Diabetes Mellitus Chapter 48

6. The nurse is teaching the patient with prediabetes ways to prevent or delay the development of type 2 diabetes. What information should be included (select all that apply)? a. Exercise regularly. b. Maintain a healthy weight. c. Have BP checked regularly. d. Assess for visual changes on a monthly basis. e. Monitor for polyuria, polyphagia, and polydipsia.

a, b, e. To reduce the risk of developing diabetes, the patient with prediabetes should maintain a healthy weight, learn to monitor for symptoms of diabetes, have blood glucose and glycosylated hemoglobin (A1C) tested regularly, exercise regularly, and eat a healthy diet.

27. The nurse assesses the technique of the patient with diabetes for self-monitoring of blood glucose (SMBG) 3 months after initial instruction. Which error in the performance of SMBG noted by the nurse requires intervention? a. Doing the SMBG before and after exercising b. Puncturing the finger on the side of the finger pad c. Cleaning the puncture site with alcohol before the puncture d. Holding the hand down for a few minutes before the puncture

c.. Cleaning the puncture site with alcohol is not necessary and may interfere with test results and lead to drying and splitting of the fingertips. Washing the hands with warm water is adequate cleaning and promotes blood flow to the fingers. Blood flow is also increased by holding the hand down. Punctures on the side of the finger pad are less painful. Self-monitored blood glucose (SMBG) should be performed before and after exercise.

Type 1 Diabetes

•Formerly known as juvenile-onset or insulin-dependent diabetes •Generally affects people under age 40 •Can occur at any age •Autoimmune disorder •Body develops antibodies against insulin and/or pancreatic β cells that produce insulin resulting in not enough insulin to survive •Genetic link •Genetic predisposition (HLAs) and exposure to virus contribute to immune-related type 1 •Latent autoimmune diabetes in adults (LADA)—slow, progressive type 1 Signs and symptoms develop when pancreas can no longer produce insulin, ketoacidosis results. Requires exogenous insulin for life.

A1C

•Glycosylated hemoglobin: reflects glucose levels over past 2 or 3 months •Glucose attaches to hemoglobin molecule; higher the glucose levels = higher the A1C •Used to diagnose, monitor response to therapy, and screen patients with prediabetes •Goal: Less than 6.5% (reduces complications)

Drug Therapy for Type 2...Oral and Noninsulin injectable

These Orals drugs work on 3 defects of Type 2: •Insulin resistance •Decrease insulin production •Increased hepatic glucose production Oral-Metforman

2. Which statement would be correct for a patient with type 2 diabetes who was admitted to the hospital with pneumonia? a. The patient must receive insulin therapy to prevent ketoacidosis. b. The patient has islet cell antibodies that have destroyed the pancreas's ability to make insulin. c. The patient has minimal or absent endogenous insulin secretion and requires daily insulin injections. d. The patient may have enough endogenous insulin to prevent ketosis but is at risk for hyperosmolar hyperglycemia syndrome.

Correct answer: d Rationale: Hyperosmolar hyperglycemia syndrome (HHS) is a life-threatening syndrome that can occur in a patient with diabetes who is able to make enough insulin to prevent diabetesrelated ketoacidosis (DKA) but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion.

Drug Therapy

•Insulin (T1) •Oral Agents (T2) •Non-insulin injectable agents (T2)

42. A patient with newly diagnosed type 2 diabetes has been given a prescription to start an oral hypoglycemic medication. The patient tells the nurse she would rather control her blood sugar with herbal therapy. Which action should the nurse take? a. Teach the patient that herbal therapy is not safe and should not be used. b. Advise the patient to discuss using herbal therapy with her HCP before using it. c. Encourage the patient to give the prescriptive medication time to work before using herbal therapy. d. Teach the patient that if she takes herbal therapy, she will have to monitor her blood sugar more often.

b. Advise the patient to seek the guidance of the HCP regarding the safety, efficacy, and specifics of using herbal therapy rather than or with the medication prescribed. Not all herbal therapy is unsafe, but dosages are not universal.

