Ch. 41 Endocrine- Diabetes
When providing nutrition education to the client with diabetes, the nurse should include which statement regarding fat intake?
"If you have diabetes, avoiding saturated fats is important."
The mother of a 2-year-old newly diagnosed with type 1 diabetes asks why insulin has to be given by injection. The best response by the nurse is:
"Insulin is destroyed by the stomach contents and has to be administered by injection."
Following an oral glucose tolerance, a 36-year-old mother of 4 has been diagnosed with gestational diabetes mellitus (GDM), a problem that was not present in any of her previous pregnancies. What should her primary care provider tell her about this new health problem?
"Your baby could become too large or have low blood sugars if we're not vigilant about controlling your sugars."
describe metabolic acidosis
-caused by excess keto acids that require buffering by bicarbonate ion > marked decrease in serum bicarbonate levels. -the severity from DKA depends on the severity of metabolic acidosis
Type 1 diabetes: manifestations
-3 Ps -polyuria -polydipsia -polyphagia -decreased conscience from acidosis -weight loss -glycosuria -fruity breath
Etiology: Risk Factors- Type I DM
-characterized by lack of insulin production. -occurs more commonly in young people -immune-mediated idiopathic genetic predisposition, but not as much as type 2
The nurse caring for a client with HHS (hyperosmolar hyperglycemic state) should perform which priority assessment on this client?
-Cerebral edema
hypoglycemia- etiology
-type 1 diabetes -error in insulin dosing -increased exercise -decreased insulin need -medication changes -change in insulin injection site -alcohol intake
DKA- manifestations
-a day or more of polyuria, nausea, vomiting, and marked fatigue, with eventual stupor that may progress to coma, commonly precedes DKA. -fruity smell on breath (due to the volatile keto acids -abdominal pain + tenderness -hypotension -tachycardia -kussmaul respiration (rate and depth of respirations increase).
autonomic nervous system response- manifestations
-anxiety -tachycardia -sweating -constriction of the skin vessels (skin cool and clammy)
diabetes: ulcer sites
-any weight bearing area -heel, plantar, big toe
altered brain function- manifestations (5)
-behavioral issues -headaches -difficulty with problem solving -mental confusion -seziures
macrovascular complications
-coronary artery disease -cerebral vascular -peripheral artery diseases/foot ulcers
three metabolic abnormalities are associated with type II
1. insulin resistance 2. deranged secretion of insulin by the pancreatic beta cells 3. increased glucose production by the liver
metabolic syndrome- manifestations
1. lipids: dyslipiedmia characterized by increased triglycerides and decreased HDLs 2. inflammation 3. hypertension 4. vascular pathology 5. abnormal coagulation
Which clients with diabetes mellitus would the nurse anticipate to have persistent elevation of blood glucose levels? Select all that apply.
A client with high anxiety A client with COPD taking steroids A client with a newly diagnosed leg fracture
A nurse is evaluating clients for the risk of developing type 2 diabetes. Which client has the highest risk for developing this metabolic disorder?
A middle aged obese adult with a sedentary lifestyle
When educating a client about type 1 diabetes, the nurse will mention that this type is caused by which mechanism?
Autoimmune destruction of pancreatic beta cells
The results of a 44-year-old obese man's recent diagnostic workup have culminated in a new diagnosis of type 2 diabetes. Which pathophysiologic process underlies the client's new diagnosis?
Beta cell exhaustion due to long-standing insulin resistance
A client with diabetes mellitus has sudden onset of slurred speech, incoordination, and cool, clammy skin. What will the nurse do first?
Check blood glucose
DKA: causes
DKA: causes -uncontrolled diabetes -insufficient insulin -new onset type 1-stress
During periods of fasting and starvation, the glucocorticoid and other corticosteroid hormones are critical for survival because of their stimulation of gluconeogenesis by the liver. When the glucocorticoid hormones remain elevated for extended periods of time, what can occur?
Hyperglycemia
The diagnosis of type 1 diabetes would be confirmed by which principle?
