Diabetes Mellitus
Disorder of pancreas where beta cells of islets of langerhans fail to produce adquate amount of insulin
-Disease in which high blood glucose results from defective insulin secretiono r action
* Juvenile or insulin dependent
(adult onset can be non-insulin
endogenous
derived or originating internally
gastroparesis
delayed gastric emptying
glycosuria
the presence of abnormally high levels of sugar in the urine
hyperglycemia
abnormally high blood sugar usually associated with diabetes
hypoglycemia
abnormally low blood sugar usually resulting from excessive insulin or a poor diet
ketoacidosis
acidosis with an accumulation of ketone bodies
*Patient will have a sweet taste in the back of the mouth.
Kussmaul's respirations
increased rate and depth with panting and long grunting exhalation
nephropathy
a disease affecting the kidneys
neuropathy
any pathology of the peripheral nerves
nocturia
excessive urination at night
polydipsia
excessive thirst (as in cases of diabetes or kidney dysfunction)
polyphagia
excessive hunger
polyuria
renal disorder characterized by the production of large volumes of pale dilute urine
postprandial
following a meal (especially dinner)
preprandial
preceding a meal (especially dinner)
retinopathy
disease of the retina
What should be included in the teaching for a 40 yr old with type 2-diabetes mellitus to prevent long term complications?
1. Have regular eye examinations
2. Maintain good oral hygiene and make regular visits to the dentist
3. Wash, dry and inspect feet daily
4. Take daily aspirin as prescribed
5. See a podiatrist or other health care professional to monitor neuropathy
Diabetes is diagnosed when the fasting plasma glucose drawn 8 hours without eating is?
126 mg/dL or higher
Which type of diabetes is most common?
Type 2 Diabetes
The nurse is caring for a patient with Type 1 diabetes mellitus being treated for pneumonia. Which lab value should the nurse monitor most closely to identify potential complications early?
Urine Ketones
A person with type 2 diabetes mellitus is scheduled for hip surgery and is upset because an infusion of glucose and insulin is being started; this is a change from the patients usual oral hypoglycemic therapy. What should the appropriate response from the
Surgery is a stressor that can alter blood glucose control and the IV medications are likely only temporary.
The nurse is caring for a patient with Type 2 diabetes mellitus who started oral hypoglycemic medication 2 months ago for fasting blood glucose level of 160 mg/dl. What would be a good indicator that the treatment was working?
HbA1c 5%
What acute high blood glucose complication can occur as a result of uncontrolled type 2 DM?
Hyperosmolar Hyperglycemia
The nurse working on the endocrine unit is reviewing preprandial glucose results. Which results indicate the patients DM is well controlled?
51yr old female with glucose = 115 mg/dL
29yr old male with glucose = 84 mg/dL
The nurse is caring for a patient with type 2-DM who has taken an oral hypoglycemic agent who is now experiencing hunger, sweating, headache and agitation. which action should a nurse take first?
Give 4oz of OJ
The nurse is assisting with community education fair on risks for diabetes and heart disease. What are criteria for metabolic syndrome and should be included in instruction?
Fasting plasma glucose = 100 mg/dL
BP = 130/85 mm/Hg
HDL cholesterol is <40 mg/dL for men and ,<50 mg/dL for woman
What is a major cause of Type 1 diabetes?
