes. They should be injected within 15 minutes of mealtime. -Short-acting regular insulin has an onset of action of 30 to 60 minutes. It is injected 30 to 45 minutes before a meal to ensure that the insulin is working at the same time as meal absorption. -Short-acting insulin is more likely to cause hypoglycemia because of a longer duration of action

Problems with Insulin Therapy - Dawn Phenomenon

-is also characterized by hyperglycemia that is present on awakening -Treatment = an increase in insulin or an adjustment in administration time -Ask the patient to measure and document bedtime, nighttime (between 2:00 and 4:00 AM), and morning fasting blood glucose levels on several occasions. If the predawn levels are less than 60 mg/dL (3.3 mmol/L) and signs and symptoms of hypoglycemia are present, the insulin dosage should be reduced. If the 2:00 to 4:00 AM blood glucose is high, the insulin dosage should be increased. Counsel the patient on appropriate bedtime snacks.

Implementation - Ambulatory Care

-major goal of patient care in these settings is to enable the patient (with the help of a caregiver as needed) to reach an optimal level of independence in selfcare activities -Insulin Therapy - Nurse's Responsibilities Oral and Noninsulin Injectable Agents Personal Hygiene - diligent skin and dental hygiene practices. -encourage daily brushing and flossing and regular dental visits -regular bathing, with an emphasis on foot care -inspect their feet daily, avoid going barefoot, and wear shoes that are supportive and comfortable -notify the HCP at once if the injury does not begin to heal within 24 hours or if signs of infection develop. Herbs and supplements that may lower blood glucose include aloe, ginger, cinnamon, St. John's wort, garlic, and ginseng.

Metabolic Syndrome (Syndrome X)

A genetic metabolic disorder People with metabolic syndrome have an increased risk for developing type 2 diabetes. Metabolic syndrome has 5 components: increased glucose levels, abdominal obesity, high BP, high levels of triglycerides, and decreased levels of high-density lipoproteins (HDLs) A person with 3 of the 5 components is considered to have metabolic syndrome.

Glycosylated Hemoglobin (A1C)

A1C measures the amount of glycosylated hemoglobin (Hgb) as a percentage of total Hgb. -The amount of glycosylated Hgb depends on the blood glucose level. When blood glucose levels are elevated over time, the amount of glucose attached to Hgb increases. This glucose stays attached to the red blood cell (RBC) for the life of the cell (about 120 days). -A1C provides a measurement of blood glucose levels over the previous 2 to 3 months, with increases in the Hb A1C reflecting elevated blood glucose levels.

Gestational Diabetes

Develops during pregnancy High risk for C-section, r babies have increased risk for perinatal death, birth injury, and neonatal complications. screened using an OGTT at 24 to 28 weeks of gestation. normal glucose levels within 6 weeks postpartum.

chronic complications of diabetes

Chronic complications associated with diabetes are primarily those of end-organ damage to blood vessels termed Angiopathy and this is due to CHRONIC HYPERGLYCEMIA or uncontrolled blood glucose for a long period of time. MACROVASCULAR MICROVASCULAR

Exogenous Insulin

Exogenous (injected) insulin is needed when a patient has inadequate insulin to meet specific metabolic needs. -type 1 diabetes require exogenous insulin to survive. -type 2 diabetes may need exogenous insulin during periods of severe stress, such as illness or surgery

What is Insulin?

FUNCTION: A hormone made by the β cells in the islets of Langerhans of the pancreas an anabolic, or storage, hormone. •Metabolizes, Stores, Signals, Inhibits, Unlocks •Released continuously into bloodstream in small increments with larger amounts released after food •Fasting causes pancreas to release basal insulin lowers blood glucose and facilitates a stable, normal glucose range of about 74 to 106 mg/dL •Daily amount of insulin secreted by adult = 40 to 50 U promotes glucose transport A counterregulatory Hormone: •Glucagon, Epinephrine, Growth Hormone, Cortisol •Stimulate glucose produce and release by the liver •Decrease movement of glucose into the cell •Help maintain normal blood glucose levels

Normal Endogenous Insulin Secretion

In the first hour or two after meals, insulin concentrations rise rapidly in blood and peak at about 1 hour. After meals, insulin concentrations promptly decline toward pre-prandial values as carbohydrate absorption from the GI tract declines. After carbohydrate absorption from the GI tract is complete and during the night, insulin concentrations are low and fairly constant, with a slight increase at dawn.

