NUR 325: glucose regulation

what is glucose regulation and the ultimate end result of glucose metabolism

- glucose regulation is the process of maintaining optimal blood glucose levels (glucose regulation = energy availability at the cellular level, when this fails cells are starved)
- the ultimate end result of glucose metabolism is cellular use of glucose for energy (ATP)

what is postprandial response (what happens after we eat)

1. carbohydrates → glucose absorbed in small intestines
2. blood glucose rises
3. insulin released within minutes
4. peak insulin ~30-60 minutes

what is fasting state

- insulin levels decrease
- glucagon increases (signals liver to breakdown stored glycogen and release glucose into bloodstream)
- liver maintains blood glucose
- prevents hypoglycemia

what are the hormones used to increase blood glucose when the body needs more fuel

epinephrine, cortisol, growth hormone, norepinephrine
- these counteract the effects of insulin and is used to raised glucose
- problems arise when hormones are deficient or excessive or when production is not balanced with the blood glucose need

how does the hormone epinephrine raise blood glucose levels

- immediate flight or fight response → aka adrenaline
- released during stress or hypoglycemia → stimulates glycogen breakdown in liver, quickly releasing glucose into bloodstream

how does the hormone cortisol raise blood glucose levels

- works a bit more slowly and supports long-term glucose availability
- promotes gluconeogenesis - creation of new glucose from non-carbs
- decreases glucose uptake in some tissues keeping more glucose in circulation

how does growth hormone raise blood glucose levels

- decreases glucose uptake in cells and promotes fat breakdown for energy → helps promote glucose for vital organs, esp brain

how does the hormone norepinephrine raise blood glucose levels

- works similarly to epinephrine
- supports glycogen breakdown and increases blood glucose esp during times of stress

what is hyperglycemia

- state of elevated blood glucose levels
- defined as more than 100 mg/dL in a fasting state or 140 mg/dL 2-hours postprandial (after eating)
- severe >180
(think sugar high = hot and dry)

what is hypoglycemia

- state of insufficient or low blood glucose levels, defined as less than 70 mg/dL in a fasting state or 99 mg/dL in 2-hours postprandial
- severe: <50
(think need some candy = cool and clammy)

what is euglycemia and labile

- euglycemia: represent normal stable blood glucose levels and physiologic homeostasis
- labile: characterized by unpredictable swings between hyperglycemia and hypoglycemia → aka brittle diabetes

what daily habits could lower someone’s blood sugar

- meal skipping
- excessive alcohol w/o proper intake of carbs
- alcohol consumption
- taking insulin w/o adequate carb intake

what daily habits could raise someone’s blood sugar

- dietary patterns
- sedentary vs active lifestyle
- stress levels
- illness
- medication timing
- sleep deprivation/lack of rest

what are endogenous (internal) causes of hyperglycemia

- insufficient insulin production or secretion (in type I this is due to autoimmune destruction of beta cells - in type II this is due to insulin production declining overtime or patients become resistant to insulin)
- excessive counterregulatory hormone secretion (like glucagon, cortisol, epinephrine, norepinephrine)
- deficient hormone signaling/insulin resistance (insulin is present but cells are not responding appropriately so glucose remains in bloodstream

what are exogenous (external) causes of hyperglycemia

- overeating (esp foods high in carbs), medications (like corticosteroids)
- hyperglycemia is rarely random, it is usually a result of a physiologic imbalance, medication side effect, stress response, or intake issue

what are the consequences of hyperglycemia regarding microvascular damage

- angiopathy and end-organ disease due to microvascular damage (long-term consequences are primarily due to vascular damage) because high blood sugar injure blood vessels, esp small blood vessels/capillaries

what are the different types of angiopathy for long-term consequences of hyperglycemia due to microvascular damage

- retinopathy: damage to retinal blood vessels in eyes leading to vision loss and blindness
- nephropathy: damage to kidneys which can progress to chronic kidney disease and endstage renal failure
- peripheral neuropathy: nerve damage

what are the two types of peripheral neuropathy with microvascular damage as a long-term consequence of hyperglycemia

- sensory: peripheral nerve damage, poor circulation (gangrene, infections and amputations)
- autonomic (affects involuntary functions): gastroparesis, postural hypotension, sexual dysfunction (ED), neurogenic bladder

what is the long-term consequences of hyperglycemia for macrovascular angiopathy

- hypertension
- cardiovascular and peripheral vascular disease
(clients with diabetes are at significant increased risk for myocardial infarction, stoke, limb eschemia)

what are complications of acute conditions of hyperglycemia

- hyperglycemia: diabetic ketoacidosis (T1) and hyperosmolar hyperglycemia syndrome (HHS - T2)
- hypoglycemia (T1)
- ketoacidosis (T1)
(acute conditions develop rapidly and require immediate recognition)

what are complications of chronic conditions of hyperglycemia

- angiopathy: cardiovascular disease, stroke, renal failure
- macrovascular: cerebrovascular, cardiovascular, PVD
(chronic conditions develop overtime due to constant hyperglycemia and vascular damage)

