Diabetes: Unit 2 Adult Health
what are signs and symptoms of DKA?
-Dehydration (poor skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension-LATE SIGNS) -lethargy and weakness (early symptoms) -Abdominal pain may be present and accompanied by anorexia, nausea, and vomiting. -Kussmaul respirations (rapid, deep breathing associated with dyspnea) -Acetone is noted on the breath as a sweet, fruity odor -confusion
what is duration?
how long the insulin lasts/works
what is DM caused by?
-genetics -autoimmune -environmental factors (a virus) -----can be one and/or a combination
what can DKA cause?
-dehydration -ketosis -metabolic acidosis -hyperglycemia
what is treatment for hypoglycemia (not acute care)?
*******Rule of 15 -15 g simple carbohydrate; soft drink, syrup, honey ****We don't want to give them milk, cookies, sugar, chocolate (these are complex carbohydrates) -Check blood glucose 15 min later -If less than 70, repeat 15 g simple carbohydrate -Check blood glucose 15 min later -If no improvement after 2-3 times, contact HCP -When more than 70, ingest complex carbohydrate and give them a meal
how do we diagnose prediabetes? what will there levels be?
-2 hour OGTT (levels are 140-199) -checking their fasting BG (levels are 100-125)
what is treatment for acute care of hypoglycemia?
-20-50 mL of 50% dextrose IVP -1 mg glucagon IM
what are a-Glucosidase inhibitors? what are side effects and education? what is its action?
-Acarbose (precose), Miglital (glyset) -Side effects: gas (flatulence), abdominal pain, diarrhea -Education: Take with first bite of meal and Check 2 hour postprandial glucose (teach them how to check it) -action: Scratch blockers: work by slowing down the production of carbohydrates in the small intestine
what is bolus insulin? what are the different types?
-mealtime insulin; the insulin given with meals -rapid acting insulin and short acting insulins
what labs do we monitor for HHS?
-BG greater than 600 -Increase in serum osmolality -Ketones absent or minimal in the blood and urine
what sites can we administer insulin at?
-Backs of the arm, buttocks, stomach/abdomen, thighs -Fasted absorption is going to be the abdomen and then the arm -must rotate the site 1 to ½ inch
What would the labs look like with DKA?
-Blood glucose level greater than 250 -Arterial blood pH less than 7.3 (acidotic) -Serum bicarb levels are less than 16 -Moderate to large ketones in urine or serum -Changes in electrolytes
what is the nurse's role for a patient who has DKA?
-Fluid and electrolyte replacement -----0.45% or 0.9 % NaCl; normal saline (large gage IV) Monitor fluid overload; crackles in the lungs -----When BG= 250, add 5% to 10% dextrose to the fluids we are already giving them because we don't want to drop the sugar too quickly- we want to do it slowly, That can result in cerebral edema -----Replace K, Cl, Na, Mg, as needed, Going to see an elevated BUN and creatinine levels also -IV insulin (regular) -----0.1 units/kg/hr -----Monitor BG frequently; every hour and titrating the insulin -----Monitor K
what is treatment for HHS? what are we most concerned with fixing?
-Fluid resuscitation (0.9% or 0.45% NS); slowly! Monitor for fluid overload, When glucose is 250 or less add dextrose in the IV -Monitor and replace electrolytes; we are still concerned about K levels, but the levels are not as low as DKA -Check I and Os (they are severely dehydrated) -IV insulin ******CORRECT UNDERLYING CAUSE- usually the infection/illness
what are long-acting insulins? do they have a peak?
-Glargine (Lantus), detemir (Levemir), degludec (Tresiba) -No peak with this medication; they have a decreased risk of the hypoglycemic event
how do we diagnose diabetes? (both types)
-HbA1C 6.5% or higher -Fasting uGlucose (FPG) ≥ 126mg/dL (greater than) -2 hour plasma glucose level ≥ 200mg/dL (greater than) -------During an OGTT, using glucose load of 75g -Random plasma glucose ≥ 200mg/dL in a patient with classic symptoms of hyperglycemia
what is Blood sugar mnemonic:
-Hot and dry= sugar high (when sugar is high you usually are dehydrated) -Cold and clammy= need some candy
What is the dawn phenomenon? what causes it and how is it treated? what kind of patients usually have this?
-Hyperglycemia on awakening -Caused by release of growth hormone and cortisol level; counterregulatory hormones -Often adolescent patients or young adults -Treated with an increase in insulin or adjustment in administering time; Need more insulin at night or giving it at night
What is the Somogyi effect? what causes it and how is it treated? what are some symptoms that can occur?