Pre- Diabetes

Increased risk for developing type 2 diabetes Defined as impaired glucose tolerance (IGT), impaired fasting glucose (IFG), or both. An intermediate stage between normal glucose homeostasis and diabetes, in which the blood glucose levels are elevated but not high enough to meet the diagnostic criteria for diabetes Diagnosis of IGT (Impaired Glucose Tolerance) is made if the 2-hour oral glucose tolerance test (OGTT) values are 140 to 199 mg/dL (7.8 to 11.0 mmol/L). IFG (Impaired Fasting Glucose) is diagnosed when fasting blood glucose levels are 100 to 125 mg/dL (5.56 to 6.9 mmol/L). usually do not have symptoms, but damage to heart and blood vessels may be occurring

Type 1 Diabetes Mellitus - Onset

The islet cell autoantibodies responsible for β-cell destruction are present for months to years before the onset of symptoms -Manifestations develop when the person's pancreas can no longer make enough insulin to maintain normal glucose. Once this occurs, the onset of symptoms is usually rapid -usually has a history of recent and sudden weight loss and the classic symptoms of polydipsia (excessive thirst), polyuria (frequent urination), and polyphagia (excessive hunger). -requires insulin from an outside source (exogenous insulin) to sustain life. -W/O insulin will develop DKA (results in metabolic acidosis) -Newly diagnosed patients may have a remission, or "honeymoon period," for 3 to 12 months after starting treatment

Type 2 Diabetes - Manifestations

Nonspecific polyuria, polydipsia, and polyphagia fatigue, recurrent infections, recurrent vaginal yeast or candida infections, prolonged wound healing, and vision problems

Type 2 Diabetes - ONSET

Onset is usually gradual May go for years w/undetected hyperglycemia or symptoms Diagnosed on routine laboratory testing or when they undergo treatment for other conditions, and elevated glucose or glycosylated hemoglobin (A1C) levels are found. Signs and symptoms of hyperglycemia develop when about 50% to 80% of β cells are no longer secreting insulin

Type 1 Diabetes Mellitus - Manifestations

Rapid First manifestations are usually acute Classic symptoms are polyuria, polydipsia, and polyphagia Excess glucose in the bloodstream causes polydipsia and polyuria Polyphagia is a result of cellular malnourishment when insulin deficiency prevents cells from using glucose for energy. Weakness and fatigue may result because body cells lack needed energy from glucose. Ketoacidosis, a complication most common in those with untreated type 1 diabetes

Type 1 Diabetes Mellitus - Etiology

an autoimmune disorder in which the body develops antibodies against insulin and/or the pancreatic β cells that make insulin. This eventually results in not enough insulin for a person to survive. A genetic predisposition and exposure to a virus are factors that may contribute to the development of immune-related type 1 diabetes

Type 2 Diabetes - ETIOLOGY

characterized by a combination of inadequate insulin secretion and insulin resistance. The pancreas usually makes some endogenous (self-made) insulin. However, the body either does not make enough insulin or does not use it effectively, or both. The presence of endogenous insulin is a major distinction between type 1 and type 2 diabetes. In type 1 diabetes, there is an absence of endogenous insulin.

Hyperglycemia

high blood sugar occur when there is not enough insulin working gradual onset -Manifestations: Increase urination Increase appetite Weakness, fatigue Blurred vision Headache Glycosuria Nausea, vomiting Abdominal cramps Progression to DKA or HHS Mood swings Cause: Illness, infection Corticosteroids Too much food Too little or no diabetes med Inactivity Emotional, physical stress Poor absorption of insulin Preventive Measures Take meds Accurately give meds

