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Insulin-dependent diabetes, the pancreas does not produce insulin as it should. Can be idiopathic or related to autoimmunity.

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Type 1 DM

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Insufficient release of insulin, or the body's ells are resistant to insulin, making it more difficult for insulin to "unlock" the cell and let glucose in.

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Type 2 DM

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Glucose does not enter the cell and instead builds up i the blood causing a host of problems including organ damage, blindness and neuropathic pain.

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What happens when there's not enough insulin produced in the body?

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Affects Type 1 diabetics Blood Glucose > 250 pH < 7.3 Serum bicarb <15 Moderate to severe ketones in the blood or urine Typical BG range 300-800 mg/dL

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DKA (Diabetic Ketoacidosis) criteria

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Polyphagia Polydipsia Polyurea Headache Fatigue

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Early symptoms of DKA

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Nausea/Vomiting (very common) Extreme fatigue Kussmaul respirations Weight loss Dehydration CNS depression Decreased LOC

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Later Symptoms DKA

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1. Fluid restriction (up to 6L) 2. Insulin gtt to decrease BS by 50-70 mg/dL each hour 3. Change IV fluids containing little glucose once BS is below 200-250 to prevent hypoglycemia. (D5W w/ 0.45% NaCl) 4. Monitor anion gap, serum osmolality, BUN, creatinine, sodium and potassium 5. When BS is within goal, anion gap is closed, and pH is normal, pt will transition off the insulin gtt and get a dose of lantus and something to eat. *Note: As insulin "unlocks" the cell, the sugar travels into the cell taking the potassium along with it which can lead to hypokalemia.

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Treat DK

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Occurs with type 2 diabetes. BS > 600 pH > 7.3 serum bicarb > 15 serum osmol > 320 mild or no ketones No utilization of fats/proteins for energy

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HHS (Hyperglycemic Hyperosmolar State)

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1. Rapid fluid resuscitation, 7-10L 2. Monitor serum sodium as you rehydrate with 0.9% NaCl, if rises, change to hypotonic solution 3. BS reaches 200-250, change fluid to D5W with 0.45% 4. Insulin gtt with goal of dropping blood glucose by 50-70 every hour 5. Hourly monitoring of blood glucose levels 6. Electrolyte monitoring and replacement (especially K, Phos, Na) 7. Monitor urine output, serum osmol, BUN, creatinine 8. CVP monitoring if patient in hypovolemic shock 9. Watch for signs of fluid overload

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Treating HHS

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1. How to take blood sugar 2. How to calculate correctional dosage 3. When to take blood sugar, when to take insulin or oral meds 4. How to calculate carbs and make good dietary choices 5. No candy 6. Exercise 7. S/S hyper/hypoglycemia 8. Sick day protocol

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Educate patient with DKA and HHS

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1. Check BS every 2-4 hours 2. Goal BS 240 for more than 24 hours 2. Vomiting/diarrhea 3. Severe pain 4. Moderate to large ketones 5. Neurological symptoms

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Sick Day Protocol

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BG level usually greater than 250 mg/dL

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Hyperglycemia

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(Excess urine production and frequency) from osmotic diuresis

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Polyuria

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(Excessive thirst) due to dehydration 1. Loss of skin turgor, skin warm and dry 2. Dry mucous membranes 3. Weakness and malaise 4. Rapid weak pulse and hypotension

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Polydipsia

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(Excessive hunger and eating) caused from inability of cells to receive glucose (cells are starving) 1. Client may display weight loss 2. Ketones accumulate in the blood due to breakdown of fatty acids when insulin is not available, resulting in metabolic acidosis 3. Kussmaul respirations

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Polyphagia

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1. Random BG level > 200 mg/dL 2. Fasting BG level > 126 mg/dL 3. 2-hr glucose > 200 mg/dL with an oral glucose tolerance test

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Diagnostic criteria for diabetes include which two findings (on separate days) of one of the following:

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Y

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For a fasting BG do you need to postpone administration of antidiabetic medications?

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4-6% With diabetes 6.5-8%, with a target goal of < 7% HbA1c is the best indicator of the average BG level for the past 120 days

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Glycosylated hemoglobin (HbA1c) expected ranges and why is it the best indicator.

