Chapter 49: Nursing Management: Diabetes Mellitus

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Diabetes mellitus is a chronic multisystem disorder of glucose metabolism related to
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absent or insufficient insulin supplies, impaired utilization of insulin, or both.
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Current theories link the causes of diabetes to
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genetic, autoimmune, and environmental factors.
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Type 1 diabetes mellitus most often occurs in people who are
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under 30 years of age, with a peak onset between ages 11 and 13, but can occur at any age.
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Type 1 diabetes is the end result of a long-standing process where the body’s own ____ attack and destroy pancreatic _____, which are the source of the body’s insulin.
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T cells, b cells
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The onset of type 1 diabetes is
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rapid
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The initial manifestations are usually
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acute.
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The classic symptoms are
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polyuria, polydipsia, and polyphagia—are caused by hyperglycemia and the accompanying spillover of excess glucose in the urine.
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The individual with type 1 diabetes requires a supply of ______ from an outside source in order to sustain life.
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insulin
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Without insulin, the patient will develop diabetic ketoacidosis (DKA), a life-threatening condition resulting in ________.
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metabolic acidosis.
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Prediabetes is a condition in which
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blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes. Those with prediabetes will usually develop type 2 diabetes within 10 years if no preventive measures are taken.
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Type 2 diabetes mellitus accounts for ____ of patients with diabetes.
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over 90%
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In _____ diabetes, the pancreas usually continues to produce some endogenous (self-made) insulin. However, the insulin that is produced is either insufficient for the needs of the body and/or is poorly used by the tissues.
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type 2
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The most important risk factor for developing _______ diabetes is believed to be obesity, specifically abdominal and visceral adiposity.
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type 2
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The manifestations of ______ diabetes are more nonspecific, and include fatigue, recurrent infections, recurrent vaginal yeast or monilia infections, prolonged wound healing, and visual changes.
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type 2
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___________ diabetes develops during pregnancy and is detected at 24 to 28 weeks of gestation, usually following an oral glucose tolerance test.
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Gestational
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A diagnosis of diabetes is based on one of three methods:
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fasting plasma glucose level, random plasma glucose measurement, or 2-hour oral glucose tolerance test.
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The ____________________ is useful in evaluating long-term glycemic levels.
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glycosated hemoglobin test (HbA1c)
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The American Diabetes Association (ADA) recommends keeping the A1C level below _______
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7%
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_________ insulin is needed when a patient has inadequate insulin to meet specific metabolic needs.
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Exogenous (injected)
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Insulin is divided into two main categories:
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short-acting (bolus) and long-acting (basal) insulin.
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________ is used to maintain a background level of insulin throughout the day.
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Basal insulin
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________ is used at mealtime to combat postprandial hyperglycemia and at bedtime.
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bolus insulin
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Routine administration of insulin is most commonly done by means of
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subcutaneous injection, intravenous administration of regular insulin can be done when immediate onset of action is desired.
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The speed with which peak serum concentrations are reached varies with the anatomic site for injection. The fastest absorption is from the
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abdomen.
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Continuous subcutaneous insulin infusion can be administered using an
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insulin pump
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_______ is programmed to deliver a continuous infusion of short-acting insulin 24 hours a day with boluses at mealtime
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insulin pump
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Hypoglycemia, allergic reactions, lipodystrophy, and Somogyi effect are problems associated with ___________.
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insulin therapy
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__________ (atrophy of subcutaneous tissue) may occur if the same injection sites are used frequently but its incidence has decreased with the use of human insulin.
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Lipodystrophy
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__________is a rebound effect in which an overdose of insulin induces hypoglycemia. Usually occurring during the hours of sleep,
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The Somogyi effect, The Somogyi effect
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___________produces a decline in blood glucose level in response to too much insulin.
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The Somogyi effect
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__________________ is characterized by hyperglycemia that is present on awakening in the morning resulting from the release of counterregulatory hormones in the predawn hours.
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The dawn phenomenon
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__________ are not insulin; they work to improve the mechanisms by which insulin and glucose are produced and used by the body.
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Oral agents (OAs)
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OAs work on the three defects of type 2 diabetes
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1. insulin resistance, 2. decreased insulin production, and 3. increased hepatic glucose production.
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Sulfonylureas are frequently the drugs of choice in treating type 2 diabetes because of the decreased chance of prolonged hypoglycemia. The primary action of the sulfonylureas is to
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increase insulin production from the pancreas.
