Final Exam Part 2 (Diabetes)

DKA Prevention For prevention of DKA related to illness, ______ for managing diabetes when ill should be reviewed with patients.

"sick day rules"

Mixing Insulins The 2 most important issues of mixing insulin are

(1) that patients are consistent in technique, so as not to draw up the wrong dose in error or the wrong type of insulin, (2) that patients not inject one type of insulin into the bottle containing a different type of insulin.

Selecting and Rotating the Injection Site In addition, to promote consistency in insulin absorption, the patient should be encouraged to use all available injection sites within one area rather than randomly rotating sites from area to area. For example, some patients almost exclusively use the abdominal area, administering each injection ______ to _____ away from the previous injection.

0.5 to 1 inches

DKA Management Rehydration Initially, _______ is given at a rapid rate, usually 0.5 to 1 L per hour for 2 to 3 hours. ________ may be used for patients with hypertension or hypernatremia and those at risk for heart failure. After the first few hours, _______ is the fluid of choice for continued rehydration, provided the blood pressure is stable and the sodium level is not low. When the blood glucose level reaches 300 mg/dL or less, the IV solution may be changed to ______ to prevent a precipitous decline in the blood glucose level

0.9% sodium chloride solution Half-strength NS solution Half-strength NS solution dextrose 5% in water (D5W)

Complications with Hyperglycemia: DKA Most common in Type ______ Onset is _____ Glucose levels great than _____ to _____ Metabolic _______ Positive _____ ______ breathing ______ breath

1 rapid 250 to 300 Acidosis ketones Kussmaul Fruity

Normal glucose level ____ to _____ mg/dl, 2 labs to observe in diabetes are _____ and ______; they could indicate risk factors

70 to 110 LDL cholesterol

Gestational Diabetes Initial management of gestational diabetes includes dietary modification and blood glucose monitoring. If hyperglycemia persists, insulin is prescribed. Goals for blood glucose levels during pregnancy are ______ before meals and _______ 2 hours after meals

95 mg/dL or less before meals 120 mg/dL or less 2 hours after meals

Inserting the Needle _______ inserting the needle and then pulling back on the plunger to assess for blood being drawn into the syringe and needle in vein is not necessary. Many patients who have been using insulin for an extended period have eliminated this step from their insulin injection routine with no apparent adverse effects.

Aspiration

Type 1 Diabetes ________ is a metabolic derangement that occurs most commonly in persons with type 1 diabetes and results from a deficiency of insulin; highly acidic ketone bodies are formed, and metabolic acidosis occurs.

Diabetic ketoacidosis (DKA)

List 2 Hyperglycemia Complications

Diabetic ketoacidosis (DKA) Hyperglycemic Hyperosmolar nonketotic syndrome (HHS)

DKA can lead to _______

Hyperglycemia

The 3 main clinical features of DKA are as follows:

Hyperglycemia Dehydration and electrolyte loss Acidosis

Methods of Insulin Delivery There is the potential for infection at needle insertion sites from use of insulin pumps. ______ may occur with insulin pump therapy; however, this is usually related to the lowered blood glucose levels that many patients achieve rather than to a specific problem with the pump itself.

Hypoglycemia

_______ It can occur when there is too much insulin or oral hypoglycemic agents, too little food, or excessive physical activity. ______ may occur at any time of the day or night. It often occurs before meals, especially if meals are delayed or snacks are omitted.

Hypoglycemia Hypoglycemia

Criteria for Determining Effectiveness of Self-Injection of Insulin Education 3 Syringes checks

Identifies concentration (U-100) marking on syringe Identifies size of syringe Describes appropriate disposal of used syringe

______ are by-products of fat breakdown, and they accumulate in the blood and urine. _______ in the urine signal that there is a deficiency of insulin and control of type 1 diabetes is deteriorating. When there is almost no effective insulin available, the body starts to break down stored fat for energy

Ketones Ketones

DKA Clinical Manifestations These _______ represent the body's attempt to decrease the acidosis, counteracting the effect of the ketone buildup. In addition, mental status in DKA varies widely. The patient may be alert, lethargic, or comatose.

Kussmaul respirations

Clinical manifestation of ______ shares the features of types 1 and 2 diabetes. The emergence of this subtype has led some to propose the diabetes classification scheme should be revised to reflect changes in the beta cells in the pancreas

Latent Autoimmune Diabetes of Adults (LADA)

In adults, ______ is a subtype of diabetes in which the progression of autoimmune beta cell destruction in the pancreas is slower than in types 1 and 2 diabetes. Patients with ______ are not insulin-dependent in the initial 6 months of disease onset.

Latent Autoimmune Diabetes of Adults (LADA) Latent Autoimmune Diabetes of Adults (LADA)

Mixing Insulins combination is available as ______ 70/30 (Novo Nordisk) and ______ 70/30

Novolin Humulin

Diabetes Clinical Manifestations _______ and _______ occur as a result of the excess loss of fluid associated with osmotic diuresis. Patients also experience ______ that results from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats

Polyuria polydipsia polyphagia

_______ increased urination _______ increased thirst _______ increased appetite

Polyuria polydipsia polyphagia

______ refers to a condition in which blood glucose concentrations fall between normal levels and those considered diagnostic for diabetes

Prediabetes

Microvascular Complications ______ retinopathy represents the greatest threat to vision and is characterized by the proliferation of new blood vessels growing from the retina into the vitreous. These new vessels are prone to bleeding. The visual loss associated with proliferative retinopathy is caused by this vitreous hemorrhage, retinal detachment, or both.

Proliferative

________ Treatment: Decrease evening (predinner or bedtime) dose of intermediate-acting insulin, or increase bedtime snack.

Somogyi Effect

_________ Normal or elevated blood glucose at bedtime, a decrease at 2-3 am to hypoglycemic levels, and a subsequent increase caused by the production of counter-regulatory hormones

Somogyi Effect

Morning Hyperglycemia _______ nocturnal hypoglycemia followed by rebound hyperglycemia

Somogyi effect

Preparations of Insulin ______ acting insulins produce a more rapid effect that is of shorter duration than regular insulin. Because of their rapid onset, the patient should be instructed to eat no more than _____ to ______ minutes after injection.

Rapid 5 to 15

DKA Management Reversing Acidosis ______ insulin, the only type of insulin approved for IV use, may be added to IV solutions. The nurse must convert hourly rates of insulin infusion (frequently prescribed as units per hour) to IV drip rates. Insulin must be infused continuously until subcutaneous administration of insulin can be resumed. Any interruption in administration may result in the reaccumulation of ketone bodies and worsening acidosis.

Regular

Ocular Complications of Diabetes _______ Damage to the small blood vessels that nourish the retina.

Retinopathy (diabetic retinopathy)

Sexual Dysfunction Erectile dysfunction occurs with greater frequency in men with diabetes than in other men of the same age. Some men with autonomic neuropathy have normal erectile function and can experience orgasm but do not ejaculate normally. ______ ejaculation occurs; seminal fluid is propelled backward through the posterior urethra and into the urinary bladder. Examination of the urine confirms the diagnosis because of the large number of active sperm present.

Retrograde

Hyperglycemic Hyperosmolar Syndrome Management Frequent ______ is important in prevention of recurrence of HHS. Fluid treatment is started with 0.9% or 0.45% NS, depending on the patient's sodium level and the severity of volume depletion. Central venous or hemodynamic pressure monitoring guides fluid replacement. Potassium is added to IV fluids when urinary output is adequate and is guided by continuous ECG monitoring and frequent laboratory determinations of potassium

SBGM

Criteria for Determining Effectiveness of Self-Injection of Insulin Education Identify 4 types of information on label of insulin bottle:

Type (e.g., NPH, regular, 70/30) Manufacturer (Lilly, Novo Nordisk) Concentration (e.g., U-100) Expiration date

Selecting Syringes The concentration of insulin used in the United States is ______; that is, there are 100 units per milliliter. Small syringes allow patients who require small amounts of insulin to measure and draw up the amount of insulin accurately. There is a ______ 500 units/mL concentration of insulin available by special order for patients who have severe insulin resistance and require massive doses of insulin.

