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medsurg
diabetes part 2
| Question | Answer |
|---|---|
| oral agents T2DM 3 ways | -increase insulin secretion (pancreas) -reduce insulin resistance (muscle/liver) -decrease absorption of glucose (gut) |
| oral agents: increase insulin secretion (pancreas) meds | sulfonyureas and meglitinides |
| sulfonyureas examples | glipizide, glyburide, glimepiride |
| sulfonyureas: | can cause hypoglycemia |
| sulfonyureas intervention | monitor symptoms of hypoglycemia increase dose gradually |
| meglitinides example | repaglinide, nateglinide |
| meglitines: | short acting peak effects in 1 hour recommended for pt w poorly controlled BG may cause weight gain |
| meglitines interventions | taken 3 times a day 15-30 minutes prior to meals monitor for symptoms of hypoglycemia |
| oral agents reduce insulin resistance (muscle/liver) | biguanides, thiazolidineodiones |
| biguanides examples | metformin |
| biguanides: | -if given with IV contrast dye may result in kidney damage (hold if pt has CKD and restart 48 hrs after IV contrast dye) -if pt has decreased kidney function can cause lactic acidosis |
| biguanides intervention | -if acute or chronic kidney disease withhold on day of IV contrast dye procedures, restart 48 hours post procedure. -hydrate pt. -monitor GFR, creat., BUN |
| thiazolidineodiones examples | pioglitazone and rosiglitazone |
| thiazolidineodiones: | causes fluid retention contraindicated in pts with heart failure and liver failure |
| thiazolidineodiones intervention | observe for fluid volume retention weigh patient |
| oral agents decrease carbohydrate absorption | alpha glucosidase inhibitors |
| alpha glucosidase inhibitors examples | acarbose, miglitol |
| alpha glucosidase inhibitors: | delays absorption of carbohydrates in GI tract reduces post prandial hyperglycemia |
| alpha glucosidase inhibitors intervention | mediation taken with first bite of food hold if pt is not eating |
| GLP-1 upon ingestion of food... | GLP-1 is secreted from the L-cell in the intestine |
| GLP-1 in turn this causes: | -stimulates glucose dependent insulin secretion -suppresses glucagon secretion -slows gastric emptying -reduces food intake (appetite suppressant) |
| incretin mimetic examples | exenatide BID bydureon weekly liraglutide daily sitagliptin daily |
| incretin mimetic: | prescribed for pts who have not been able to control BG with oral medication. stimulate the release of insulin. inhibit the release of glucagon. reduces the rate that stomach digests food and empties |
| incretin mimetic intervention | Given SQ or PO depending on drug Frequency depends on type of incretion mimetic May cause loss of appetite, weightloss. Rarely causes hypoglycemia unless taken with oral medications. |
| SGLT2i examples | empaglifozin, canaglifozin, dapagliflozin, ertugliflozin |
| SGLT2i: | lower blood sugar by causing the kidneys to remove glucose from the body through the urine |
| SGLT2i intervention | taken orally once a day can result in euglycemia DKA |
| ADA- EASD glycemia targets in T2DM- pre-prandial (before meals) | plasma glucose <130 mg/dL |
| ADA- EASD glycemia targets in T2DM- post- prandial (after meals) | plasma glucose <180 mg/dL |
| ADA- EASD A1C | individualization is key; no 'one size fits all' number for everyone |
| ADA- EASD A1C tighter targets | 6-6.5% Patients who are younger, healthier, and have a long life expectancy. The goal is to prevent long-term complications. |
| ADA- EASD A1C looser targets | 7.5-8% Patients who are older, have other serious health conditions (comorbidities), or are prone to dangerous drops in blood sugar. |
| avoidance of hypoglycemia | Hypoglycemia can be life-threatening in older adults. DR will accept a slightly higher A1C if it means the patient stays safe from severe lows |
| outpatient treatment type 2 | if A1C > 7%... start/change therapy |
| outpatient treatment type 2 step one | lifestyle/risk reduction + metformin |
| outpatient treatment type 2 step two | if step one fails within 2-3 months, add a second agent choose sulfonylurea or insulin (basal) if A1C >8.5% |
| outpatient treatment type 2 step three | start or intensify insulin therapy a third oral agent usually ineffective and more $$$ |
| normal pancreatic insulin release | insulin release increases when BGL rise and continue at a low steady rate between meals ("basal rate") |
| rapid acting insulin | Lispro, aspart, glulison onset: 15 minutes. peak: 1 hour. duration: 24 hours |
| short acting insulin | human regular Onset: 30 minutes. Peak: 2-3 hours. Duration: 3-6 hours. |
| intermediate-acting | NPH Onset: 2-4 hours. Peak: 4-12 hours. Duration: 12-18 hours. |
| Long acting | Glargine, Detemir, Degludec Onset: several hours. Peak: DOES NOT PEAK. Duration: 24 hours or longer, sometimes give Q12h |
| insulin types | basal and prandial |
| basal insulin | amount of insulin required between meals and overnight to meet insulin needs and control glucose output from the liver ex: glargine, detemir, NPH (long acting) |
| prandial insulin | amount of insulin required with meals to convert food into energy/ stored forms of energy (prevents blood glucose excursion after food intake) ex: Lispro, aspart, glulison, regular (fast acting, given w meals) |
| correction insulin | use the sliding scale correct 150- 2 units then more if glucose is higher |
| insulin storage and disposal | avoid heat, light, and storage only good for 28 days after opening Expiration date and correct color |