4. What characterizes type 2 diabetes (select all that apply)? a. β-cell exhaustion b. Insulin resistance c. Genetic predisposition d. Altered production of adipokines e. Inherited defect in insulin receptors f. Inappropriate glucose production by the liver

a, b, c, d, e, f. Type 2 diabetes is characterized by β-cell exhaustion, insulin resistance, genetic predisposition, altered production of adipokines, inherited defect in insulin receptors, and inappropriate glucose production by the liver. The roles of the brain, kidneys, and gut in type 2 diabetes development are being studied.

29. Priority Decision: A patient with diabetes calls the clinic because she has nausea and flu-like symptoms. Which advice from the nurse will be the best for this patient? a. Administer the usual insulin dosage. b. Hold fluid intake until the nausea subsides. c. Come to the clinic immediately for evaluation and treatment. d. Monitor the blood glucose every 1 to 2 hours and call if it rises over 150 mg/dL (8.3 mmol/L).

a. During minor illnesses, the patient with diabetes should continue drug therapy and fluid and food intake. Insulin is important because counter regulatory hormones may increase blood glucose during the stress of illness. Food or a carbohydrate liquid substitution is important because during illness the body requires extra energy to deal with the stress of the illness. Blood glucose monitoring should be done every 4 hours, and the HCP should be notified if the level is >240 mg/dL (13.9 mmol/L) or if fever, ketonuria, or nausea and vomiting occur.

18. When teaching the patient with type 1 diabetes, what should the nurse emphasize as the major advantage of using an insulin pump? a. Tight glycemic control can be maintained. b. Errors in insulin dosing are less likely to occur. c. Complications of insulin therapy are prevented. d. Frequent blood glucose monitoring is unnecessary.

a. Insulin pumps provide tight glycemic control by continuous subcutaneous insulin infusion based on the patient's basal profile, with bolus doses at mealtime at the patient's discretion and related to blood glucose monitoring. Errors in insulin dosing and complications of insulin therapy are still potential risks with insulin pumps.

Nutrition Therapy...Alcohol

•Alcohol •Limit to moderate amount if no risk for other alcohol-related problems •1 drink/day for women; 2 drinks/day for men •Inhibits gluconeogenesis by liver •Can cause severe hypoglycemia (with lots or chronic use of alcohol) •Eat carbohydrates when drinking unless drinks have sweetened mixers •Create trust so patients honestly report intake; glucose harder to manage

Clinical ManifestationsType 1 Diabetes

•Classic symptoms •Polyuria (frequent urination) •Polydipsia (excessive thirst) •Polyphagia (excessive hunger) •Weight loss •Weakness •Fatigue •Diabetic Ketoacidosis (DKA)

Drug Therapy for Type 1...Insulin Pump

•Continuous subcutaneous infusion of rapid-acting insulin •Small, battery-operated device connected to a catheter inserted into subcutaneous tissue in abdominal wall •Change set and site every 2 to 3 days •Program basal and bolus doses that increase or decrease throughout the day based on carbohydrate intake, activity, or illness •Major advantage—keeps blood glucose in a tighter range; avoid highs and lows •Potential concerns: •Infection, DKA, Cost

Nutrition Therapy...Patient Teaching

•Dietitian provides initial instruction •Carbohydrate counting—track amount of carbohydrates with each meal •Serving size is 15 g of CHO •Typically 45 to 60 g per meal •Patient teaching: read labels and serving sizes •USDA: MyPlate guidelines •9" plate: ½ nonstarchy vegetables, ¼ starch, and ¼ protein •Add 8 oz nonfat milk and small piece of fruit •See text for website

Nutrition Therapy: Type 2 Diabetes

•Emphasis on achieving glucose, lipid, and BP goals •Moderate weight loss (5% to 7%) improves insulin sensitivity •Nutritionally adequate meal plan appropriate serving sizes and reduced saturated and trans fats and low CHO can decrease calories •Spacing meals and regular exercise •Effectiveness of therapy monitored by blood glucose levels, A1C, lipids, and BP

Type 2 Diabetes

•Formerly known as adult-onset diabetes (AODM) or non-insulin-dependent diabetes (NIDDM) •Many risk factors: overweight or obese, advanced age, family history •# prevalence in children due to obesity •Greater prevalence in ethnic groups •Gradual onset. Often discovered with routine glucose or A1C testing.