Hypoglycemia

low blood sugar occur when there is too much insulin working worsens rapidly Manifestation: Blood glucose <70 Cold, clammy skin Numbness of fingers, toes, mouth Tachycardia Emotional Changes Headache Nervousness, tremors Faintness, dizziness Unsteady gait, slurred speech Hunger Changes in vision Seizure, coma Cause: Alcohol intake w/o food Too little food-delayed, omitted, inadequate intake Too much exercise w/o adequate food intake Diabetes meds or food taken at wrong time Loss of weight w/o change in medication Use of B-adrenergic blockers interfering with recognition of symptoms Preventive Measures: Take prescribed dose of medication at proper time Accurately give insulin, noninsulin injectables, OA Coordinate eating w/ medications Eat adequate food intake needed for calories for exercise Be able to recognize Carry simple carbs check BG Interventions: Initial • Check blood glucose. • Determine cause of hypoglycemia (after correction of condition). Management Conscious Patient • Have patient eat or drink 15 g of quick-acting carbohydrate (4-6 oz of regular soda, 5-8 LifeSavers, 1 Tbsp syrup or honey, 4 tsp jelly, 4-6 oz orange juice, commercial dextrose products [per label instructions]). • Wait 15 min. Check blood glucose again. • If blood glucose is still <70 mg/dL, have patient repeat treatment of 15 g of carbohydrate.

What is diabetes?

most often referred to as diabetes, is a chronic multisystem disease characterized by hyperglycemia from abnormal insulin production, impaired insulin use, or both. a disorder of glucose metabolism related to absent or insufficient insulin supply and/or poor use of the available insulin. more than half of adults with diabetes have hypertension and high cholesterol levels (hyperlipidemia) leading cause of adult blindness, end-stage renal disease (ESRD), and nontraumatic lower limb amputations major contributing factor to heart disease and stroke.

Needles

syringe needles come in 3 lengths: 6 mm (½ in), 8 mm (5⁄16 in), and 12.7 mm (½ in) The needle gauges available are 28, 29, 30, and 31. The higher the gauge number, the smaller the diameter, thus resulting in a more comfortable injection. given at a 90-degree angle thin or muscular patients in the hospital, perform injections at a 45-degree angle

Type 1 Diabetes Mellitus

three P's. (Polyuria, Polydipsia, Polyphagia) unexplained weight loss type 1 diabetes, formerly known as juvenile-onset diabetes or insulin dependent diabetes mellitus (IDDM) generally affects people under 40 years of age, although it can occur at any age

Goal of diabetes management

to reduce symptoms, promote well-being prevent acute complications related to hyperglycemia and hypoglycemia prevent or delay the onset and progression of long-term complications.

Biguanides (Metformin) - DRUG ALERT

• Do not use in patients with kidney disease, liver disease, or heart failure. Lactic acidosis is a rare complication of metformin accumulation. • IV contrast media that contain iodine pose a risk for CIN, which could worsen metformin-induced lactic acidosis. • To reduce risk for CIN, discontinue metformin 2 days before the procedure. • May be resumed 48 hours after the procedure, assuming kidney function is normal. • Do not use in people who drink excess amounts of alcohol. • Take with food to minimize GI side effects

Thiazolidinediones

•"Insulin sensitizers" •Most effective in those with insulin resistance •Improve insulin sensitivity, transport, and utilization at target tissues •Examples: •Pioglitazone (Actos) •Rosiglitazone (Avandia) •Rarely used because of adverse effects Because they do not increase insulin production, they do not cause hypoglycemia when used alone ADVERSE EFFECTS: Rosiglitazone is associated with adverse cardiovascular events (e.g., myocardial infarction [MI]) and can be obtained only through restricted access programs. Pioglitazone can worsen heart failure (HF) and is associated with an increased risk for bladder cancer

Exercise

•30 minutes, 5 days per week •Decreases insulin resistance •Contributes to weight loss; decreases insulin resistance • DECREASE Triglycerides, LDL, BP • Increases HDL •Education 48.10 •Type I delay if BG >250 + Ketones in urine

Sulfonylureas

•Action: Increases insulin production from pancreas •Major side effect: hypoglycemia EXAMPLES: •Glipizide (Glucotrol) •Glyburide (Glynase) •Glimepiride (Amaryl)

Meglitinides

•Action: Increases insulin production from pancreas •Rapid onset: Decreases risk of hypoglycemia •Patient education: •Take 30 minutes to just before each meal to mimic normal response to eating •Do not take if skip a meal EXAMPLES: nateglinide (Starlix) and repaglinide (Prandin) increase insulin production by the pancreas more rapidly absorbed and eliminated than sulfonylureas, they are less likely to cause hypoglycemia

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors

•Action: block reabsorption of glucose by kidney •Increase urinary glucose excretion EXAMPLES: •Canagliflozin (Invokana) •Dapagliflozin (Farxiga) •Empagliflozin (Jardiance)

amylin analogs: pramlintide (Symlin)

