Glucose maintenance & DKA

Alcohol Intake

• Inhibits gluconeogenesis by liver

• Can cause severe hypoglycemia

• Eat carbohydrates when drinking unless drinks have sweetened mixers

• Limit to moderate amount if no risk for other alcohol-related problems

  • 1 drink/day for women

  • 2 drinks/day for men

Exercise

• ADA recommends at least 150 minutes/week moderate-intensity aerobic activity & resistance training 3 times/week

• Benefits

  • Decreases insulin resistance and glucose

  • Weight loss

  • Reduce need for DM drugs (type 2)

  • Reduce triglycerides and LDL , ↑ HDL

  • Decrease BP and improve circulation

• Get medical clearance; start slowly and progress to goal

• Glucose-lowering effect of exercise may last up to 48 hours

  • Encourage exercise 1 hour after a meal or 10 to 15 g CHO snack and check glucose before exercise

  • CHO snack every 30 minutes to prevent hypoglycemia

• Exercise at the same time every day & when glucose is peaking from a meal & NOT when medications are peaking

• At risk for hypoglycemia

  • Insulin, sulfonylureas, or meglitinides

• Risk for hypoglycemia when exercising

  • Carry fast-acting source of carbohydrates

  • If frequent low glucoses from exercise, consult HCP about lowering medications

  • Do not inject insulin into an area of the body that will be exercised – exercise speeds up absorption

• Strenuous exercise can be perceived as stress by body

  • Temporary increase in glucose

  • Type 1

    • Delay activity if glucose ≥ 250 mg/dL and ketones are present in the urine; makes condition worse

Blood Glucose Monitoring Teaching

• Initial and follow-up - Instructions how to test, use and calibrate meter

• When to test

  • Before meals

  • Two hours after first bite

  • When hypoglycemia is suspected

  • Every 4 hours during illness

  • Before and after exercise

• Consider impaired vision, cognition, or dexterity; use adaptive devices, identify caregiver

Nursing Implementation: Acute Illness

• Physical and emotional stress can increase glucose – may require more intense treatment

• Glucose levels increase secondary to counterregulatory hormones cause hyperglycemia

• Encourage to check glucose at least every 4 hours when ill

• Person with Type 2 DM may need insulin therapy during illness

Nursing Implementation: Operative Needs

Pre-operative Phase

• Long-acting oral hypoglycemic agents are held 24-48 hours pre-op

  • Don’t want them to drop during surg.

• Metformin discontinued 48 hours before & held until renal function returns to baseline

• All other oral hypoglycemic agents held day of surgery

• Insulin dosage held or lowered

• Need close glucose monitoring

Nursing Implementation: Operative Needs

Intraoperative Phase

• IV fluids and insulin if needed

• Inform type 2 diabetics that insulin is temporary and not a sign of worsening diabetes

• Unconscious surgical patient

  • Frequent monitoring of glucose due to body being “stressed”

  • Monitor for hypoglycemia

    • Sweating, tachycardia, and tremors

Nursing Implementation: Operative Needs

Post-operative Phase

• IV fluids & glucose as prescribed until PO intake tolerated

• Supplemental short-acting insulin based on glucose readings

• Monitor blood glucose frequently

• When PO intake starts – ensure CHO intake to prevent hypoglycemia

• At high risk for cardiac, renal, & wound healing complications

  • Hyperglycemia prevents proper wound healing

• Inform type 2 diabetics that insulin is temporary

Nursing Implementation: Personal Hygiene & Identification

• Regular oral care and dental visits

• Regular bathing and foot care

  • Inspect daily

  • Avoid going barefoot

  • Proper footwear

  • How to treat and monitor wounds; when to report to HCP

• Medical ID Bracelet

Hypoglycemia

• Too much insulin in proportion to glucose in the blood

• Glucose level < 70 mg/dL

• Counterregulatory neuroendocrine hormones released

• Autonomic nervous system activated & epinephrine released

• Shakiness, palpitations, nervousness, diaphoresis, anxiety, hunger, & pallor

Hypoglycemia saying 

“Cold & Clammy, Need Some Candy”

Causes of Hypoglycemia

• Too much insulin or oral hypoglycemic agents

• Too little food

• Delaying time of eating

• Too much exercise

• Usually occurs at peak time for meds or with disruption in daily routine

• Symptoms can also occur when high glucose level falls too rapidly

  • If we give too much insulin too fast

Moderate Hypoglycemia (<40 mg/dL)

• Confusion

• Double vision

• Drowsiness

• Emotional changes

• Headache

• Impaired coordination

• Inability to concentrate

• Irrational or combative behavior

• Light-headedness

• Numbness of the lips and tongue

• Slurred speech

What can moderate hypoglycemia be confused for?

Alcohol intoxication

Severe Hypoglycemia (<20 mg/dL) - Neuroglycopenia

• Difficulty arousing

• Disoriented behavior

• Loss of consciousness

• Seizures

• Mimics alcohol intoxication

• Untreated hypoglycemia

  • → Loss of consciousness

    • → Seizures

      • → Coma

        • → Death

When to Treat Hypoglycemia?