U-100 U-500

Nephropathy Clinical Manifestations Most of the signs and symptoms of kidney dysfunction in patients with diabetes are similar to those seen in patients without diabetes In addition, as kidney failure progresses, the catabolism (breakdown) of both exogenous and endogenous insulin _______, and frequent hypoglycemic episodes may result. Insulin needs change as a result of changes in the catabolism of insulin, changes in diet related to the treatment of nephropathy, and changes in insulin clearance that occur with decreased kidney function.

decreases

DKA Management Rehydration In addition to treating hyperglycemia, management of DKA is aimed at correcting ______, _______, and ______ before correcting the ______ with insulin.

dehydration, electrolyte loss, acidosis hyperglycemia

Self-Monitoring of Blood Glucose self-monitoring of blood glucose (SMBG) is also recommended for patients with the following 3 conditions. Unstable ______. A tendency to develop severe ______ or _____. ______ without warning symptom

diabetes. ketosis or hypoglycemia. Hypoglycemia

Hypoglycemia Management Injectable glucagon is packaged as a powder in 1-mg vials and must be mixed with a _____ immediately before being injected. After injection of glucagon, the patient may take as long as ______ minutes to regain consciousness. A concentrated source of ______ followed by a _____ should be given to the patient on awakening to prevent recurrence of hypoglycemia

diluent 20 carbohydrate snack

It is important to check the patient's blood glucose level and correlate it with the patient's symptoms. If the patient's blood glucose level is low, but he or she is not exhibiting any symptoms, the nurse should ______ the glucose level to ensure that it is correct.

double-check

Systemic Allergic Reactions Systemic allergic reactions to insulin are rare. When they do occur, there is an immediate local skin reaction that gradually spreads into generalized urticaria (hives). These rare reactions are occasionally associated with generalized ______ or ______ The treatment is _______, with small doses of insulin given in gradually increasing amounts using a ________ kit.

edema or anaphylaxis desensitization desensitization

Hypoglycemia Clinical Manifestations In mild hypoglycemia, as the blood glucose level falls, the sympathetic nervous system is stimulated, resulting in a surge of ________ and _______.

epinephrine norepinephrine

Sexual Dysfunction Sexual dysfunction, especially _____ dysfunction in men, is a complication of diabetes. The effects of autonomic neuropathy on female sexual functioning are not well documented. Reduced vaginal lubrication has been mentioned as a possible neuropathic effect. Other possible changes in sexual function in women with diabetes include decreased libido and lack of orgasm.

erectile

Exercise Recommendations For patients who are older than 30 years and who have two or more risk factors for heart disease, an _______ test is recommended prior to starting an exercise program

exercise stress test

Caloric Distribution Increased ______ in the diet may improve blood glucose levels, decrease the need for exogenous insulin, and lower total cholesterol and low-density lipoprotein levels in the blood

fiber

Diabetic Retinopathy Clinical Manifestations Even patients with a significant degree of proliferative retinopathy and some hemorrhaging may not experience major visual changes. However, symptoms indicative of hemorrhaging include _______ or ______ in the visual field, sudden visual changes including _____ or ______ vision, or complete _____ of vision.

floaters or cobwebs spotty or hazy loss

Storing Insulin Bottles of intermediate-acting insulin should also be inspected for ______, which is a frosted, whitish coating inside the bottle. ______ occurs most commonly with insulins that are exposed to extremes of temperature. If a frosted, adherent coating is present, some of the insulin is bound, inactive, and should not be used.

flocculation flocculation

Hyperglycemic Hyperosmolar Syndrome Management The overall approach to the treatment of HHS is similar to that of DKA: _______, ________, and ________

fluid replacement, correction of electrolyte imbalances, and insulin administration.

Initially, the liver produces glucose through the breakdown of _________. After 8 to 12 hours without food, the liver forms glucose from the breakdown of noncarbohydrate substances, including amino acids

glycogen

Testing for Ketones Urine ketone testing should be performed whenever patients with type 1 diabetes have one of the 5 conditions ______uria persistently elevated blood ______ levels during ______, in ______ with preexisting diabetes, and in ______ diabetes

glycosuria glucose illness, pregnancy gestational

General Considerations for Exercise in People With Diabetes Avoid exercise in extreme ______ or ______ Avoid exercise during periods of poor metabolic control. _______ for 10 to 15 minutes before exercising.

heat or cold. Stretch

Hypoglycemia Management It is not necessary to add sugar to juice, even if it is labeled as unsweetened juice, because the fruit sugar in juice contains enough carbohydrate to raise the blood glucose level. Adding table sugar to juice may cause a sharp increase in the blood glucose level, and patients may experience ______ for hours after treatment.

hyperglycemia

Type 1 Diabetes The three major metabolic derangements in DKA are _______, _______, and _______

hyperglycemia, ketosis, metabolic acidosis.

________ elevated blood glucose level ________ low blood glucose level

hyperglycemia: hypoglycemia:

________ a metabolic disorder of type 2 diabetes resulting from a relative insulin deficiency initiated by an illness that raises the demand for insulin

hyperglycemic hyperosmolar syndrome (HHS):

Diabetic Retinopathy Medical Management Other strategies that may slow the progression of diabetic retinopathy include control of ______, control of blood ______, and cessation of ______.

hypertension glucose smoking

nephropathy Management Control of _____, because it may decrease or delay the onset of early proteinuria Prevention or vigorous treatment of urinary tract infections Avoidance of nephrotoxic medications and contrast dye Adjustment of medications as kidney function changes Low ______ diet and Low ______ diet

hypertension sodium protein

Macrovascular Management In addition, the use of medications to control ______ and _______ is indicated. _______ cessation is essential. Control of blood glucose levels may reduce triglyceride concentrations and can significantly reduce the incidence of complications

hypertension and hyperlipidemia Smoking

Diabetes Medical Management The therapeutic goal for diabetes management is to achieve normal blood glucose levels (euglycemia) without ______ while maintaining a high quality of life.

hypoglycemia

Food Classification Systems In general, the same precautions regarding the use of alcohol by people without diabetes should be applied to patients with diabetes. Moderation is recommended. A major danger of alcohol consumption by the patient with diabetes is _______, especially for patients who take insulin

hypoglycemia

Intensive Regimen While intensive treatment (3 or 4 injections of insulin per day) reduces the risk of complications, not all people with diabetes are candidates for very tight control of blood glucose. The risk of severe ______ increases threefold in patients receiving intensive treatment Patients who have received a kidney transplant because of nephropathy and chronic kidney failure should follow an intensive (complex) insulin regimen to preserve function of the new kidney.

hypoglycemia

Methods of Insulin Delivery The tight diabetes control associated with the use of an insulin pump may increase the incidence of _____ unawareness because of the very gradual decline in serum glucose level, from more than 70 mg/dL to less than 60 mg/dL

hypoglycemia

prevention of hypoglycemia: Educates family, friends, and coworkers about signs and treatment of _______ Has family, roommates, and traveling companions learn to use injectable ______

hypoglycemia glucagon

Exercise Precautions Patients taking insulin and participating in extended periods of exercise should test their blood glucose levels before, during, and after the exercise period, and they should snack on carbohydrates as needed to maintain blood glucose levels. Other participants or observers should be aware that the person exercising has diabetes, and they should know what assistance to give if severe ______ occurs. Patients with ______ diabetes who are not taking insulin or an oral agent may not need extra food before exercise.

hypoglycemia type 2

Caloric Distribution One risk involved in suddenly increasing fiber intake is that it may require adjusting the dosage of insulin or oral agents to prevent ________. Other problems may include abdominal fullness, nausea, diarrhea, increased flatulence, and constipation if fluid intake is inadequate. If fiber is added to or increased in the meal plan, it should be done gradually and in consultation with a dietitian. _______ serve as an excellent guide for increasing fiber intake.

hypoglycemia Exchange lists

Self-Monitoring of Blood Glucose Using SMBG and learning how to respond to the results enable people with diabetes to individualize their treatment regimen to obtain optimal blood glucose control. This allows for detection and prevention of ______ and ______ and plays a crucial role in normalizing blood glucose levels, which in turn may reduce the risk of long-term diabetic complications.

hypoglycemia and hyperglycemia

Type 2 Diabetes The two main problems related to insulin in type 2 diabetes are _______ and impaired _______.

insulin resistance insulin secretion

Morning Hyperglycemia _______ the progressive increase in blood glucose from bedtime to morning ________ is frequently seen if the evening NPH dose is given before dinner; it is prevented by moving the evening dose of NPH insulin to bedtime.

insulin waning insulin waning

Meal Planning and Related Education For patients who can master the _______ calculations, lifestyle can be more flexible and diabetes control more predictable. For those using intensive insulin therapy, there may be greater flexibility in the timing and content of meals by allowing adjustments in insulin dosage for changes in eating and exercise habits.

insulin-to-carbohydrate

_______ a hormone secreted by the beta cells of the islets of Langerhans of the pancreas that is necessary for the metabolism of carbohydrates, proteins, and fats; a deficiency of ______ results in diabetes ______ is a hormone your pancreas makes to lower blood glucose, or sugar.

insulin: insulin Insulin

Methods of Insulin Delivery As an alternative to needle injections, ______ devices deliver insulin through the skin under pressure in an extremely fine stream. These devices are more expensive and require thorough training and supervision when first used.

jet injection

Patients who feel unduly restricted by their meal plan may view hypoglycemic episodes as a time to reward themselves with desserts. Instructing these patients to incorporate occasional desserts into the ______ may be more effective, because this may make it easier for them to limit their treatment of hypoglycemic episodes to simple low-calorie carbohydrates such as juice or glucose tablets.

meal plan

prevention of hypoglycemia: Avoids delays in _______ Eats a meal or snack approximately every _____ to ____ hours (while awake) Does not ______ meals Increases food intake before exercise if blood glucose level is less than ______ mg/dL

meal timing 4 to 5 skip 100

Diabetes Medical Management ________ therapy prescribed for management of diabetes usually given by a registered dietician

medical nutrition therapy (MNT)

Type 2 Diabetes Insulin resistance may also lead to ______, which is a constellation of symptoms, including hypertension, hypercholesterolemia, abdominal obesity, and other abnormities

metabolic syndrome

Nephropathy Monitor for _____, ______, and _______

microalpbiminuria, serum creatinine and BUN.