Prediabetes

•Increased risk for developing type 2 diabetes •Impaired glucose tolerance (IGT) •Oral Glucose Tolerance Test (OGTT)—140 to 199 mg/dL •Impaired fasting glucose (IFG) •Fasting glucose of 100 to 125 mg/dL •May have both IGT and IFG •Asymptomatic but long-term damage already occurring • •Patient teaching important •Undergo screening; glucose and Glycosylated hemoglobin (HgbA1C) •Learn and manage risk factors •Monitor for symptoms of diabetes •Maintain healthy weight (diet), exercise, make healthy food choices •Lifestyle modifications

Clinical ManifestationsType 2 Diabetes

•Nonspecific symptoms •Classic symptoms of type 1 may manifest •Polyuria (frequent urination) •Polydipsia (excessive thirst) •Polyphagia (excessive hunger) •Fatigue •Recurrent infection •Recurrent vaginal yeast or candida infection •Prolonged wound healing •Visual problems

33. The patient with diabetes has a blood glucose level of 248 mg/dL. Which assessment findings would be related to this blood glucose level (select all that apply)? a. Headache b. Unsteady gait c. Abdominal cramps d. Emotional changes e. Increase in urination f. Weakness and fatigue

a, c, e, f. Manifestations of hyperglycemia include abdominal cramps, polyuria, weakness, fatigue, and headache. The headache may also be seen with hypoglycemia that is manifested by the remaining options.

Priority Problems

•Lack of knowledge •Hyperglycemia •Hypoglycemia •Risk for injury •Impaired peripheral neurovascular function

3. Analyze the following diagnostic findings for your patient with type 2 diabetes. Which result will need further assessment? a. A1C 9% b. BP 126/80 mmHg c. FBG 130 mg/dL (7.2 mmol/L) d. LDL cholesterol 100 mg/dL (2.6 mmol/L)

. Correct answers: a Rationale: Lowering hemoglobin A1C (to less than 7%) reduces microvascular and neuropathic complications. Keeping blood glucose levels in a tighter range (normal hemoglobin A1C level, less than 6%) may further reduce complications but increases hypoglycemia risk.

Diagnostic Studies

1.A1C level: 6.5% or higher 2.Fasting plasma glucose (FPG) level > 126 mg/dL 3.2-hour plasma glucose level during Oral Glucose Tolerance Test (OGTT) greater than 200 mg/dL (with glucose load of 75 g) •Repeat criteria 1 to 3 on another visit to confirm •Be attentive to influencing factors 4.Classic symptoms of hyperglycemia or hyperglycemic crisis or a random plasma glucose level greater than 200 mg/dL

8. Which are appropriate therapies for patients with diabetes? (select all that apply) a. Use of statins to reduce CVD risk b. Use of diuretics to treat nephropathy c. Use of ACE inhibitors to treat nephropathy d. Use of serotonin agonists to decrease appetite e. Use of laser photocoagulation to treat retinopathy

Correct answers: a, c, e Rationale: In patients with diabetes who have albuminuria, angiotensin-converting enzyme (ACE) inhibitors (e.g., lisinopril [Prinivil, Zestril]) or angiotensin II receptor antagonists (ARBs) (e.g., losartan [Cozaar]) are used. Both classes of drugs are used to treat hypertension and delay the progression of nephropathy in patients with diabetes. The statin drugs are the most widely used lipid-lowering agents. Laser photocoagulation therapy is indicated to reduce the risk of vision loss in patients with proliferative retinopathy, in those with macular edema, and in some cases of Nonproliferative retinopathy.

5. You are caring for a patient with newly diagnosed type 1 diabetes. What information is essential to include in your patient teaching before discharge from the hospital? (select all that apply) a. Insulin administration b. Elimination of sugar from diet c. Need to reduce physical activity d. Use of a portable blood glucose monitor e. Hypoglycemia prevention, symptoms, and treatment

Correct answers: a, d, e Rationale: The nurse ensures that the patient understands the proper use of insulin. The nurse teaches the patient how to use the portable blood glucose monitor and how to recognize and treat signs and symptoms of hypoglycemia and hyperglycemia. These are referred to as "survival skills."

