Endocrine System

type 1 diabetes

- juvenile onset (less than 30 years old)
- destruction of pancreatic beta cells
- no/minimal insulin production
- usually not obese
- insulin dependent
- abrupt onset with weight loss

type 2 diabetes

- genetic and environmental
- desensitization: limited response by beta cells
- insulin resistance: liver and peripheral tissues
- occurs around peak age of 50
- typically obese (60-80%)
- 20-30% require insulin
- slow onset with fatigue

pre-diabetes

- mild to moderate hyperglycemia
- slightly elevated blood glucose with a FSBG on multiple occasions or an elevated HgA1C (5.9-7.9)

SSAs for diabetes

- polydipsia, polyphagia, polyuria
- unintended weight loss (type 1)
- fatigue and weakness
- irritability and mood changes
- blurred vision: retinopathy
- slow healing sores
- acanthuses nigricans: (back of neck is darkened)
- neuropathies
- HTN and hype

hemoglobin A1C

- 5.7-6.4: prediabetic
- >6.5: diabetic

fasting plasma glucose (FPG)

greater than 126mg/dL
**Need at least 2 different occasions for diagnosis

oral glucose tolerance test

- greater than >200mg/dL
**completed at a random time

diabetes

- systemic, chronic, and progressive metabolic disease that requires lifelong lifestyle modification
- inability to metabolize carbohydrates, proteins, and fats
- results in hyperglycemia

alpha cells

- secrete glucagon
- carbohydrates, fats, and protein metabolism

beta cells

- secrete insulin
- carbohydrate, fat, and protein metabolism

priority interventions for pre-diabetes

- goal of A1C less than 6
- lifestyle modifications including weight loss and exercise 150min/week
- metformin therapy if BMI is >35
- possible blood glucose monitoring

priority interventions for type 1 DM

- goal of A1C less than 7
- lifestyle modifications
- start insulin therapy that will be lifelong
- basal insulin, short acting, and intermediate acting
- blood glucose monitoring

priority interventions for type 2 DM

- goal of A1C of less than 7
- lifestyle modifications
- oral hypoglycemic agents
- insulin possible
- blood glucose monitoring

priority interventions for nutrition

- medical nutritional therapy every 3 months
- carbohydrate amount and quality
- dietary fat and protein
- alcohol (monitor amount taken and adjust insulin accordingly)
- food diary
- ADA and Mediterranean diet
- monitor sodium intake
- increase fiber int

education on diabetes

- physical activity (not restriction any kind of physical activity)
- medication purpose, dosing, schedule, side effects
- blood sugar monitoring
- immunizations such as flu, pneumonia, and shingles
- carb counting
- s/s of hypoglycemia
- importance of fo

priority interventions for hypertension

- treat to a goal of systolic < 140 and diastolic < 80
- ACE or ARB to start, and then add diuretic
- monitor BP at home and every HCP visit
- monitor electrolytes, BUN, creatinine, and GFR

priority interventions for dyslipidemia

- decrease saturated fat and cholesterol
- statin therapy for prevention
- antiplatelet therapy
- lipid panel targets every 6 months
- LDL < 100 with CVD LDL <70
- HDL > 40 in men, > 50 in women
- triglycerides < 150

priority interventions for CVD

- ACE or ARBs
- statin therapy
- ASA therapy
- prior MI use a beta blocker
- smoking cessation
- EKG yearly

priority interventions for nephropathy

- prevented by glucose control
- optimize BP control
- primary prevention with ACE or ARB
- monitor urine micro albumin yearly
- monitor electrolytes, BUN, creatinine
- GFR < 60 (market for kidney disease)

priority interventions for retinopathy

- prevented by glucose control
- comprehensive eye exam yearly
- macular edema
- retinal hemorrhage
- diabetic retinopathy
- blindness is possible if untreated/uncontrolled

priority interventions for neuropathy

- prevented by glucose control
- monofilament testing 6mos-yearly
- foot care
- smoking cessation
- high risk for PVD
- medication to help with pain (gabapentin)
- ankle brachial index

oral hypoglycemic agents

- Metformin
- sulfonylureas (can cause hypoglycemia quicker than the others)
- meglitnide
- alpha glucosidase inhibitor
- combination agents

rapid acting insulin

- onset 15 minutes
- duration of 3-5 hours

short acting insulin

- onset 30 minutes
- duration of 8 hours

intermediate acting insulin

- onset of 30-90 minutes
- duration of 8-14 hours

long acting insulin

- onset of 2-4 hours
- duration of 24 hours

initial insulin therapy

- basal insulin dose
- 0.5-1 units/kg/day
- intermediate or long acting
- may be combined with a oral agent

multiple component insulin therapy

- combination of short and intermediate acting insulin
- basal dose + short acting for meal times
- 2/3 of daily dose before breakfast (1 injection)
- 1/3 in the evening (1 injection)

