Disorders of the Pancreas
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| Endocrine portion called: | Islets of Langerhans
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| Alpha cells produce: | Glucagon
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| Glucagon | Stimulates the liver to break down (catabolize) glycogen to glucose (glycogenolysis). Increase gluconeogenesis to use fats and excess amino acids for energy production (ketones are a by-product).
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| Glucagon release is stimulated by: | hypoglycemia.
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| Beta cells produce | Insulin
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| Insulin | Enables cells to take in fatty acids & amino acids to use in synthesis of lipids & protein. Increasing use of glucose for energy, promoting storage of excess glucose. Decrease energy production from other food sources, transports trigly into fat tissue.
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| Delta cells produce | Somatostatin, which inhibits secretion of both insulin and glucagon.
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| Diabetes Mellitus - Pathophysiology | Glucose intolerance (faulty production of insulin or tissue insensitivity to insulin). Altered CHO, fat, protein metabolism.
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| Long-term complications of Diabetes | Blindness, kidney failure, heart attacks, strokes. Leading cause of lower limb amputations in the U.S.
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| What is Glucose | Simple sugar provided by foods we eat, used by body for energy, able to enter the cells only w/the help of insulin.
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| What is insulin | Storage hormone, facilitates transport of glucose into cell, helps body store excess glucose in the liver in the form of glycogen.
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| What is Glucagon | Raises blood glucose when needed by releasing the stored glucose from the liver and muscles. Insulin and glucagon work together to keep blood glucose at a constant level.
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| Type 1 diabetes | IDDM (insulin), juvenile (old name). 5-10% cases. Genetic component(10%), autoimmune response to virus, Destruction of beta cells, Pancreas secretes no insulin, common in young thin pts, prone to ketosis.
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| Type 2 diabetes | NIDDM (non-insulin), adult onset, 90-95% cases. lg genetic component(90%), decreased beta cells responsiveness to glucose, reduced # beta cells and tissue sensitivity to insulin, antibodies develop against insulin & become insulin resistant. no ketosis.
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| Gestational diabetes | During pregnancy
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| Pre-diabetes | Glucose intolerance. Occurs prior to the onset of type 2 diabetes, pts may be able to prevent onset of diabetes w/weight loss and exercise.
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| Secondary Diabetes | Pancreatitis, cystic fibrosis, prolonged use of steroids.
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| Diabetes - s/s | The 3 p's (polyuria, polydipsia, polyphagia), fatigue, blurred vision, infection prone, abdominal pain, headache, ketosis/acidosis (only in type 1), Glycosuria (sugar in urine).
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| Fasting plasma glucose | > 126 mg/dL, After at least 8 hours of fasting, drawn by lab, fasting levels over 140 are diagnostic of diabetes. Casual plasma glucose > 200 mg/dL, regardless of when last meal was.
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| Glucose tolerance test | diagnosed >200 mg/dL after 2h, used to evaluate response to carb challenge throughout a 3-5 hr period, normally blood sugar level rises in response to glucose load w/peak levels occ 30-60 mins after challenge, & return to normal fast levels 2-3 hrs later.
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| Glycohemoglobin HgA1c | Normal 4-6%, Through RBC lifespan(120 days), glucose in blood attaches to hemoglobin. irreversible, & occurs at stable rate. Amt of glucose permanently bound to Hgb(HgA1c) reflect avg blood sugar over period of 2-3 mths.
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| C-Peptide | Formed during the making of insulin. Used to evaluate hypoglycemia.
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| C-Peptide can determine: | Distinguishing b/w type 1 & 2 diabetes. Pts whose C-Peptide values are over 1.8 can be managed w/o insulin treatment.
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| How to prevent Type 2 diabetes | Lose 5-7% body weight. 30min exercise 5 days per week. Reduce fat and calories. No way to prevent type 1.
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| What is the tx for diabetes? | No cure for diabetes, but it can be controlled. Diet, exercise, insulin w/type 1, oral hypoglycemic medication in type 2, blood glucose monitoring, education.
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| Goals of tx of diabetes | To prevent or delay complicatons of diabetes. Pre-prandial glucose 90-130 mg/dL (before eating) Peak Postprandial glucose <180 mg/dL (after eating). Blood pressure <130/80 mm/Hg, glycohemoglobin <7%
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| Medical Nutrition Therapy | Goal: maintain blood glucose and lipid levels as close to normal as possible. ADA exchange lists, carb counting, glycemic index, Simple CHO vs. complex CHO, Remember clutural dietary needs.