12. When teaching the patient with diabetes about insulin administration, the nurse should include which instruction? a. Pull back on the plunger after inserting the needle to check for blood. b. Consistently use the same size of insulin syringe to avoid dosing errors. c. Clean the skin at the injection site with an alcohol swab before each injection. d. Rotate injection sites from arms to thighs to abdomen with each injection to prevent lipodystrophies.

b. Patients should consistently use the same size of insulin syringe to avoid dosing errors. Errors can be made if patients switch back and forth between different sizes of syringes. Aspiration before injection of the insulin is no longer recommended, nor is the use of alcohol to clean the skin. Because the rate of peak serum concentration varies with the site selected for injection, injections should be rotated within a particular area, such as the abdomen, before changing to another area. Lipodystrophies are rare with the use of human insulin.

7. In type 1 diabetes, glucose has an osmotic effect when insulin deficiency prevents the use of glucose for energy. Which classic symptom is caused by the osmotic effect of glucose? a. Fatigue b. Polydipsia c. Polyphagia d. Recurrent infections

b. Polydipsia is caused by fluid loss from polyuria when high glucose levels cause osmotic diuresis. Cellular starvation from lack of glucose and the use of body fat and protein for energy contribute to fatigue, weight loss, and polyphagia in type 1 diabetes.

23. Priority Decision: The nurse is assessing a newly admitted patient with diabetes. Which observation should be addressed as the priority by the nurse? a. Bilateral numbness of both hands b. Rapid respirations with deep inspiration c. Stage II pressure injury on the right heel d. Areas of lumps and dents on the abdomen

b. Rapid deep respirations are symptoms of diabetic ketoacidosis (DKA), so this is the priority of care. Stage II pressure injuries and bilateral numbness are chronic complications of diabetes. The lumps and dents on the abdomen indicate the patient has lipodystrophy and may need to learn about site rotation of insulin injections.

2. Which tissues require insulin to enable movement of glucose into the tissue cells (select all that apply)? a. Liver b. Brain c. Adipose d. Blood cells e. Skeletal muscle

c, e. Adipose tissue and skeletal muscle require insulin to allow the transport of glucose into the cells. Brain, liver, and blood cells require adequate glucose supply for normal function but do not depend directly on insulin for glucose transport.

34. A patient with diabetes is found unconscious at home, and a family member calls the clinic. After determining that a glucometer is not available, what should the nurse advise the family member to do? a. Have the patient drink some orange juice. b. Administer 10 U of regular insulin subcutaneously. c. Call for an ambulance to transport the patient to a medical facility. d. Administer glucagon 1 mg intramuscularly (IM) or subcutaneously.

d. If a patient with diabetes is unconscious, immediate treatment for hypoglycemia must be given to prevent brain damage, and IM or subcutaneous administration of 1 mg of glucagon should be done. If the unconsciousness has another cause, such as ketosis, the rise in glucose caused by the glucagon is not as dangerous as the low glucose level. Following administration of the glucagon, the patient should be transported to a medical facility for further treatment and evaluation. Oral carbohydrates cannot be given when patients are unconscious, and insulin is contraindicated without knowledge of the patient's glucose level.

11. The nurse determines that a patient with a 2-hour OGTT of 152 mg/dL has a. diabetes. b. elevated A1C. c. impaired fasting glucose. d. impaired glucose tolerance.

d. Impaired glucose tolerance exists when a 2-hour OGTT level is higher than normal but lower than the level diagnostic for diabetes (i.e., > 200 mg/dL). Impaired fasting glucose exists when fasting glucose levels are greater than the normal of 100 mg/dL but < the 126 mg/dL diagnostic of diabetes. Both abnormal values indicate prediabetes.

7. A patient with diabetes has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. After assessing the patient, the nurse suspects diabetes-related ketoacidosis rather than hyperosmolar hyperglycemia syndrome based on the finding of a. polyuria. b. severe dehydration. c. rapid, deep respirations. d. decreased serum potassium.