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High ketones in the urine associated with hyperglycemia (exceed 300 mg/dL)

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Urine Ketones

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1. Accidental cessation of insulin administration 2. Obstruction of the tubing/needle 3. Pump failure 4. Infection

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Complications of insulin pump therapy

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1. Rapid-acting 2. Short-acting 3. Intermediate-acting 4. Long-acting

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Types of insulin

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Names: 1. Lispro (Humalog) 2. Aspart (Novolog) 3. Glulisine (Apidra) When to administer: 1. Before meals to control postprandial rise in BG Onset: 1. Rapid, 10-30min depending on which insulin is administered How to administer: 1. In conjuction with intermediate or long-acting insulin to provide glycemic control between meals and at night

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Rapid-acting insulin (Names, when to administer, onset, how to administer)

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Names: 1. Regular Insulin (Humulin R, Novolin R) When to administer: 1. 30-60 min before meals to control postprandial hyperglycemia Concentrations: 1. U-500 for the client who has insulin resistance and is never administered IV 2. U-100 prescribed for most clients and may be administered IV

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Short-acting insulin (Names, when to administer, concentrations available)

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Names: 1. NPH (Humulin N) 2. Detemir (Levemir) When to administer: 1. For glycemic control between meals and at night 2. Not before meals Protein contained: 1. Protamine, causes a delay in the insulin absorption or onset and extends the duration of action of the insulin How to administer: 1. Only insulin to mix with short-acting insulin

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Intermediate-acting insulin (Names, when to administer, what protein does it contain, how to administer)

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Name: 1. Glargine (Lantus) Administer: 1. Once daily, anytime during the day but always at the same time each day Onset: 1. Forms microprecipitates that dissolve slowly over 24 hours and maintains a steady blood sugar level with no peaks or troughs

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Long-acting insulin (Names, when to administer, onset, how to administer)

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Lump under the skin from not rotating injection sites

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Lipohypertrophy

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Draw up the shorter-acting insulin into the syringe first and then the longer-acting insulin.

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How to mix rapid/short-acting with a longer-acting insulin

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1. Mild shakiness 2. Mental confusion 3. Sweating 4. Palpitations 5. Headache 6. Lack of coordination 7. Blurred vision 8. Seizures 9. Coma

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Hypoglycemia symptoms

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Glucose of 70mg/dL or less: 1. Take 15-20g of simple carbs and recheck BG in 15 min. 2. Repeat the administration of carbs if not within normal limits, recheck BG in 15 min. 3. If BG is within normal limits, have a snack containing a carb and protein. (BG should increase 40 mg/dL over 30 min following ingestion of 10g of simple carbs) 4. If patient is unconscious or unable to swallow, administer glucagon IM, repeat in 10 min if still unconscious. 5. In acute care, administer 50% dextrose if IV access is available. Consciousness should occur in 20 min. 6. Once conscious, have client ingest oral carb.

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Hypoglycemia protocol

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1. Glucose > 180mg/dL 2. Blurry vision 3. Difficulty concentrating 4. Frequent urination (polyuria) 5. Increased fatigue 6. Increased thirst (polydipsia) 7. Weight loss

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Hyperglycemia symptoms

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Glucose > 250 mg/dL 1. Encourage oral fluid intake of sugar-free fluids to prevent dehydration 2. Administer insulin as prescribed 3. Restrict exercise when BG levels are greater than 250 mg/dL 5. Test urine for ketones and report if outside of expected reference range.

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Hyperglycemia protocol

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Action 1. Reduces the production of glucose by the liver (gluconeogenesis) 2. Increases tissue sensitivity to insulin Considerations 1. Monitor significance of GI effects 2. Monitor for lactic acidosis, especially in clients who have renal insufficiency or liver dysfunction 3. Stop medication for 48 hr before any type of radiographic test with iodinated contrast dye (may cause lactic acidosis) Education 1. Take with food to decrease adverse GI effects 2. Instruct the client to take B12 and folic acid supplements 3. Contact provider if manifestations of lactic acidosis develop (mylagia, sluggishness, somnolence, and hyperventilation)

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Metformin (Glucophage) (Action, considerations, client education)

