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Diabetes Mellitus
Affects
End
Review A&P
Role of Insulin
Insulin:
Counters metabolic activity that would increase blood glucose levels Enhances transport of glucose into body cells Lowers blood glucose levels
Patho: DM Type 1
Normal Physiology
PathophysiologyPathophysiology-Cont.:DM Type 2
DM TYPE 2
Some endogenous insulin Tx diet and exercise 1st, then pills and /or insulin Usually over 30 yrs. (peaks at 50) NO KETOSIS NIDDM (maturity/adult- onset) (maturity/adultDiabetes Type II Usually Overweight CHRONIC VASCULAR COMPLICATIONS
POLYURIA
POLYPHAGIA
13
Diabetes: Dx Tests
Check MD orders or agency protocol for frequency of BS Monitoring In General: AC&HS if pt able to eat; Q4-6 hours if NPO or tube feedings
Oral Glucose Tolerance Test (OGTT): < 140 mg/dL mg/dL Glycosylated Hemoglobin (HgbA1C): 4-6% 4-
HbA1C Control
100-125 140-200
Acute Complications
Diabetic Ketoacidosis (DKA) BS > 300 mg/dL mg/dL Classic symptoms Ketosis
HyperglycemicHyperglycemicHyperosmolar Nonketotic Syndrome (HHNS) BS > 800 mg/dL mg/dL Similar symptoms No Ketosis
(ADA)
Chronic Complications of DM
heart disease
Cerebrovascular
Stroke
DM pts have heart disease and stroke risks 2 to 4 X higher than non-DM pts
Peripheral
vascular
disease
Chronic ComplicationsComplicationsMicrovascular :
Diabetic
Retinopathy
Chronic ComplicationsComplicationsMicrovascular
Nephropathy
The leading cause of end-stage renal disease (ESRD), occurs in about 20 40% of patients with diabetes
Chronic Complications
Amputation of Toes
Chronic ComplicationsComplicationsMicrovascular
Complications: Lipodystrophy
indurated areas of subcutaneous tissue injecting cold insulin or not rotating sites
Cellulitis
Chronic ComplicationsComplicationsMicrovascular
Gastroparesis
Nerve damage to the digestive system most commonly causes constipation. Damage can also cause the stomach to empty too slowly
patient to maintain control of the illness & to consistently keep blood sugar within normal ranges
MANAGEMENT OF DM
Regular
DRUG THERAPY
DIET
39
EXERCISE
Management: Exercise
Increases insulin effectiveness and sensitivity in the body. Must monitor insulin and food intake to match exercise regimen.
Drug Therapy
Insulin & Oral Antidiabetic Agents
Interventions: Insulin
Insulin therapy:
Opens
the door for glucose to enter the cell & be used for energy
Fast-acting insulin
Rapid Acting Insulin Analogs
Intermediate-acting insulin
NPH Human Insulin Pre-Mixed Insulin
Long-acting insulin
Insulin Glargine, Insulin Detemir
BASAL Used to lower blood sugar throughout the day and night
Drug Therapy-Insulin Cont: TherapyRapid Acting (Humalog/Novolog) VS. Short Acting (Regular Insulin)
Delayed onset Peaks in 2-4 hr Lasts 6-8 hours
Basal insulin: covers blood sugar between meals Satisfies overnight insulin requirement Onset 1-2 hrs, peaks 6-10 hrs, lasts 12+ hrs Need snack if NPH given at 5 pm (only) Ideal to be given at 9 pm (HS) to address Dawn Phenomenon
Insulin Onset 1.5 hrs; no peak (max effect in 5 hrs); lasts 24 hours No risk for hypoglycemia Do not mix with other insulins becomes
inactivated when mixed with other insulins
Lantus
BS < 60-70 mg/dL 60An acute complication of insulin administration Tx: (15/15 or 20/20 Rule) Give 15/20 g simple carb and recheck BG in 15/20 minutes
Synthetic injectables
Byetta:
Symlin:
Rapid-acting insulin
Used to maintain glycemic control in hospitalized patients with high blood glucose levels; in DKA and HHNS Regular insulin may be used IV May also be given preoperatively or postoperatively More frequent BS monitoring ( q12 hours per agency protocol)
(Sitagliptin)
An oral drug that reduces blood sugar levels in patients with type 2 diabetes. Sitagliptin is the first approved member of a class of drugs that inhibit the enzyme, dipeptidyl peptidase-4 (DPP-4).
Hyperglycemia
Health Teaching
cleanse feet in warm soapy water Rinse and dry carefully Inspect, dont break blisters Trim nails to follow natural curve of toe
Always
wear breathable shoes such as leather No crossing of the legs No cream between toes Inspect visually daily
Health Teaching
Health Teaching
Injection
techniques ( intrasite
rotation)
Dietary
management
Quit
smoking
Stress
Diabetes Mellitus
Practice Questions
The client, an 18-year old female, 18comes to the clinic with a wound on her left lower leg that has not healed for 2 weeks. Which disease process would the nurse suspect that the client developed?
A. B. C. D. Type 1 DM Type 2 DM Gestational DM Secondary DM
The client diagnosed with Type 1 DM has a glycosylated Hgb (A1C) of 8.1%. Which interpretation should the nurse make based on this result?
A. B. C. D. This This This This result result result result is is is is below normal levels within acceptable range above recommended levels dangerously high
The nurse administered 28 units of Humulin N, an intermediate acting insulin, to a client diagnosed with Type 2 DM at 1700. Which action should the nurse implement?