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| Exercise: | Lowers glucose up to 24 hrs, lowers blood lipids, best done regularly, refer to MD or Exercise Physiologist. Avoid exercise during acute hyperglycemia(blood thick), carry fast sugar(life saver)
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| Medication for diabetes | Very short acting insulin, short acting insulin, intermediate acting insulin, long acting insulin, mixed insulins.
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| Insulin medication - action | Activate process that glucose enter cells of striated muscle & adipose tissue, stimulates sythesis of glycogen by liver, promotes protein synthesis of glycogen by liver, promotes protein synthesis & helps body store fat by preventing breakdown for energy.
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| Insulin meds - Routes | SubQ, IM(fast acting), IV(fast acting), Inhaled, Insulin pump.
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| Insulin meds - How to do injections | Site rotation, give at a different SQ site ea time to avoid injury to the tissue. No need to aspirate, do not rub site after injection, U100 insulin-100 units per mL, U500 insulin-500 units per mL.
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| What should be done before/after each injection | Before each dose of insulin is given, the nurse checks the pts chart for the site of the previous injection and uses a different site. Write on MAR where you give the shot. After giving the injection, the nurse records the site used.
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| Onset | Period of time b/w injection & when it begins to lower blood sugar.
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| Peak | When insulin is working at its hardest and blood glucose is at its lowest point.
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| Duration | Length of time insulin works before it is used up.
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| Regular insulin given IM should be administered w/what type of syringe? | TB syringe.
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| What do you add to insulin to change absorption rates? | Protein and zinc
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| Very short acting insulin | Lispro(humalog), Aspart(novalog), Human rDNA for inhalation(Exubra)
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| Human rDNA for inhalation(Exubra) | Inhaled insulin delivery designed for admin of rapid onset or short duration insulins. Inhaled 10mins ac mealtime, Powder, enters circulation via lungs faster than SQ. May be used w/oral agts or insulin injections.
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| adverse effects of Exubra | Can cause cough, dry mouth, sore throat, chest discomfort or SOB. Not meant to be used by those w/breathing difficulties (disease or smoking).
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| Lispro(humalog) | Very short acting insulin. Onset 5-10mins, Peak 30mins-1.5hrs, Duration 3-5hrs.
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| Aspart(Novalog) | Very short acting insulin. Onset 5-10mins, Peak 1-3hrs, Duration 3-5hrs
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| Regular (Humulin R, Novalin R) | Short acting insulin. Onset 30-60 mins, Peak 2-4hrs, Duration 8-12hrs.
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| NPH (Humulin N, Novalin N) | Intermediate acting insulin. Onset 1.5 hrs, Peak 4-12 hrs, Duration 24hrs.
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| Ultralente (Humulin U) | Long acting insulin. Onset 4-8hrs, Peak 10-30hrs, Duration 20-36hrs.
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| Glargine (Lantus) | NOT TO BE MIXED W/ANYTHING ELSE! Onset 1hr, Peak 5hrs, Duration 24hrs.
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| Mixed insulins | Combine regular insulin w/the longer acting NPH insulin. Available in ratios of 70/30 and 50/50 of NPH to Regular. Helpful for pts who have difficulty drawing up their insulin & seeing the markings on the syringe but may be less effective.
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| Storage of insulin | Kept at room temp away from heat & direct sun, used w/in 1 month (up to 3 if in fridge) vials not in use stored in fridge. Prefilled insluin in glass/plastic syringes stable for week under refrigeration. Before injection, roll syringe b/w palms to remix.
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| How to dispose a needle and syringe | Puncture proof containers specifically used for disposal may be obtained from pharmacies, clinics or PCP. Teach pt not to dispose in trash. Filled container should be rtnd to where container was purchased for disposal. Hospitals will take containers.
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| Intensive Insulin therapy | A single dose of intermediate or long acting insulin is taken in a.m. or at h.s. Small doses of reg insluin are taken ac meals based on pts blood glucose levels. Allows for greater flexibility in pts lifestyle, but can be inconvenient.
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| Insulin pump | Provide continuous administration of short acting insulin SQ. Change insertion site every 48-72 hrs & refill the pump w/insulin. Pump delivers a basal rate of insulin 24hrs a day. Boluses can be delivered at mealtimes. Allows for tighter Glycemic control.
