Lecture 5

Which is a higher priority? DKA or HHNK

o DKA is a more acute condition and responds very quickly to insulin o HHN pts show up late in the emergency room and do not readily respond to treatment

What insulin can be given IV?

regular insulin

Glargine (Lantus)

long acting insulin · No Peak · Duration 12 to 24 hrs · Little to no risk for hypoglycemia (only one you can safely give at bedtime)

Which is more dependent on insulin? DKA or HHNK

o DKA pt is more dependent on insulin o HHNK pt needs to be rehydrated

Does DM and DI have high urine output

Both have high urine output

What action invalidates the manufacturers exp date on insulin? and why?

· Opening the package · Once the package is open, the new expiration date is 30 days after that · Open package without an opening or expiration date should be thrown out · Label the package either with o "OPEN" and date package is open or o "EXP" and expiration date

long term complications of diabetes

· Related to o Poor tissue perfusion or o Peripheral neuropathy · Examples of long-term complications: Renal failure, Gangrene, Heart failure, Urinary incontinence, Pt can't feel a burn on the foot · For instance o Renal failure is a cause of poor perfusion o Urinary incontinence is a cause of peripheral neuropathy

What happens when a diabetic is sick? flu, fever, etc 2 problems with them?

· Serum glucose levels go up · Need their insulin even though pt isn't eating · Take sips of water because they get dehydrated · Any sick diabetic pt has 2 problems o Hyperglycemia and Dehydration

Type 2 diabetes. Insulin involvement? When can you get it? Ketosis prone y/n?

· Type II—Non-insulin dependent, Adult onset, Non-ketosis prone

Type 1 diabetes. Insulin involvement? When can you get it? Ketosis prone y/n?

· Type I—Insulin dependent, Juvenile onset, Ketosis prone

HHNK or HHS or HHNS S/Sx

· Whenever you see HHNK, think dehydration · Severe Dehydration! o Skin is dry, flushed, decreased turgor, increased HR o #1 Nursing diagnosis: fluid volume deficit (same as dehydration) o #1 Nursing intervention: Rehydration! o Outcomes in successful treatment: Increase urine output, Moist mucous membrane, etc. o Long-term complications: Poor perfusion, Peripheral neuropathy

S/sx of Diabetes Mellitus

3 P's o Polyuria—pee a lot o Polydipsia—thirsty o Polyphagia -(eat/swallow a lot)

NPH insulin Characteristics? They have what letter in their name? Onset? Peak? Duration? Pattern?

All have N in name Intermediate insulin—it is cloudy N = Not So Clear, Fast (Cloudy = Suspension—it precipitates—can't give IV drip), N = not so fast, not in the bag Onset: 6 hours Peak: 8-10 hours Duration: 12 hours Pattern: 6-8-10-12

Regular insulin. They have what letter in their names? onset? peak? duration?

All have R in name. clear solution, IV drip (HESI-intermediate, Rapid, Run IV) Onset: 1 hour Peak: 2 hours Duration: 4 hours Pattern: 1-2-4

Diabetes mellitus? and what are the 2 types?

An error in glucose metabolism ... Glucose is the body's primary fuel source · Can be a lack of insulin DM1 · Can be insulin resistance DM2

What is the best dietary action a DM2 should take? a. Restrict calories b. Divide meal into 6 feedings a day

Answer: (a) because pt can eat 6 meals but does not limit the Cal with each meal

#1 nursing diagnosis for HHNK or HHS or HHNS and #1 nursing intervention

Fluid volume deficit (same as dehydration) Intervention: rehydration

Treatment for DKA

Insulin IV (regular) IV fluid 200 mL/hr (some of the fastest rate)

diabetes insipidus. What is it? Symptoms?

Caused by low ADH Not a type of DM! ... It is insidious, diabetes w/out the glucose element · It is Polyuria, Polydipsia leading to dehydration, due to low ADH. It is just the fluidpart, not the glucose

Symptoms of SIADH

DM has polyuria, polydipsia Therefore, DI also has polyuria, polydipsia However, SIADH is the opposite of the above 2 conditions ... · It presents w/ oliguria and no thirst · Decrease urine output · And then, decrease serum specific gravity (due to retention of water) Low serum osmolality low serum sodium · Increase urine specific gravity (due to decrease urine volume)

Diet for DM2

Primary treatment modality is calorie restriction 1200 Cal, 1400 Cal, 1600 Cal These pmts need to eat 6 small feedings per day- smaller more frequent meals- keeps blood sugar more stable

Nursing diagnosis for SIADH

Fluid Volume Excess

Nursing diagnosis for DM, DI?