•Amylin—hormone secreted by b-cells in response to food intake slows gastric emptying, reduces postprandial glucagon secretion, and increases satiety •Used concurrently with mealtime insulin but can't mix together in same syringe; i bolus insulin dose •Administer subcutaneous in thigh or abdomen before meals with at least 250 cal •Watch for severe hypoglycemia ~ 3 hours after injection; have fast-acting glucose available The concurrent use of pramlintide and insulin increases the risk for severe hypoglycemia during the 3 hours after injection, especially in patients with type 1 diabetes. Teach patients to eat a meal with at least 250 calories and keep a form of fast-acting glucose on hand in case hypoglycemia develops. When pramlintide is used, the bolus dose of insulin should be reduced

Dopamine Receptor Agonist

•Bromocriptine (Cycloset)—improves glucose levels •Mechanism of action unknown; the thought is that patients with type 2 diabetes have low levels of dopamine that may interfere with the body's ability to control blood glucose •Action: increases dopamine receptor activity •Alone or in combination with other type 2 treatments

chronic complications of diabetes - Microvascular complications of DM

•Capillaries and Arterioles •Thickening of Vessel Membrane •Etiology --> Chronic Hyperglycemia • •Eyes (Retinopathy) •Most common cause of new cases of adult blindness •2 classifications •Kidneys (Nephropathy) •Nerves (Neuropathy) •Sensory versus Autonomic

Combination Therapy & Other Medications

•Combinations of two different classes of medications to treat diabetes •Advantage: fewer pills for patient to take •Other drugs affecting blood glucose levels •Drug interactions can potentiate hypoglycemia and hyperglycemia effects •Examples: •b-adrenergic - can mask symptoms of hypoglycemia •Thiazide and loop diuretics - can worsen hyperglycemia

chronic complications of diabetes - Macrovascular complications of DM

•Diseases of the Large and Medium Sized Blood Vessels •Cerebrovascular Disease •Cardiovascular Disease •Peripheral Vascular Disease •Women > Men •4-6x risk for CVD •Treat CVD Risk Factors •Yearly Screening

Dipeptidyl Peptidase-4 (DDP-4) Inhibitors

•Incretin hormones come in pill form •Increases insulin synthesis and release from pancreas and decreases hepatic glucose production when glucose levels are normal or elevated; DDP-4 inactivate incretin hormones •Action: DDP-4 inhibitors block action of DDP-4 Increases insulin release, decreases glucagon secretion, and decreases hepatic glucose production Levels increase in response to a meal Are glucose dependent, they lower the potential for hypoglycemia •Examples ("gliptins"): •Alogliptin (Nesina) •Sitagliptin (Januvia) •Saxagliptin (Onglyza) •Linagliptin (Tradjenta) The main benefit of these drugs over other medications with similar effects is the absence of weight gain as a side effect.

Inhaled Insulin (Afrezza)

•Rapid-acting inhaled insulin •Administered at beginning of each meal or within 20 minutes after starting a meal •Used in combination with long-acting insulin in Type I •Common adverse reactions: hypoglycemia, cough, throat pain or irritation •Not recommended for: treatment of DKA, smokers; patients with asthma or COPD due to risk of bronchospasm

Oral Agents (OA) & Non-Insulin Injectables

•Work on 3 defects of Type II DM •Insulin Resistance •Decreased Insulin Production •Increased Hepatic Glucose Production May be used in combination or with insulin

α-Glucosidase Inhibitors

"Starch blockers" most effective in lowering postprandial blood glucose. Their effectiveness is measured by checking 2-hour postprandial glucose levels Slow down absorption of carbohydrate in small intestine Take with first bite of each meal Check 2-hour postprandial glucose to determine effectiveness Examples: Acarbose (Precose) Miglitol (Glyset)

Insulin Regimens- Basal -Bolus Plan

- Aka intensive or physiologic insulin therapy -closely mimics endogenous insulin production -consists of multiple daily insulin injections (or an insulin pump) together with frequent self-monitoring of blood glucose (or a continuous glucose monitoring system) -rapid- or short-acting (bolus) insulin before meals and intermediate- or long acting (basal) background insulin once or twice a day -goal is to achieve a glucose level as close to normal as possible, as much of the time as possible. This is referred to as "time in range."