. Correct answer: c Rationale: Signs and symptoms of DKA include manifestations of dehydration, such as poor skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension. Early symptoms may include lethargy and weakness. As the patient becomes severely dehydrated, the skin becomes dry and loose, and the eyeballs become soft and sunken. Abdominal pain is another symptom of DKA that may be accompanied by anorexia and vomiting. Kussmaul respirations (i.e., rapid, deep breathing associated with dyspnea) are the body's attempt to reverse metabolic acidosis through the exhalation of excess carbon dioxide. Acetone is identified on the breath as a sweet, fruity odor. Laboratory findings include a blood glucose level greater than 250 mg/dL, arterial blood pH less than 7.30, serum bicarbonate level less than 15 mEq/L, and moderate to high ketone levels in the urine or blood.

4. Which statement by the patient with type 2 diabetes is accurate? a. "I will limit my alcohol intake to 1 drink each day." b. "I am not allowed to eat any sweets because of my diabetes." c. "I cannot exercise because I take a blood glucose-lowering medication." d. "The amount of fat in my diet is not important. Only carbohydrates raise my blood sugar."

Correct answer: a Rationale: The guideline for alcohol consumption in men with diabetes is 0-2 drinks per day. For women with diabetes it is 0-1 drink per day.

6. What is the priority action for the nurse to take if the patient with type 2 diabetes reports blurred vision and irritability? a. Call the provider. b. Give insulin as ordered. c. Assess for other neurologic symptoms. d. Check the patient's blood glucose level.

Correct answer: d Rationale: Check blood glucose whenever hypoglycemia is suspected so that immediate action can be taken if necessary.

10. During routine health screening, a patient is found to have fasting plasma glucose (FPG) of 132 mg/dL (7.33 mmol/L). At a follow-up visit, a diagnosis of diabetes would be made based on which laboratory results (select all that apply)? a. A1C of 7.5% b. Glycosuria of 3 + c. FPG ≥ 127 mg/dL (7.0 mmol/L). d. Random blood glucose of 126 mg/dL (7.0 mmol/L) e. A 2-hour oral glucose tolerance test (OGTT) of 190 mg/dL (10.5 mmol/L)

a, c. The patient has 1 prior test result of fasting plasma glucose (FPG) ≥ to 126 mg/dL (7.0 mmol/L) that meets criteria for a diagnosis of diabetes, and the result is confirmed on this follow-up visit. The A1C is 7.5% and greater than diagnostic criteria of 6.5% or higher. The other diagnostic criteria include a 2-hour OGTT level ≥ 200 mg/dL (11.1 mmol/L), or a patient with classic symptoms of hyperglycemia (polyuria, polydipsia, polyphagia, unexplained weight loss) or hyperglycemic crisis, a random plasma glucose ≥ 200 mg/dL (11.0 mmol/L).

24. Individualized nutrition therapy for patients using conventional, fixed insulin regimens should include teaching the patient to a. eat regular meals at regular times. b. restrict calories to promote moderate weight loss. c. eliminate sucrose and other simple sugars from the diet. d. limit saturated fat intake to 30% of dietary calorie intake.

a. The body needs food at regularly spaced intervals throughout the day. Omission or delay of meals can result in hypoglycemia, especially for the patient using conventional insulin therapy or OAs. Weight loss may be recommended in type 2 diabetes if the person is overweight, but many patients with type 1 diabetes are thin and do not require a decrease in caloric intake. Fewer than 7% of total calories should be from saturated fats and simple sugar should be limited, but moderate amounts can be used if counted as a part of total carbohydrate intake.

26. To prevent hyperglycemia or hypoglycemia related to exercise, what should the nurse teach the patient using glucose-lowering agents about the best time for exercise? a. Plan activity and food intake related to blood glucose levels b. When blood glucose is greater than 250 mg/dL and ketones are present c. When glucose monitoring reveals that the blood glucose is in the normal range d. When blood glucose levels are high, because exercise always has a hypoglycemic effect

a. To plan for exercise, a person with diabetes must monitor blood glucose and make adjustments to insulin dose (if taken) and food intake to prevent exercise-induced hypoglycemia. Exercise is delayed if blood glucose is ≥ 250 mg/dL with ketones. Before exercise if blood glucose is ≤ 100 mg/dL a 15-g carbohydrate snack is eaten. Blood glucose levels should be monitored before, during, and after exercise to determine the effect of exercise on the levels.