Fluid volume deficit

DKA what is it? and causes? which is #1?

High Glucose in a Type I (keto is the clue!) Causes · Too much food · Not enough insulin · Not enough exercise · #1 cause acute is a viral Upper Respiratory Infection within last 2 weeks

HHNK or HHS or HHNS what does it mean?

High blood sugar in a type 2 pt These pt don't burn ketones, no acid

Treatment for DM type 1

If you don't treat They will "DIE" Diet (calories from carbs, least important) Insulin (most important) Activity

Which has the higher mortality rate? DKA or HHNK

More die with HHNK (don't respond to treatment fast)

Pattern for regular and NPH insulin onset peak duration

Onset, peak, duration 1-2-4-6-8-10-12

Lispro (Humalog) When to give? Onset? Peak? Duration?

Rapid acting · Don't give it AC (before meal) ... Give it with the meal · Onset: 15 min · Peak: 30 min · Duration: 3 hrs · Pattern: 15-30-3

S/Sx of DKA

S/Sx is "DKA" Dehydration (Dry, poor skin elasticity and turgor, war,)... Water is a coolant (you overheat) Ketones in serum, Kussmauls, High K+ Acidosis, Acetone breath (fruity, nail polish), Anorexia due to nausea

What is the opposite of Diabetes insidious?

SIADH = Syndrome of inappropriate ADH (antidiuretic hormone) high ADH

treatment for type 2 DM

They are DOA Diet (most important) Oral hypoglycemic Activity

What does hypoglycemia look like?

Think of a drunk patient in shock · Drunk o Staggering gait o Slurred speech o Cerebral impairment (labile) o Slow reaction time o Decrease social inhibition · Shock—Vasomotor collapse o Tachycardia, tachypnea, Low BP o Cold/clammy, mottledskin Pallor

How would the board ask question about peak of insulin? For instance, you give 30 units of insulin to a pt at 7 a.m. When do you check for hypoglycemia?

· Answer = Add the insulin peak time to the time of insulin administration · For instance, if the pt was given NPH at 7 a.m., add 8 to 10 hours to the time · Answer = Check for hypoglycemia between 3 and 5 p.m.

What does exercise do when you have diabetes? What do you do with the insulin?

· Exercise is like another shot of insulin · Therefore, if a student is schedule to play soccer (exercise) this afternoon ... It is necessary to decrease the dosage of insulin · In addition, the school nurse must give the student rapidly metabolized carbohydrates— snacks or juice

Treatment for hypoglycemia conscious and unconscious

· Give pt sugars or Rapidly metabolizable carbohydrate such as o Juice (any), candy, regular soda, milk (lactose), honey, icing, jelly, jam · Boards want sugar + starch or protein o For example, apple juice + turkey, Milk is sugar/protein—1/2 cup Skim milk · Bad answer o Candy + Soda—1 sugar is good, 2 sugars are bad o 5 packs of sugar emptied into a glass of orange juice · Unconscious pts—pay attention to location · Glucagon IM if the mother is on the phone · Dextrose IV (D10, D50) if in the ER

Which lab test is the best indicator of long-term blood glucose level? normal levels?

· Hb A1C, a.k.a. glycosated Hb or glycosylated Hb o Average blood sugar over last 90 days · Hb < 6 is normal · Hb > 8 is out of control · Hb 7 Borderline—have pt come in for evaluation

Acute complications of diabetes? and causes? which is the major cause?

· Low blood glucose—a.k.a. Hypoglycemia or Hypoglycemic shock or Insulin shock/reaction · Why are some of the causes o Not enough food o Too much insulin (#1 cause, can lead to permanent brain damage) o Too much exercise

When do you refrigerate insulin?

· Once the package is open, refrigeration is optional o However, unopened bottle must be kept refrigerated o Although it is good practice to teach pt to refrigerate insulin at home