Microvascular Complications Diabetic _______ disease is characterized by capillary basement membrane thickening. The basement membrane surrounds the endothelial cells of the capillary.

microvascular

The _____ test is used to assess the sensory threshold in patients with diabetes. The test instrument is gently applied to about five pressure points on the foot

monofilament

Hypoglycemia Management Some patients experience ______ after the administration of glucagon. If this occurs, the patient should be ______ to prevent aspiration in case the patient vomits.

nausea turned to the side

Foot Care: Visual inspection Put feet up when ______ and do not ______ legs for a long period of time Wear shoes Check water temperature with hands before putting feet inside

sitting cross

Type 1 Diabetes DKA is commonly preceded by a day or more of polyuria, polydipsia, nausea, vomiting, and fatigue with eventual ______ and ______ if not treated. DKA has a breath has a characteristic ______ odor due to the presence of _______.

stupor and coma fruity ketoacids

Inserting the Needle The correct technique is based on the need for the insulin to be injected into the ______ tissue For a normal or overweight person, a _____ degree angle is the best insertion angle.

subcutaneous 90

DKA Management Reversing Acidosis Even if blood glucose levels are decreasing and returning to normal, the insulin drip must not be stopped until _______ insulin therapy has been started. In general, bicarbonate infusion to correct severe acidosis is avoided during treatment of DKA because it precipitates further, sudden (and potentially fatal) decreases in serum potassium levels. _______ is usually sufficient for reversal of DKA

subcutaneous Continuous insulin infusion

4 Methods of insulin delivery include:

subcutaneous injections, insulin pens, jet injectors, insulin pumps.

The neuropathic condition called _______ refers to a decrease or absence of sweating (anhidrosis) of the extremities, with a compensatory increase in upper body sweating. Dryness of the feet increases the risk for the development of foot ulcers.

sudomotor neuropathy

Hypoglycemia means low _______ in the blood and occurs when the blood glucose falls to less than ______ mg/dL Severe hypoglycemia is when glucose levels are less the ______ mg/dL

sugar 70 40

Diabetes Medical Management Patients who are obese, have ______ diabetes, and require insulin or oral agents to control blood glucose levels may be able to reduce or eliminate the need for medication through weight loss. A weight loss as small as 5% to 10% of total weight may significantly improve blood glucose levels.

type 2

Insulin Therapy In addition, some patients in whom _______ diabetes is usually controlled by meal planning alone or by meal planning and an oral antidiabetic agent may require insulin temporarily during illness, infection, pregnancy, surgery, or some other stressful event

type 2

Meal Planning and Related Education The first step in preparing a meal plan is a thorough review of the patient's diet history to identify eating habits and lifestyle and cultural eating patterns. In most instances, people with ______ diabetes require weight reduction.

type 2

Gestational Diabetes After delivery, blood glucose levels in women with gestational diabetes usually return to normal. However, many women who have had gestational diabetes develop ______ later in life. Approximately 35% to 60% of women who have had gestational diabetes develop ______ in the next 10 to 20 years

type 2 diabetes diabetes

Foot Care Tips Put your feet ____ when sitting. Wiggle your toes and move your ankles up and down for 5 minutes, two or three times a day. Do not ______ your legs for long periods of time.

up cross

Withdrawing Insulin Most (if not all) of the printed materials available on insulin dose preparation instruct patients to inject air into the bottle of insulin equivalent to the number of units of insulin to be withdrawn. The rationale for this is to prevent the formation of a ______ inside the bottle, which would make it difficult to withdraw the proper amount of insulin.

vacuum

Diabetes Medical Management For patients who are obese and have diabetes, _______ loss is the key to treatment. In general, overweight is considered to be a BMI of 25 to 29; obesity is defined as 20% above ideal body weight or a BMI equal to or greater than ______

weight loss 30

Selecting Syringes Currently, 3 sizes of U-100 insulin syringes are available:

1-mL syringe, 100-unit capacity 0.5-mL syringe, 50-unit capacity 0.3-mL syringe, 30-unit capacity

Diabetes Nursing Management: Managing Glucose Control in the Hospital Setting Nursing management of hyperglycemia in the hospital uses the following 4 principles: 1. Blood glucose targets are _____ to _____ mg/dL. 2. ______ (subcutaneous or IV) is preferred to oral antidiabetic agents to manage hyperglycemia. 3. Hospital insulin protocols or order sets should minimize complexity, ensure adequate staff training, include standardized hypoglycemic treatment, and make guidelines available for glycemic goals and insulin dosing. 4. Appropriate timing of blood glucose checks, meal consumption, and insulin dose are all crucial for glucose control and to avoid hypoglycemia.

140 to 180 Insulin

Hypoglycemia Management Immediate treatment must be given when hypoglycemia occurs. The usual recommendation is for ______ grams of a fast-acting concentrated source of ______

15 g carbohydrate

Hypoglycemia Treatment Follow Agency protocol Carbs _____ Rule Unresponsive with an IV access _____ IV Unresponsive with no IV access _____

15-15 D50 Glucagon

Exercise Precautions The physiologic decrease in circulating insulin that normally occurs with exercise cannot occur in patients treated with insulin. Initially, patients who require insulin should be taught to eat a ______ carbohydrate snack (a fruit exchange) or a snack of complex carbohydrates with a protein before engaging in moderate exercise to prevent unexpected hypoglycemia.

15-g

Type 1 Diabetes If the concentration of glucose in the blood exceeds the renal threshold for glucose, usually ______ to ______, the kidneys may not reabsorb all of the filtered glucose; the glucose then appears in the urine (glycosuria).

180 to 200 mg/dL

Preparations of Insulin Because of the short duration of action of rapid-acting insulins, patients with type 1 diabetes and some patients with type 2 or gestational diabetes also require a long-acting insulin (basal insulin) to maintain glucose control. Basal insulin is necessary to maintain blood glucose levels irrespective of meals. A constant level of insulin is required at all times. Intermediate-acting insulins function as basal insulins but may have to be split into ______ injections to achieve 24-hour coverage.

2

Complications with Hyperglycemia: HHS Type ______ Disorder ______ onset-days to weeks Glucose levels greater than _____ No ______ Absent ______

2 slow 600 acidosis ketones

Selecting and Rotating the Injection Site A few general principles apply to all rotation patterns. First, the patient should try NOT to use the exact same site more than once in _____ to _____ weeks. In addition, if the patient is planning to exercise, insulin should not be injected into the limb that will be exercised because this will cause the drug to be absorbed faster, which may result in ______.

2 to 3 hypoglycemia

Mixing Insulins For patients who have difficulty mixing insulins, several options are available. They may use a premixed insulin, they may have prefilled syringes prepared, or they may take 2 injections. Premixed insulins are available in many different ratios of NPH insulin to regular insulin. The ratio of 70/30 (______% NPH and ______% regular insulin in one bottle) is most common

70 30

Criteria for the Diagnosis of Diabetes Symptoms of diabetes plus casual plasma glucose concentration equal to or greater than _______ mg/dL. Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss. Fasting plasma glucose greater than or equal to ______ mg/dL. Fasting is defined as no caloric intake for at least 8 hours. Two-hour postload glucose equal to or greater than ______ mg/dL during an oral glucose tolerance test. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water. A1C ≥ ______%

200 126 200 6.5

Criteria for diagnosis of diabetes Symptoms plus random glucose ≥ ______ FBS greater than or = to _______ A1c greater than or equal to _____

200 126 6.5

Diabetes Prevention The Diabetes Prevention Program Research Group reported that type 2 diabetes can be prevented with appropriate changes in lifestyle. Persons at high risk for type 2 diabetes BMI greater than ______, received standard lifestyle recommendations plus ______ an oral antidiabetic agent, standard lifestyle recommendations plus placebo, or an intensive program of lifestyle modifications.

24 metformin

Gestational Diabetes If these high-risk women do not have gestational diabetes at initial screening, they should be retested between ______ and ______ of gestation. All women of average risk should be tested at ______ and ______ of gestation. Testing is not specifically recommended for women identified as being at low risk. Low-risk women are those who meet all of the following criteria: age younger than 25 years, normal weight before pregnancy, member of an ethnic group with low prevalence of gestational diabetes, no history of abnormal glucose tolerance, no known history of diabetes in first-degree relatives, and no history of poor obstetric outcome

24 and 28 weeks 24 and 28 weeks

Hypoglycemia Management In hospitals and emergency departments, for patients who are unconscious or cannot swallow, _______ of ______ may be administered IV. The effect is usually seen within minutes. The patient may complain of a headache and of pain at the injection site. Ensuring ______ of the IV line used for injection of 50% dextrose is essential because hypertonic solutions such as 50% dextrose are very irritating to veins.

25 to 50 mL dextrose 50% in water (D50 IV) patency

Exercise Precautions Patients who have blood glucose levels exceeding ______ and who have _____ in their urine should not begin exercising until the urine test results are negative for _______ and the blood glucose level is closer to normal.