Insulin is not available for use by the body.
Which metabolic abnormality can lead to the development of type 2 diabetes?
Insulin resistance
select the most common symptoms of diabetes. Select all that apply.
Polydipsia Polyuria Polyphagia
The nurse is teaching a client with diabetes about the signs and symptoms of hypoglycemia. The client asks, "Why will I get headache, disturbed behavior, coma, and seizures if it's my pancreas that's impaired?" Which response is the best explanation?
The brain relies on blood glucose as its main energy source.
altered brain function
brain relies heavily on blood glucose as its main energy source
An obese adult has recently been diagnosed with type 2 diabetes. The nurse knows that the most likely treatment plan for this client will include which topics?
Weight loss, glucose monitoring, and oral antihyperglycemic medications
The obstetrical nurse is caring for a client who has been treated for gestational diabetes. When teaching the client about the causes of gestational diabetes, the nurse should include which risk factor in the teaching?
Woman with a family history of diabetes
dawn phenomenon- pathogenesis
characterized by increased fasting blood glucose and/or insulin requirements during the early morning hours that are not triggered by a preceding hypoglycemic event such as in the Somogyi effect
microvascular and macrovascular complications result from
damage to blood vessels and nerves
a group of common metabolic disorders which are characterized by hyperglycemia
diabetes mellitus (DM)
diabetic foot ulcers
effects of neuropathy and vascular insufficiency. -impaired pain sensation and unaware of the constant trauma to the feet. -due to poorly fitting shoes, improper weight bearing, hard objects or pebbles in the shoes, or infections. -another factor may be= weakness to the intrinsic muscles of the foot with deformities with high pressure points.
cause of DKA
emotional and physical stress such: -infections -inflammation -pregnancy -extreme anxiety -omitting or insufficient insulin
excessive thirst
polydipsia
hypoglycemia- manifestations
rapid onset and progression of symptoms two categories: -manifestations from altered brain function and those related to activation of the autonomic nervous system. -brain relies heavily on glucose to function
dawn phenomenon- etiology
result of circadian variations in hormone secretion, with glucagon secretion releasing energy stores in preparation for the activity of the day
Research has identified a cycle of insulin-induced posthypoglycemic episodes. What is this phenomenon called?
somogyi effect
DKA: manifestations
-decreased LOC -severe hypovolemia -polyuria -glycosuria/ketonuria
diabetes complications: blood vessel damage
-hyperglycemia + other factors
Pathophysiology: Type I DM
-sudden onset, symptomatic, often in ketoacidosis -autoimmune destruction of beta cells of the pancreas. The pancreas no longer makes insulin. -a catabolic disorder characterized by an absolute lack of insulin, an elevation in blood glucose and breakdown of body fats and proteins making these patients at high risk for ketoacidosis. -see acute complications. -beta cells of pancreas make little or no insulin.
hypoglycemia: manifestations
-sweating, increased pulse, increased pulse, irritability, tremors -dizziness, headache, slurred speech, decreased coordination, confusion
For what complication does the nurse assess an infant when the mother has uncontrolled gestational diabetes mellitus (GDM)?
macrosomia
excessive hunger
polyphagia
frequent urination/diuresis
polyuria
is the somogyi effect or dawn phenomenon more common
somogyi effect is much less common than dawn phenomenon
diabetic ketoacidosis (DKA) most commonly occurs in who
type I DM - lack of insulin leads to increased release of fatty acids from adipose tissue
other clinical manifestations of DM
weight -weight loss despite normal or increased appetite is more common with type 1 diabetes. -obesity is more common with type 2 diabetes plasma volume -low plasma volume produces weakness and fatigue -Increased sugar in blood goes out through kidneys and takes water with it. infections -high incidence from hyperglycemia and glycosuria lead to skin and yeast infections eyes -lens and retina exposed to hyperosmolar fluids: blurred vision
describe the risk factors, and potential complications of gestational diabetes
-complications of pregnancy, mortality, and fetal abnormalities including: -macrosomia (large body size) -hypoglycemia -hypocalcemia -polycythemia -hyperbilirubinemia -develop type 2 DM after pregnancy. -their offspring are also at greater risk for developing diabetes type 2
describe the definition of gestational diabetes
-gestational diabetes mellitus (GDM) is any degree of glucose intolerance that occurs initially during pregnancy, generally presenting during the second and third trimesters.