• First sign, check glucose, if possible

  • Less than 70 mg/dL, immediately begin treatment

  • If glucose is greater than 70 mg/dL, look for other possible causes of the signs and symptoms

• Manifestations but no monitoring equipment OR history of fluctuating glucose levels

  • Start treatment

Hypoglycemia: Out of Hospital Setting

• Rule of 15 - Consume 15 g of a simple carbohydrate

  • Fruit juice or regular soft drink, 4 to 6 oz

  • Commercial products; gels or tablets

• Recheck- Recheck glucose level in 15 minutes

  • Repeat if still < 70 g/dL; if remains low after 2 to 3x, contact HCP

  • If glucose stable; give carb and protein

• Avoid

  • Avoid foods with fat; slows glucose absorption

  • Avoid overtreatment

Hypoglycemia: Acute Care Setting

• Patient alert?

  • Start with oral CHO

• Patient not alert & IV access?

  • 50% dextrose 20 to 50 mL

• Patient not alert & no IV access?

  • Glucagon 1 mg

• Watch for nausea: Prevent aspiration

• Teach family/caregiver how to inject glucagon

Diabetic Ketoacidosis (DKA)

• Caused by profound deficiency of insulin

  • Sugar too high ≥ 250

• Characterized by

  • Hyperglycemia

  • Ketosis

  • Acidosis

  • Dehydration

• Most likely to occur in type 1 DM

• May occur in people with type 2 DM with severe illness or stress

DKA: Precipitating Factors

• Illness

• Infection

• Inadequate insulin dosage

• Undiagnosed type 1 DM

• Lack of education, understanding, or resources

• Neglect

What REALLY Happens in DKA?

• Body thinks it’s starving

• Insulin Deficiency

  • Body needs to find another source of energy!

• Body burns fat as fuel source

  • By-product of fat metabolism is acidic ketones (accumulates) → alters pH → metabolic acidosis

  • Ketones excreted in urine along with electrolytes

• Impairs protein synthesis

  • Protein degradation → nitrogen loss from tissues

• Stimulates glucose production from amino acids in liver (glycogenolysis & gluconeogenesis) leading to further hyperglycemia that can cause osmotic diuresis

  • fluid loss + dehydration = hypovolemia MEDICAL EMERGENCY

• Hypovolemia → shock → renal failure → retention of ketones and glucose → worsening acidosis → dehydration, electrolyte imbalance, and acidosis → coma → death

• Without treatment:

  • Severe depletion of sodium, potassium, chloride, magnesium, and phosphate

  • Acidosis → vomiting and further fluid and electrolyte losses

DKA: Clinical Manifestations

• Early Manifestations

  • Lethargy and weakness

• Dehydration

  • Dry mucous membranes

  • Tachycardia

  • Orthostatic hypotension

DKA: Clinical Manifestations as it progresses

• Glucose ≥ 250 mg/dL

• Blood pH < 7.30

• Anion gap > 14-15 mEq/L

• (Na+ + K+) – (Cl- + HCO3-)

• Extra acid in bld

• Serum bicarbonate < 16 mEq/L

• Moderate to high ketone levels in urine or serum

• Skin dry and loose; eyes soft and sunken

• Hypovolemic

• Abdominal pain, anorexia, nausea/vomiting

• Kussmaul (rapid, deep respirations breathing associated with dyspnea)

• Sweet, fruity breath odor (acetone)

  • = MEDICAL EMERGENCY

DKA Management

• Less severe form may be treated on outpatient basis

• Factors for hospitalization:

  • Severe fluid and electrolyte imbalance, fever, nausea/vomiting, diarrhea, altered mental state, cause of DKA

  • Ability to communicate with health care provider every few hours

DKA: Emergency Management

• Monitor and replace potassium before starting insulin therapy

  • Insulin drives water, K+, & glucose into cells → hypovolemia & hypokalemia; potentially life-threatening

• Continuous infusion - IV regular insulin 0.1 units/kg/hr to correct hyperglycemia and ketosis

  • 36 to 54 mg/dL/hr drop in serum glucose will avoid complications

• Cardiac monitoring because of electrolyte imbalances

• Protect from cerebral edema due to rapid drops in glucose

• Hourly urine output for fluid overload, renal and cardiac compromise

  • Strict I&Os

Hyperosmolar Hyperglycemia Syndrome (HHS)

• Life-threatening syndrome

• Less common than DKA

• Occurs with type 2 diabetes; over age 60

• Causes:

  • UTIs, pneumonia, sepsis, acute illness, Impaired thirst sensation and/or inability to replace fluids such as history of inadequate fluid intake, increasing mental depression or cognitive impairment, and polyuria

    • Will not have ketone acidosis!!!

      • Due to Type II still producing some insulin

• Enough circulating insulin to prevent ketoacidosis

• Fewer early symptoms lead to higher glucose levels (greater than 800 mg/dL)

• More severe neurologic manifestations because of increased serum osmolality

  • Somnolence, coma, seizures, hemiparesis, aphasia; similar to stroke

• Ketones absent or minimal in blood and urine

HHS Management

• More fluid replacement needed than DKA

  • Need hemodynamic monitoring to avoid overload during fluid replacement

• IV insulin and NaCl infusions

• Monitor: fluid and electrolytes (*K+), serum osmolality, VS, I & O, skin turgor, neuro, renal, and cardiac status

• Correct underlying precipitating cause

Blood Sugar Mnemonic

• Hot & Dry= Sugar Dry

• Cold & Clammy= Need Some Candy