somogyi phenonmenon

- morning hyperglycemia from the counter regulatory response to nighttime hypoglycemia
- give adequate evening and nighttime intake of food
- evaluate and adjust insulin dosage

dawn phenomenon

- common in type 1
- nighttime release of growth hormone
- elevation of blood glucose between 3 & 6am
- increase insulin at night

signs of hypoglycemia

- cool and clammy skin
- tachycardia and palpitations
- anxious and irritability
- LOC changes
- seizures and/or coma
- glucose < 70mg/dL
- double/blurred vision
- extreme hunger

signs of hyperglycemia

- warm and moist skin
- poor skin turgor
- dehydration
- kussmaul rapid brathing
- fruity breath
- orthostatic hypotension
- tachycardia
- nausea and vomiting
- cramping
- glucose > 250mg/dL
- metabolic acidosis
- ketones present
- DKA (sudden onset) and

priority interventions for mild hypoglycemia

- 10-15 g rapidly absorbed carbs such as crackers or juice
- recheck glucose in 15 minutes; if still low give another snack
- eat a small meal

priority interventions for moderate hypoglycemia

- 15-30 g of rapidly absorbed carbs such as crackers or juice
- small meal in 15-30 minutes (include protein to maintain blood glucose)

priority interventions for severe hypoglycemia

- glucagon 1mg IM/SQ and reassess in 15 minutes
- 2nd dose if patient remains unconscious
- resolved: eat a small meal
- unresolved: transport to ED or rapid response

diabetic ketoacidosis (DKA)

- sudden onset
- common in type 1, but can happen in type 2
- kussmaul respirations
- glucose >300mg/dL

precipitating factors of DKA

- inadequate insulin
- infection
- stress

manifestations of DKA

- dehydration
- ketosis
- kussmauls respirations
- glucose >300mg/dL
- urine + for ketones
- BUN and creatinine elevated
- pH < 7.35
- HCO3 < 15mEq

hyperglycemic hyperosmolar state (HHS)

- gradual onset
- common in type 2 that don't know they are diabetics
- glucose > 600mg/dL
- correct with fluids first

precipitating factors of HHS

- poor fluid intake
- infection
- stressors

manifestations of HHS

- altered CNS resposne
- dehydration
- glucose >600mg/dL
- BUN and creatinine elevated
- ph >7.40
- HCO3 >20mEq

priority interventions for DKA

- monitor RR, VS, and LOC changes q15minutes
- IV bolus short acting insulin at 0.1unit/kg/hr infusion
- decrease glucose by 75mg/dL/hr
- monitor for ketones
- hypotonic fluids
- monitor electrolytes and replace as necessary
- GOAL: blood glucose <200

priority interventions HHS

- monitor RR, VS, and LOC changes q15minutes
- insulin after fluid replacement
- bolus 0.15units/kg/hr
- decrease glucose by 50-75mg/dL/hr
- replace 1/2NS infuse at 1 liter/hr until BP *+& UO are stabilized
- higher risk for hyperkalemia so monitor electr

interventions for diabetics in hospital

- pre-meal glucose: <140mg/dL
- randome glucose: <180mg/dL
- pt should have basal insulin + nutrition + regular insulin correction
- glucose monitoring for high risk patients
- monitor risk for infection

Upon initial assessment of a client with a history of diabetes, what initial finding would you report to the HCP?
a.Numbness & tingling bilaterally of the hands and feet
b.Kussmaul respirations
c.Hammer toe of the right foot
d.Soft NT & ND abdomen

b.Kussmaul respirations

carbohydrate counting

- educate pt to count # of carbs from nutritional content labels of food
- total grams of carbs per day
- # of grams of carbs is planned for each meal and snack
- coverage of regular insulin is administered for each 15g of carbs eaten
- Total number of ca

education on oral medications

- name of medication
- action of the medication
- dosing schedule
- blood glucose monitoring
- interactions
- importance of keeping record of meds
- missing dose instructions
- s/s of hypoglycemia and how to manage
- regimen of Anti-hypertensives, statins

blood glucose monitoring

- blood glucose values are established for each patient
- frequency is determined by the drug regime and target goals
- teach infection control measures
- never share blood glucose testing equipment (needles)
- calibration of monitor

education on foot care

- inspect feet day and use mild soap and warm water
- pat gently including between the toes when drying feet
- perform nail care following a bath or shower or go to podiatrist
- use cotton or lamb's wool to separate overlapping toes
- use a powder with co

follow up exams

- ophthalmologist: yearly exam
- PCP: newly diagnosed 2 weeks-1 months until controlled and then every 3-6 months then once stable: 1 year
- nutritionist initially then follow up until controlled
- nephrologist: yearly if renal impairment is present
- pod

For a client with diabetes, what are the desired outcomes of glycemic control? (Select all that apply)
a.Quality of life
b.HbA1c of < 6.5%
c.Intact skin
d.BP 150/88
e.LDL < 100

a.Quality of life
b.HbA1c of < 6.5%
c.Intact skin
e.LDL < 100