15. A patient with diabetes is learning to mix regular insulin and NPH insulin in the same syringe. The nurse determines that additional teaching is needed when the patient does what? a. Withdraws the NPH dose into the syringe first b. Injects air equal to the NPH dose into the NPH vial first c. Removes any air bubbles after withdrawing the first insulin d. Adds air equal to the insulin dose into the regular vial and withdraws the dose

a. When mixing regular and intermediate-acting insulin, regular insulin should always be drawn into the syringe first to prevent contamination of the regular insulin vial with intermediate-acting insulin additives. Air is added to the NPH vial first. Then air is added to the regular vial and the regular insulin is withdrawn, bubbles are removed, and then the dose of NPH is withdrawn.

28. A nurse working in an outpatient clinic plans a screening program for diabetes. What recommendations for screening should be included? a. OGTT for all minority populations every year b. FPG for all persons at age 45 years and then every 3 years c. Testing people under the age of 21 years for islet cell antibodies d. Testing for type 2 diabetes in all overweight or obese persons

b. The American Diabetes Association recommends that testing for type 2 diabetes with a FPG, A1C, or 2-hour OGTT should be considered for all persons at the age of 45 years and above and, if normal, repeated every 3 years. Testing for immune markers of type 1 diabetes is not recommended. Testing at a younger age or more frequently should be done for members of a high-risk ethnic population, including blacks, Hispanics, Native Americans, Asian Americans, and Pacific Islanders. Overweight adults with additional risk factors should be tested.

25. What should the goals of nutrition therapy for the patient with type 2 diabetes include? a. Ideal body weight b. Normal serum glucose and lipid levels c. A special diabetic diet using dietetic foods d. Five small meals per day with a bedtime snack

b. The specific goals of nutrition therapy for people with diabetes include maintaining near-normal blood glucose levels and achievement of optimal serum lipid levels and BP. Dietary modifications are believed to be important factors in preventing both short- and long-term complications of diabetes. Loss of weight, which may or may not be to ideal body weight, may improve insulin resistance. There is no longer a specific "diabetic diet," and use of dietetic foods is not necessary for glucose control. Most patients with diabetes eat 3 meals a day, and some require a bedtime snack for control of nighttime hypoglycemia. The other goals of nutrition therapy include prevention of chronic complications of diabetes, attention to individual nutritional needs, and maintenance of the pleasure of eating.

19. Priority Decision: A patient taking insulin has recorded fasting glucose levels above 200 mg/dL (11.1 mmol/L) on awakening for the last 5 mornings. What should the nurse have the patient to do first? a. Increase the evening insulin dose to prevent the dawn phenomenon. b. Use a single-dose insulin regimen with an intermediate-acting insulin. c. Monitor the glucose level at bedtime, between 2:00 am and 4:00 am, and on arising. d. Decrease the evening insulin dosage to prevent night hypoglycemia and the Somogyi effect.

c. The patient's high glucose on arising may be the result of either dawn phenomenon or Somogyi effect. The best way to determine whether the patient needs more or less insulin is by monitoring the glucose at bedtime, between 2:00 am and 4:00 am, and on arising. If the 2:00 am to 4:00 am blood glucose levels are below 60 mg/dL, the insulin dose should be reduced to prevent Somogyi effect; if it is high, the insulin should be increased to prevent dawn phenomenon.

8. Which patient should the nurse plan to teach how to prevent or delay the development of diabetes? a. An obese 40-year-old Hispanic woman b. A 20-year-old man whose father has type 1 diabetes c. A 34-year-old woman whose parents both have type 2 diabetes d. A 12-year-old boy whose father has maturity-onset diabetes of the young (MODY)

c. Type 2 diabetes has a strong genetic influence (8% to 14% risk for offspring) and offspring of parents who both have type 2 diabetes have an increased chance of developing it. In contrast, type 1 diabetes is associated with a genetic susceptibility that is related to human leukocyte antigens (HLAs). Offspring of a mother with type 1 diabetes have a 1% to 4% chance of developing the disease, while offspring of a father with diabetes have 5% to 6% risk. Other risk factors for type 2 diabetes include obesity; Native American, Hispanic, or African ancestry; and age of 55 years or older. Although 50% of people with a parent with maturity-onset diabetes of the young (MODY) will develop MODY, it is autosomal dominant, and treatment depends on which genetic mutation caused it. It is not associated with obesity or hypertension and is not currently considered preventable.