Insulin Regimens -Combination

-1 or 2 injections per day, a short- or rapid-acting insulin is mixed with intermediate-acting insulin in the same syringe -- This allows the patient to have both mealtime and basal coverage without having to give 2 separate injections

Acute Complication of Diabetes Mellitus: DKA - Manifestations

-Dehydration -dry mucous membranes, tachycardia, and orthostatic hypotension -Early symptoms may include lethargy and weakness -skin becomes dry and loose, and the eyes become soft and sunken. -Abdominal pain may be present and accompanied by anorexia, nausea, and vomiting. -Acetone is noted on the breath as a sweet, fruity odor -Kussmaul respirations (rapid, deep breathing associated with dyspnea) are the body's attempt to reverse metabolic acidosis through the exhalation of excess CO2 -Laboratory findings include a blood glucose level of 250 mg/dL (13.9 mmol/L) or greater, arterial blood pH less than 7.30, and serum bicarbonate level less than 16 mEq/L (16 mmol/L) - -fluid imbalance is potentially life threatening, the first goal of therapy is to establish IV access and begin fluid and electrolyte replacement. Typically, the initial fluid therapy involves an IV infusion of 0.45% or 0.9% NaCl at a rate to raise BP and restore urine output to 30 to 60 mL/hr. When blood glucose levels approach 250 mg/dL (13.9 mmol/L), 5% to 10% dextrose is added to prevent hypoglycemia and a sudden drop in glucose that can be associated with cerebral edema.

Problems with Insulin Therapy - Somogyi Effect

-Hyperglycemia in the morning may be due to the Somogyi effect. A high dose of insulin causes a decline in blood glucose levels during the night -If a patient has morning hyperglycemia, checking blood glucose levels between 2:00 and 4:00 AM for hypoglycemia will help determine if the cause is the Somogyi effect. -patient may report headaches on awakening and recall having night sweats or nightmares. -Treatment = bedtime snack, reducing the dose of insulin, or both.

Insulin Regimens - Long- or Intermediate-Acting (Basal) Background Insulin

-In addition to mealtime insulin, people with type 1 diabetes use a long- or intermediate-acting basal (background) insulin to maintain blood glucose levels in between meals and overnight -Without 24- hour background insulin, people with type 1 diabetes are more prone to developing DKA. -Many people with type 2 diabetes who use OAs will need basal insulin to adequately manage blood glucose levels. -degludec (Tresiba), detemir (Levemir), and glargine (Lantus, Toujeo, Basaglar -insulin is released steadily and continuously -For most people, it does not have a peak of action. The action time for long-acting insulin varies -Because they lack peak action time, the risk for hypoglycemia from this type of insulin is greatly reduced -Glargine and detemir must not be diluted or mixed with any other insulin or solution in the same syringe. -Intermediate-acting insulin (NPH) can be used as a basal insulin. It has a duration of 12 to 18 hours. The disadvantage of NPH is that it has a peak ranging from 4 to 12 hours, which can result in hypoglycemia. NPH can be mixed with short- and rapid-acting insulins. It should never be given IV - -All insulins are clear solutions except NPH, lispro protamine, and aspart protamine. They are cloudy because they contain a protein called protamine, which makes them work longer

Drug Therapy for Diabetes

-Insulin -OA and noninsulin injectables -Enteric-coated aspirin -ACE -ARBs -Antihyperlipidemic drugs They are categorized as rapid-acting, short-acting, intermediate acting, and long-acting insulin

Diagnostic Studies: Diagnosis of diabetes is made using 1 of the following 4 methods:

1. A1C (Glycosylated Hemoglobin) of 6.5% or higher 2. Fasting plasma glucose (FPG) level of 126 mg/dL (7.0 mmol/L) or greater. Fasting is defined as no caloric intake for at least 8 hours 3. A 2-hour plasma glucose (OGTT) level of 200 mg/dL (11.1 mmol/L) or greater during an OGTT, using a glucose load of 75 g 4. In a patient with classic symptoms of hyperglycemia (polyuria, polydipsia, unexplained weight loss) or hyperglycemic crisis, a random plasma glucose level of 200 mg/dL (11.1 mmol/L) or greater ● If a patient is seen with a hyperglycemic crisis or clear symptoms of hyperglycemia (polyuria, polydipsia, polyphagia) with a random plasma glucose level of 200 mg/dL or greater, repeat testing is not needed criteria 1 through 3 require confirmation by repeat testing Fructosamine is another way to assess glucose levels. It is formed by a chemical reaction of glucose with plasma protein. It reflects glycemia in the previous 1 to 3 weeks.