250 mg/dL ketones ketones

Selecting Syringes Most insulin syringes have a disposable _____ to _____ gauge needle that is approximately _____ in long. The smaller syringes are marked in _____ unit increments and may be easier to use for patients with visual deficits and those taking very small doses of insulin. The 1-mL syringes are marked in _____ and _____ unit increments.

27 to 29 0.5 1 1 and 2

Methods of Insulin Delivery During an insulin pump a patient inserts the needle or catheter into subcutaneous tissue usually on the abdomen and secures it with tape or a transparent dressing. The needle or catheter is changed at least every ______ days The pump is then worn either on the patient's clothing or in a pocket. Some women keep the pump tucked into the front or side of the bra.

3 days

Diabetes Medical Management intensive glucose control dramatically reduced the development and progression of complications such as retinopathy, nephropathy, and neuropathy. Intensive treatment is defined as ______ or an _______

3 or 4 insulin injections per day insulin pump plus frequent blood glucose monitoring and weekly contacts with diabetes educators

Methods of Insulin Delivery Insulin pumps contain a _____ syringe attached to a long 24 to 42-in, thin, narrow-lumen tube with a ____ or _____ catheter attached to the end

3-mL needle Teflon

Selecting Syringes A small disposable insulin needle _______ gauge _____ mm long is available for very thin patients and children.

31 gauge 8 mm long

Hypoglycemia Symptoms Glucose less than ______ ______ Weakness and ______ Headache and Mental status changes

60 Diaphoresis (sweating) tremors

nephropathy Management If the patient has already developed microalbuminuria with levels that exceed 30 mg/24 hours on two consecutive tests, an _____ should be prescribed. ______ lower blood pressure and reduce microalbuminuria, thereby protecting the kidney

ACE inhibitor ACE inhibitor

Methods of Insulin Delivery The FDA has conditionally approved an inhaled form of insulin to treat patients who require mealtime insulin administration. ______ is a fast-acting, powdered form of human insulin to treat type 1 or type 2 diabetes; however, because of the serious risk of acute ______; it will only be available once postmarketing studies and communication plans required by the FDA have been conducted

Afrezza bronchospasm

nephropathy Assessment and Diagnostic Findings ______ is one of the most important blood proteins that leak into the urine. Although small amounts may leak undetected for years, its leakage into the urine is among the earliest signs that can be detected. The urine should be checked annually for the presence of _______. If the ________ exceeds 30 mg/24 hours on two consecutive random urine tests, a 24-hour urine sample should be obtained and tested. If results are positive, treatment is indicated

Albumin microalbumin microalbumin

Hypoglycemic Unawareness _________ neuropathy affecting the adrenal medulla is responsible for diminished or absent adrenergic symptoms of hypoglycemia. Patients may report that they no longer feel the typical shakiness, sweating, nervousness, and palpitations associated with hypoglycemia. Frequent blood glucose monitoring is recommended for these patients.

Autonomic

Food Classification Systems ________ is a nutritional tool used for blood glucose management because carbohydrates are the main nutrients in food that influence blood glucose levels. ________ method provides flexibility in food choices, can be less complicated to understand than the diabetic food exchange list, and allows more accurate management with multiple daily injections

Carbohydrate counting Carbohydrate counting

Ocular Complications of Diabetes Opacity of the lens of the eye; _____ occur at an earlier age in patients with diabetes. The lens of the eye can swell when blood glucose levels are elevated. For some patients, visual changes related to lens swelling may be the first symptoms of diabetes. It may take up to 2 months of improved blood glucose control before hyperglycemic swelling subsides and vision stabilizes. Therefore, patients are advised not to change eyeglass prescriptions during the 2 months after discovery of hyperglycemia.

Cataracts

Criteria for Determining Effectiveness of Self-Injection of Insulin Education 5 Checks appearance of insulin:

Clear or milky white Checks for flocculation (clumping, frosted appearance) Identifies where to purchase and store insulin: Indicates approximately how long bottle will last Indicates how long opened bottles can be used

_______ Regimen. With this type of simplified regimen, one or more injections of a mixture of short- and intermediate-acting insulins per day, the patient should not vary meal patterns and activity levels. The simplified regimen would be appropriate for the terminally ill, the older adult who is frail and has limited self-care abilities, or patients who are completely unwilling or unable to engage in the self-management activities that are part of a more complex insulin regimen.

Conventional

DKA Management Restoring Electrolytes Rehydration also leads to increased urinary excretion of potassium. Insulin administration enhances the movement of potassium from the extracellular fluid into the cells. Because a patient's serum potassium level may drop quickly as a result of rehydration and insulin treatment, potassium replacement must begin once potassium levels drop to normal in the patient with _______.

DKA

Methods of Insulin Delivery When an insulin pump is used, insulin is delivered by subcutaneous infusion at a basal rate 0.25 to 2 units per hour Possible disadvantages of insulin pumps are unexpected disruptions in the flow of insulin from the pump that may occur if the tubing or needle becomes occluded, if the supply of insulin runs out, or if the battery is depleted, increasing the risk of ______

DKA

Type 2 Diabetes Despite the impaired insulin secretion that is characteristic of type 2 diabetes, there is enough insulin present to prevent the breakdown of fat and the accompanying production of ketone bodies. Therefore, ________ does not typically occur in type 2 diabetes. However, uncontrolled type 2 diabetes may lead to another acute problem ________

DKA hyperglycemic hyperosmolar syndrome (HHS)

______ Relatively normal blood glucose until about 3 am, when the level begins to rise

Dawn Phenomenon

__________ Treatment: Change time of injection of evening intermediate-acting insulin from dinnertime to bedtime.

Dawn Phenomenon

DKA Prevention During DKA "sick days rule" the patient should take the usual insulin dose and then attempt to consume frequent small portions of carbohydrates including foods usually avoided, such as juices, regular sodas, and gelatin. ______ every hour is important to prevent dehydration. _______ and _______ must be assessed every 3 to 4 hours.

Drinking fluids Blood glucose and urine ketones

Ocular Complications of Diabetes _______ This may occur as a result of diabetic neuropathy. The involvement of various cranial nerves responsible for ocular movements may lead to double vision. This usually resolves spontaneously. ______ Results from occlusion of the outflow channels by new blood vessels.

Extraocular Muscle Palsy Glaucoma

8 RISK FACTORS of Diabetes

Family history of diabetes Obesity Race/ethnicity Age equal to or greater than 45 years Previously identified impaired fasting glucose or impaired glucose tolerance Hypertension (≥140/90 mm Hg) High-density lipoprotein (HDL) cholesterol level ≤35 mg/dL and/or triglyceride level ≥250 mg/dL History of gestational diabetes or delivery of a baby over 9 lb

Diabetes Assessment and Diagnostic Findings _______ blood glucose determination obtained in the laboratory after fasting for at least 8 hours

Fasting plasma glucose (FPG)

______ is a hormone produced by the alpha cells of the pancreas that stimulates the liver to breakdown glycogen, the stored glucose

Glucagon

Hypoglycemia Management _______ is sold by prescription only and should be part of the emergency supplies available to patients with diabetes who require insulin. Family members, friends, neighbors, and coworkers should be instructed in the use of ______, especially for patients who have little or no warning of hypoglycemic episodes.

Glucagon Glucagon

_______ is a measure of glucose control for the past 3 months. When blood glucose levels are elevated, glucose molecules attach to hemoglobin in red blood cells. The longer the amount of glucose in the blood remains above normal, the more glucose binds to hemoglobin and the higher the ________ level becomes.

Glycated hemoglobin Glycated hemoglobin

______ occurs most often in older adults who have no known history of diabetes or who have type 2 diabetes

HHS

Hyperglycemic Hyperosmolar Syndrome Management _______ plays a less important role in the treatment of HHS because it is not needed for reversal of acidosis, as in DKA. Nevertheless, ______ is usually given at a continuous low rate to treat hyperglycemia, and replacement IV fluids with dextrose are given after the glucose level has decreased

Insulin Insulin

_______ is a hormone secreted by beta cells, which are one of four types of cells in the islets of Langerhans in the pancreas. _______ is an anabolic, or storage, hormone. When a person eats a meal, ______ secretion increases and moves glucose from the blood into muscle, liver, and fat cells

Insulin Insulin Insulin

When blood sugar levels are too low, the pancreas releases ______. _______ instructs the liver to release stored glucose, which causes blood sugar to rise.

Insulin glucagon

Methods of Insulin Delivery _______ are continuous subcutaneous insulin infusion involves the use of small, externally worn devices that closely mimic the functioning of the normal pancreas.

Insulin Pumps

_______ Progressive rise in blood glucose from bedtime to morning

Insulin Waning

________ Treatment: Increase evening (predinner or bedtime) dose of intermediate- or long-acting insulin, or institute a dose of insulin before the evening meal if one is not already part of the treatment regimen.

Insulin Waning

Methods of Insulin Delivery _______ use small 150 to 300 unit, prefilled insulin cartridges that are loaded into a penlike holder. A disposable needle is attached to the device for insulin injection.

