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TERMINOLOGY

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alpha glucosidase inhibitor

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type of oral anti diabetic agent that delays the absorption of carbohydrates in the intestines

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beta cell

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type of cell in the pancreas that secretes insulin

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diabetes insipidus

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disorder of the posterior pituitary gland that causes excessive thirst and excretion of large volumes of dilute urine

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fasting

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ingesting only water or nothing at all for a predetermined length of time

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insulin resistance

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impairment of the expected response to insulin

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ketoacidosis

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accumulation of ketones ( acids formed from the breakdown of free fatty acids in the absence of insulin) in the blood, associated with uncontrolled diabetes and resulting in metabolic acidosis

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microalbuminuria

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early sign of renal disease involving the presence of albumin in the urine in amounts greater than expected but too low to be detected by dipstick testing

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nephropathy

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long term complication of diabetes that involves damage to the cells of the kidneys and eventually leads to ESRD

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neuropathy

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any of numerous disturbances or pathologic changes in the peripheral nervous system, most often affecting sensation, and often a long-term complication of diabetes

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non sulfonylurea secretagogue

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type of oral antidiabetic agent that stimulates insulin release; also called glinide

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peak

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the point when a drug is at its highest concentration in the body

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polydipsia

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excessive thirst and fluid intake

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polyphagia

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excessive hunger

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polyuria

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excretion of abnormally large amounts of fluid

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postprandial

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after a meal

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thiazolidinedione

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oral antidiabetic agent that reduces insulin resistance

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ANTOMY AND PHYSIOLOGY

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diabetes is diagnosed when a patient has what classic disease manifestations:

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polydipsia polyuria polyphagia and unexplained weight loss and a casual plasma glucose of 200mg/dL or higher or when a patient has a fasting glucose level of 126 or higher or when a patient has a 2 hour postprandial plasma glucose of 200mg or higher during an oral glucose tolerance test

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what medication is not given to pregnant woman

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metformin (glucophage)

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1. acute complications of diabetes

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hyperglycemia

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fasting blood sugar greater than 110 or random plasma glucose greater than 200 -manifestations=the three P's , nausea, fatigue and blurred vision

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hypoglycemia

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fasting blood sugar below 60 -can result from overtx with meds, unplanned physical activity, nutritional changes -characterized as pallor, tremor, diaphoresis, palpitations, hunger, visual disturbances, weakness, paresthesias, confusion, agitation, coma and death

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ketoacidosis

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-occurs in type 1 DM pt -characterized by hyperglycemia, ketone in urine, increased RR, fruity breath odor -glucose levels are typically 300mg or higher

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non ketotic hyperglycemia hyperosmolar coma

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-common in type 2 -characterized by severe hyperglycemia -profound dehydration -glucose levels are typically over 600

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infections

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-of skin, urinary tract and vagina are common and healing time is slow -ulcer as well

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2. chronic complications of diabetes

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macrovascular complications

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-CAD, CVA and peripheral vascular disease -consider macro vascular because they result from alterations in large BV

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microvascular complications

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-retinopathy, neuropathy, nephropathy.. DT hyperglycemia induced thickening of retinal and glomerular basement membranes -called micro DT changes in small BV

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EXERCISE AND ACTIVITY

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how does exercise reduce glucose levels

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-promotes the uptake of glucose by active muscle cells

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patients whose glucose level is close to 250 should do what?

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-refrain from exercise until glucose are closer to expected range DT exercise can increase glucose levels due to the release of glucoagon , growth hormone and catechomaines which all prompt the liver to release more glucose

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illness, infection and stress do what to glucose levels

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increase

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INJECTABLE MEDICATIONS

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1. rapid acting and short acting

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-used for managing postprandial increase in blood glucose -RAPID ACTING=lispro (humalog), insuling aspart (novolog), insulin glulisine (apidra) ) onset=10-30 min peak= 30 min to 3 hours duration=3-5 hours -SHORT ACTING= onset=30-60 min peak=1-5 hours duration= up to 10 hours

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2. intermediate acting insulin

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-has delayed action, which makes it less effective for mealtime increases in blood glucose -ex=NPH onset=60-120 min peak=6-14 hours duration=16-24 hours -ex 2= levemir onset=slower onset peaks=12-24 hours duration= varies with dosage

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3. long acting insulin

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-provides basal glucose control ex= insulin glargine (lantus) onset= 70 min peakless duration= 24 hours

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4. combination/ mixed insulins

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70/30= 70% NPH and 30% regular insulin

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5. other injectable medications

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Exenatide (Byetta)

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Exenatide (Byetta) is an incretin mimetic medication available for treating type 2 diabetes. This medication is prescribed for patients who are already taking metformin (Glucophage), a sulfonylurea, or both and have not achieved adequate blood glucose control. This is an injectable medication with some risk of hypoglycemia and delayed gastric emptying. Most patients experience some weight loss with exenatide, which is an advantage over insulin therapy. This drug works in several locations of the body to promote better glucose control. It slows gastric emptying, stimulates glucose-dependent release of insulin, inhibits postprandial release of glucagon, and suppresses appetite. Adverse effects include hypoglycemia, nausea, and pancreatitis.