-Hypoglycemia at night; Blood sugar dips too low and the body's natural response is to release cortisol and GH causing hyperglycemia in the morning -Rebound hyperglycemia in the morning -caused by missed meals or excess insulin -symptoms: Headaches, night sweats, nightmares -Treatment is to check blood glucose levels between 2-4 am, have a bedtime snack, and decrease insulin at night
what causes DKA to occur?
-Illness and infection (pneumonia or UTI-most common cause) -Inadequate insulin dosing -Undiagnosed type 1 diabetes -Poor self management -Lack of education, understanding, or resources (type 2 diabetes) -Neglect (parent is neglecting their child) -Alcohol or drug abuse (especially cocaine) -Corticosteroid or some diuretics can cause this as well
what are the 4 metabolic conditions of type 2?
-Insulin resistance; doesn't allow the insulin to attach to it -Decreased ability to produce insulin; because the beta cells are tired (they have a bad diet/doesn't exercise) -Inappropriate glucose production by the liver -Altered production of hormones and cytokines by adipose tissue; can cause chronic inflammation of the insulin receptors causing the insulin to not be able to attach to them
what is type 1 diabetes?
-Juvenile onset diabetes/ insulin dependent -Autoimmune disorder: the body producing antibodies against insulin and/or the pancreatic beta cells that produce insulin. The body is attacking itself -Pancreas not producing insulin
What are the rapid acting insulins? When do we give them?
-Lispro (Humalog), aspart (NovoLog), and glulisine (Apidra) -We give this within 15 minutes of a meal either before or after -these are bolus insulins
what is sensory neuropathy? what is treatment for it?
-Loss of sensation, or a tingling sensation/painful sensation in the hands and feet bilaterally -Treatment: managing the BG, meds to treat the symptoms (gabapentin)
what are intermediate acting insulins? what must you do before you give them?
-NPH (Humulin N, Novolin N) -Have to roll it to get the protamine at the bottom of the bottle
what are clinical manifestations of type 2 diabetes?
-Nonspecific -Fatigue, recurrent infections -Prolonged wound healing, visual changes
what are normal, prediabetes, and diabetes values of HbA1C?
-Normal: less than 5.7 % -Prediabetes: 5.7%-6.4% -Diabetes: 6.5% or higher
what are some risk factors of macrovascular disease? what test do we do annually to catch these diseases early?
-Obesity, smoking, hypertension, high fat intake diet, sedentary lifestyle, and poor BP control (we want them to be less than 140/90) -cardiac stress test
what are risk factors of type 2 diabetes?
-Overweight (obesity) -Being older (greater than 40) -family history -Ethnicity (african americans, asian americans, hispanics, native hawaiians and native americans are all at an increased risk) -Metabolic syndrome
S/S of type 1 diabetes:
-Polyuria -Polydipsia -Polyphagia -fatigue -weight loss -increased frequency of infections -ketoacidosis
what are the short acting insulins? when do we give them?
-Regular (Humulin R, Novolin R) -We give 30-40 minutes before a meal; this is why patients don't prefer this
why does dehydration occur for a pt with DKA? what else can happen as a result of not having enough electrolytes?
-the kidneys are trying to excrete the ketones which causes all the other electrolytes/water to follow -------These patients are peeing alot -Cardiac dysrhythmias can happen when there is not enough K and insulin can cause K to be even lower
What do beta blockers do for a diabetic patient?
-blocks the release of epinephrine -masks the signs of hypoglycemia
what is endogenous and exogenous insulin?
-endogenous is the insulin produced by our body and -exogenous is the insulin that is given to us through a shot
What are underlying causes of HHS?
-infection (pneumonia, sepsis, UTI) -illness
what is basal insulin? what are the different types?
-insulin that maintains the homeostasis of the body's glucose levels; only given once a day or twice (morning/night) -long-acting and intermediate acting
what is an insulin pump?
-it's SQ and goes into the belly to stim them -Uses rapid-acting insulin -They must check their glucometers at least 4 times a day and must change the site every 2-4 days -There is an increased risk for infection, Puts the patient at a risk for complications
What is LOPS?
-loss of protective sensation that often prevents the pt from being aware that a foot injury has occurred
what are biguanides? what are the side effects of this med? what are some education points? what it's action?
-metformin -side effects are diarrhea, weight loss, metallic taste -education: do not use with contrast dye the patient must stop taking metformin 48 hours prior to a procedure and will start it back up again 48 hours after the procedure (like a CT). Always check their BUN and Cr levels before the dye is given or when taking metformin (if it's elevated, they will not give that contrast dye) -action: Reduce glucose production and Enhances insulin sensitivity through the cells
what med is the first line of defense for type 2 diabetes?