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| Prepare insulin for Administration | Check exp date. Make sure insulin syringe matches the concentration of insulin to be given. When insulin is in suspension, rotate vial b/w palms of hands/tilt end to end before w/drawing. No air bubbles. Check type & dosage. Double ck w/other nurse.
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| Mixing insulin | Clear to cloudy (draw clear first). When regular and another insulin mixed in same syringe, must be administered w/in 5mins. DO NOT MIX LANTUS (GLARGINE)
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| Drawing up 2 types of Insulin | After cleansing tops of both Humulin R insulin and Humulin N, w/the container upright, the nurse injects air into the Humulin N (cloudy) then air into Humulin reg vial and w/draw insulin then w/draw from Humulin N. Nurse double check.
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| Sliding scale insulin | Used during times of stress or illness. Involves determining each dose of short acting insulin based on blood glucse results, usually before meals and at bedtime. Ex. FSBS QID & HS w/sliding scale as follows: <200 - No insulin; 201-250 2 units regular.
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| Oral hypoglycemics for Type 2. | NOT INSULIN. Affect the way insulin & glucose are made and used by the body. Necessary for pt to have some endogenous insulin ffor it to take effect. Not used for Type 1.
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| Oral - Action | Depends on medication. Stimulate pancreas. Increase tissue sensitivity to insulin. Slow CHO Digestion and absorption.
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| Two groups of oral antidiabetic drugs | Sulfonylureas and Nonsulfonylureas
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| Sulfonylureas | Lowers blood glucose by stimulating the beta cells of the pancreas to release insulin. Not effective if cells can't release a sufficient amt of insulin to meet needs. Help make more insulin.
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| Sulfonylureas - 1st generation | Diabenese (Chlorpropamide). Not commonly used today because long duration of action & higher incidence of adverse reaction
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| Sulfonyureas - 2nd & 3rd generation | Amaryl (glimepiride), Glucotrol (glipizide), DiaBeta, Micronase(glyburide)
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| Meglitinides | Nateglinide (Starlix), Repaglinide (Prandin)
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| Repaglinide (Prandin) | Used in type 2 diabetes in combination w/metformin (glucophage), a nonsulfonylurea, to improve glycemic control.
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| Nonsulfonylureas | Alpha Glucosidase Inhibitors, Biguanides, precose(acarbose) and Avandia(rosiglitazone)& Actos(pioglitazone)
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| Nonsulfonylureas - Adverse reactions | GI upset major adverse reaction associated w/nonsulfonylureas. Metallic tase, abdominal bloating, nausea, cramping, flatulence, and diarrhea.
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| Alpha Glucosidase Inhibitors | Precose(acarbose), Glyset(miglitol) Lower blood glucose levels by delaying the digestion of carbs and absoroption of carbs in the intestines. Given w/1st bite of meal because food increases absorption.
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| Biguanides | Metformin. Sensitizes liver to circulating insulin levels & reduces hepatic glucose production. Risk acute renal failure when iodinated contrast material for radiologic studies admin w/metformin. Metformin therapy stopped for 48 hrs before/after studies.
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| Precose | acarbose. Lower blood glucose levels by delaying the digestion of carb and absorption of carb in the intestines.
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| Avandia & Actos | Rosiglitazone & Pioglitazone. Decrease insulin resistance and increase insulin sensitivity by modifying several processes.
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| Oral New Developments | Sitagliptin(Januvia), Exenatide(byetta)injectable, Pramlintide (symlin)injectable.
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| Exenatide (Byetta) | injectable. Works in conjunction w/oral hypoglycemic agents to stimulate insulin secretion, lower the production of glucagon, slow gastric emptying, and promote weight loss.
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| Pramlintide (Symlin) | Injectable. Used w/insulin, reduces glucose levels following meal, may also promote weight loss.
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| Alternate sites (other than fingertips) to use lancets. | Forearm, bicep area, palm of hand, t/w fingers, and sometimes the calf. Consistently use same alternate site. Rub area vigorously before pricking.
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| Hyperglycemia | BS>126 mg/dL
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| Hyperglycemia - Causes | Overeating, Stress, Illness, Not enough medication.
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| Hyperglycemia - S/S | 3 P's (Polyuria, Polydipsia, Polyphagia), blurred vision, fatigue, lethargy, HA, abdominal paine ketonuria, coma, Chronic high blood sugars can lead to long term complications.
