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Nursing 4 Exam 1

Care of client with diabetes

what is diabetes mellitus? metabolic disorder characterized by hyperglycemia due to an absolute or relative lack of insulin or to a cellular resistance to insulin
impact on health of american population sixth leading cause of death due to cardiovascular effects resulting in atherosclerosis, coronary artery disease, and stroke
impact on health of american population leading cause of end stage renal failure, major cause of blindness, and most frequent cause of non-traumatic amputations
glucagon increase BG by stimulating liver and other cells to release stored glucose
insulin helps the body store and use CHO, faats and protein
beta cells release insulin
alpha cells release glucagon
what releases glucose into blood? liver
what takes in glucose from the blood? fat cells
Type 1 DM primary beta-cell destruction & pancreas can't produce insulin
triggers of type 1 DM environmental disorder(diet-cow's milk, viruses) and genetic susceptibility
type 2 DM Insulin resistance, decreased insulin secretion, too much glucose released by the liver
DM cardinal signs polyuria, polydipsia, polyphagia and wt loss(type 1 only)
polyuria occurs b/c... H2O not absorbed from renal tubles b/c of osmotic activity of glucose in tubules
polydipsia occurs b/c... polyuria causes severe dehydration which causes thirst
polyphagia occurs b/c... tissue breakdown and wasting cause a state of starvation that increases hunger
wt loss occurs in type 1 DM b/c... glucose not available to cells, thus body breaks down fat and protein stores for energy
DM diagnosing... fasting plasma glucose(nothing to eat 8hrs prior, >126), casual plasma glucose(random glucose, >200), oral glucose tolerance test(>200, 2hrs post consumption of fluid)
DM diagnosing of FBS, Casual plasma glucose and OGTT requirements... one of the three tests must be positive and must be confirmed on another day with one of the three tests
FPG range <100=normal 100-126 is prediabetic > or = 126 is diabetes
OGTT range <140 is normal 140-200 prediabetic > or = 200 is diabetic
normal fasting blood sugar <100
normal post prandial blood sugar <140
normal HbA1c <6%
prediabetes not high enough for diabetes dx, increased risk for developing type 2 diabetes, if no preventive measure taken-usually develop diabetes w/in 10 years
DM prevention/delay onset maintain normal body weight, exercise regularly, eat a well balanced diet, FBG checks as indicated for early diagnosis
DM intervention Triad of control diet, exercise, and medication
DM interventions home glucose monitoring to assess management status and make adjustments
DM medications insulins, sulfonylureas, biguanides, alpha-glucosidase inhibitors, glitazones, meglitinides, glucagon
insuline indication all type 1 and some type 2 diabetics, diabetics enduring stressors, women w/gestational diabetes, some pt's receiving high caloric feedings including tube feedings or parenteral nutrition
Types of insulin rapid, short, intermediate, and long acting
rapid acting insulin onset 15 minutes
rapid acting insulin peak 60-90 minutes
rapid acting insulin duration 3-4 hours
rapid acting insulins humalog, novolog, and apidra
short acting insulins Regular (Humulin R, Nololin R)-clear
short acting insulin onset 30 mins to 1 hr
short acting insulin peak 2-3 hours
short acting insulin duration 3-6 hours
intermediate acting insulin NPH (Humulin N, Novolin N)-cloudy
intermediate acting insulin onset 2-4 hours
Intermediate acting peak 4-10 hours
intermediate acting duration 10-16
long acting insulin lantus and levemir
long acting onset 1-2 hours
long acting peak no pronounced peak b/c it's a basal insulin
long acting duration 24+ hours
onset the time span after admin when insulin will begin to affect the blood glucose level
peak the time span afer dmin when insulin will have the greatest effect on the blood glucose level
duration the time span after admin when insulin will continue to affect the blood glucose level
long-acting insulin(basal) injected once a day at HS or in the am, released steadily and continuously, no peak action, cannot be mixed w/any other insulin or solution
mixing insulins technique roll bottle of cloudy mix, inject air in cloudy(intermediate), inject air in R or Humalog, withdraw clear insulin, withdraw cloudy without contaminating contents of the clear
insulin is stored at what temp? room temp for 30 days
what will allow insulin to have a longer life being refrigerated
in extreme heat what should you do with your insulin? keep cool and do not freeze
Insulin pump is... continuous subQ infusion and battery operated
how is the insulin pump connected via plastic tubing to a catheter inserted into subQ tissue in the abd wall
insulin pump gives a potention for... tight glucose control
oral hypoglycemic agents are used to treat... DM type 2
what may affect the blood glucose levels while on a hypoglycemic agent specific drugs
oral agents sulfonylureas, meglitinides, biguanides, a-Glucosidase inhibitors, thiazolidinedionesl
sulfonyureas action stimulates pancreatic cells t secrete more insulin & increases sensitivity of periphral tissues to insulin
