Care of client with diabetes
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| 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
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| impact on health of american population | sixth leading cause of death due to cardiovascular effects resulting in atherosclerosis, coronary artery disease, and stroke
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| 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
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| glucagon | increase BG by stimulating liver and other cells to release stored glucose
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| insulin | helps the body store and use CHO, faats and protein
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| beta cells release | insulin
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| alpha cells release | glucagon
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| what releases glucose into blood? | liver
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| what takes in glucose from the blood? | fat cells
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| Type 1 DM | primary beta-cell destruction & pancreas can't produce insulin
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| triggers of type 1 DM | environmental disorder(diet-cow's milk, viruses) and genetic susceptibility
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| type 2 DM | Insulin resistance, decreased insulin secretion, too much glucose released by the liver
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| DM cardinal signs | polyuria, polydipsia, polyphagia and wt loss(type 1 only)
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| polyuria occurs b/c... | H2O not absorbed from renal tubles b/c of osmotic activity of glucose in tubules
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| polydipsia occurs b/c... | polyuria causes severe dehydration which causes thirst
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| polyphagia occurs b/c... | tissue breakdown and wasting cause a state of starvation that increases hunger
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| wt loss occurs in type 1 DM b/c... | glucose not available to cells, thus body breaks down fat and protein stores for energy
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| 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)
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| 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
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| FPG range | <100=normal 100-126 is prediabetic > or = 126 is diabetes
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| OGTT range | <140 is normal 140-200 prediabetic > or = 200 is diabetic
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| normal fasting blood sugar | <100
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| normal post prandial blood sugar | <140
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| normal HbA1c | <6%
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| 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
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| DM prevention/delay onset | maintain normal body weight, exercise regularly, eat a well balanced diet, FBG checks as indicated for early diagnosis
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| DM intervention Triad of control | diet, exercise, and medication
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| DM interventions | home glucose monitoring to assess management status and make adjustments
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| DM medications | insulins, sulfonylureas, biguanides, alpha-glucosidase inhibitors, glitazones, meglitinides, glucagon
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| 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
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| Types of insulin | rapid, short, intermediate, and long acting
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| rapid acting insulin onset | 15 minutes
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| rapid acting insulin peak | 60-90 minutes
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| rapid acting insulin duration | 3-4 hours
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| rapid acting insulins | humalog, novolog, and apidra
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| short acting insulins | Regular (Humulin R, Nololin R)-clear
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| short acting insulin onset | 30 mins to 1 hr
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| short acting insulin peak | 2-3 hours
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| short acting insulin duration | 3-6 hours
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| intermediate acting insulin | NPH (Humulin N, Novolin N)-cloudy
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| intermediate acting insulin onset | 2-4 hours
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| Intermediate acting peak | 4-10 hours
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| intermediate acting duration | 10-16
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| long acting insulin | lantus and levemir
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| long acting onset | 1-2 hours
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| long acting peak | no pronounced peak b/c it's a basal insulin
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| long acting duration | 24+ hours
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| onset | the time span after admin when insulin will begin to affect the blood glucose level
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| peak | the time span afer dmin when insulin will have the greatest effect on the blood glucose level
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| duration | the time span after admin when insulin will continue to affect the blood glucose level
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| 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
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| 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
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| insulin is stored at what temp? | room temp for 30 days
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| what will allow insulin to have a longer life | being refrigerated
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| in extreme heat what should you do with your insulin? | keep cool and do not freeze
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| Insulin pump is... | continuous subQ infusion and battery operated
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| how is the insulin pump connected | via plastic tubing to a catheter inserted into subQ tissue in the abd wall
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| insulin pump gives a potention for... | tight glucose control
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| oral hypoglycemic agents are used to treat... | DM type 2
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| what may affect the blood glucose levels while on a hypoglycemic agent | specific drugs
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| oral agents | sulfonylureas, meglitinides, biguanides, a-Glucosidase inhibitors, thiazolidinedionesl
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| sulfonyureas action | stimulates pancreatic cells t secrete more insulin & increases sensitivity of periphral tissues to insulin
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| examples of sulfonylureas | glyburide, glipizide, glimepiride
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| meglitinides action | increase insulin production from pancreas
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| when are meglitinides taken | 30 minutes before each meal up to time of meal, should not be takenn if meal is skipped
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| examples of meglitinides | Prandin (repaglinide) & Starlix (nateglinide)
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| biguanides action | reduce glucose production by liver, enhance insulin sensitivity at tissues, improve glucose transport in cells, does not promote wt gain
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| example of biguanides | metformin (glucophage)
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| when should biguanides never be given? | before surgery
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| when should you stop taking glucophage when your having surgery | the night before surgery
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| when should you start taking glucophage again after surgery | not until kidney are checked and you are eating normally
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| when should you stop taking glucophage when having a prcedure w/injectable iodinated dye | the day of the test or the night before
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| 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
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| what can the glucophage cause if you don't stop taking it before a surgery or procedure with injectable iodine dyes? | renal failure
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| a-Glucosidase inhibitors are | "starch blockers" they slow down absorption of carbs in small intestine
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| example of a-Glucosidase | Acarbose (Precose)
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| s/e of a-Glucosidase inhibitors | causes huge amt of gas and stomach cramping
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| thiazolidinediones is the most effective with those with | insulin resistance
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| Thiazolidinediones improves | insulin sensitivity, transport and utilization at target tisues
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| examples of thiazolidinediones | Actos and Avandia
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| 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
