Diabetes

Type 1 Diabetes Mellitus Etiology and Pathophysiology

End result of long-standing process - Progressive destruction of pancreatic B cells by body's own T cells - Autoantibodies cause a reduction of 80% to 90% of normal B cell function before manifestations occur Causes 1. Genetic predisposition - Related to human leukocyte antigens (HLAs) 2. Exposure to a virus

Activity Time

Answer the following questions: How soon after you check the blood sugar should you administer insulin? How soon before/after insulin administration should your patient eat? What is the recommended combination of insulin for treatment in the acute care setting? Any additional thoughts?

Type 2 Diabetes Mellitus Onset of Disease

Gradual onset Person may go many years with undetected hyperglycemia Osmotic fluid/electrolyte loss from hyperglycemia may become severe - Hyperosmolar coma (because cells are swollen) - try to rehydrate them and control BG

American Diabetes Association

Diabetes Myths - can eat fruits is true http://www.diabetes.org/diabetes-basics/myths/ Food and Fitness

Secondary Diabetes

Results from 1. Another medical condition - Cushing syndrome - Hyperthyroidism - Pancreatitis - Parenteral nutrition - Cystic fibrosis - Hematochromatosis Treatment of a medical condition that causes abnormal blood glucose level - Corticosteroids (Prednisone) - Thiazides - Phenytoin (Dilantin) - Atypical antipsychotics (clozapine) - q6 check with NPO patients - AC and HS (check before meals and before bedtime) Usually resolves when underlying condition treated

Diabetes Mellitus

A chronic multisystem disease characterized by hyperglycemia related to abnormal insulin production, impaired insulin utilization, or both Affects 29.1 million people Seventh leading cause of death Diabetes mellitus (DM) is a chronic multisystem disease characterized by hyperglycemia related to abnormal insulin production, impaired insulin utilization, or both. Diabetes mellitus is a serious health problem throughout the world, and its prevalence is rapidly increasing. Currently in the United States, an estimated 29.1 million people, or 9.3% of the population, have diabetes mellitus, and 86 million more people have prediabetes. In approximately 8.1 million people with diabetes mellitus, the disease has not been diagnosed, and they are unaware that they have the disease. Diabetes mellitus is the seventh leading cause of death in the United States, but it is likely to be underreported. Leading cause of - Adult blindness (diabetic retinopathy) - End-stage renal disease - Nontraumatic lower limb amputations (wear footwear) Major contributing factor - Heart disease - Stroke The long-term complications associated with diabetes can make it a devastating disease. Diabetes is the leading cause of adult blindness, end-stage kidney disease, and nontraumatic lower limb amputations. It is also a major factor contributing to heart disease and stroke. - Adults with diabetes have heart disease death rates two to four times higher than adults without diabetes. - The risk for stroke is also two to four times higher among people with diabetes. - In addition, more than half of adults with diabetes have hypertension and high cholesterol levels.

Diagnostics for Prediabetes

A1c - > 5.7 - > 6.4 FPG - > 100 - < 125 OGTT - > 140 - < 189 Normal A1c - < 5.7 FPG - < 99 OGTT - < 139

Diagnostics for Diabetes

A1c - > 6.5 FPG - >126 OGTT - >200

Safety & Infection Control

Blood glucose testing - What are we doing to minimize the risk of infection? - What are we doing to promote safety surrounding testing? Insulin administration - What are we doing to minimize the risk of infection? - What are we doing to promote safety surrounding administration? In general, how are we promoting safety and infection control for our diabetic patients? What about safety and infection control in the home setting?

Type 1 Diabetes Mellitus

Formerly known as "juvenile onset" or "insulin dependent" diabetes Most often occurs in people under 30 years of age Peak onset between ages 11 and 13

Diabetes Mellitus Collaborative Care

Goals of diabetes management - Decrease symptoms - Promote well-being - Prevent acute complications - Delay onset and progression of long-term complications Patient teaching - Self-monitoring of blood glucose Nutritional therapy Drug therapy - metFORMIN - glucophage - each class either act on liver, pancreas, etc Exercise

Potential Nursing Diagnoses

Ineffective health management r/t knowledge deficit Risk for unstable blood glucose levels Risk for peripheral neuromuscular dysfunction Injury Infection Coping Nutrition Fluid imbalance