Pathophysiology: Type II DM
-gradual onset -insulin resistance is the decreased ability of insulin to act effectively on target tissues especially muscle, liver, and fat. It is the predominant characteristic of type 2 diabetes. -progressive impairment of beta-cell function in people with type 2 diabetes. Beta cells may initially make insulin but tissues may not be able to use the insulin. -over time beta cells cease to produce insulin.
DKA- the three major metabolic derangements
-hyperglycemia -keto acidosis -metabolic acidosis
describe hyperosmolar hyperglycemic state
-hyperglycemia which leads to osmotic diuresis, dehydration and critical loss of electrolytes -hyperosmolality of the extracellular fluid because hyperglycemia leads to a shift of water from the intracellular to the extracellular compartments -extracellular sodium concentration may be low or normal despite increase urinary losses of water -serum potassium levels may be normal or elevated despite total potassium depletion resulting from protracted polyuria and vomiting.
hyperosmolar hyperglycemic state (HHS)- what is it characterized by
-hyperglycemia, hyperosmolarity with dehydration, the absence of ketoacidosis and depressions of the sensorium -this high glucose level leads to large volume water loss through osmotic diuresis. -dehydration is normally more severe in HHS than DKA. -as the plasma volume decreases, renal insufficiency will occur -thus, as the kidney function declines, the kidneys will be unable to eliminate glucose which further elevates the blood glucose level. -the increase serum osmolarity pulls water out of body cells, including brain cells -this occurs frequently in people with Type 2 diabetes. -you are looking at blood sugars equal to or higher than 600 mg/dl.
diabetes complications: risk factors
-hypertension, increased cholesterol, smoking-about 10 years after diagnosis
somogyi effect- pathogenesis
-hypoglycemic episodes occur at night or at a time when It is not recognized, renders serum blood glucose levels high in am. -difficult to diagnose
DM results from
-imbalances between insulin secretion and cellular responsiveness to insulin. unable to transport glucose to cells > cells are starved > increased breakdown of fat & protein to generate energy for cells
describe nephropathy
-increased proteinuria
somogyi effect- etiology
-insulin-induced hypoglycemia produces a compensatory increase in blood levels of the counter-regulatory hormones such as catecholamines, glucagen, cortisol, and GH. -these counter-regulatory hormones cause blood glucose to become elevated and produce some degree of insulin resistance.
acute complications of DM
-ketoacidosis (DKA) -hypotension -hyperosmolar hyperglycemic state (HHS)
Diabetic Ketoacidosis (DKA)
-lack of insulin -glucose can't enter cells -ketone formation-metabolic acidosis -**body breaking down fat/protein
diabetes: ulcer complications
-loss of pain/sensations -lead to amputations -bacteria loves sugar
Etiology: Risk Factors- Type II DM
-majority of diabetes mellitus -strong genetic component -obesity
microvascular complications
-nephropathy -CAD -neuropathies -retinopathy -disorders of GI motility
diabetes complications: microvascular
-nephropathy, retinopathy, paresthesia's -neuropathy= nerve damage, can't feel, ex. burning in feet
metabolic syndrome- risk factors
-obesity -body shape (apple shape more at risk for type II than pear)
Type 1 diabetes (childhood)
-pancreas does not work properly -affects beta cells= destroyed= can't make insulin -90% autoimmune/genetic
clinical manifestations of (DM) hyperglycemia (not complications).