what are endogenous (internal) causes of hypoglycemia

- increased insulin
- comorbidities (other health problems like renal insufficiency)

what are exogenous (external) causes of hypoglycemia

- insufficient nutritional intake
- adverse reaction to medications
- excessive exercise
- delayed or missed meals after insulin administration

what are warning signs consequences of hypoglycemia

- nervousness/agitation/anxiety
- irritability
- diaphoresis (excessive sweating as epinephrine is released)
- palpitations (develop as heart rate increases)
(early symptoms are primarily related to activation of sympathetic nervous system)

what are actual consequences of hypoglycemia

- neurological changes (confusions)
- seizures
- unconsciousness
- death
- repeated hypoglycemia episodes lowers the threshold that stimulates counter regulatory hormones (aka body stops recognizing low glucose quickly/hypoglycemia unawareness → no longer experience early warning signs)
(as glucose continues to fall, we see neuro changes as brain is not getting enough glycose)

what are non-modifiable risk factors for impaired glucose regulation

- family history of diabetes
- age >45 years
- history of gestational diabetes
- polycystic ovary syndrome (PCOS)
- certain ethnic backgrounds (type I more common in white patients, type 2 more common in hispanic and native american patients)

what are modifiable risk factors for impaired glucose regulation

- overweight or obesity (esp central adiposity)
- physical inactivity
- high intake of refined carbohydrates/sugary beverages
- hypertension
- dyslipidemia (increased triglycerides and decreased HDL)
- smoking

what are clinical/health-related risk factors for impaired glucose regulation

- prediabetes (impaired fasting glucose or impaired glucose tolerance)
- metabolic syndrome
- chronic stress
- long-term corticosteroids use
(these are warning signs for developing diabetes)

what is diabetes mellitus

- chronic multisystem disease characterized by hyperglycemia from abnormal insulin production, impaired insulin use, or a combination of both
- root of issue is insulin dysfunction (either body is not producing enough insulin or body cells are resistance to insulin or both)

what are the classes of diabetes mellitus

- diabetes mellitus type I: autoimmune → immune system destroys beta cells in pancreas leading to little or no insulin overtime and blood glucose rises - aka insulin dependent or juvenile onset
- diabetes mellitus type II: insulin is present but body’s cells become resistant to insulin and pancreas attempts to compensate by producing more but overtime beta cell function declines - aka non-insulin dependent or adult diabetes
- gestational diabetes (pregnancy)
- other types of various causes (caused by genetic defects)

what is impaired glucose tolerance vs impaired fasting glucose for prediabetes

- impaired glucose tolerance: 140-199 mg/dL after 2-hour oral glucose tolerance test (OGTT)
- impaired fasting glucose is diagnosed when fasting glucose levels are 100 to 125 mg/dL (5.56 to 6.9 mmol/L)

what are clinical manifestations, primary prevention, and secondary prevention for prediabetes

- clinical manifestation: asymptomatic → long-term macrovascular and microvascular and damage may already be occurring
- primary prevention: healthy weight, regular exercise, balanced diet
- secondary prevention: monitor for BG level and HGB A1C; symptoms of DM

how do you preform assessment: health history

- personal or family medical history markers: central obesity, diabetes, current medications, hypertension, cardiovascular disease, cancer
- review of symptoms

what are symptoms of hypoglycemia

- symptoms related to degree of hypoglycemia and can include weakness, dizziness, headache, hunger, blurred vision, difficulty concentrating, feeling shaky, palpitations
(think need some candy = cool and clammy)

what are symptoms of hyperglycemia

- no specific symptoms for elevated blood glucose but symptoms may be associated with dehydration, or acidosis and may include nausea, vomiting, abdominal cramps, fatigue, excessive hunger (polyphagia), excessive thirst (polydipsia)
(think sugar high = hot and dry)

what mental status, skin, respiratory/cardiovascular, and other symptoms would someone with hypoglycemia present with

- mental status: anxious, irritability, confusion, seizures, unconsciousness, coma
- skin: diaphoresis, cool, clammy
- respiratory/cardiovascular: tachycardia, no change in respirations
- other: muscle tremors, normal hydration, no ketones

what mental status, skin, respiratory/cardiovascular, and other symptoms would someone with hyperglycemia present with

- mental status: can range from alert to confused and coma, particularly if in untreated ketoacidosis
- skin: warm, moist
- respiratory/cardiovascular: deep/rapid respirations, acetone odor to breath, tachycardia if dehydrated
- other: dehydration, polyuria, ketones, (pt have thicker blood = easier to form clots)

what are exam findings of diabetes

- anthropometric measurements = overweight or obese
→ body mass index
→ waist-to-hip ratio
- vital signs = HTN
- evidence of peripheral vascular disease

what are causes of hyperglycemia

- infection, ilness
- corticosteroids (Prednisone)
- too much food
- too little or no DM medication
- inactivity
- emotional, physical stress
- poor absorption of insulin

what are clinical manifestations of hyperglycemia

- glucose higher than 140 mg/dL
- increased urination (polyuria) and thirst (polydipsia)
- increased appetite (polyphagia) followed by anorexia
- weakness, fatigue
- blurred vision
- headache
- glycosuria
- nausea and vomiting
- abdominal cramps
- mood swings
- progression to DKA or HHS