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| what is usually transplanted withthe pancreas transplant | kidney
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| why is the pancreas transplanted? | eliminates need for exogenous insulin and can also eliminate hypoglycemia and hyperglycemia
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| HbA1c is? | glycosolated hemoglobin which measures average BS for last 3 months
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| DM management? | HbA1c, urine ketones & protein, decrease smoking, lipid profile, foot and eye exams, BP & BS readings, liver studies if indicated
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| normal A1C reduces risk of? | retinopathy, nephropathy and neuropathy
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| acute complications of DM? | DKA, HHNK, and hypoglycemia (insulin shock)
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| long term complications of DM? | vascular changes, peripheral neuropathy, visual changes, and infections
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| 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
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| 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
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| 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
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| in children with diabetes it is very important to? | monitor and change tx with activity and growth
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| hypoglycemia is... | a s/e of the tx of diabetes. it is an abnormally low level of glucose in the blood
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| hypoglycemic level... | <70 mg/dL
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| complications of hypoglycemia arise when... | an imbalance of glucose intake (or production) and glucose utilization is present
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| hypoglycemia onset is... | rapid
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| causes of hypoglycemia.. | too much insulin, exercise, alcohol intake, skipping meals
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| 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)
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| 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
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| 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
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| why is hypoglycemia so dangerous? | reduced levels of glucose in the brain, may sustain permanent damage, and coma & death
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| Beta blocker block effects of? | epinhephrine
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| CV symptons of hypoglycemia? | r/t the release of epinephrine, rapid HR, sweating, tremors, anxiety, hunger, nausea
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| 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
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| 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
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| 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
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| 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
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| Glucagon? | raises BS by stimulating the release of glucose from the liver
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| how is glucagon given? | IV, subQ or IM(kit)
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| when can glucagon be given again if no improvement? | 20 mins
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| if no response of glucagon subQ or IM what must be given? | IV glucose & give supplemental CHO when pt responds
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| 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
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| warning signs of hypoglycemia events? | 1st sign apparent-confusion
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| 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
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| 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
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| 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
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| definition of DKA? | metabolic disturbance in which BG levels rise too high resulting in dehydration and excessive fat metabolism
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| why does fat breakdown occur in DKA? | occurs in the liver in an attempt to feed teh starving cells
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| ketones that are released into the urine during DKA causes... | acidosis
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| protein breakdown in DKA occurs and releasing... | urea into the serum
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| what is the leading cause of death in type 1 diabetics? | DKA
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| Factors that put a pt at risk for DKA? | elevated BS's, stress, infection, new onset diabetics, inadequate insulin on board, certain meds(steroids)
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| What occurs in DKA? | the body attempts to rid itself of glucose; osmotic diuresis & water loss occurs
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| what does the patient lose during DKA? | large amounts of extra and intracellular fluid, electrolytes including:K+, Na, Cl, Mag, Phospate
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| 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
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| bicarb (CO2) normal level? | 22-26
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| PO2 normal level? | 35-45
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| pH normal level? | 7.35-7.45
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| s/s of DKA are related to? | severe hyperglycemia, dehydration, and metabolic acidosis
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| neurological s/s of DKA? | lethargy, confusion, coma, and hyperthermia
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| pulmonary s/s of DKA? | kussmaul respirations, fruity acetone breath(indicates worsening of ketoacidosis)
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| cardiovascular s/s of DKA? | tachycarida, hypotension, dysrhthmias
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| integumentary s/s of DKA? | flushed skin, dry mucous membranes, poor skin turgor(tenting)
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| renal s/s of DKA? | polyuria, ketonuria, glucosuria
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| GI s/s of DKA? | N/V, abd cramps, ileus(intestinal obstruction)
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| 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)
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| possible complications of DKA? | fluid volume overload, hypo/hyperglycemia, hypo/hyperkalemia(can occur in the 1st 4hrs), hyponatremia, cerebral edema, risk for infection
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| normal K+ level? | 3.6-5
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| Normal Na level? | 135-145
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| 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
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| HHNS? | Hyperglycemic Hyperosmolar Nonketotic State
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| 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
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| patients that are most likely to get HHNS? | type 2 diabetics, usually over the age of 65yrs, pts with TPN and pancreatitis
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| The main difference between DKA and HHNS is that... | the pt has SOME insulin in HHNS. This is why ketosis does not occur.
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| In HHNS blood sugars can rise as much as? | 600-2000 mg/dL
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| a HHNS pt loses large amounts of extra and intracellular fluid, electrolytes including: | potassium, sodium, chloride, magnesium, phosphate
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| plasma glucose in HHNS? | >600 mg/dL
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| arterial pH in HHNS? | >7.35
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| serum bicarb in HHNS? | >15
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| steroids make our blood sugars... | go high
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| causes of HHNS (same as DKA) | insufficient insulin, increased endogenous glucose intake(stressed/meds), increased exogenous glucose
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| neuro s/s of HHNS? | confusion, lethargy, seizures, coma
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| pulmonary s/s of HHNS? | shallow or normal respirations
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| renal s/s of HHNS? | polyuria and glucosuria
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| cardiovascular s/s of HHNS? | tachycardia, elevated T waves, and dysrhthmias(sign of K+ imbalance)
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| GI s/s of HHNS? | mild abd discomfort, N/V
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| 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
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| when the BS gets to this level you should switch the 0.9% NS to D5% NS? | 250
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| complications of HHNS? | dehydration, fluid volume overload, hypo/hyperglycemia, hyper/hypokalemia, seizures
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| hot & dry... | sugar high
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| cold & clammy... | need some candy
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