-polyuria -polydipsia -polyphagia
infections
-the presence of chronic vascular complications contribute to suboptimal response to infection in a person with diabetes, as does hyperglycemia and altered neutrophil function. -sensory deficits may predispose a person with diabetes to wounds and infections. -vascular disease may impair circulation and delivery of red blood cells and other necessary substances for promotion of adequate inflammatory response and effective healing. -hyperglycemia and glycosuria may influence the growth of microorganisms and increase severity of infections
hypoglycemia: causes
-too much insulin -decreased food intake -increased activity
metabolic syndrome- 3 abnormalities associated with type II
1. insulin resistance-the tissues are resistant to the action of insulin, and the insulin will be unable to get into the cells where it is needed. Insulin receptors on the target cell may malfunction. 2. deranged secretion of insulin by the pancreatic beta cells 3. increased glucose production by the liver leads to hyperglycemia. -eventually the beta cells of the pancreas will exhaust themselves and will cease to make insulin. -It is found that adipose tissues are among the tissues that demonstrate inadequate responses to insulin, contributing to the pancreatic response of hyperinsulinemia to attempt to reduce the hyperglycemia. -Insulin normally inhibits lipolysis; however, in Type 2 it causes increased lipolysis which ultimately increases the very low lipoproteins, and triglycerides. -systemic inflammation, increased oxidative stress, endothelial dysfunction, and increased blood lipids all contribute to the constellation of metabolic alterations that are present in metabolic syndrome.
A male client is being evaluated for metabolic syndrome. Which are diagnostic criteria for this syndrome? Select all that apply.
Client's body mass index (BMI) is 31. Client's high-density lipoprotein (HDL) cholesterol is 25. Client's blood pressure (BP) is 150/90 mm Hg.
A client tells his health care provider that his body is changing. It used to be normal for his blood glucose to be higher during the latter part of the morning. However, now his fasting blood glucose level is elevated in the early AM (07:00). The health care provider recognizes the client may be experiencing:
Dawn phenomenon
A client with type 2 diabetes experiences unexplained elevations of fasting blood glucose in the early morning hours. Which conditions can account for this effect?
Dawn phenomenon
A 15-year-old child with type 1 diabetes asks nurse about the potential to "lose sight." Which response would be the most appropriate?
Explain that many people with diabetes experience some complications like retinopathy, but these are best prevented with tight control of glucose levels.
Which assessment finding of a client constitutes a criterion for a diagnosis of metabolic syndrome?
Has a high blood pressure that is consistently in the range of 140/90 mm Hg or greater
A man is brought into the emergency department by paramedics who state that the client passed out on the street. The man smells of alcohol, and when roused says he has not eaten since yesterday. He is wearing a medic alert bracelet that says he is a diabetic. What would the nurse suspect as a diagnosis?
Hypoglycemia
A client presents to the emergency room with fatigue, weakness, dehydration, and thirst. What additional symptoms would correlate with a diagnosis of type 1 diabetes mellitus? Select all that apply.
Recent weight loss Polyuria Blurred vision
The nurse knows that the client with which complication of diabetes has the greatest risk for the development of foot ulcers?
Sensory neuropathy
define hypoglycemia
any blood glucose concentration of less than 70 mg/dl, with or without symptoms
complications of diabetes
autonomic neuropathy -dizziness and syncope microangiopathy -cerebral infarcts -hemorrhage nephropathy -glomerulosclerosis -chronic kidney disease atherosclerosis -peripheral vascular disease -ischemic heart disease -myocardial infarct somatic neuropathy -abnormal sensory and motor function -foot ulcers genitourinary tract -bladder stasis and infection -erectile dysfunction (male) disorders of gastrointestinal motility -delayed gastric emptying -diarrhea -constipation eye -retinopathy -cataracts -glaucoma -hypertension -gangrene -infections
autonomic nervous system response
initial parasympathetic response is followed by the sympathetic nervous system response.
predominant characteristic of type II diabetes
insulin resistance
Which pregnant woman likely faces the greatest risk of developing gestational diabetes? A client who:
is morbidly obese (defined as greater than 100 pounds over ideal weight).
adipose tissue is broken down into fatty acids and glycerol
keto acidosis