| mixing insulin | NPH and regular 6units NPH and 3 units regular in same syringe draw up rapid acting first since it's clear, then the cloudy one |
| insulin injection sites | SubQ abdomen most commonly, mid thigh, back of arm, buttock |
| insulin adjustment consideration | insulin variables: type, dose, peak, duration food intake: quantity, timing physical activity: increased or decreased exercise |
| pre-mixed insulin | pre-mixed formulations of intermediate and short or rapid acting insulin inpatient setting- not used often outpatient setting- easier for pts at home |
| common premixed formulas | Human (70/30), Humalog (75/25), Humalog (50/50), Novolog (70/30) |
| U-500 concentration insulin | 5x more potent than U-100 regular insulin double check orders before administering |
| insulin reminders | do not mix Glargine or Detemir in same syringe with any other. Correction (sliding scale) insulin should be given within 30 minutes to an hour after fingerstick glucose is checked. |
| insulin reminders aspart, humalog | give when meal is in front of the pt |
| insulin reminders regular insulin | 30 minutes prior to meal |
| poor BG control increases risk of | sepsis, infection, dehydration, electrolyte imbalance, delayed wound healing, cardiac dysrhythmias, longer ICU and hospital stays, inpatient mortality |
| AACE/ADA summary of recommendations - inpatient ICU patients | glucose range 140-180 mg/dL |
| AACE/ADA summary of recommendations - inpatient non-ICU patients | glucose range: premeal BG target: <140mg/dL random BG target < 180mg/dL |
| pre-operative management of insulin and hyperglycemia | basal insulin: -should receive all or portion of basal insulin dose |
| pre-operative management of insulin and hyperglycemia- if patient has an insulin pump: | endocrine consult, patient provides all supplies, never stop pump without giving SQ or IV insulin |
| nursing management | assess for RF, complications avoid hypo/hyperglycemic emergencies provide EBP care to maintain optimal state of health educate and assist with diabetes self-management |
| nursing management- educate and assist with diabetes self-management | teach the pt to safely self-manage diabetes, maintain target range of Blood glucose levels, and prevent complications |
| inpatient diabetes education: survival skills and discharge planning | Tx of hypoglycemia Tx of Hyperglycemia glucose monitoring medication outpatient follow up |
| when does teaching begin? | at admission!! |
| hospital discharge: transition | many pts are admitted to the hospital with undiagnosed diabetes or hyperglycemia hyperglycemia may have occured in some pts due to 'special' circumstances. |
| pts with prediabetes | monitor blood glucose levels and schedule a follow-up at 1 month is appropriate for all pts with in-hospital hyperglycemia |
| outpatient tx for T1DM | insulin- prevent DKA education, ongoing support |
| outpatient tx for T1DM education, ongoing support: | consistent carbs/carb counting healthy lifestyle including regular exercise control risk factors (BP, lipids) |
| outpatient tx for T1DM optional | adjunct medications (amylin) technology (insulin pen, pump, continuous glucose monitoring systems) |
| daily management | causes of Hyperglycemia extra insulin needed contact MD for persistent BGL >250, fever, ketonuria, and N/V |
| causes of Hyperglycemia | stress, infection, injury, surgery |
| daily manangement for an unconscious patient | be aware of sweating, tachycardia, and tremors as a sign of hypoglycemia |
| first line therapy | lifestyle intervention: optimize weight, eat a healthy diet, increase activity level |
| time it takes to complete ADA recommended tasks to manage blood glucose per day | 122 minutes/day *look at chart on slide 38* |
| nutrition and DM: consistent carb heart healthy diet | -consistent carb meal planning/ counting -limiting intake of high sugar food -increase fiber to dec. glycemic index (whole grains, legumes) -don't skip meals -reduce fats -maintain weight or if overweight or obese lose 5-7% of bodyweight |
| exercise recommendations | daily exercise is recommended |
| EBP of exercise rec | 30 mins 5 days/week (may be done in 3x 10 minute increments or 2.5 hrs/week) exercise stress test prior to start: if over 30 and have 2 or more risk factors for CVD |
| exercise precautions | avoid exercise when: - blood sugar is about 250 with ketonuria (T1D) to prevent DKA - insulin requirements normally decrease with exercise - blood glucose monitoring |
| before exercising... | either decrease insulin dose OR eat a 15-20g snack before to prevent hypoglycemia during exercise |
| sick day management | need for insulin continues and may increase test BG Q4h and record, test urine for ketones (T1D), eat carbs per plan, call HCP if needed |
| when to call HCP for sick day management | persistent BG >240mg/dL (T1D) persistent BG >300mg/dL (T2D) N/V, inability to retain fluids |
| foot care | check for neuropathy thoroughly inspect your feet daily, keep clean and dry. have podiatry clip toe nails. prevent cracks or cuts. no moisturizer between toes because can cause fungal infection! |
| insulin injection devices | -insulin pens, easier to see -insulin pumps, continuous subq insulin infusion (CSII) -freestyle libre flash glucose monitoring system |
| insulin pumps | basal, regular insulin, continuous can give bolus if person wants to eat more some connect to apps on iphones, others have devices that come with it |
Created by:
ago24