Destruction of beta cells in the Islets of Langerhans in the Pancreas
Symptoms of uncontrolled DM
Polydipsia, polyuria, polyphagia, glycosuria, nocturia, fatigue, blurred vision, abdominal pain, headache
Treatment options for DM
Nutrition, exercise, insulin or oral hypoglycemic agents, blood glucose monitoring, education
Symptoms of Hypoglycemia
Hunger sweating, tremor, blurred vision, headache and irritability;
If not treated, confusion, seizures and coma
Symptoms of diabetic neuropathy
Numbness and pain in extremities, sexual dysfunction, gastroparesis
Pathophysiology of type 2 DM
Pancreas does not produce enough insulin or tissues are resistant to insulin, causing elevated blood glucose. heredity and obesity are major factors
Criteria for metabolic or cardiometabolic syndrome
Abdominal obesity,
elevated triglycerides,
decreased HDLs,
BP >130/85 mm Hg,
fasting plasma glucose (FPG) >110 mg/dL
Acute, life threatening complication of uncontrolled type 2 diabetes
Hyperosmolar hyperglycemia
Nursing interventions to prevent amputation in DM
Wash and dry feet daily in warm water,
Apply non-alcohol-based lotion,
Inspect for lesions daily,
Wear cotton socks and leather shoes,
Avoid crossing legs and wearing constricting clothing,
Use care when cutting toenails,
Have feet checked regularly by a
Causes of hypoglycemic episodes in diabetes
Under-eating, skipping a meal,
too much medication,
too much exercise,
poor timing of medication,
food,
exercise
Steps for mixing insulins;
Remember "clear to cloudy":
-Assemble equipment
-Check orders to conform type/dose of regular (clear) and intermediate acting (cloudy) insulins
-Roll bottle of cloudy insulin
-wipe tops of both bottles with alcohol
-Draw up amount of air equal to dose of cloudy insulin
1. Inject air
Mrs. Brown is a 52-year-old cook in a fast-food restaurant. She is 5'2" tall and weighs 190lbs. She says she is "shaped like a pumpkin" because her arms and legs are relatively thin compared to her middle. Because she tends to eat her meals at work, she h
1. What factors place Mrs. Brown at risk for diabetes?
Heredity
Obesity
Body shape
Age
2. What actions can Mrs. Brown take to reduce her risk of developing diabetes?
Lose weight
Exercise regularly
3. Mrs. Brown tries to lose weight butis unsuccessful and,
Endogenous hormone
Is made by the body and does not need to be ingested or injected
Glycosuria results when...
the kidneys are unable to reabsorb all the glucose in the renal tubules
Diabetic ketoacidosis or ketoacidosis is an acute complication risk for persons with type 1 DM if...
Blood glucose is uncontrolled and insulin is deficient
Kussmaul's respirations are used to ....
Eliminate excess acidity in patients with diabetic ketoacidosis
Nephropathy
Diabetic kidney disease
Postprandial blood glucose tests are recommended to....
Determine the response of blood glucose to a meal
Retinopathy
A microvascular disease caused by complication of DM
4% - 6% is the normal level of...
glycohemoglobin
Believed to be caused by an auto immune response, what percentage of diabetic patients have Type 1 diabetes?
5% - 10%
Difference between Type 1 and Type 2 diabetes is...
Type 1-Must have insulin because body is not producing it
Type 2- Body not producing enough and body needs the glucose for energy
Goal in management of DM is...
To maintain sugar levels in the 70 -125 mg/dL range
Prediabetes
Diagnosed when fasting glucose levels are higher than normal (100 mg/dL) but lower than 126 mg/dL;
Or when Glucose Tolerance Test is higher than normal (140 mg/dL) but lower than 199 mg/dL;
Or when HbA1c levels are higher than normal (6.0%) but lower than
Tests for Diabetes are...
Fasting Blood Glucose
Glucose Tolerance Test
HbA1c
Diabetes can be diagnosed when...
fasting glucose levels are 126 mg/dL or higher;
Or when Glucose Tolerance Test is200 mg/dL or higher;
Or when HbA1c levels are 6.5% or higher
Type 1 Diabetes
ONSET - Rapid
AGE AT ONSET - Usually younger than 40
RISK FACTORS - Virus, autoimmune response, heredity
USUAL BODY TYPE - Lean
HIGH BLOOD GLUCOSE COMPLICATION - Ketoacidosis
TREATMENT - Diet, exercise; Must have insulin to survive
Type 2 Diabetes
ONSET - Slow
AGE AT ONSET - Usually older than 40
