Glucose Control
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| Insulin | Hormone produced by beta cells of the islets of Langerhans. Released into circulation when the levels of glucose around these rise. Stimulates the synthesis of glycogen, the conversion of lipids into fat stored in the form of adipose tissue.
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| Metabolic Changes occurring when insufficient insulin is released | Hyperglycemia: Increased blood sugar. Glycosuria: sugar in urine. Polyphagia: increased hunger. Polydipsia: increased thirst. Lipolysis: fat breakdown. Ketosis: Ketones cannot be removed effectively. Acidosis: liver cannot remove all of the waste products
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| Symptoms of diabetes (the three P's) | Increased serum glucose causes an osmotic pull of fluid from cells into vascular compartment-then diuresis in kidney from excess glucose-then thirst due to increased serum osmolarity.
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| The three P's | Polyuria: increase urination
Polydipsia: increased thirst
Polyphagia: increased hunger
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| Diagnosis of Diabetes Mellitus | Average serum glucose over months <7%.
>200=DM
>120 fasting=prediabetes
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| Atherosclerosis | Heart attacks and strokes related to the development of atherosclerotic plaques in the vessel lining. Associated with DM
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| Retinopathy | With resultant loss of vision as tiny vessels. In the eye are narrow and closed. Associate with DM.
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| Neuropathies | With motor and sensory changes in the feet and legs and progressive changes in other nerves as the oxygen is cut off. Associated with DM
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| Nephropathy | With renal dysfunction related to changes in the basement membrane of the glomerulus. Associate with DM
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| Clinical Signs and symptoms of hyperglycemia | Fatigue, lethargy, irritation, glycosuria, polyphagia, polydipsia, itchy skin
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| Signs of Impending Dangerous Complications of Hyperglycemia | Fruity breath: ketones build up in system & excreted thru lungs. Dehydration: fluid & important electrolytes lost through kidneys. Slow, deep resp (Kussmaul's resp): body tries to rid itself of high acid levels. Loss of orientation: brain cells dehydrated
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| Commercially prepared insulin | Beek, pork (not currently in USA). Human (Humulin) made through recombinant DNA** Available in vials and pens and inhalant.
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| Rapid acting Insulin* | Lispro (Humalog), aspart (Novolog)
Onset 15 mins Peak 2-4 hrs
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| Short Acting Insulin* | Regular (Humulin)
Onset 30 mins Peak 4-10 hours
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| Long Acting Insulin* | Provide basal insulin. Detemir (Levemir). Lantus (Glargine)-analog of human insulin, give once/day at bedtime, 24hr duration, less nighttime hypoglycemia. Does not have a peak as does other type of insulin*. NO mixing with other insulins
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| Combining Insulins | Humulin or Novolin 70/30=70% intermediate with 30% short-acting= NPH+Regular. Used for pts when it is difficult for pt to mix insulins, such as elderly or pts with neuropathy** Also should be a fairly stable dose
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| Storage of insulin | Refrigerate unopened vials**. Once opened it can be at room temp for 1 month or in the refrigerator for 3 months** Insulin injector pens good for approx. 4 weeks. Pre-filled syringes in refrigerator (use in 1-2 weeks)**
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| Some insulins may be combined in syringe--NOT ALL | Short acting should always be drawn into syringe first if mixing with longer acting insulin**
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| Regular Insulin | should be crystal clear in vial** Only type that can be given IV** can be given in infusion/insulin drip**
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| Lispro, aspart insulin | Rapid onset, give within 5-10 minutes before eating. Do not mix.
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| Insulin resistance | Most common with beef or pork insulin. Also more common in obese clients.
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| Main side effect of insulin | Hypoglycemia.
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| Diabetic Ketoacidosis (DKA) | Cause by lack of insulin, Type I DM. Frequently triggered by illness, URI, UTI.
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| HHNK Hyperosmolar hyperglycemic nonketotic (HHNK) | Cause by relative lack of insulin, Type II DM. Too much CHO
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| What is the current preferred tx of DM | The use of short and longer acting combinations and several injections per day** Type I always this way. Type II maybe.
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| Requirements for insulin | Change with exercise, illness, drugs. Decreased insulin needed if more exercise*** More insulin needed if illness (stress response)*** Insulin may be administered in adjustment doses that depend on individual blood glucose test results (sliding scales)***
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| Methods of Insulin administrations | Sub Q Injection. Insulin pumps: contain regular or rapid acting insulin** Expensive. Keep blood glucose levels close to normal b/c deliver basal dose and then additional dose depending on need.