1. In addition to promoting the transport of glucose from the blood into the cell, what does insulin do? a. Enhances the breakdown of adipose tissue for energy b. Stimulates hepatic glycogenolysis and gluconeogenesis c. Prevents the transport of triglycerides into adipose tissue d. Increases amino acid transport into cells and protein synthesis

d. Insulin is an anabolic hormone that is responsible for growth, repair, and storage. It facilitates movement of amino acids into cells, synthesis of protein, storage of glucose as glycogen, and deposition of triglycerides and lipids as fat into adipose tissue. Fat is used for energy when glucose levels are depleted. Glucagon is responsible for hepatic glycogenolysis and gluconeogenesis.

5. Which laboratory results indicate the patient has prediabetes? a. Glucose tolerance result of 132 mg/dL (7.3 mmol/L) b. Glucose tolerance result of 240 mg/dL (13.3 mmol/L) c. Fasting blood glucose result of 80 mg/dL (4.4 mmol/L) d. Fasting blood glucose result of 120 mg/dL (6.7 mmol/L)

d. Prediabetes is defined as impaired glucose tolerance and impaired fasting glucose or both. Fasting blood glucose results between 100 mg/dL (5.56 mmol/L) and 125 mg/dL (6.9 mmol/L) indicate prediabetes. A diagnosis of impaired glucose tolerance is made if the 2-hour oral glucose tolerance test (OGTT) results are between 140 mg/dL (7.8 mmol/L) and 199 mg/dL (11.0 mmol/L).

Diabetes mellitus (DM)

is a chronic multisystem disease characterized by hyperglycemia from abnormal insulin production, impaired insulin use, or both •Leading cause of: •Adult blindness •End-stage renal disease •Nontraumatic lower limb amputations • Major contributing factor •Heart disease and stroke (2 to 4 times higher) •Many have HTN and high cholesterol

Etiology and Pathophysiology... Insulin

•Insulin is a hormone produced by the cells of the pancreas •Insulin is released continuously into bloodstream in small increments with larger amounts released after food (Fig. 48-1 in the textbook) •Insulin stabilizes glucose level in range of 74 to 106 mg/dL (70-100) •Insulin enhances glucose transport from the bloodstream across the cell membrane to the cytoplasm of the cell to be used for energy (Fig. 48-2 in the textbook) •Cells break down glucose to make energy •Liver and muscle cells store excess glucose as glycogen. For this reason, insulin is an anabolic (or storage) hormone. •The fall in insulin during normal overnight fasting promotes the release of stored glucose from the liver, protein from the muscle, and fat from the adipose tissue. • insulin—inhibits gluconeogenesis, enhances fat deposition, and increases protein synthesis •i insulin—release glucose from liver, protein from muscle, and fat from adipose tissue •Other hormones (glucagon, epinephrine, growth hormone, cortisol) work against the effect of insulin, increasing blood glucose levels.

Nutrition Therapy: Type 1 Diabetes

•Meal planning •Based on usual food intake and preferences •Balanced with insulin and exercise patterns •Day-to-day consistency makes it easier to manage blood glucose levels •Rapid or short-acting insulin, multiple daily injections, and insulin pump offer flexibility based on current blood glucose level and carbohydrate content of meal •If pt eats a big meal (not within the content of the pt's meal plan), must monitor BG and seek direction from physician. Cannot randomly change insulin amount. •If pt ordered an evening dose of intermediate insulin, will need a snack to maintain BG overnight.