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| Hyperglycemia - Treatment | Check B/S. Sliding scale insulin as ordered. If B/S >300, check ketones if ordered, determine cause and eliminate >200 for 2d, call MD. Call MD if ill or vomiting.
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| Hypoglycemia | Insulin reaction. B/S <50. Pts will experience symptoms at higher levels.
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| Hypoglycemia - causes | Too much insulin, exercise, not enough food, repeated or extremely low blood glucose levels can cause neurological damage because there is not enough glucose for breain function.
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| Hypoglycemia - Symptoms | Headache, Hunger, Fight/Flight (shaky, cold sweat, palpitations) Neuroglycopenia (brain deprived of glucose) act immediately! irritability, confusion, sizures, coma. CAUTION! People on B-blockers may not have symptoms.
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| Hypoglycemia - Treatment | Check blood glucose, administer 15g Fast acting CHO(simple sugar) Recheck in 15min, Repeat PRN. When normal Protein snack if >1h until meal
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| What are fast sugars? | 4oz OJ, 6oz Soda(not diet), Miniature box of raisins, Commercial glucose tablet. 6-8 life savers.
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| Acute tx if patient unable to swallow to get sugar up? | IV D50 (in hospital) SQ Glucagon (goes to liver to release sugar) Homrone produced by the alpha cells of the pancreas, Acts to increase blood glucose b stimulating conversion of glycogen to glucose in liver. Return to consciousness 5-20min after admin.
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| Diabetic Ketoacidosis - Causes | High blood sugar in type 1 diabetes, stress, illness.
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| Diabetic Ketoacidosis - Pathophysiology | No insulin, Cells starving, fat breaks down, byproduct of fat breakdown is ketones, ketones are acidic.
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| Diabetic Ketoacidosis - S/S | Flu-like symptoms, symptoms of hyperglycemia, kussmaul's respirations (fast blowing), Fruity breath-caused by ketones, electrolyte imbalance-dehydration, coma, death.
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| Diabetic Ketoacidosis - Therapeutic interventions | IV fluids, IV insulin drip, frequent glucose monitoring(once glucose down to 180, glucose added to IV to prevent hypoglycemia. Electrolyte monitoring.
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| Diabetic Ketoacidosis - Prevention | Check Ketones if BS>300, drink fluids, check again w/next urination, call MD if still present. Good diabetes control!
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| HHNK(Hyperglycemic hyperosmolar nonketotic syndrome)- causes | Hyperglycemia in Type 2 diabetes, sress, illness, most common in elderly.
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| HHNK - Pathophysiology | Blood glucose elevated, polyuria, profound dehydration (dry mucous membranes), no nausea and vomiting, so slower to get help, mortality rate 10-20%
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| HHNK - S/S | Extreme dehydration, lethargy, blood glucose may be 1000-1500, electrolyte imbalance, coma, death.
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| HHNK - Therapeutic Interventions | IV fluids, IV Insulin drip, frequent glucose monitoring, electrolyte monitoring.
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| HHNK - Prevention | Accuchecks
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| HHNK - What to do if glucose rising? | Drink fluids, lower glucose.
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| HHNK - Long term complications | Macrovascular changes, stroke, MI, peripheral Vascular Disease, Risk of Cardiovascular disease and strokes 2-4x more common in people w/diabetes than the general population.
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| Microvascular changes | Retinopathy, nephropathy(kidneys), Primary risk factor for diabetic nephropathy is poor control of blood glucose. Leading cause of end stage renal failure (ESRD)
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| Neuropathy | Damage to nerves as result of chronic hyperglycemia. Numbness & pain in extremities. New drug Lyrica for nerve pain. Erectile dysfunction in males, Sexual dysfunction in women, gastroparesis(delayed stomach emptying), infection, foot problems.
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| Care of pt undergoing surgery | Frequent glucose monitoring, sliding scale insulin or insulin drip. High blood sugars interfere w/immune function & healing, & can increse risk of infection. People who were not previously on insulin may be put on a sliding scale post op.
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| Diabetes Self Mgmt Education | Disease process & treatment, Nutrition therapy, exercise, medications, accuchecks, acute complications, chronic complications, goal setting, psychosocial adj, pregnancy mgmt.
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| Reactive hypoglycemia | Hyperresponsiveness of pancreas, low blood glucose, sympathetic "fight or flight" response.
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| Reactive hypoglycemia - therapeutic interventions | Frequent small meals, high protein, low CHO diet, Avoid simple sugars.
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