-metformin (biguanides)
what causes hypoglycemia?
-mismatch of peak of insulin medication and food intake -a diabetic who hasn't eaten or has just exercised
what is type 2 diabetes?
-the most common type -The body is producing some insulin but the body is not using it effectively or not producing enough
what is the only insulin we can give through IV?
-regular insulins (humulin R, and novolin R)
What can hypoglycemia lead to? what can it mimic?
-we can have some neurological symptoms such as difficulty speaking, slurred speech, visual disturbances, confusion, seizures, LOC, and can lead to a coma. -Can mimic alcohol intoxication
who is at most risk for DKA
type 1 diabetic patients
how long are prefilled syringes good for?
2 insulins mixed together; 1 week 1 insulin; 30 days
What is the onset, peak, and duration of long-acting insulin?
onset: 0.8-4 hours peak: no pronounced peak duration: 16-24 hours
Vials and pens currently in use are good for how long?
4 weeks at room temp
what is the normal blood glucose range?
70-110 mg/dL
what is the onset, peak, and duration of intermediate acting insulin?
onset: 1.5-4 hours peak: 4-12 hours duration: 12-18 hours
What is the onset, peak, and duration of rapid acting insulin?
onset: 10-30 min peak: 30 min- 3 hours duration: 3-5 hours
What is the onset, peak, and duration of short acting insulin?
onset: 30 min-1 hour peak: 2-5 hours duration: 5-8 hours
Hypoglycemia is what? what is happening in the body? what hormones does the body release?
Blood glucose below 70 -there is too much insulin in the blood and not enough glucose -Our body releases glucagon and epinephrine to try and compensate for the body not having enough glucose
Acute complications of diabetes
DKA, HHS, hypoglycemia
what are type 1 diabetes patients dependent on?
Dependent on exogenous insulin (will always have to take insulin shots) -They take the insulin shot to replicate the normal pathophysiology
What are some psychological complications of diabetes?
Depression, anxiety, and eating disorders
What is diabetic ketoacidosis? (DKA)
profound deficiency of insulin (hyperglycemia; 250 or higher)
What are sulfonylureas? what are side effects and educational points? what it's action?
Glipizide (glucotrol, glucotrol XL) Glyburide (diaBeta, Glynase) Glimepiride (amaryl) -side effects: hypoglycemia -education: never skip a meal, it can lead to hypoglycemia -action: Increase insulin production by the beta cells of the pancreas- These patients have to have SOME beta cell function on their own
what is prediabetes? what is impaired? they have an increased risk at developing what?
Glucose levels are high but not high enough to be diagnosed with diabetes yet, they are often asymptomatic -impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) -increased risk at developing type 2 DM
a patient who has DKA is usually where in the hospital?
ICU -this condition is very life-threatening and can lead to death
what is ketosis? what does it cause for DKA pts?
Increased fatty acid broken down resulting in an abnormal increase in ketone bodies in the blood -this causes DKA patients to have ketourina (ketones in the urine)
What is HbA1C? how long is the test? the higher the %.....
Is a measurement of what your average blood glucose -is over 2-3 months (the average life cycle of RBC) -The higher the percentage the less controlled your diabetes
what can happen if we use one site of the body too much to administer insulin?
Lipodystrophy: when the tissues atrophy/waste away or when the tissues thicken
what are Thiazolidinediones (TZDs)? what are side effects? whats it's action?
Pioglitazone (Actos), Rosiglitazone (Avendia) -Action: Insulin sensitizers, Most successful with patient who have insulin deficiency, Makes your body produce more fat cells -Side effects: Rarely used because of the adverse effects: cardiovascular events (MI, Strokes), can worsening heart disease, and is associated with bladder cancer
what are Meglitinides? what are side effects and education? what is it's action?
Repaglinide (prandin), nateglinide (starlix) -Very similar to sulfonylureas but hypoglycemia less likely- this med is more rapidly absorbed -Education: take within 30 min of a meal, Do not take if meal is skipped -action: Increase insulin production by pancreas
How do we administer insulin? what is the exception?
SQ: 90 angle and pinch the fat up -45 degrees in a thin patient
What is Hyperosmolar hyperglycemia syndrome (HHS)? does ketoacidosis occur? What are their BG levels? who is this more common in?
Severe hyperglycemia, osmotic diuresis, and dehydration -ketoacidosis does not occur -When they are presented to us their BG is usually greater than 600 -more common in type 2, older than 60 patients
what are DDP-4 Inhibitors? what is their action and side effects?
Sitagliptin (Januvia), Saxagliptin (Onaglyza), Linagliptin (Tradjenta), alogliptin (nesina) -Action: block action of DDP-enzyme, protects incretins -side effects: pancreatitis
what is dermopathy?