•Objective data: Nursing Assessment

•Objective data •Eyes •Soft, sunken eyeballs, history of vitreal hemorrhages, cataracts •Integumentary •Dry, warm, inelastic skin, pigmented skin lesions, ulcers, loss of hair on toes, acanthosis nigricans •Respiratory •Kussmaul respirations •Cardiovascular •Hypotension, weak, rapid pulse •Gastrointestinal •Dry mouth, vomiting, fruity breath •Neurologic •Altered reflexes, restlessness, confusion, stupor, coma •Musculoskeletal •Muscle wasting ••Possible diagnostic findings •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 •Increased triglycerides, cholesterol, LDL, VLDL •Decreased HDL •A1C value > 6.0% •Glycosuria •Ketonuria •Albuminuria •Acidosis

Type 2 Diabetes Etiology and Pathophysiology

•Pancreas continues to produce some endogenous insulin but •Not enough insulin is produced and/or •Body does not use insulin effectively •Major distinction Type 1 vs. Type 2: •In type 1 diabetes, there is an absence of endogenous insulin

Nursing Implementation: Sick Day Care

•Patients with diabetes should check their blood glucose every 4 hours during times of illness •If glucose greater than 240 mg/dL, check urine for ketones every 3 to 4 hours •Two consecutive glucose levels greater than 300 mg/dL or moderate to high urine ketone levels should be reported to HCP •If needed, increase insulin for type 1 diabetes to avoid DKA •Increased glucose increases risk of infection and reduces healing •Call HCP if illness lasts more than 2 days •Acute illness •Maintain normal diet if able •Increase noncaloric fluids •Continue taking diabetic medications •If unable to eat or drink, contact HCP •Intraoperative period •IV fluids and insulin when NPO •Consult with physician if pt has ordered insulin or oral diabetic medication and is scheduled for sx. •Unconscious patient

Drug Therapy for Type 1...Exogenous Insulin

•Rapid-acting (onset 15 min, duration 4 hrs) •Short-acting (onset 30 min, duration 5 hrs) •Intermediate-acting (onset 90 min, duration 14 hrs) •Long-acting (Onset 45 min, duration 24 hrs) • •Basal (background insulin that lasts longer) •Bolus (usu at meals to cover food intake or high BG) • •Physician orders amount of insulin. •Unless ordered, pt cannot change amount of insulin given

How to test

•Wash and dry hands completely •Warm hands or let arms hang down for a few minutes prior to puncture •Turn machine on •Place test strip in machine •Use side of finger, rather than center, for puncture •Use lancet to puncture •Place drop of blood on test strip •See results •Patient and caregiver teaching (Table 48-11 in the textbook) •Initial and follow-up •Instructions how to test, use, and calibrate meter •When to test •Before meals •Two hours after first bite •When hypoglycemia is suspected •Every 4 hours during illness •Before and after exercise •Consider impaired vision, cognition, or dexterity; use adaptive devices

Exercise

•Regular, consistent exercise plan essential •ADA recommends •At least 150 minutes/week moderate-intensity aerobic activity (Table 48-9 in the textbook ) •Resistance training 3 times/week •Benefits •Decreases insulin resistance and blood glucose •Weight loss •Reduce need for medications (type 2) •Decreases triglycerides and LDL , ↑ HDL •Decreases BP and increases circulation •Get medical clearance; start slowly and progress to goal •Glucose-lowering effect of exercise lasts up to 48 hours •Risk for hypoglycemia when exercising •Carry fast-acting source of carbohydrates •Frequent low glucoses, consult HCP about lowering medications •Patient and Caregiver Education •See Table 48-10 for Exercise Guidelines •Effect of strenuous activity makes body perceive "stress" causing release of counter regulatory hormones and temporary increase glucose. Check BG and urine for ketones. •Exercise best done about an hour after a meal •Monitor BG before, during (if exercise more than 1 hr), and after exercise •If BG less than 100 mg/dL before exercise, eat a snack and then recheck BG before exercise. •If BG greater than 250 mg/dL and ketones are present in the urine before exercise, delay activity and drink fluids (water) until ketones are gone. •Carry fast acting source of carbohydrates during exercise, just in case.

Monitoring of Blood Glucose

•Self-monitoring of blood glucose (SMBG) •Enables decisions regarding food intake, activity patterns, and medication dosages •Accurate record of glucose fluctuations and trends •Recommended for all diabetics who use insulin and others to help achieve and maintain glycemic goals •Frequency of testing varies according to: •Goals, Medication plan, and Ability