Glucose Monitoring

Let's review the steps of obtaining a blood glucose reading. Colors of lancets Test strips and expiration dates Using the control solution http://www.mayoclinic.org/diseases-conditions/diabetes/expert-blog/blood-glucose-control-solution/bgp-20094453 Steps: - Review my order - Use 2 patient identifiers - Scan patient's wristband - Scan strip bottle's barcode - Insert test strip - Alcohol wipe patient's finger - let air dry - Use lancet - Wipe off first drop of blood - Use second drop of blood as sample - Dispose of trash (lancet to sharp's container) Test strips have expiration date on bottle. Know institution's policy. Each test strip manufacturer has different guidelines. What affects integrity of strips (light, heat/cold, moisture)? Control test done on meters every 24 hours in hospital. High and low solution. What are other occasions we want to do this (opening a new test strip bottle, meter is dropped, suspected abnormal readings)? Know institution's policy for how soon to discard solutions after opening.

Type 1 Diabetes Mellitus Onset of Disease

Long preclinical period Antibodies present for months to years before symptoms occur Manifestations develop when pancreas can no longer produce insulin - Rapid onset of symptoms - Present at ER with ketoacidosis History of recent, sudden, weight loss Classic symptoms - Polydipsia (high concentration of sugar in the blood, so try to put water into the blood to dilute the sugar) - Polyuria (body is trying to get rid of the extra glucose.) - Polyphagia Will require exogenous insulin to sustain life Diabetic ketoacidosis (DKA) - Occurs in absence of exogenous insulin (give an insulin drip, check BG often) - Life-threatening condition - Results in metabolic acidosis - More in next class. - give fluids as well as insulin

Type 2 Diabetes Mellitus

Most prevalent type of diabetes Over 90% of patients with diabetes Usually occurs in people over 35 years of age 80% to 90% of patients are overweight Prevalence increases with age Genetic basis Greater in some ethnic populations - Increased rate in African Americans, Asian Americans, Hispanic Americans, and Native Americans - Native Americans and Alaskan Natives: Highest rate of diabetes in the world

Clinical Manifestations Type 2 Diabetes Mellitus

Nonspecific symptoms - May have classic symptoms of type 1 if BG high (polydipsia, etc) Fatigue Recurrent infections Recurrent vaginal yeast infections Prolonged wound healing Visual changes

Prediabetes

Not high enough for diabetes diagnosis Increase risk for developing type 2 diabetes If no preventive measure taken—usually develop diabetes within 10 years Long-term damage already occurring - Heart, blood vessels Usually present with no symptoms Must watch for diabetes symptoms - Polyuria - Polyphagia - Polydipsia

Type 2 Diabetes Mellitus Etiology and Pathophysiology

Pancreas continues to produce some endogenous insulin Insulin produced is either insufficient or poorly utilized by tissues Obesity (abdominal/visceral) - Most powerful risk factor Genetic mutations - Lead to insulin resistance - Increased risk for obesity Four major metabolic abnormalities 1. Insulin resistance - Body tissues do not respond to insulin - Insulin receptors either unresponsive or insufficient in number - Results in hyperglycemia 2. Pancreas ↓ ability to produce insulin - β cells fatigued from compensating - β -cell mass lost 3. Inappropriate glucose production from liver - Liver's response of regulating release of glucose is haphazard - Not considered a primary factor in development of type 2 4. Individuals with metabolic syndrome at increased risk for type 2 diabetes - Cluster of abnormalities that increase risk for cardiovascular disease and diabetes - Characterized by insulin resistance Individuals with metabolic syndrome at increased risk for type 2 diabetes - Elevated insulin levels, ↑ triglycerides, LDLs, ↓ HDLs, hypertension - Risk factors - Central obesity, sedentary lifestyle, urbanization, certain ethnicities