Skin lesions characterized by red/dark brown patches on the legs
Vials and pens unopened need to be stored where? what is some patient education you must tell the patient?
Store in refrigerator -always educate the pt to roll the syringe in their hand before use to warm the insulin a bit
What are the symptoms of hypoglycemia?
TIRED -tachycardia -Irritability -restlessness -excessive hunger -diaphoresis/depression
In DM is the blood glucose too high or too low?
This causes the blood glucose to be TOO HIGH: there is not enough insulin to attach to the insulin receptors on the cells causing too much glucose in the blood
what is autonomic neuropathy? what does it lead to?
affects all body systems and lead to hypoglycemic unawareness, bowel incontinence, diarrhea, and urinary retention
when the blood glucose increases in the body what happens? (think after you eat in a normal body)
after you eat your blood glucose will increase causing the release of insulin from the pancreas.
what are the two types of insulin?
basal and bolus
why are diabetics at more risk for chronic infections?
because there is a change in the blood filtering, the WBCs can't get to the infection quick enough to fight it off
What are the macrovascular complications of diabetes? what vessels do they affect?
cardiovascular disease, PVD, cerebrovascular (stroke) -large and medium blood vessels
when mixing insulins what must it look like?
clear before cloudy -we must mix regular insulin before intermediate insulin
What is diabetic retinopathy? what are screening for type 1 and type 2? what instrument is used? how do we treat it?
damage to the blood vessels in the retina -Type 2: eye exam on diagnosis and annually -Type 1: eye exam within 5 years of diagnosis and annually -funduscopic is used to dilate the eyes -Iluvien: an eye injection of corticosteroid to treat this
what is diabetic nephropathy? what are screenings? how do we treat it? what will lab values look like for this?
damage to the glomeruli of the kidneys -Screening: monitor random urine collection annually to look at albumin and serum Cr ****They will have high BUN and Cr and low GFR -treatment: ACE inhibitors (prils), angiotensin II receptors antagonists (sartans)
What is diabetic neuropathy?
damage to the nerves that leads to the loss of sensation -there are two types on another flashcard
what are the two insulins we can NEVER mix with other insulins or solutions?
detemir (levemir) and glargine (lantus)
What is diabetes mellitus?
disorder of glucose metabolism due to absence of insulin/insufficient supply of insulin, or poor utilization of insulin
What kind of cells can the insulin attach to?
fat cells, RBCs, and muscle cells
Insulin is the key for what?
for blood glucose to move into the cells via the insulin receptors on the cell to lower our blood glucose
what is metabolic syndrome?
if the patient has ⅗ of these, they have an increased risk of developing type 2 diabetes -Elevated glucose levels -Abdominal obesity -Elevated BP -High levels of triglycerides -Decreased levels of HDL's
where is glucagon produced? Does it increase or decrease blood glucose?
in the alpha cells of the pancreas -it increases the blood glucose
where is insulin produced? Does it increase or decrease blood glucose?
in the beta cells of the pancreas -it decreases blood glucose
what is onset?
is when the insulin starts working
What is the monofilament test?
it is a small flexible wire device attached to a handle. it is used to test for sensation on lower extremities (its a feather) -we also use a tuning fork
we see type 1 diabetes more in who?
kids/adolescents -usually ages 10-15
What are the chronic complications of diabetes?
microvascular and macrovascular disease
Normal ABG values
pH: 7.35-7.45 PCO2: 45-35 HCO3: 22-28
the brain requires what to function?
requires glucose
why do we always want to educate the patient after having a hypoglycemia episode? who can educate the pt?
so they don't happen again -we want to find out what caused this hypoglycemic event -the RN can only educate the pt, the LPN can redirate the teachings
What is charcot foot? what can it lead to?
their is such severe neuropathy, that the bones in the ankle and foot weaken/fracture -This can lead to pressure ulcers
How is blood glucose controlled?
through homeostasis of glucagon and insulin -when insulin senses that the blood glucose is too high, it is released to decrease it -when glucagon senses that the blood glucose is too low, it is released to increase it
What is the difference between type 1 and type 2 diabetes related to the onset and dependence?
type 1 has a rapid onset while type 2 has a delayed onset -type 1 is also dependent on insulin, type 2 doesn't always have to be
what is peak?
when the insulin is exerting maximum action -they have a risk for hypoglycemic event at this stage
What is hypoglycemic unawareness? when does this happen?
where a person does not experience the warning signs and symptoms of hypoglycemia -this happens when a diabetic patient is on beta blockers for their BP because they mask the symptoms of hypoglycemia