A. Determine how much food the client ate at lunch B. Perform a glucometer reading at 0700 C. Ensure the client eats a bedtime snack D. Offer the client protein after administering insulin
client diagnosed with Type 2 DM is receiving Humalog, a rapid-acting insulin, Humalog, rapidby sliding scale. The order reads blood glucose level: <150, give 0 units 151-200, give 3 units 151201201-250, give 6 units >251, contact MD The clients BS is 189 mg/dL. mg/dL.
The
How much insulin should you administer? What is the most important follow-up followassessment for this patient and when?
76 year old client with Type 2 DM that must be controlled with 70/30 combination insulin. Which intervention should be included in the plan of care?
A. Assess the clients ability to read small print B. Monitor the clients coagulation studies C. Teach the client how to perform a HgbA1C test daily D. Instruct the client to check the feet weekly.
The client with Type 2 DM controlled with biguanide oral diabetic medication is scheduled for a computed tomography with contrast of the abdomen to evaluate pancreatic function. Which intervention should the nurse implement? A. Provide a high fat diet 24 hours prior to test B. Hold the biguanide medication for 48 hours to test C. Obtain an informed consent for the test D. Administer pancreatic enzymes prior to test
The diabetic educator is teaching a class on diabetes Type 1 and is discussing sicksickday rules. Which interventions should the educator include in the discussion?
A. Take diabetic medication even if unable to eat the clients normal diabetic diet B. If unable to eat, drink liquids equal to clients normal caloric intake C. It is not necessary to notify health care provider if ketones are present in urine D. Test blood glucose levels frequently and test urine for ketones once a day and keep a record
The client received 10 units of Humulin R, a fast acting insulin, at 0700. At 1030, the unlicensed nursing assistant tells the nurse the client has a headache and is asking for his lunch tray early because he is feeling very hungry. Which action should the nurse implement first?
A. Order the clients lunch tray from the kitchen and give it to him early B. Have the client drink 8 ounces of orange juice C. Go to the clients room and assess the client for hypoglycemia D. Prepare to administer 1 amp of 50% Dextrose intravenously E. Instruct the nursing assistant to obtain a blood glucose level
The client diagnosed with Type 1 DM is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first?
A. B. C. D. Notify the physician Check the serum glucose level Administer 50% dextrose IVP Move the client to the ICU
The nurse is discussing ways to prevent DKA with the client diagnosed with Type 1 DM. Which instruction would be most important to discuss with the client? A. Refer the client to American Diabetes Association B. Do not take any over the counter medications C. Take the prescribed insulin even when unable to eat because of illness D. Be sure to get you annual flu and pneumonia vaccines
Your patient will initially be taking Humulin N/Humulin N/Humulin R 70/30 insulin subcutaneously q a.m., a sliding-scale dose of regular insulin slidingsubcutaneously before lunch and dinner, and Humulin N insulin at bedtime. Which statement made by a client indicates that she correctly understands selfselfadministration of insulin?
A) "My daily dose of 70/30 insulin is based on how much I ate the day before." B) "The amount of short-acting insulin I take shortevery day is based on my blood sugar readings." C) "I should store my insulin in the refrigerator and remove it thirty minutes before I need it." D) "I will alternate my injection sites from leg to abdomen each day to avoid overuse." 11.
An hour before the next dose of slidingslidingscale insulin is scheduled, the client tells the nurse, "I guess Im really nervous about giving myself insulin injections. Look how shaky and sweaty I am. What is the priority nursing action? A) Obtain Laras vital signs. B) Check Laras blood glucose. C) Assure Lara that she will be able to give herself the injections. D) Offer to bring Lara an orange so she can practice giving injections.
13
After discharge, Lara is scheduled for a followfollowup evaluation at the outpatient clinic. A glycosylated Hgb level is drawn, and the results were 11%. Which statement by Lara reflects understanding of glycosylated Hgb? Hgb?
A) "The results of the test are probably high, because I was not fasting before my blood was drawn this morning." B) "The results of my test are probably high, because I went to a party last night and did not follow my diet." C) "I know that I need to check my glycosolated Hgb before each meal and at bedtime, but I dont always have time." D) "At least I won't have this done again for 3 months. I will really work at following my diet between now and then." 21.
Lara tells the nurse that her 15-year-old sister 15-yearhad a fasting blood glucose test last week, because she felt that she had some of the same symptoms that Lara had before being diagnosed with diabetes. Lara states her sister's results were 135 mg/dl.
How should the nurse respond? A) "She needs a second test performed before a diagnosis is made." B) "Since her value is high, it sounds like both of you have diabetes." C) "Her value is low and indicates that she does not have diabetes." D) "She is too young to develop Type 1 diabetes. She may have Type 2."
22.
Lara talks to the nurse about what to do if she gets sick. She states, "It just doesnt make sense to take my insulin when I feel sick, knowing I wont want to eat anything. How should the nurse respond?
A) "You are right. You should not take your insulin if you are feeling sick." B) "Take only sliding-scale insulin, not your slidingregular dose, if you are feeling sick." C) "Being sick increases your blood sugar. Taking your usual insulin dose is important." D) "When you are sick, you should test your urine and only take insulin if ketones are present."
23.
Which
finding indicates that Lara is experiencing a complication of diabetes? A) Burning sensation in her toes. B) Visual acuity of 60/20. C) Lack of protein in her urine. D) Blood pressure of 110/60.