examples of sulfonylureas glyburide, glipizide, glimepiride
meglitinides action increase insulin production from pancreas
when are meglitinides taken 30 minutes before each meal up to time of meal, should not be takenn if meal is skipped
examples of meglitinides Prandin (repaglinide) & Starlix (nateglinide)
biguanides action reduce glucose production by liver, enhance insulin sensitivity at tissues, improve glucose transport in cells, does not promote wt gain
example of biguanides metformin (glucophage)
when should biguanides never be given? before surgery
when should you stop taking glucophage when your having surgery the night before surgery
when should you start taking glucophage again after surgery not until kidney are checked and you are eating normally
when should you stop taking glucophage when having a prcedure w/injectable iodinated dye the day of the test or the night before
when should you start taking glucophage again after a procedure w/injectable iodinated dye at least 48 hrs after or until your kidneys are checked
what can the glucophage cause if you don't stop taking it before a surgery or procedure with injectable iodine dyes? renal failure
a-Glucosidase inhibitors are "starch blockers" they slow down absorption of carbs in small intestine
example of a-Glucosidase Acarbose (Precose)
s/e of a-Glucosidase inhibitors causes huge amt of gas and stomach cramping
thiazolidinediones is the most effective with those with insulin resistance
Thiazolidinediones improves insulin sensitivity, transport and utilization at target tisues
examples of thiazolidinediones Actos and Avandia
when is pancreas transplantation used for patients with type 1 diabetes who also have end-stage renal dx or had, or plan to have, a kidney transplant
what is usually transplanted withthe pancreas transplant kidney
why is the pancreas transplanted? eliminates need for exogenous insulin and can also eliminate hypoglycemia and hyperglycemia
HbA1c is? glycosolated hemoglobin which measures average BS for last 3 months
DM management? HbA1c, urine ketones & protein, decrease smoking, lipid profile, foot and eye exams, BP & BS readings, liver studies if indicated
normal A1C reduces risk of? retinopathy, nephropathy and neuropathy
acute complications of DM? DKA, HHNK, and hypoglycemia (insulin shock)
long term complications of DM? vascular changes, peripheral neuropathy, visual changes, and infections
surgial car for diabetics preop include: euglycemia for several weeks before if possible, NPO & hold insulin, check BS vefore goeing to OR, verify otherr antidiabetic drugs if short procedure
surgical care of diabetics intra operatively? no insulin or glucose if short procedure and will regulate with 5 or 10% IV glucose & insulin drip if necessary
surgical care of diabetics post op? eat as soon as possible, IV drip will remain until BG are stable & pt is eating, may wean from the drip while resuming subQ insulin, may be controlled by insulin even if not on it at home but prob wont go home on
in children with diabetes it is very important to? monitor and change tx with activity and growth
hypoglycemia is... a s/e of the tx of diabetes. it is an abnormally low level of glucose in the blood
hypoglycemic level... <70 mg/dL
complications of hypoglycemia arise when... an imbalance of glucose intake (or production) and glucose utilization is present
hypoglycemia onset is... rapid
causes of hypoglycemia.. too much insulin, exercise, alcohol intake, skipping meals
What happens when sugar levels drop? glucagon is made(stimulating glycogenolysis & gluconeogenesis) and epinephrine is produced by adrenal glands (suppresses insulin release and inhibits cells responsiveness to insulin)
what is also released by the adrenal glands besides epinephrine? cortisol, which slowly raises BG levels through stimulating gluconeogenesis and suppresses cells respnsiveness to insulin
What is released by the pituitary gland when sugar drop? growth hormone which slowly raises BG levels and causes the cells to respnd less efficiently to insulin
why is hypoglycemia so dangerous? reduced levels of glucose in the brain, may sustain permanent damage, and coma & death
Beta blocker block effects of? epinhephrine
CV symptons of hypoglycemia? r/t the release of epinephrine, rapid HR, sweating, tremors, anxiety, hunger, nausea
CNS symptoms of hypoglycemia? Brain is directly affected due to lack of glucose; light-headedness, confusion, lethargy, h/a, loss of consciousness, seizures, delayed reflexes, slurred speech, coma
treatment of pt with hypoglycemia who is CONSCIOUS? confirm glucose level, admin 15g of rapid acting carb, recheck glucose level in 15 mins, repeat admin of 15g of carb if necessary
What are some kind of 15g carbs to give a pt with hypoglycemia? 1/2 cup OJ, 1 cup milk, 1/3 cup apple juice or reg soda, 1/2 box raisins, 10 jelly beans, 3 tsp honey, 3 glucose tabs, 8 lifesavers, 8 small sugar cubes, 4 tsp sugar, 2 small tube frosting, 1 small tube glucose gel
What is the treatment of a SEMI-CONSCIOUS pt with hypoglycemia? assistance is needed, confirm BG, admin glucagon, if no improvement after 20 mins repeat glucagon, once pt can swallow give 20g of carbs PO, if pt doesn't repsond call 911