Problems with Insulin Therapy

1.Hypoglycemia 2.Allergic RXN -Local inflammatory rxn (itching, erythema, and burning around the injection site.) -true insulin allergy, which is rare, is manifested by a systemic response with urticaria and possibly anaphylactic shock. - 3. Lipodystrophy and Hypertrophy -Lipodystrophy (loss of subcutaneous fatty tissue) may occur if the same injection sites are used frequently -Atrophy, which is uncommon, is the wasting of subcutaneous tissue and presents as indentations in injection sites. - Hypertrophy happens more often and is a thickening of the subcutaneous tissue 4. Somogyi Effect and Dawn Phenomenon -Ask the patient to measure and document bedtime, nighttime (between 2:00 and 4:00 AM), and morning fasting blood glucose levels on several occasions. If the predawn levels are less than 60 mg/dL (3.3 mmol/L) and signs and symptoms of hypoglycemia are present, the insulin dosage should be reduced. If the 2:00 to 4:00 AM blood glucose is high, the insulin dosage should be increased. Counsel the patient on appropriate bedtime snacks.

Implementation - Acute Care

Acute Care situations include hypoglycemia, DKA, and hyperosmolar hyperglycemic syndrome (HHS) Acute Illness and Surgery -emotional and physical stress can increase the blood glucose level and result in hyperglycemia -Acute illness, injury, and surgery may evoke a counterregulatory hormone response, resulting in hyperglycemia. -check blood glucose at least every 4 hours during times of illness. -type 1 diabetes and a blood glucose greater than 240 mg/dL (13.3 mmol/L) to check urine for ketones every 3 to 4 hours. - -During the intraoperative period, adjustments in the diabetes plan can be made to ensure safe and healthy blood glucose levels. The patient is given IV fluids and insulin (if needed) just before, during, and after surgery when there is no oral intake. -When caring for an unconscious surgical patient receiving insulin, be alert for signs of hypoglycemia, such as sweating, tachycardia, and tremors

Glucagon-Like Peptide-1 Receptor Agonists

Albiglutide (Tanzeum), dulaglutide (Trulicity), exenatide (Byetta), exenatide extended-release (Bydureon), liraglutide (Victoza), and lixisenatide (Adlyxin) simulate GLP-1 (an incretin hormone), which is decreased in people with type 2 diabetes. increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, slow gastric emptying, and reduce food intake by increasing satiety. may be used as monotherapy or adjunct therapy for patients with type 2 diabetes who have not achieved optimal glucose levels on OAs. given using a subcutaneous injection in a prefilled pen. Byetta is given twice daily. Liraglutide is given once daily. Albiglutide, dulaglutide, and Bydureon are given once every 7 days Advise patients to take fast acting oral medications at least 1 hour before injecting a GLP-1 agonist drug.

Acute Complication of Diabetes Mellitus: DKA

DKA is caused by insulin deficiency It is characterized by hyperglycemia, ketosis, acidosis, and dehydration. It is most likely to occur in people with type 1 diabetes Precipitating factors include illness; infection; inadequate insulin dosage; undiagnosed type 1 diabetes; lack of education, understanding, or resources; and neglect. When the circulating supply of insulin is insufficient, glucose cannot be properly used for energy. The body compensates by breaking down fat stores as a secondary source of fuel. Ketones are acidic by-products of fat metabolism that can cause serious problems when they become excessive in the blood. Ketosis alters the pH balance, causing metabolic acidosis to develop. Ketonuria is a process that occurs when ketone bodies are excreted in the urine. Insulin deficiency impairs protein synthesis and causes excessive protein degradation = nitrogen loss Because of the insulin deficiency, the additional glucose cannot be used and the blood glucose level rises further, adding to the osmotic diuresis. If not treated, the patient will develop severe depletion of sodium, potassium, chloride, magnesium, and phosphate leading to hypovolemia, shock, renal failure and acidosis