RISK FACTORS - heredity, obesity
USUAL BODY TYPE - Obese
HIGH BLOOD GLUCOSE COMPLICATION - Hyperosmolar hyperglycemia; may develop ketoacidosis
TREATMENT - Diet, exercise; May need oral hypoglycemics or in
Diabetes Goals and recommendations:
-Capillary plasma glucose should be measured at least three times a day for patients using multiple insulin injections
-BP measured every office visit
-Serum creatnine and Urine microalbumin should be assessed yearly
Target levels are:
-HbA1c s/b <7%
-pre
More Diabetes Goals and recommendations:
*Yearly flu vaccine for all patients 6mos and older
*1 lifetime pneumococcal vaccine for patients older than 2, re-vaccination for patients older than 64 if first vaccine was more than 5 years earlier
*Aspirin therapy 75-162 mg/day if older than 30 years
Onset, Peak and Duration of VERY SHORT ACTING Insulins
EXAMPLE- Insulin lispro
BRAND NAME- Humalog
ONSET- 5-15 min
PEAK- 30-90 min
DURATION- 5 hrs or less
EXAMPLE- Insulin aspart
BRAND NAME- Novolog
ONSET- 10-20 min
PEAK- 1-3 hrs
DURATION- 3-5 hrs
EXAMPLE- Insulin glulisine
BRAND NAME- Apidra
ONSET- 15-20 min
Onset, Peak and Duration of SHORT ACTING Insulins
EXAMPLE- Regular
BRAND NAME- Humulin R, Novolin R
ONSET- 30 min
PEAK- 2-5 hrs
DURATION- 5-8 hrs
**Remember Rule of Odds 1-3-5
INTERMEDIATE ACTING Insulins
EXAMPLE- NPH
BRAND NAME- Humulin N, Novolin N
ONSET- 1-2 hrs
PEAK- 6-12 hrs
DURATION- 18-26 hrs
**Remember Rule of evens 2-12-24 hrs
Onset, Peak and Duration of BASAL Insulins
EXAMPLE- Insulin glargine
BRAND NAME- Lantus AE
ONSET- 1-2 hrs
PEAK- No Peak
DURATION- Up to 24 hrs
Onset, Peak and Duration of BASAL Insulins
EXAMPLE- Insulin detemir
BRAND NAME- Levemir
ONSET- 1hr
PEAK- No Peak
DURATION- Up to 24 hrs
What insulins can not be mixed with other insulins?
glargine (Lantus)
detemir (Levemir)
Oral hypoglycemic agents
ABSORPTION DELAYERS
ALPHA-GLUCOSIDASE INHIBITORS (AGIs)-Lower postprandial glucose by reducing rate of carb digestion and absorption
EXAMPLES- acarbose (Precose)
miglitol (Glyset)
S/E- Flatulance, Bloating
NURSING IMPLICATIONS:
-Give at start of each meal
-No weight gain or
Oral hypoglycemic agents
ABSORPTION DELAYERS
DPP-4 INHIBITOR - Inhibits DPP-4, an enzyme that breaks incretins (hormones secreted by GI in response to food), they reduce glucogon secretion and increase insulin synthesis and release
EXAMPLES- sitagliptin (Januvia)
S/E- Upper respiratory infection, he
Oral hypoglycemic agents
INSULIN SENSITIZERS
BIGUANIDE-
Decreases glucose production by liver;
Increases glucose uptake by muscle
EXAMPLES- metformin (Glocophage, Fortamet, Riomet, Glumetza)
S/E- Nausea, diarrhea, decreased appetite, less likely to cause hypoglycemia than other agents
NURSING IMPLIC
Oral hypoglycemic agents
INSULIN SENSITIZERS
THIAZOLIDINEDIONES (glitazones)- reduce insulin resistancein muscles, Improve blood lipids, may lower blood pressure and improve cardiovascular risk
EXAMPLES- pioglitazone (Actos)
rosiglitizone (Avandia)
S/E- Nausea, weight gain, fluid retention
NURSING I
Oral hypoglycemic agents
INSULIN STIMULATORS
SULFONYUREAS- Stimulate insulin secretion by pancreas, increase insulin receptor sensitivity
EXAMPLES- glipizide (Glucotrol)
glimepride (Amaryl)
glyburide (Micronase, Diabeta)
S/E- Hypoglycemia, weight gain, possible increased risk of cardiovascular disea
Subjective data collection for patient with DM
-Age and symptoms at onset
-Understanding of Diabetes (1 & 2) and self care
-Current treatment plan (medication, nutrition therapy, exercise) and adherence to plan
-Frequency of blood glucose monitoring and pattern of BG levels (check diary)
-History of d
Objective data collection for patient with DM
-Vital signs
-Height, Weight, Body Mass Index
-Skin, Integrity Turgor, condition of injection sites
-Feet; pulses, color, temp, skin integrity, pressure points, sensation
-Lab results: blood glucose, HbA1c, creatnine, lipid profile, albuminuria, urine and
One of the risk factors for type 2 diabetes is...
Obesity
Which symptom is commonly associated with hyperglycemia?
Polyuria
Protein in the urine is a sign of which long-term complication of diabetes?
Nephropathy
What is the best way for patients to avoid long-term complications of diabetes?