Insulin pens

Methods of Insulin Delivery ______ Insulin is delivered by dialing in a dose or pushing a button for every 1- or 2-unit increment given. _______ people using these devices still need to insert the needle for each injection; however, they do not need to carry insulin bottles or draw up insulin before each injection.

Insulin pens Insulin pens

Methods of Insulin Delivery _______ these devices are most useful for patients who need to inject only one type of insulin at a time or who can use the premixed insulins. _______ are convenient for those who administer insulin before dinner if eating out or traveling. ______ are also useful for patients with impaired manual dexterity, vision, or cognitive function, which makes the use of traditional syringes difficult.

Insulin pens Insulin pens Insulin pens

_______ Regimen. The second approach is to use a more complex insulin regimen to achieve as much control over blood glucose levels as is safe and practical. A more complex insulin regimen allows the patient more flexibility to change the insulin doses from day to day in accordance with changes in eating and activity patterns, with stress and illness, and as needed for variations in the prevailing glucose level.

Intensive

Insulin Lipodystrophy ______ is the loss of subcutaneous fat; it appears as slight dimpling or more serious pitting of subcutaneous fat. The use of human insulin has almost eliminated this disfiguring complication. _______, the development of fibrofatty masses at the injection site, is caused by the repeated use of an injection site. If insulin is injected into scarred areas, absorption may be delayed. This is one reason that rotation of injection sites is so important. Patients should avoid injecting insulin into these areas until the hypertrophy disappears.

Lipoatrophy Lipohypertrophy

______ refers to a localized reaction, in the form of either lipoatrophy or lipohypertrophy, occurring at the site of insulin injections.

Lipodystrophy

______ Changes Cardiac effects Cerebral effects Foot and leg problems

Macrovascular

Methods of Insulin Delivery Many insurance companies cover the cost of pump therapy. If not, the extra expense of the pump and associated supplies may be a deterrent for some patients. _______ covers insulin pump therapy for patients with type 1 diabetes. There is no risk of DKA when there is an interruption of the flow of insulin in people with ______ diabetes wearing an insulin pump.

Medicare type 2

_______ is the only oral antidiabetic drug approved for children. It has established dosing for children 10 years of age and older. With the increasing number of children being diagnosed with type 2 diabetes, the use of other agents in children is being tested. _______ It is effective in lowering blood glucose levels and does not cause hypoglycemia as the sulfonylureas do.

Metformin

_____ Changes Neuropathy Nephropathy Retinopathy Foot and Leg problems

Microvascular

Food Classification Systems The Food Guide ________ is another tool used to develop meal plans. It is commonly used for patients with type 2 diabetes who have a difficult time following a calorie-controlled diet. The _______ guide is appropriately used only as a first-step educational tool for patients who are learning how to control food portions and how to identify which foods contain carbohydrate, protein, and fat.

MyPlate MyPlate

Preparations of Insulin Intermediate-acting insulins are called _____ or _____ Intermediate-acting insulins, which are similar in their time course of action, appear ______ and ______.

NPH insulin (neutral protamine Hagedorn) Lente insulin white and cloudy

Preparations of Insulin If ______ or _____ insulin is taken alone, it is not crucial that it be taken before a meal but patients should eat some food around the time of the onset and peak of these insulins.

NPH or Lente

Foot and Leg Problems 3 Complications of diabetes that contribute to the increased risk of foot problems and infections include the following:

Neuropathy: Peripheral vascular disease immunocompromised

Resistance to Injected Insulin Patients may develop insulin resistance and require large insulin doses to control symptoms of diabetes. In most patients with diabetes who take insulin, immune antibodies develop and bind the insulin, thereby decreasing the insulin available for use. All insulins cause some antibody production in humans. Very few patients who are resistant develop high levels of antibodies. Many of these patients have a history of insulin therapy interrupted for several months or longer. Treatment consists of administering a more concentrated insulin preparation, such as ______, which is available by special order

U-500

Resistance to Injected Insulin Never store _______ insulin with other insulin preparations due to the risk of overdose if accidentally given to the wrong patient. Occasionally, ______ is needed to block the production of antibodies. This may be followed by a gradual reduction in the insulin requirement. Therefore, patients must monitor their blood for ______.

U-500 prednisone hypoglycemia

Selecting and Rotating the Injection Site The speed of absorption is greatest in the _____ and decreases progressively in the arm, thigh, and hip, respectively.

abdomen

Selecting and Rotating the Injection Site The 4 main areas for injection are the

abdomen, upper arms (posterior surface back), thighs (anterior surface front), hips

DKA Clinical Manifestations The ketosis and acidosis of DKA lead to gastrointestinal symptoms, such as anorexia, nausea, vomiting, and _____ pain. The patient may have _____ breath or a ______ odor, which occurs with elevated ketone levels. In addition, hyperventilation may occur

abdominal acetone fruity

DKA treatment Insulin IV Rehydration-NS IV Monitor/replace electrolytes Reverse metabolic _____

acidosis

HHS treatment Insulin IV Rehydration Monitor/replace electrolytes No _____ to treat

acidosis

Hypoglycemia Assessment and Diagnostic Findings This occurs in some patients who have had diabetes for many years. As the blood glucose level falls, the normal surge in ______ does not occur, and the usual adrenergic symptoms, such as sweating and shakiness, do not take place. The hypoglycemia may not be detected until moderate or severe CNS impairment occurs. Affected patients must perform ______ on a frequent regular basis, especially before driving or engaging in other potentially dangerous activities.

adrenalin Self-monitoring of blood glucose (SMBG)

Hypoglycemia Clinical Manifestations The clinical manifestations of hypoglycemia may be grouped into two categories: ______ symptoms and ______ symptoms

adrenergic symptoms central nervous system (CNS) symptoms.

Preparing the Skin The use of ______ to cleanse the skin is not necessary, but patients who have learned this technique often continue to use it. They should be cautioned to allow the skin to dry after cleansing with _____. If the skin is not allowed to dry before the injection, the ______ may be carried into the tissues, resulting in a localized reddened area and a burning sensation.

alcohol alcohol alcohol

Complications of Insulin Therapy A local ________ reaction may appear at the injection site 1 to 2 hours after the administration of insulin. Reactions usually resolve in a few hours or days. If they do not resolve, another type of insulin can be prescribed

allergic

In older patients with diabetes, hypoglycemia is a particular concern for many reasons: Older adults frequently live ______ and may not recognize the symptoms of hypoglycemia. With decreasing _____ function, it takes longer for oral hypoglycemic agents to be excreted by the ______. Skipping meals may occur because of decreased ______ or ______ limitations. Decreased ______ acuity may lead to errors in insulin administration.

alone kidney kidneys appetite financial visual

Hypoglycemia Clinical Manifestations In severe hypoglycemia, CNS function is so impaired that the patient needs the ______ of another person for treatment of hypoglycemia.

assistance

Macrovascular Management The focus of management is an aggressive modification and reduction of risk factors. This involves prevention and treatment of the commonly accepted risk factors for ______. MNT and exercise are important in managing obesity, hypertension, and hyperlipidemia.

atherosclerosis

Neuropathy of the _____ nervous system results in a broad range of dysfunctions affecting almost every organ system of the body

autonomic

Morning Hyperglycemia It may be difficult to tell from a patient's history what the cause is for morning hyperglycemia. To determine the cause, the patient must be _______ once or twice during the night to test blood glucose levels. Testing at bedtime, at ______, and on awakening provides information that can be used to make adjustments in insulin to avoid morning hyperglycemia.

awakened 3 am

Furthermore, in type 1 diabetes, elimination of the insulin dose may lead to the development of DKA. Administration of ______ insulin to patients with type 1 diabetes who are NPO is an important nursing action.

basal

Preparations of Insulin very long-acting insulins are approved by the FDA for use as a ______ that is, the insulin is absorbed very slowly over 24 hours and can be given once a day. Because the insulin is in a suspension with a pH of _____, it cannot be mixed with other insulins because this would cause precipitation.

basal insulin 4

Responding to Self-Monitoring of Blood Glucose Results Patients with type 2 diabetes are encouraged to test daily ______ and _______ hours after the largest meal of the day until individualized blood glucose levels are reached. Patients who take insulin at bedtime or who use an insulin infusion pump should also test at ______ once a week to document that the blood glucose level is not decreasing during the night. If the patient is unwilling or cannot afford to test frequently, then once or twice a day may be sufficient if the time of testing is varied

before and 2 3 am

Responding to Self-Monitoring of Blood Glucose Results Patients are asked to keep a record or logbook of blood glucose levels so that they can detect patterns. Testing is done at the peak action time of the medication to evaluate the need for dosage adjustments. To evaluate basal insulin and determine bolus insulin doses, testing is performed ______. To determine the need for bolus doses of regular or rapid-acting insulin, testing is done ______. Patients are more likely to discontinue SMBG if they are not instructed how to use the results to alter the treatment regimen, if they receive no positive reinforcement, and if testing costs increase.

before meals 2 hours after meals

DKA Pathophysiology Three main causes of DKA are _______, _______, and _______

decreased or missed dose of insulin, illness / infection, undiagnosed and untreated diabetes