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| Insulin pen injectors | convenient increase compliance
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| Intranasal insulin | Available but difficult to regulate
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| Insulin jet injectors | needles systems that inject insulin
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| Major complication of Insulin use | Hypoglycemia-glucose <70**. Feed pt if able, 6gm of glucose. Administer Dextrose 50% IV. If insulin induced-correct by glucagon* Only for Type II DM.
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| Criteria for use of oral antidiabetic drugs | Onset of DM at > 40yrs. Diagnosis < 5yrs. Need <40 U insulin/day. Fasting glucose <200mg. Normal renal & hepatic function. Some pts may use oral med + insulin, or combo of oral agents. Must be taught signs & symptoms of hyper & hypoglycemia
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| Type II DM | make insulin, but not enough, or no receptors
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| Type I DM | Do not make insulin
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| Sulfonylureas | Must check sulfa allergy***. Act by stimulating secretion of insulin so must have functioning islets.
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| First-Generation Sulfonylureas | Short acting (Orinase). Intermediate-acting (Tolinase). Long-acting (Diabinese).
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| Second-generation Sulfonylureas | Glipizide (Glucotrol)** Glyburide (Diabeta) Glimepiride (Amaryl)
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| Characteristics of Second-Generation Sulfonylureas | Less drug interactions, more potent. Increase tissue response. Decrease liver production of glucose. Longer duration. Less drug interactions with other protein bound drugs. Glimepiride less expensive.
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| Sulfonylureas Characteristics | Some may be given with insulin. Second generation not used if the client has liver or kidney dysfunction. Avoid alcohol with Sulfonyureas** -Can increase 1/2 life. Highly protein bound drug.
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| Hypoglycemic reaction** Sulfonyureas | Similar to those of insulin. More frequent in older patients.
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| Biguanides: Metformin (Glucophage) | Oral antidiabetic drug. Decrease hepatic glucose production from stored glycogen. Decrease absorption of glucose from small intestine. Increase insulin receptor sensitivity. Doesn't cause hyper or hypoglycemia**
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| Metformin (Glucophage)Nursing Directives | Hold 48 hrs prior to and after IV contrast dye due to increased risk of lactic acidosis or renal failure** (Use insulin in meantime)
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| Alpha-glucosidase Inhibitors | Oral AntiDM. Acarbose (Precose) Migiltol (Glyset). Decrease CHO absorption from intestine doesn't cause hypoglycemia if used alone** Only mild effect on glucose levels. Associated with Hepatic toxicity. Frequently used with other oral antiDM drugs.
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| Thiazolidinediones | Pioglitazone (Actos). Rosiglitazone (Avandia). Act by: Decreasing insulin resistance** (Work at receptor sites). Can be used in combination with sulfonylureas.
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| Meglitinides | Repaglinide (Prandin) Nateglinide (Starlix). Act: similar action to sulfonylureas. Rapid acting. Do not use with liver dz. Can be used with metformin.
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| Incretin Mimetics | Luraglutide (Victoza). Act by enhance insulin secretion, decrease glucagon secretion, slow gastric emptying. Given by injection**
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| Dipeptidyl peptidase-4 inhibitors | Sitagliptin (Januvia). Prolong effects of insulin, decrease glucagon secretion, slow gastric empty. Oral, take once a day
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| Using Insulin to treat hyperglycemia | Usually give short acting to cover pre meal, or when expect changes. Add intermediate acting when estimated daily needs found and supplement as needed with short acting
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| Other treatments to hyperglycemia | Fluids: to replenish loss from osmotic diuresis. May need K replaced. Start with normal saline 0.9% then switch to more specific to match loss. Electrolytes: K replacement, watch change if acidotic.
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| Causes of hyperglycemia | Frequently infection or other physiologic stressor, maybe too much food or didn't take drugs.
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| Glucagon** | Emergency treatment for hypoglycemia. Counteracts insulin effects (counter current effect). Stimulates glycogen breakdown. Use if other method to give glucose not available. Give IV, IM, SC.
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| Diazoxide (Proglycem) | Not for emergency use. Inhibits insulin release from the beta cells. For clients with hyperinsulinism.
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| Treatment of Hypoglycemia | EAT-juice, hard candy. Oral glucose tablets, or solution. IV dextrose, usually give 1/2 to 1 amp of dextrose 50%. Glucagon-IV, IM, Sub Q.
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| Causes of hypoglycemia | Too much drug. Didn't eat. Too much exercise.
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