Insulin

Storage of insulin - Do not heat/freeze - In-use vials may be left at room temperature up to 4 weeks - Extra insulin should be refrigerated - Avoid exposure to direct sunlight, extreme heat or cold - Store prefilled syringes upright for 1 week if 2 insulin types; 30 days for one - As a protein, insulin requires special storage considerations. - Heat and freezing alter the insulin molecule and can make it less effective. - Insulin vials and insulin pens currently in use may be left at room temperature for up to 4 weeks unless the room temperature is higher than 86º F (30º C) or below freezing (less than 32º F [0º C]). - Store unopened insulin vials and insulin pens in the refrigerator. Prolonged exposure to direct sunlight should be avoided. - A patient who is traveling in hot climates may store insulin in a thermos or cooler to keep it cool (not frozen). Patients who are traveling or caregivers of patients who are sight impaired or who lack the manual dexterity to fill their own syringes may prefill insulin syringes. - Prefilled syringes containing two different insulins are stable for up to 1 week when stored in the refrigerator; syringes containing only one type of insulin are stable up to 30 days. - Teach patients to store syringes in a vertical position with the needle pointed up to avoid clumping of suspended insulin in the needle. - Before injection, gently roll prefilled syringes between the palms 10 to 20 times to warm the insulin and resuspend the particles. - Some insulin combinations are not appropriate for prefilling and storage because the mixture can alter the onset, action, and/or peak times of either of the types. Consult a pharmacy reference as needed when mixing and prefilling different types of insulin. Administration of insulin - Given by subcutaneous injection - Regular insulin may be given IV - Cannot be taken orally - Absorption is fastest from abdomen, followed by arm, thigh, and buttock - Abdomen is often preferred site - Do not inject in site to be exercised - Rotate injections within and between sites - Usually available as U100 insulin (1 mL contains 100 U of insulin) - Syringes marked for units: various sizes - Only user recaps syringe - No alcohol swab for self-injection; wash with soap and water - Inject at 45- to 90-degree angle Routine doses of insulin are administered by subcutaneous injection. Regular insulin can be given IV when immediate onset of action is desired. Insulin is not taken orally because it is inactivated by gastric juices. Teach patients to avoid injecting insulin intramuscularly because rapid and unpredictable absorption could result in hypoglycemia. The speed with which peak serum concentrations are reached varies with the anatomic site for injection. The fastest subcutaneous absorption is from the abdomen, followed by the arm, thigh, and buttock. Although the abdomen is often the preferred injection site, other sites also work well. 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, which could increase the rate of insulin absorption and speed it onset of action, thus resulting in hypoglycemia. - Teach patients to rotate the injection within and between sites. This allows for better insulin absorption. - For example, it may be helpful to think of the abdomen as a checkerboard, with each half-inch square representing an injection site. Injections are rotated systematically across the board, with each injection site at least ½ to 1 inch away from the previous injection site. - It can be helpful to inject fast-acting insulin into faster absorbing sites and slow-acting insulin into slower absorbing sites. Most commercial insulin is available as U100, indicating that 1 mL contains 100 U of insulin. U100 insulin must be used with a U100-marked syringe. Disposable plastic insulin syringes are available in a variety of sizes, including 1.0, 0.5, and 0.3 mL. The 0.5-mL size may be used for doses of 50 U or less, and the 0.3-mL syringe can be used for doses of 30 U or less. The 0.5- and 0.3-mL syringes are in 1-U increments. This provides more accurate delivery when the dose is an odd number. The 1.0-mL syringe is necessary for patients who require more than 50 U of insulin. The 1.0-mL syringe is in 2-U increments. When patients change from a 0.3- or a 0.5-mL to a 1.0-mL syringe, make them aware of the dose increment difference. Only the person using the syringe should do the recapping. Never recap a needle used by a patient. The use of an alcohol swab on the site before self-injection is no longer recommended. Routine hygiene such as washing with soap and rinsing with water is adequate. - This applies primarily to patient self-injection technique. - When injection occurs in a health care facility, policy may dictate site preparation with alcohol to prevent health care-associated infection (HAI). Insulin injections are typically given at a 90-degree angle. For extremely thin or muscular patients in the hospital, perform injections at a 45- degree angle. At home, patients inject at a 90-degree angle using the shortest needle desired. Pinching up of the skin to avoid intramuscular injection is no longer necessary because of the availability of short needles.

Types of Insulin

Today only genetically engineered human insulin is made in laboratories. The insulin is derived from common bacteria (e.g., Escherichia coli) or yeast cells through recombinant DNA technology. - In the past, insulin was extracted from beef and pork pancreas, but these forms of insulin are no longer available. Insulins differ by their onset, peak action, and duration and are categorized as rapid-acting, short-acting, intermediate-acting, and long-acting insulin. - The base of all insulin preparations is regular insulin. The onset of activity, peak, and duration times are manipulated by adding zinc, acetate buffers, and protamine. - The zinc and protamine added to make intermediate-acting NPH (neutral protamine Hagedorn) can cause an allergic reaction at the injection site in susceptible individuals.