Gestational Diabetes Women who are considered to be at high risk for gestational diabetes should be screened by ______ at their ______ visit are those with marked obesity, a personal history of gestational diabetes, glycosuria, or a strong family history of diabetes. A woman with gestational diabetes may, after delivery, move into _______.

blood glucose testing first prenatal type 2 diabetes

DKA Clinical Manifestations In addition, the patient may experience ______ vision, weakness, and headache. Patients with marked intravascular volume depletion may have orthostatic _______. Volume depletion may also lead to frank _______ with a weak, rapid pulse.

blurred hypotension hypotension

Diabetic Retinopathy Clinical Manifestations Retinopathy is a painless process. In nonproliferative and preproliferative retinopathy, ______ vision secondary to macular edema occurs in some patients, although many patients are ______.

blurry asymptomatic

Diabetes Medical Management For patients who are obese, decreasing the overall ______ is of greater importance. Meals should not be skipped. Pacing food intake throughout the day decreases demands on the _______.

caloric intake pancreas

Diabetes Medical Management Consistently following a meal plan is one of the most challenging aspects of diabetes management. It may be more realistic to restrict ______ only moderately.

calories

Caloric Distribution Currently, the ADA and the Academy of Nutrition and Dietetics recommend that for all levels of caloric intake, 50% to 60% of calories should be derived from ______, 20% to 30% from _____, and the remaining 10% to 20% from ______

carbohydrates fat protein

Autonomic Neuropathies Clinical Manifestations Three manifestations of autonomic neuropathy are related to the ______, ______, and _______ systems.

cardiac, gastrointestinal, and renal

Foot and Leg Problems Management Wearing ______ shoes that fit well. A podiatrist can provide the patient with inserts (orthotics) to remove pressure from pressure points on the foot. New shoes should be broken in slowly to avoid blister formation. Patients with bony deformities may need custom-made shoes with extra width or depth. High-risk behaviors, such as walking barefoot, using heating pads on the feet, wearing open-toed shoes, soaking the feet, and shaving calluses, should be avoided.

closed-toed

Hypoglycemia Clinical Manifestations Signs of moderate hypoglycemia impaired function of the CNS may include inability to ______, headache, lightheadedness, confusion, ______ lapses, numbness of the _____ and ______, slurred ______, impaired coordination, emotional changes, irrational or ______ behavior, double _______, and drowsiness

concentrate memory lips and tongue speech combative vision

Mixing Insulins Injecting cloudy insulin into a vial of clear insulin ______ the entire vial of clear insulin and alters its action.

contaminates

A _______ can be used to monitor blood glucose levels. A sensor attached to an infusion set, which is similar to an insulin pump infusion set, is inserted subcutaneously in the abdomen and connected to the device worn on the patient's clothing or placed in a pocket.

continuous glucose monitoring system (CGMS)

Insulin Regimens There are two general approaches to insulin therapy: _______ and _______

conventional and intensive

nephropathy Assessment and Diagnostic Findings In addition, tests for serum ______ and ______ levels should be conducted annually.

creatinine and BUN

Morning Hyperglycemia The _______ is characterized by a relatively normal blood glucose level until approximately 3 am, when blood glucose levels begin to rise. The _______ is thought to result from nocturnal surges in growth hormone secretion, which creates a greater need for insulin in the early morning hours in patients with type 1 diabetes.

dawn phenomenon dawn phenomenon

Diabetic Retinopathy Assessment and Diagnostic Findings Diagnosis is by direct visualization of the retina through dilated pupils with an ophthalmoscope or with a technique known as _______. ________ can document the type and activity of the retinopathy. Dye is injected into an arm vein and is carried to various parts of the body through the blood, but especially through the vessels of the retina of the eye. _______ Side effects of this diagnostic procedure may include nausea during the dye injection; yellowish, fluorescent discoloration of the skin and urine lasting 12 to 24 hours; and occasionally allergic reactions, usually manifested by hives or itching. However, the diagnostic procedure is generally safe.

fluorescein angiography fluorescein angiography fluorescein angiography

DKA Management Reversing Acidosis When hanging the insulin drip, the nurse must ______ the insulin solution through the entire IV infusion set and discard the first 50 mL of fluid. Insulin molecules adhere to the inner surface of plastic IV infusion sets; therefore, the initial fluid may contain a decreased concentration of insulin.

flush

DKA Prevention Patients are taught to have ______ available for use on sick days. In addition, a supply of ______ and ______ should be available on sick days. These materials should be assembled in a ______

foods urine test strips and blood glucose test strips "sick day" kit

Educating Patients About Basic Skills For patients with newly diagnosed type 2 diabetes, emphasis is initially placed on meal planning and exercise. Those who are starting to take oral antidiabetic agents need to know about detecting, preventing, and treating hypoglycemia. some patients with newly diagnosed type 2 diabetes, basic diabetes education must include information on preventive skills, such as ______ care and ______ care

foot care and eye care

Patients are advised to refrain from eating high-calorie, high-fat dessert foods to treat hypoglycemia because their high fat content may slow the absorption of the glucose and resolution of the hypoglycemic symptoms. The patient may subsequently eat more of the foods when symptoms do not resolve rapidly, which may cause very high blood glucose levels for several hours and may contribute to weight _______.

gain

Peripheral Neuropathy Clinical Manifestations In addition, a decrease in proprioception (awareness of posture and movement of the body and of position and weight of objects in relation to the body) and a decreased sensation of light touch may lead to an unsteady ______. Decreased sensations of pain and temperature place patients with neuropathy at increased risk for injury and undetected foot infections. Deformities of the foot may also occur; neuropathy-related joint changes are sometimes referred to as ______

gait Charcot joints

Insulin helps the cells absorb glucose, reducing blood sugar and providing the cells with glucose for energy. When blood sugar levels are too low, the pancreas releases ______. _______ instructs the liver to release stored glucose, which causes blood sugar to rise.

glucagon glucagon

When blood sugar levels are too low, the pancreas releases ______. ______ instructs the liver to release stored glucose, which causes blood sugar to rise.

glucagon glucagon

Hypoglycemia Management In emergency situations, for adults who are unconscious and cannot swallow, an injection of ______ can be given either subcutaneously or intramuscularly.

glucagon 1 mg

Exercise Precautions Exercising with elevated blood glucose levels increases the secretion of ______, _______, and _______. The liver then releases more glucose, and the result is an increase in the blood glucose level

glucagon, growth hormone, catecholamines

Insulin has the following 6 actions: Transports and metabolizes ______ for energy Stimulates storage of ______ in the liver and muscle Signals the ______ to stop the release of glucose Enhances storage of dietary ______ in adipose tissue Accelerates transport of ______ into cells Inhibits the breakdown of stored ______, _____, and ______

glucose glucose liver fat amino acids glucose, protein, and fat

prevention of hypoglycemia: Checks blood ______ regularly Identifies safe modification of _____ doses consistent with management plan Carries a form of fast-acting _____ at all times Wears a medical identification ______

glucose insulin sugar bracelet

Guidelines to Follow During Periods of Illness DKA "Sick Day Rules" Take insulin or oral antidiabetic agents as usual. Test blood ______ and urine ______ every 3 to 4 hours. Report elevated glucose levels as specified or urine ketones to your primary provider. Take supplemental doses of _____ insulin every 3 to 4 hours, if needed, if you take insulin.

glucose ketones regular

Diabetes Medical Management Nutritional management of diabetes includes the following 3 goals To achieve and maintain: Blood ______ levels in the normal range or as close to normal as is safely possible A lipid and lipoprotein profile that reduces the risk for _____ disease Blood _____ levels in the normal range or as close to normal as is safely possible

glucose vascular pressure

A ______ test is more effective in diagnosis than urine testing for glucose in older patients due to the higher renal threshold for glucose

glucose tolerance test

Food Classification Systems One of the main goals of diet therapy in diabetes is to avoid sharp, rapid increases in blood glucose levels after food is eaten. The term ________ is used to describe how much a given food increases the blood glucose level compared with an equivalent amount of glucose.

glycemic index

Frequency of Self-Monitoring of Blood Glucose Those not receiving insulin may be instructed to assess their blood glucose levels at least two or three times per week, including a 2-hour postprandial test. For all patients, SMBG testing is recommended whenever ______ or _______ is suspected; with changes in medications, activity, or diet; and with stress or illness.

hypoglycemia or hyperglycemia

There are three major acute complications of diabetes related to short-term imbalances in blood glucose levels: _______, ______, and ______

hypoglycemia, Diabetic ketoacidosis (DKA) Hyperglycemic Hyperosmolar Syndrome

___________ Symptoms: shakiness, sweating, nervousness, hunger, weakness Causes: too much insulin, too much exercise, not enough food

hypoglycemia:

____________ Treatment: 15 g concentrated carbohydrate, such as 2 or 3 glucose tablets, 1 tube glucose gel, 0.5 cup juice After initial treatment, follow with snack including starch and protein, such as cheese and crackers, milk and crackers, half sandwich.

hypoglycemia:

Autonomic Neuropathies Clinical Manifestations Cardiovascular symptoms range from a fixed, slightly tachycardic heart rate and orthostatic ______ to silent, or painless, myocardial ischemia and infarction. Delayed gastric emptying may occur with the typical gastrointestinal symptoms of early satiety, bloating, nausea, and vomiting. "Diabetic" constipation or diarrhea (especially nocturnal diarrhea) may occur as a result. Urinary retention, a decreased sensation of bladder fullness, and other urinary symptoms of neurogenic bladder result from autonomic neuropathy. The patient with a neurogenic bladder is predisposed to development of urinary tract infections because of the inability to empty the bladder completely.

hypotension

Hyperglycemic Hyperosmolar Syndrome Clinical Manifestations The clinical picture of HHS is one of ______, ______, ______, and _______

hypotension, profound dehydration, tachycardia, variable neurologic signs

Prediabetes is classified as impaired ______ or impaired ______

impaired glucose tolerance (IGT) impaired fasting glucose (IFG)

Foot and Leg Problems If the patient is not in the habit of thoroughly inspecting both feet on a daily basis, the injury or fissure may go unnoticed until a serious ________ has developed. Drainage, swelling, redness of the leg, or gangrene may be the first sign of foot problems that the patient notices. Treatment of foot ulcers involves bed rest, antibiotics, and débridement.

infection

Educating the Patient About Self-Care The nurse must also assess the patient for _____ or ______, which may lead to elevated blood glucose levels despite adherence to the treatment regimen.

infection or emotional stress

Foot and Leg Problems The typical sequence of events in the development of a diabetic foot ulcer begins with a soft tissue injury of the foot, formation of a fissure between the toes or in an area of dry skin, or formation of a callus. Patients with an insensitive foot do not feel ______, which may be thermal, chemical, or traumatic

injuries

DKA Prevention The most important concept in DKA "sick days rule" is to never eliminate ______ doses when nausea and vomiting occur.

insulin

DKA Management Reversing Acidosis Ketone bodies (acids) accumulate as a result of fat breakdown. The acidosis that occurs in DKA is reversed with ______, which inhibits fat breakdown, thereby ending ketone production and acid buildup. ______ is usually infused IV at a slow, continuous rate

insulin Insulin

When blood sugar is too high, the pancreas secretes more ______. When blood sugar levels drop, the pancreas releases ______ to raise them. If blood glucose is HIGH, then NO ______ is secreted. When blood glucose goes LOW, however, (such as between meals, and during exercise) more and more ______ is secreted.

insulin glucagon glucagon glucagon

During fasting periods, the pancreas continuously releases a small amount of ______; another pancreatic hormone called _______ is released when blood glucose levels decrease, which stimulates the liver to release stored glucose. The ______ and the _______ together maintain a constant level of glucose in the blood by stimulating the release of glucose from the liver.

insulin glucagon insulin and glucagon

Peripheral Neuropathy Management Intensive ______ therapy and control of blood ______ levels delay the onset and slow the progression of neuropathy. In some cases, neuropathic pain spontaneously resolves within 6 months; for others, pain persists for many years. Duloxetine and pregabalin are approved specifically for treating painful diabetic peripheral neuropathy

insulin glucose

Increased glucose leads to a Release of _____ and then _____ enters cells Decreased glucose leads to Release of ______ and then Release of ______ which turns into glucose

insulin glucose glucagon glycogen

Type 2 Diabetes To overcome insulin resistance and to prevent the buildup of glucose in the blood, increased amounts of _______ must be secreted to maintain the glucose level at a normal or slightly elevated level. If the beta cells cannot keep up with the increased demand for insulin, the glucose level rises and ______ develops.

insulin type 2 diabetes

Type 1 Diabetes Regardless of the specific cause, the destruction of the beta cells results in decreased ______ production, increased ______ production by the liver, and fasting ______ In addition, glucose derived from food cannot be stored in the liver but instead remains in the bloodstream and contributes to postprandial (after meals) hyperglycemia.

insulin glucose hyperglycemia

Methods of Insulin Delivery In addition, patients should be cautioned that absorption rates, peak insulin activity, and insulin levels may be different when changing to a _______. Insulin given by _______ is usually absorbed faster. The use of _______ has been associated with bruising in some patients

jet injector jet injector jet injector

Methods of Insulin Delivery The most common risk of insulin pump therapy is ______, which can occur if there is an occlusion in the infusion set or tubing. Because only rapid-acting insulin is used in the pump, any interruption in the flow of insulin may rapidly cause the patient to be without insulin. The patient should be taught to administer insulin by manual injection if an insulin interruption is suspected

ketoacidosis

DKA Assessment and Diagnostic Findings Evidence of ______ is reflected in low serum bicarbonate and low pH values. A low partial pressure of carbon dioxide reflects respiratory compensation or ______ for the metabolic acidosis.

ketoacidosis Kussmaul respirations

DKA Assessment and Diagnostic Findings Accumulation of _____ bodies is reflected in blood and urine ______ measurements. Increased levels of creatinine, blood urea nitrogen (BUN), and hematocrit may also be seen with dehydration. After rehydration, continued elevation in the serum creatinine and BUN levels suggests underlying renal insufficiency.

ketone ketone

What distinguishes HHS from DKA is that ______ and ______ generally do not occur in HHS, partly because of differences in insulin levels. In DKA, no insulin is present In HHS, the insulin level is too ______

ketosis and acidosis low

Selecting and Rotating the Injection Site Systematic rotation of injection sites within an anatomic area is recommended to prevent localized changes in fatty tissue _______ Another approach to rotation is always to use the same area at the same time of day. For example, patients may inject morning doses into the abdomen and evening doses into the arms or legs.

lipodystrophy

Guidelines to Follow During Periods of Illness DKA "Sick Day Rules" Substitute soft foods six to eight times a day if you cannot follow your usual meal plan. Take _____ every 1 hour to prevent dehydration and to provide calories, if vomiting, diarrhea, or fever persists. Report _______, _______, and _______ to your primary provider, because extreme fluid loss may be dangerous. Be aware that if you are unable to retain oral fluids, you may require ______ to avoid diabetic ketoacidosis and possibly coma.

liquids nausea, vomiting, and diarrhea hospitalization

Like insulin, glucagon has an effect on many cells of the body, but most notably the ______. Insulin is normally secreted by the beta cells (a type of islet cell) of the pancreas. The stimulus for insulin secretion is a ______

liver HIGH blood glucose

Preparations of Insulin _______ It was originally approved to be given once a day at bedtime; however, it has now been approved to be given once a day at any time of the day but must be given at the same time each day to prevent overlap of action. ________ Many patients fall asleep, forgetting to take their bedtime insulin, or may be wary of taking insulin before going to sleep. Having these patients take their insulin in the morning ensures that the dose is taken.

long acting insulin or basal insulin long acting insulin or basal insulin

Diabetes Clinical Manifestations Other symptoms of diabetes include fatigue and weakness, sudden vision changes, tingling or numbness in hands or feet, dry skin, skin lesions or wounds that are slow to heal, and recurrent infections. The onset of type 1 diabetes may also be associated with sudden weight _____ or nausea, vomiting, or abdominal pains, if DKA has developed.

loss

General Considerations for Exercise in People With Diabetes Use proper footwear and, if appropriate, other protective equipment Avoid trauma to the ______ extremities, especially if you have numbness due to peripheral neuropathy. Inspect ______ daily after exercise.

lower feet

Diabetic _______ complications result from changes in the medium to large blood vessels. Blood vessel walls thicken, sclerose, and become occluded by plaque that adheres to the vessel walls. Eventually, blood flow is blocked. These atherosclerotic changes tend to occur more often and at an earlier age in patients with diabetes.

macrovascular

The general categories of long-term diabetic complications are ______, ______, and _______

macrovascular disease, microvascular disease, neuropathy

If blood glucose levels are elevated consistently for a significant period of time, the kidney's filtration mechanism is stressed, allowing blood proteins to leak into the urine. As a result, the pressure in the blood vessels of the kidney increases. It is thought that this elevated pressure serves as the stimulus for the development of _______.

nephropathy

Microvascular Complications Retinopathy has three main stages:

nonproliferative (background), preproliferative, proliferative.

Gestational Diabetes Women considered to be at high risk or average risk for gestational diabetes should have either an ______ or a _______ followed by ______ in women who exceed the glucose threshold value of ______

oral glucose tolerance test (OGTT) glucose challenge test (GCT) oral glucose tolerance test (OGTT) 140 mg/dL

Type 1 Diabetes When excess glucose is excreted in the urine, it is accompanied by excessive loss of fluids and electrolytes. This is called ______

osmotic diuresis.