Maintain pre-meal blood glucose levels under 1.30 mg/dL
What is a breakfast menu must appropriate for a patient with diabetes?
One slice whole grain toast with peanut butter, skim milk, orange juice
Correct sequential order for mixing insulin
1. Roll cloudy vial
2. Clean vial tops with alcohol
3. Inject air into cloudy insulin
4. Inject air into clear insulin
5. Draw up clear insulin
6. Draw up cloudy insulin
A patient who is preparing for surgery asks the nurse why his physician took him off his oral hypoglycemic and placed him on sliding-scale insulin. Which response by the nurse is best?
It helps us to maintain better control of your blood glucose during surgery. you will most likely be back on pills before you go home.
Which meal plan is best for the patient with reactive hypoglycemia?
Small, frequent meals
Glucose in urine is called
Glycosuria
Too much sugar in the blood is called...
Hyperglycemia
Too little sugar in the blood is called...
Hypoglycemia
Deep, sighing respiration's from diabetic acidosis are called...
Kussmaul's respirations
Excessive hunger is called...
Polyphagia
Excessive thirst is called...
Polydipsia
The patient who gets up to urinate at night has...
Nocturia
The time when insulin is working its hardest after injection is called...
Peak Action Time
The length of time insulin works is called its...
Duration
The Diabetes Control and Complications Trial (DCCT) found that individuals who maintain _______ control of their diabetes will have fewer long-term complications.
Tight
Hypoglycemia symptoms
Tremor
Irritability
Sweating
Hyperglycemia symptoms
Polydipsia
Polyuria
Lethargy
Fruity Breath
Abdominal Pain
Retinopathy
SYMPTOM- Impaired vision
Neuropathy
SYMPTOM- Burning pain in legs and feet
Hyperosmolar hyperglycemia
SYMPTOM- Profound hyperglycemia without ketonemia
Diabetic Ketoacidosis
SYMPTOM- Ketones in the blood and urine
Nephropathy
SYMPTOM- Microalbuminuria
Gastroparesis
SYMPTOM- Food intolerance
Infection
SYMPTOM- Fever
What is an acceptable pre-meal blood sugar range for a patient with diabetes?
70-130 mg/dL
Before giving insulin, the nurse always checks which result?
Blood sugar level
At what point after injection does the peak action of regular insulin occur?
2-5 hours
What is a symptom of hypoglycemia?
Cold sweats and Tremors
In addition to stimulating insulin production, glyburide (Micronase) has what effects?
Increases tissue sensitivity to insulin
A 26 yr old patient is admitted to the hospital with a new diagnosis of diabetes, a blood glucose of 690 mg/dL, and ketones in the blood and urine. Which type of diabetes should the nurse expect?
Type 1
A 45 yr old with diabetes forgot to take a daily dose of glyburide (Micronase). What symptom should the nurse be vigilant about ?
Fatigue, thirst, blurred vision
Which routes can Insulin be administered?
Intravenous (IV)
Sub Q
Intramuscular
While providing discharge instructions to a patient newly taking NPH insulin every morning, the nurse recognizes that teaching has been effective if the patient knows to observe for signs and symptoms of low blood sugar level at which of the following tim
6-12 hours after administration of insulin
A patient with newly diagnosed diabetes asks the nurse what to take for low blood sugar. What would be appropriate for the nurse to suggest?
Raisins
The nurse recognizes that teaching is effective if a patient with diabetes knows to use sub Q glucagon for an emergency episode of which of the following conditions?
Hypoglycemia
A patient on an American Diabetes Association diet receives a breakfast tray and does not care for the oatmeal. What is a food can the nurse substitute for a 1/2 cup of oatmeal?
A slice of wheat toast
Oral hypoglycemic agents
COMBINATION AGENTS
EXAMPLES-
metformin and glyburide (Glucovance)
metformin and rosiglitazone (Advandamet)
glipizide and metformin (Metaglip)
S/E- See individual agents
NURSING IMPLICATIONS:
-See individual agents
Diabetes Summary
SIGNS AND SYMPTOMS:
Polyuria
Polydipsia
Polyphagia
Fatigue
Blurred Vision
Headache
Abdominal pain
DIAGNOSTIC TESTS:
Fasting Plasma Glucose
HbA1c (glycosylated hemoglobin)
Oral glucose tolerance test
Additional testing for complications
THERAPUTIC MEASURES