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Pramlintide (Symlin)

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is an amylin mimetic medication used to supplement the effects of insulin in patients who have type 1 or type 2 diabetes. Pramlintide helps reduce postprandial glucose by delaying gastric emptying and suppressing glucagon secretion. It also helps increase feelings of satiety, thus helping to reduce caloric intake. Pramlintide is recommended for supplementing mealtime insulin in patients with type 1 or type 2 diabetes who cannot achieve glycemic control even with optimal insulin therapy. It can cause nausea, hypoglycemia when combined with insulin, and various drug interactions because of the effect of delayed gastric emptying.

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INSULIN PUMPS

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change the needle or catheter

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q 1-3 days -rotate needle sites and lee them at least 1 in apart -acceptable to remove the pump for amounts of time, ex= taking a shower

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purpose-

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provides continuous glycemic control with insulin and to stimulate normal pancreatic function -delivers a basal rate of regular insulin all day with the patient calculating additional insulin needs based on meals

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risks

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-low battery power occlusion of tubing or needles lack of insulin in pump -rf DKA increases -pumps only deliver rapid acting insulin

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NUTRITION

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medical nutrition therapy

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-nutritional plan geared not only to prevent and manage diabetes but also to be an overall component of a healthy lifestyle -helps patients learn to incorporate good dietary choices into everyday life to promote healthful weight loss as needed -lifelong therapy

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when hypoglycemia is suspected and checked by fingerstick...

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-give the patient 15-20 grams of rapid acting, concentrated carbohydrate, such as 4-6 ounces of fruit juice, 8 oz of skim milk, 1 table spoon of honey or three or four prepared glucose tabs -retest in 15 minuted -if glucose is still below 70-75, retreat and recheck in 15 min -once glucose stabilizes, make sure patient consumes a snack that contains protein and carbs such as milk or cheese and crackers if the patients next meal is longer than an hour away.

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ORAL HYPOGLYCEMIC MEDICATIONS

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sulfonylureas glyburide (Micronase), glipizide (Glucotrol), and glimepiride (Amaryl).

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-increase insulin secretion by beta cells -can cause weight gain and hypoglycemia -can be used alone or with insulin or metformin, thiazolidinediones or alpha glucosidase inhibitor

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meglitinides (GLINIDES) Repaglinide (Prandin) and nateglinide (Starlix) are examples of this type of medication.

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-increase insulin secretion by beta cells -targets postprandial glycemia -can be mono therapy or used with metformin or thiazolidinediones

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biguinaides Metformin (Glucophage)

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-reduce hepatic glucose production while increasing insulin action on muscle glucose uptake -can have GI side effects, bit b12 and folic acid deficiencies and lactic acidosis -can be used alone or in combo with insulin, sulfonylureas, non sulfonylurea, secretagogues or thiazolidinediones -have been used for pts with metabolic syndrome and polycystic ovarian syndrome

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Thiazolidinediones (glitazones) pioglitazone (Actos) and rosiglitazone (Avandia).

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-increase the cellular response to insulin by decreasing insulin resistance -result = increased glucose uptake and decreased glucose production -can cause weight gain, edema, impaired liver function and elevated lipid levels and reduction and reduction in the effectiveness of oral contraceptives -can be used alone or in combo with insulin, sulfonylureas or metformin

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alpha glucosidase inhibitor acarbose (Precose) and miglitol (Glyset).

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-delay carbohydrate digestion -adv= targets postprandial glucose and effects are not systemic -does not depend the presence of insulin -no GI side effects

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gliptins Sitagliptin (Januvia)

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-augement natually occurring incretin hormones which promote the release of insulin and decrease the secretion of glucagon -result= reduced fasting and postprandial glucose levels

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PATIENT EDUCATION

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-start off with pathophysiology -discuss info about obtaining meds, how to store insulin and the importance of sharps containers for needle disposal -review prevention, detection and management of chronic complications associated with DM -emphasize importance of foot, skin and dental care

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MIXING INSULIN

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-clear before cloudy -roll the NPH ( intermediate acting) between palms of hands -draw up regular insulin first, then the NPH

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DOCUMENTAION

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Documentation for diabetes management should include the following information specific to the procedure being performed and any other pertinent information. For all facets of diabetes management, be sure to document the patient's response and tolerance of the procedure as well as any patient and family teaching done. Also, be sure to include: the patient's health status and assessments specific to diabetes blood glucose measurements, vital signs, current laboratory findings current treatment regimen administration of medication

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