Methods of Insulin Delivery Transplantation of the whole ______ or a segment of the _____ is being performed on a limited population (mostly patients with diabetes who are receiving a kidney transplantation simultaneously). Patients must weigh the risks of antirejection medications against the advantages of _____ transplantation

pancreas pancreas pancreas

Peripheral Neuropathy Clinical Manifestations Although approximately half of patients with diabetic neuropathy do not have symptoms, initial symptoms may include ______ (prickling, tingling, or heightened sensation) and _____ sensations (especially at night). As the neuropathy progresses, the feet become ________

paresthesias burning numb

Testing for Glycated Hemoglobin Glycated hemoglobin this complex is _____ and lasts for the life of an individual red blood cell, approximately _______ days If near-normal blood glucose levels are maintained, with only occasional increases, the overall value will not be greatly elevated. However, if the blood glucose values are consistently high, then the test result is also elevated.

permanent 120 days

Diabetes insipidus major symptom is _______ and _______ Diabetes insipidus mainly affects the ______ gland

polyuria and concreate dilute urine pituitary

DKA Clinical Manifestations The hyperglycemia of DKA leads to ______, ______, and _______

polyuria, polydipsia (increased thirst), marked fatigue.

hyperglycemia Clinical Manifestations Clinical manifestations depend on the patient's level of hyperglycemia. Classic clinical manifestations of hyperglycemia include the "three Ps": _______, _______, and _______

polyuria, polydipsia, and polyphagia.

Type 2 Diabetes Because type 2 diabetes is associated with a slow, progressive glucose intolerance, its onset may go undetected for many years. If the patient experiences symptoms, they are frequently mild and may include fatigue, irritability, polyuria, polydipsia, _______, _______, and _______

poorly healing skin wounds, vaginal infections, blurred vision

DKA Management Restoring Electrolytes The major electrolyte of concern during treatment of DKA is _______. The initial plasma concentration of ______ may be low, normal, or high, but more often it, tends to be High from disruption of the cellular sodium-potassium pump Therefore, the serum _______ level must be monitored frequently

potassium potassium potassium

DKA Prevention If the patient cannot take fluids without vomiting, or if elevated glucose or ketone levels persist, the _______ must be contacted.

primary provider

Hypoglycemia Management Patients should be instructed to notify their _______ after severe hypoglycemia has occurred and been treated. Close monitoring for 24 hours following a hypoglycemic episode is indicated because the patient is at increased risk of another episode

primary provider

Testing for Ketones The patient may use a urine dipstick to detect ketonuria. The reagent pad on the strip turns ______ when ketones are present.

purple

Identifies need to delay food until 5 to 15 minutes after injection of _______ acting insulin Knows that ______ time delays are safe when blood glucose level is HIGH and that time delays may need to be ______ when blood glucose level is LOW

rapid longer shortened

Preparations of Insulin ______ acting insulin: Used for rapid reduction of glucose level, to treat postprandial hyperglycemia, and/or to prevent nocturnal hypoglycemia ______ acting insulin: Usually given 20-30 minutes before a meal; may be taken alone or in combination with ______ acting insulin: Usually taken after food ______ acting insulin: Used for basal dose

rapid short intermediate long

Preparations of Insulin ______ and ______ acting insulins are expected to cover the increase in glucose levels after meals, immediately after the injection _______ acting insulins are expected to cover subsequent meals _______ acting insulins provide a relatively constant level of insulin and act as a basal insulin

rapid and short intermediate long

Storing Insulin Whether insulin is the short- or the long-acting preparation, vials not in use, including spare vials or pens, should be ______ Extremes of temperature should be avoided; insulin should not be allowed to freeze and should not be kept in direct sunlight or in a hot car. The insulin vial in use should be kept at ______ temperature to reduce local irritation at the injection site, which may occur if cold insulin is injected

refrigerated room

Mixing Insulins For patients who can inject insulin but who have difficulty drawing up a single or mixed dose, syringes may be prefilled with the help of home care nurses or family and friends. A 3-week supply of insulin syringes may be prepared and kept in the _______ but warmed to ______ temperature before administration. The prefilled syringes should be stored with the needle in an _______ position to avoid clogging of the needle; they should be mixed thoroughly by _____ syringe several times before the insulin is injected.

refrigerator room upright inverting

Mixing Insulins There are varying opinions regarding which type of insulin short-acting or longer-acting should be drawn up into the syringe first when they are going to be mixed, but the ADA recommends that the _______ insulin be drawn up first.

regular (short)

Preparations of Insulin Short-acting insulins are called _____. _______ is a clear solution and is usually given 15 minutes before a meal, either alone or in combination with a longer-acting insulin. _______ can be administered IV

regular insulin (marked R on the bottle) regular insulin (marked R on the bottle) regular insulin (marked R on the bottle)

Microvascular Complications Two areas affected by microvascular changes are the ______ and the _______

retina kidneys

Storing Insulin If a vial of insulin will be used up within 1 month, it may be kept at _____ temperature. The patient should be instructed to always have a spare vial of the type or types of insulin that he or she uses. _______ insulins should be thoroughly mixed by gently inverting the vial or rolling it between the hands before drawing the solution into a syringe or a pen

room Cloudy

Mixing Insulins When rapid- or short-acting insulins are to be given simultaneously with longer-acting insulins, they are usually mixed together in the ______ syringe; the longer-acting insulins must be mixed thoroughly before drawing into the syringe. It is important that patients prepare their insulin injections consistently from day to day.

same

Caloric Distribution Both fibers increases _____, which is helpful for weight loss.

satiety

Hypoglycemia Clinical Manifestations Symptoms of severe hypoglycemia may include disoriented behavior, _______, difficulty arousing from ______, or loss of ______.

seizures sleep consciousness

Monitoring Glucose Levels and Ketones Blood glucose monitoring is a cornerstone of diabetes management, and ______ levels has dramatically altered diabetes care. _______ is a method of capillary blood glucose testing in which the patient pricks their finger and applies a drop of blood to a test strip that is read by a meter. It is recommended that ______ occurs when circumstances call for it for patients prescribed frequent insulin injections or an insulin pump

self-monitoring of blood glucose (SMBG) self-monitoring of blood glucose (SMBG) self-monitoring of blood glucose (SMBG)

Macrovascular complications Therefore, the patient may not experience the early warning signs of decreased coronary blood flow and may have "______" MIs, which may be discovered only as changes on the ECG. In some cases, ECG changes may not be apparent. Because symptoms of a stroke may be similar to symptoms of acute diabetic complications (HHS or hypoglycemia), it is very important to assess the blood glucose level (and treat abnormal levels) rapidly in patients with these symptoms so that testing and treatment of a stroke can be initiated promptly if indicated.

silent

________ is characterized by the destruction of the pancreatic beta cells

type 1 diabtetes

Misleading Food Labels Foods labeled "_______" or "_______" may still provide calories equal to those of the equivalent sugar-containing products if they are made with nutritive sweeteners. Therefore, these foods should not be considered "free" foods to be eaten in unlimited quantity, because they can elevate blood glucose levels. Foods labeled "_______" are not necessarily reduced-calorie foods. Patients are advised that foods labeled ______ may still contain significant amounts of sugar or fat.

sugarless sugar-free dietetic dietetic

Hypoglycemia Clinical Manifestations _______, tremor, ______, palpitation, _______, and ______.

sweating (diaphoresis) tachycardia nervousness hunger

Morning Hyperglycemia An elevated blood glucose level on arising in the morning is caused by an insufficient level of insulin, which may be caused by 3 factors: _______, _______, and ________

the dawn phenomenon, the Somogyi effect, insulin waning.

Preparations of Insulin A number of insulin preparations are available. They vary according to three main characteristics: ______, _______, _______

time course of action, species (source), manufacturer

Foot and Leg Problems Management Properly bathing, drying, and lubricating the feet, taking care not to allow moisture to accumulate between the toes. Trimming ______ straight across and filing sharp corners to follow the contour of the toe. If the patient has visual deficits, is unable to reach the feet because of disability, or has thickened toenails, a podiatrist should cut the nails. Reducing risk factors, such as smoking and elevated blood lipids, that contribute to peripheral vascular disease. Avoiding home remedies, over-the-counter agents, and self-medicating to treat foot problems.

toenails

Caloric Requirements Patients may be underweight at the onset of _____ diabetes because of rapid weight loss from severe hyperglycemia. The goal initially may be to provide a higher-calorie diet to regain lost weight and blood glucose control.

type 1

DKA may be the initial manifestation of ______ diabetes

type 1

People do not inherit ______ diabetes itself but rather a genetic predisposition, or tendency, toward the development of ______. This genetic tendency has been found in people with certain human leukocyte antigen types. There is also evidence of an autoimmune response in type 1 diabetes. This is an abnormal response in which antibodies are directed against normal tissues of the body, responding to these tissues as if they were foreign

type 1 type 1

Insulin Therapy In _______ diabetes, exogenous insulin must be given for life because the body loses the ability to produce insulin. In _______ diabetes, insulin may be necessary on a long-term basis to control glucose levels if meal planning and oral agents are ineffective or when insulin deficiency occurs.

type 1 type 2

The main difference between the two types of diabetes is that ______ diabetes is a genetic disorder that often shows up early in life, and _______ is largely diet-related and develops over time. If you have ______ diabetes, your immune system is attacking and destroying the insulin-producing cells in your pancreas, producing no insulin If you have ______ diabetes the body still produces a small amount of insulin.

type 1 type 2 type 1 type 2

Using a Continuous Glucose Monitoring System After 120 to 168 hours, the data from the device are downloaded, and blood glucose readings are analyzed. Although the continuous glucose monitoring system (CGMS) cannot be used for making decisions about specific insulin doses, it can be used to determine whether treatment is adequate over a 24-hour period. This device is most useful in patients with _______

type 1 diabetes