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Loss of fat tissue

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Lipoatrophy

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1. Inspect feet daily 2. Test water temperature with hands before washing feet as decreased sensation can occur in feet 3. Pat feet dry gently, especially between toes, avoid lotions between toes to decrease excess moisture and infection 4. Use mild foot powder on sweaty feet 5. Best time to perform nail care is after bath/shower 6. Avoid open-toe , open-heel shoes 7. Clean absorbent socks 8. Trim nails straight across

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Foot care

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1. Plan meals to achieve appropriate timing of food intake, activity, onset, and peak of insulin. 2. Eat at regular intervals, and do not skip meals. 3. Count grams of carbs consumed for glycemic control 4. Restrict calories and increase physical activity as appropriate 5. Include fiber in diet 6. Keep saturated fats within 7% of the recommendations of the daily total caloric intake

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Nutrition guidelines

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1. BG > 250mg/dL 2. Fever > 38.6C (101.5F) and does not respond to Tylenol or lasts > 24 hr. 3. Feeling disoriented or confused 4. Rapid breathing 5. Vomiting occurs more than once 6. Diarrhea occurs more than 5 times or > 24 hr 7. Unable to tolerate liquids 8. Illness lasts longer than 2 days

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When to call HCP during sick day protocol

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Cardiovascular and cerebrovascular disease 1. HTN 2. MI 3. Stroke Teaching 1. Encourage checks of cholesterol yearly 2. Monitor BP (130/80) 3. Hb1AC every 3 months 4. Participation in regular activity for weight loss and control 5. Report SOB, headaches, numbness in distal extremities, swelling of feet, infrequent urination, and changes in vision.

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Complications of DM, client teaching

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Impaired vision and blindness. Education: 1. Yearly eye exams to ensure the health of the eyes and protect vision

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Diabetic retinopathy (definition and education)

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Caused from damage to sensory nerve fibers resulting in numbness and pain. May affect every aspect of the body and can lead to ischemia and infection.

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Diabetic neuropathy

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Damage to kidneys from prolonged elevated blood glucose levels and dehydration. Monitor I/O, serum creatinine) Report an hourly output of < 30 mL/hr Teach client to avoid soda, alcohol, toxic levels of tylenol and NSAIDs. Teach client to consume 2-3L of fluid per day.

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Diabetic nephropathy

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C. Provide 4 oz grape juice

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A nurse is caring for a client who has blood glucose of 52 mg/dL. The client is lethargic but arousable. Which of the following actions should the nurse perform first? A. Recheck blood glucose in 15 min. B. Provide carbohydrate and protein food. C. Provide 4 oz grape juice. D. Report findings to the provider.

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B. Administer the insulin when breakfast arrives

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A nurse is preparing to administer a morning dose of aspart insulin (Novolog) to a client who has type 1 diabetes mellitus. Which of the following is an appropriate action by the nurse? A. Check the client's blood glucose immediately after breakfast. B. Administer the insulin when breakfast arrives C. Hold breakfast for 1 hr after insulin administration D. Clarify the prescription because insulin should not be administered at this time.

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C. Draw up and administer regular and glargine insulin in separate syringes.

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A nurse is preparing to administer the morning doses of glargine (Lantus) insulin and regular (Humulin R) insulin to a client who has a blood glucose of 278 mg/dL. Which of the following is an appropriate nursing action? A. Draw up the regular insulin and then the glargine insulin in the same syringe. B. Draw up the glargine insulin then the regular insulin in the same syringe. C. Draw up and administer regular and glargine insulin in separate syringes. D. Administer the regular insulin, wait 1 hr, and then administer the glargine insulin.

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A. B. C. E.

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A nurse is presenting information to a group of clients about nutrition habits that prevent type 2 diabetes. Which of the following should the nurse include in the information? (Select all that apply) A. Eat less meat and processed foods B. Decrease intake of saturated fats C. Increase daily fiber intake D. Limit saturate fat intake to 15% of daily caloric intake E. Include omega-3 fatty acids in the diet.

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C. D. E.

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A nurse is teaching foot care to a client who has diabetes. Which of the following information should the nurse include in the teaching? (Select all that apply) A. Remove calluses using OTC remedies B. Apply lotion between toes C. Perform nail care after bathing D. Trim toenails straight across E. Wear closed-toe shoes

ATI: Ch 83 Diabetes Mellitus Management – Flashcards

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