Hypoglycemia

Too much insulin in proportion to glucose in the blood Blood glucose level < 70 mg/dL Hypoglycemia, or low blood glucose level, occurs when there is too much insulin in proportion to available glucose in the blood. This causes the blood glucose level to drop to less than 70 mg/dL (3.9 mmol/L). Common manifestations - Shakiness - Palpitations - Nervousness - Diaphoresis - Anxiety - Hunger - Pallor Altered mental functioning - Difficulty speaking - Visual disturbances - Stupor - Confusion - Coma Untreated hypoglycemia can progress to loss of consciousness, seizures, coma, and death Because the brain requires a constant supply of glucose in sufficient quantities to function properly, hypoglycemia can affect mental functioning. - The manifestations are speaking difficulties, visual disturbances, stupor, confusion, and coma. - Manifestations of hypoglycemia can mimic those of alcohol intoxication. Untreated hypoglycemia can progress to loss of consciousness, seizures, coma, and death. Causes of Hypoglycemia - Too much insulin or oral hypoglycemic agents - Too little food - Delaying time of eating - Too much exercise Symptoms can also occur when high glucose level falls too rapidly Causes of hypoglycemia are often related to a mismatch in the timing of food intake and the peak action of insulin or oral hypoglycemic agents that increase endogenous insulin secretion. The balance between blood glucose and insulin can be disrupted by administering too much insulin or medication, ingesting too little food, delaying the time of eating, and performing unusual amounts of exercise. Hypoglycemia can occur at any time, but most episodes occur when the OA or insulin is at its peak of action or when the patient's daily routine is disrupted without adequate adjustments in diet, medications, and activity. Although hypoglycemia is more common with insulin therapy, it can occur with OAs, and it may be severe and persist for an extended time because of the longer duration of action of these drugs. Symptoms of hypoglycemia may occur when a very high blood glucose level falls too rapidly (e.g., a blood glucose level of 300 mg/dL [16.7 mmol/L] falling quickly to 180 mg/dL [10 mmol/L]). - Although the blood glucose level is above normal by definition and measurement, the sudden metabolic shift can evoke hypoglycemia symptoms. Overly vigorous management of hyperglycemia with insulin can cause this type of situation. Check blood glucose level - If < 70 mg/dL, begin treatment - If > 70 mg/dL, investigate further for cause of signs/symptoms - If monitoring equipment not available, treatment should be initiated Hypoglycemia can usually be quickly reversed with effective treatment. At the first sign of hypoglycemia, check the blood glucose level if possible. - If it is less than 70 mg/dL (3.9 mmol/L), immediately begin treatment for hypoglycemia. - If the blood glucose is greater than 70 mg/dL (3.9 mmol/L), investigate other possible causes of the signs and symptoms. - If the patient has manifestations of hypoglycemia and monitoring equipment is not available or the patient has a history of fluctuating blood glucose levels, hypoglycemia should be assumed and treatment should be initiated. Treatment: rule of 15 1. Consume 15 g of a simple carbohydrate - Fruit juice or regular soft drink, 4 to 6 oz 2. Recheck glucose level in 15 minutes - Repeat if still < 70 gm/dL 3. Avoid foods with fat - Decrease absorption of sugar Avoid over treatment Give complex carbohydrate after recovery Follow the "Rule of 15" to treat hypoglycemia. - A blood glucose level less than 70 mg/dL is treated by ingestion of 15 g of a simple (fast-acting) carbohydrate, such as 4 to 6 oz of fruit juice or a regular soft drink. - Commercial products such as gels or tablets containing specific amounts of glucose are convenient for carrying in a purse or pocket to be used in such situations. - Recheck the blood glucose level 15 minutes later. If the value is still less than 70 mg/dL, ingest 15 g more of carbohydrate and recheck the blood glucose in 15 minutes. - If there is no significant improvement in the patient's condition after two to three doses of 15 g of simple carbohydrate, contact the physician. - After an acute episode of hypoglycemia, have the patient ingest a complex carbohydrate after recovery to prevent repeat hypoglycemia. Avoid treatment with carbohydrates that contain fat, such as candy bars, cookies, whole milk, and ice cream. - The fat in those foods will slow down the absorption of the sugar and delay the response to treatment. Avoid overtreatment with large quantities of quick-acting carbohydrates so that a rapid fluctuation to hyperglycemia does not occur. Treatment In acute care settings - Fifty percent dextrose 20 to 50 mL IV push Patient not alert enough to swallow - Glucagon 1 mg IM or subcutaneously Explore reason why occurred In an acute care setting, patients with hypoglycemia may be treated with 20 to 50 mL of 50% dextrose, IV push. If the patient is not alert enough to swallow and no IV access is available, another option is to administer 1 mg of glucagon by intramuscular (IM) or subcutaneous injection. - An IM injection in a site such as the deltoid muscle will result in a quicker response. - Glucagon stimulates a strong hepatic response to convert glycogen to glucose and therefore makes glucose rapidly available. - Nausea is a common reaction after glucagon injection. - Therefore, to prevent aspiration if vomiting occurs, turn the patient on the side until he or she becomes alert. Once the acute hypoglycemia has been reversed, explore with the patient the reasons why the situation developed. This assessment may indicate the need for additional teaching of the patient and the family to avoid future episodes of hypoglycemia.