Glucagon? raises BS by stimulating the release of glucose from the liver
how is glucagon given? IV, subQ or IM(kit)
when can glucagon be given again if no improvement? 20 mins
if no response of glucagon subQ or IM what must be given? IV glucose & give supplemental CHO when pt responds
What is the treatment for a UNCONSCIOUS pt with hypoglycemia? confirm BG, admin 50% dextrose 20 to 50 ml IV, a continuous infusion of D5W OR D10W
warning signs of hypoglycemia events? 1st sign apparent-confusion
hypoglycemic unawareness causes... the body to adapts to the hypoglycemia so that it takes a lower and lower BG to cause a release of epinephrine and the associated warning signs
nursing diagnosis for hypoglycemic pt's? altered nutrition: less than body requirements, r/t decreased intake or altered metabolism of glucose and knowledge defecit r/t disease process and self care
nursing interventions for a pt with hypoglycemia? supply O2 (semi conscious & conscious), monitor VS, determine BG, give oral glucose(if gag reflex is present) admin 50% dextrose or glucagon (unconscious or no gag reflex), monitor mental status, educate pt and sig others, instruct pt s/s
definition of DKA? metabolic disturbance in which BG levels rise too high resulting in dehydration and excessive fat metabolism
why does fat breakdown occur in DKA? occurs in the liver in an attempt to feed teh starving cells
ketones that are released into the urine during DKA causes... acidosis
protein breakdown in DKA occurs and releasing... urea into the serum
what is the leading cause of death in type 1 diabetics? DKA
Factors that put a pt at risk for DKA? elevated BS's, stress, infection, new onset diabetics, inadequate insulin on board, certain meds(steroids)
What occurs in DKA? the body attempts to rid itself of glucose; osmotic diuresis & water loss occurs
what does the patient lose during DKA? large amounts of extra and intracellular fluid, electrolytes including:K+, Na, Cl, Mag, Phospate
hallmark signs of DKA? blood glucose level above 250, arterial blood Ph below 7.35, serum bicarb less than 15, presence of ketones in the blood and urine
bicarb (CO2) normal level? 22-26
PO2 normal level? 35-45
pH normal level? 7.35-7.45
s/s of DKA are related to? severe hyperglycemia, dehydration, and metabolic acidosis
neurological s/s of DKA? lethargy, confusion, coma, and hyperthermia
pulmonary s/s of DKA? kussmaul respirations, fruity acetone breath(indicates worsening of ketoacidosis)
cardiovascular s/s of DKA? tachycarida, hypotension, dysrhthmias
integumentary s/s of DKA? flushed skin, dry mucous membranes, poor skin turgor(tenting)
renal s/s of DKA? polyuria, ketonuria, glucosuria
GI s/s of DKA? N/V, abd cramps, ileus(intestinal obstruction)
what thing should you do first in a pt with DKA? IV fluids(0.9% NS push), Insulin therapy(hourly glucometers, insulin drip-IV), potassium replacement(insulin drives K+ into cell), bicarbonate replacement(b/c acidotic)
possible complications of DKA? fluid volume overload, hypo/hyperglycemia, hypo/hyperkalemia(can occur in the 1st 4hrs), hyponatremia, cerebral edema, risk for infection
normal K+ level? 3.6-5
Normal Na level? 135-145
nursing diagnosis for DKA? decreased c/o r/t alterations in preload, fluid volume deficit r/t absolute loss, risk for infection, ineffective individual coping r/t situational crisis, knowledge defecit
HHNS? Hyperglycemic Hyperosmolar Nonketotic State
Definition of HHNS? a metabolic disturbance resulting from extremely high blood glucose level resulting in hyperosmolarity and severe dehydrations w/out the production of ketones
patients that are most likely to get HHNS? type 2 diabetics, usually over the age of 65yrs, pts with TPN and pancreatitis
The main difference between DKA and HHNS is that... the pt has SOME insulin in HHNS. This is why ketosis does not occur.
In HHNS blood sugars can rise as much as? 600-2000 mg/dL
a HHNS pt loses large amounts of extra and intracellular fluid, electrolytes including: potassium, sodium, chloride, magnesium, phosphate
plasma glucose in HHNS? >600 mg/dL
arterial pH in HHNS? >7.35
serum bicarb in HHNS? >15
steroids make our blood sugars... go high
causes of HHNS (same as DKA) insufficient insulin, increased endogenous glucose intake(stressed/meds), increased exogenous glucose
neuro s/s of HHNS? confusion, lethargy, seizures, coma
pulmonary s/s of HHNS? shallow or normal respirations
renal s/s of HHNS? polyuria and glucosuria
cardiovascular s/s of HHNS? tachycardia, elevated T waves, and dysrhthmias(sign of K+ imbalance)
GI s/s of HHNS? mild abd discomfort, N/V
what do you do for a pt with HHNS? corret fluid deficit(0.9% NS), insulin therapy, potassium replacement, monitor pt's response to therapy, provide comfort & emotional support, watch for complications
when the BS gets to this level you should switch the 0.9% NS to D5% NS? 250
complications of HHNS? dehydration, fluid volume overload, hypo/hyperglycemia, hyper/hypokalemia, seizures
hot & dry... sugar high
cold & clammy... need some candy
Created by: jbittner