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Meglitinides increase insulin production from the
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pancreas.
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Metformin (Glucophage) is a biguanide glucose-lowering agent. The primary action of metformin is to reduce glucose production by the
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liver
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α-Glucosidase inhibitors, also known as “starch blockers,” work by slowing down the absorption of carbohydrate in the
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small intestine.
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Sometimes referred to as “insulin sensitizers,” thiazolidinediones are most effective for people who have insulin resistance. They improve insulin sensitivity, transport, and utilization at
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target tissues.
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Pramlintide (Symlin) is a synthetic analog of human amylin, a hormone secreted by the β cells of the
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pancreas. When taken concurrently with insulin, it provides for better glucose control.
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Exenatide (Byetta) is a synthetic peptide that stimulates the release of insulin from the pancreatic β cells. Exenatide is administered using
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a subcutaneous injection.
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The overall goal of nutritional therapy is to assist people with diabetes in
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making healthy nutritional choices, eating a varied diet, and maintaining exercise habits that will lead to improved metabolic control.
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For those with type 1 diabetes, day-to-day consistency in timing and amount of food eaten is important for those individuals using conventional,
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fixed insulin regimens.
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Patients using ______________ can make adjustments in dosage before the meal based on the current blood glucose level and the carbohydrate content of the meal.
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rapid-acting insulin
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The emphasis for nutritional therapy in type 2 diabetes should be placed on
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achieving glucose, lipid, and blood pressure goals.
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In a general diabetic meal plan, _________ and ______________ should provide 45% to 65% of the total energy intake each day. ______ should compose no more than 25% to 30% of the meal plan’s total calories, with less than 7% of calories from __________ and _______ contributing less than 10% of the total energy consumed.
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carbohydrates, monounsaturated fat, Fats, saturated fats, protein
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__________increases insulin receptor sites in the tissue and can have a direct effect on lowering the blood glucose levels.
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Exercise
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_______________enables the patient to make self-management decisions regarding diet, exercise, and medication.
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Self-monitoring of blood glucose (SMBG)
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__________ also referred to as “diabetic acidosis” and “diabetic coma,” is a life-threatening condition caused by a profound deficiency of insulin and is characterized by hyperglycemia, ketosis, acidosis, and dehydration. It is most likely to occur in people with type 1 diabetes.
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Diabetic ketoacidosis (DKA),
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_________________ is a life-threatening syndrome that can occur in the patient with diabetes who is able to produce enough insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion.
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Hyperosmolar hyperglycemic syndrome (HHS)
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Chronic complications of diabetes are primarily those of end-organ disease from damage to blood vessels as a result of chronic hyperglycemia. These chronic blood vessel dysfunctions are divided into two categories:
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macrovascular complications and microvascular complications.
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____________are diseases of the large and medium-sized blood vessels that occur with greater frequency and with an earlier onset in people with diabetes.
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Macrovascular complications
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_____________result from thickening of the vessel membranes in the capillaries and arterioles in response to conditions of chronic hyperglycemia.
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Microvascular complications
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Diabetic retinopathy refers to the process of __________________ to the retina as a result of chronic hyperglycemia in patients with diabetes.
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microvascular damage
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There are two types of diabetic retinopathy :
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proliferative and nonproliferative.
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Diabetic nephropathy is a____________________associated with damage to the small blood vessels that supply the glomeruli of the kidney.
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microvascular complication
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Diabetic ____________ is nerve damage that occurs because of the metabolic derangements associated with diabetes mellitus.
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neuropathy
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The two major categories of diabetic neuropathy are
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sensory neuropathy, which affects the peripheral nervous system, and autonomic neuropathy.
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The most common form of sensory neuropathy is _____________________, which affects the hands and/or feet bilaterally. This is sometimes referred to as “stocking-glove neuropathy.”
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distal symmetric neuropathy
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____________________ can affect nearly all body systems and lead to hypoglycemic unawareness, bowel incontinence and diarrhea, and urinary retention.
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Autonomic neuropathy
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__________________ are the most common cause of hospitalization in the person with diabetes.
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Foot complications
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Because the thin skin is prone to injury, special care must be taken to protect affected areas from
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injury and ulceration.
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A patient with diabetes is more susceptible to infections because of a defect in the mobilization of inflammatory cells and an impairment of phagocytosis by
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neutrophils and monocytes.
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Patients with diabetes have high rates of psychiatric disorders, particularly
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depression

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