Diabetes Mellitus Etiology and Pathophysiology

Two most common types - Type 1 - Type 2 Other types - Gestational - Prediabetes - Secondary diabetes (steroids, TPN, tube feeds, all are high in sugar) Normal insulin metabolism - Produced by the cells - Islets of Langerhans (pancreas) - Released continuously into bloodstream in small increments with larger amounts released after food intake - stabilizes glucose range to 70 to 120 mg/dl - Average daily secretion 0.6 units/kg body weight Insulin 1. Promotes glucose transport from bloodstream across cell membrane to cytoplasm of cell - Decreases glucose in the bloodstream 2. ↑ Insulin after a meal - Stimulates storage of glucose as glycogen in liver and muscle - Inhibits gluconeogenesis (production of glucose in liver) - Enhances fat deposition - ↑ Protein synthesis Glucagon - when hypoglycemic - produced from the liver Skeletal muscle and adipose tissue—insulin-dependent tissues - dependent has to use the insulin to get the glucose into the cells. Other tissues (brain, liver, blood cells) do not directly depend on insulin for glucose transport - like liver has cells on it that uses the insulin to make glucagon. Counterregulatory hormones - Oppose effects of insulin - Increase blood glucose levels - Provide a regulated release of glucose for energy - Help maintain normal blood glucose levels Examples - Glucagon, epinephrine, growth hormone, cortisol

Orders

What do you think our typical orders will look like regarding: - Glucose monitoring? - Medications? Differences between home meds and hospital meds? - Insulin pump management - patient and nursing responsibilities? - Diet? - Activity? - Interdisciplinary collaboration? Monitoring: - Eating = AC/HS - NPO = every 4-6 hours Medications: insulin vs oral diabetic meds Insulin pump: know institution's requirements for nurses; need to coordinate with patient to track glucose readings, basal rates, and bolus doses Diet: diabetic diet (balanced, complex carbs, proteins, fats, fiber, fluids) Diabetic nurse educator, registered dietician

Admission & Assessment

You are admitting a patient to your unit with an acute illness who also has diabetes. - What baseline information would you want to obtain from the patient? - Assessment findings? - What diagnostic tests might you expect the physician to order? Past medical history/co-morbidities = Think about what co-morbidities may be present in a diabetic patient (HTN, CAD, diabetic retinopathy, diabetic neuropathy, kidney disease, impaired skin integrity, obesity) Ability to provide self-care/complete ADLs Diet Medications Do you manage your diabetes independently or does someone else assist you? Current knowledge level on diabetes management History of present illness - How has your present illness impacted your ability to manage your diabetes? Eating, drinking, medication management, self-care Diagnostic tests - CBC, BMP, A1C, kidney function, liver function, urinalysis, lipid panel Assessment Findings: Malaise Obesity, weight loss or gain Thirst, hunger, nausea/vomiting Poor healing Dietary compliance Constipation/diarrhea Frequent urination, bladder infections Nocturia, urinary incontinence Muscle weakness, fatigue Abdominal pain, headache, blurred vision Numbness/tingling, pruritus Impotence, frequent vaginal infections Decreased libido Depression, irritability, apathy Commitment to lifestyle changes Sunken eyeballs, cataracts Dry, warm, inelastic skin Pigmented skin lesions, ulcers, loss of hair on toes Kussmaul respirations (abnormal deep, rapid, labored breathing that occurs as an involuntary response to severe acidosis (such as that associated with diabetes or kidney failure) Hypotension Weak, rapid pulse Dry mouth Vomiting Fruity breath (DKA) Altered reflexes, restlessness Confusion, stupor, coma Muscle wasting Serum electrolyte abnormalities Fasting blood glucose level of 126 mg/dL or higher Oral glucose tolerance test and/or random glucose level exceeding 200 mg/dL Leukocytosis ↑ Blood urea nitrogen, creatinine ↑ Triglycerides, cholesterol, LDL, VLDL ↓ HDL Hemoglobin A1C value > 6.0% Glycosuria Ketonuria (DKA) Albuminuria Acidosis