Hyperosmolar Hyperglycemia Syndrome

Hyperosmolar hyperglycemia syndrome (HHS) is a life-threatening syndrome that can occur in the patient with diabetes who is able to make enough insulin to prevent DKA, but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion Less common than DKA Common causes of HHS are UTIs, pneumonia, sepsis, any acute illness, and newly diagnosed type 2 diabetes usually a history of inadequate fluid intake, increasing mental depression or cognitive impairment, and polyuria. The main difference between HHS and DKA is that the patient with HHS usually has enough circulating insulin so that ketoacidosis does not occur. Laboratory values in HHS include a blood glucose level greater than 600 mg/dL (33.33 mmol/L) and a marked increase in serum osmolality. Ketone bodies are absent or minimal in both blood and urine. Interprofessional Care -HHS is a medical emergency. It has a high mortality rate. -The management of HHS is similar to DKA. It includes immediate IV administration of insulin and either 0.9% or 0.45% NaCl. HHS usually requires large volumes of fluid replacement. -When blood glucose levels fall to about 250 mg/dL (13.9 mmol/L), IV fluids containing dextrose are given to prevent hypoglycemia.

Insulin Feedback Loop

Insulin promotes glucose transport from the bloodstream across the cell membrane to the cytoplasm of the cell Cells break down glucose to make energy. Liver and muscle cells store excess glucose as glycogen The fall in insulin level during normal overnight fasting promotes the release of stored glucose from the liver, protein from muscle, and fat from adipose tissue. Skeletal muscle and adipose tissue have specific receptors for insulin and are considered insulin-dependent tissues. Although liver cells are not considered insulin-dependent tissue, insulin receptor sites on the liver facilitate uptake of glucose and its conversion to glycogen.

Insulin Administration

Insulin vials and pens in use may be left at room temperature for up to 4 weeks unless the room temperature -avoid prolonged exposure to direct sunlight -Store unopened insulin vials and pens in the refrigerator. -Prefilled syringes with 2 different insulins are stable for up to 1 week when stored in the refrigerator. Syringes with only 1 type of insulin are stable up to 30 days. -Store in vertical position with needle pointed up to avoid clumping Given SubQ Regular can be given IV Not taken oral cause inactivated by gastric fluids Ovoid IM injection Table 48.5 p4212 fastest subcutaneous absorption is from the abdomen, followed by the arm, thigh, and buttock. Caution the patient about injecting into a site that is to be exercised. For example, injecting into the thigh and then going jogging could increase body heat and circulation. This could increase the rate of insulin absorption and speed the onset of action, resulting in hypoglycemia

Etiology of Diabetes Mellitus

Linked singly or in combination, to genetic, autoimmune, and environmental factors (e.g., virus, obesity)

Type 2 Diabetes - PATHO

Metabolic abnormalities have a role in the development of type 2 diabetes 1. first factor is insulin resistance, a condition in which body tissues do not respond to the action of insulin because insulin receptors are unresponsive, are insufficient in number, or both. When insulin is not properly used, the entry of glucose into the cell is impeded, resulting in hyperglycemia. In the early stages of insulin resistance, the pancreas responds to high blood glucose by producing greater amounts of insulin 2. second factor is a marked decrease in the ability of the pancreas to make insulin, as the β cells become fatigued from the compensatory overproduction of insulin or when β-cell mass is lost. the α cells of the pancreas increase production of glucagon. 3. Third Factor, inappropriate glucose production by the liver. Instead of properly regulating the release of glucose in response to blood levels, the liver does so in a haphazard way that does not correspond to the body's needs at the time 4. Fourth factor, altered production of hormones and cytokines by adipose tissue (adipokines)..

Biguanides (Metformin)

Metformin (Glucophage) Most effective 1st line treatment for type 2 Available as immediate release, extended release, and liquid forms Action: reduces glucose production by liver Enhances insulin sensitivity Improves glucose transport May cause weight loss Used in prevention of type 2 diabetes Forms of metformin include Glucophage (immediate release), Glucophage XR (extended release), Fortamet (extended release), and Riomet (liquid) Patients who are undergoing surgery or radiologic procedures that involve the use of a contrast medium need to temporarily discontinue metformin before surgery or the procedure -should not resume the metformin until 48 hours afterward, once their serum creatinine has been checked and is normal

Interprofessional Care

Nutrition therapy, drug therapy, exercise, and self monitoring of blood glucose are the tools used in managing diabetes

Type 2 Diabetes

type 2, can have 3 P's and may have not symptoms (may lose beta cells) Formerly known as adult-onset diabetes or non-insulin dependent diabetes mellitus (NIDDM) RISK Factors - being overweight or obese, being older, and having a family history of type 2 diabetes. more prevalent in some ethnic populations