what are causes of hypoglycemia

- alcohol intake without food
- too little food, delayed/omitted/inadequate intake
- too much DM medication
- too much exercise without adequate food intake
- DM medication or food taken at the wrong time
- loss of weight without change in medication
- use of B-adrenergic blockers (mask symptoms)

what are clinical manifestations of hypoglycemia

- glucose less than 70 mg/dL
- cold, clammy skin
- numbness of fingers, toes, mouth
- tachycardia
- emotional changes
- headache
- nervousness, tremors
- faintness, dizziness
- unsteady gait, slurred speech
- hunger
- changes in vision
- seizures, coma, death

how is diabetes mellitus diagnosed

DM is diagnosed using 1 of 4 methods:
1. A1C of 6.5 or higher (measures how high glucose has been over several months)
2. fasting plasma glucose (FPG) level of 126 mg/dL or greater (fasting = no sugary drinks, food, for 8 hours)
3. oral glucose tolerance test (glucose level of 200 mg/dL or greater 2 hours after drinking glucose drink)
4. classic symptoms of hyperglycemia (polyuria, polydipsia, unexplained weight loss) or hyperglycemic crisis (random plasma glucose level of 200 or greater)

what are diagnostic tests of diabetes mellitus

- blood glucose testing: includes fasting plasma glucose and random glucose levels
- antibody testing (GAD): assess antibodies to confirm type I
- lipid analysis: evaluate cardiovascular risk (insulin resistance often cause elevated triglycerides and decreased HDL levels)
- renal function tests: microalbuminuria
- C-reactive protein

what are clinical management: primary prevention of diabetes mellitus

- goal: healthy lifestyle behaviors
- optimal body weight
- regular physical activity
- healthy balanced diet

what are clinical management: secondary prevention of diabetes mellitus

- screening: blood glucose screen in high risk individuals

what are collaborative interventions for diabetes mellitus

- education for self-management
- monitor and manage blood glucose: correct imbalance
- nutrition therapy
- pharmacologic agents: oral hypoglycemic agents, insulin, statin agents (used to treat high cholesterol)
- glucose control

what are the levels for hypoglycemic, euglycemia, and hyperglycemia

- hypoglycemic: less than 70
- euglycemia: 70-140 - A1C of less than 7%
- hyperglycemia: above 140

what are interprofessional care: ABC’s of diabetes mellitus

A: A1C → B: BP → C: cholesterol (hyperlipidemia)

what are diabetic (DM) patient education

- self monitoring of blood glucose (SMBG): type 1 and 2 with insulin use
- monitoring for DM complications: s/s of hypoglycemia and hyperglycemia, BP monitoring, monitoring renal function (microalbuminuria testing, BUN, Cr, GFR), daily foot exams, annual eye checks, monitoring GI function: gastroparesis, monitor sexual functions

what are diabetic (DM) patient education regarding healthy lifestyles

- alcohol avoidance
- diet: carb counting, glycemic index education (avoid high index, eat moderate amounts of low index foods)
- regular aerobic exercise (150 mins moderately intensity/week)
- maintain weight (type 1) or weight loss (type 2)

what are diabetic (DM) patient education regarding safety

- medic alert registration
- preparing for hypoglycemia: carry carbohydrate snacks or glucose tabs
- pregnancy considerations: insulin and metformin
- drug intolerances on blood sugars

what are management of hyperglycemia

first check blood glucose level!
- IV fluid administration: electrolyte replacement
- IV administration of short-acting insulin
- frequent assessments: BGM and K levels, mental status, intake/output, assess blood/urine for ketones, assess cardiovascular/respiratory status

what are conscious management of hypoglycemia

first check blood glucose level!
1. eat or drink 15-20g fast-acting carbohydrates
2. wait 15 mins, recheck blood glucose level
→ if less than 70, give another 15-20g of fast-acting carbs
→ if stable and next meal is +1 hr away: give simple carbs with protein (crackers with PB or cheese)
3. notify HCP if symptoms do no subside after 2-3 doses of fast-acting carbs

what are unconscious management of hypoglycemia

first check blood glucose level!
1. 1 mg glucagon subcutaneously or IM or 20-50 mL of 10% glucose IV
2. turn client on side to prevent aspiration

what are the 15-20g of fast-acting carbohydrates

- 4-6oz of regular soda or orange juice
- 5-8 lifesavers
- 1 tbsp honey or syrup
- 4 tsp jelly
- 1 pkg dextrose (per label instructions)

what are short-term outcome evaluation for DM

- clinical focus: immediate safety and education
- blood glucose within target range
- client recognizes signs of hypo/hyperglycemia
- client demonstrates correct glucose monitoring
- client administers insulin safely (if prescribed)

what are long-term outcome evaluation for DM

- clinical focus: prevention of vascular damage
- A1C at or below target (typically <7%)
- stable weight or improved BMI
- lipid levels improved
- blood pressure controlled
- no evidence of acute complications