Lecture 6: Drug Therapy for Endocrine Disorders

Diabetes Mellitus (DM):

a disease of insulin availability that results in high blood glucose concentrations

Complications of Diabetes Mellitus (DM):

atherosclerosis throughout the body

retinopathy

neuropathies

nephropathy

What is hyperglycemia:

fasting blood glucose levels >126 mg/dL

What is impaired fasting glucose (pre-diabetes):

fasting blood glucose of 100-125 mg/dL

Diabetes Onset Symptoms:

• polyphagia

• glucosuria

• polydipsia

• polyuria

• dehydration

Polyphagia:

extreme, persistent hunger or excessive eating that does not go away after a meal

Glucosuria:

the presence of detectable sugar (glucose) in the urine

Polydipsia:

excessive, unrelenting thirst that does not go away no matter how much fluid you drink

Polyuria:

medical term for producing an abnormally large volume of urine

Dehydration:

happens when your body loses more fluid than you take in

What happens to carbohydrates after we eat them?

digestion breaks down carbohydrates down into glucose, which enters the bloodstream

What does insulin do with glucose?

insulin allows glucose to enter cells, where it can be used for energy

How often are fingerstick blood glucose levels usually checked?

check MD order; usually at least 4x/day-meals and bedtime

Based on the slide, what is the normal blood glucose range?

80-120 mg/dL

What should nurses check when a patient uses a CGM (continuous glucose monitoring)?

ensure parameters are correctly set and alarms are active

What does Glycosylated hemoglobin (Hgb A1c) reflect?

it reflects the average blood glucose level over the past 3 months

What is the normal Glycosylated hemoglobin (Hgb A1c) level?

normal level is <7%

Type 1 Diabetes:

chronic disorder often diagnosed in childhood but can occur at any age

What causes Type 1 diabetes?

• an autoimmune response destroys the pancreatic beta cells that make insulin

• patients often have genetic predisposition

What can trigger the onset of Type 1 diabetes?

• acute illness or stress may precipitate onset

• sudden onset with severe symptoms

What serious complication can Type 1 diabetes cause?

diabetic ketoacidosis (DKA)

Treatment for Type 1 Diabetes:

requires exogenous insulin for life; insulin is usually the only drug treatment

Diabetic Ketoacidosis (DKA):

a dangerous medical emergency that happens when the body does not have enough insulin to use sugar for energy, forcing it to break down fat so fast that the blood becomes toxic and acidic

Type 1 Disease Process:

1. immune system malfunction

2. beta cells killed

3. no insulin made

4. ketoacidosis results

What characterizes Type 2 Diabetes?

hyperglycemia and insulin resistance

Insulin Resistance:

• higher than usual concentrations of insulin and required

• insulin is present but unable to work effectively (cells not accepting)

When does Type 2 diabetes often occur?

• after age 40, but can happen anytime

• is increasing in children and adolescents

Risk Factors of Type 2 Diabetes:

• obesity

• metabolic syndrome

• PCOS

• certain medications

• family history

How does Type 2 diabetes usually develop?

gradually, and often goes undetected until damage has occurred

Type 2 Disease Process:

1. obesity/age/metabolic syndrome/other causes

2. insulin resistance

3. increased insulin needs

4. cannot make enough insulin

5. blood glucose increases

Drug Therapy - Insulins:

• only effective drug treatment for Type 1 diabetes

• may also be used with Type 2 diabetics

• insulin in US is human insulin (identical to endogenous insulin)

• always verify dose with another nurse before giving

Rapid Acting Insulins

rapid onset (15 minutes or less) and a short duration of action (4-8 hours)

Insulin lispro (HumaLOG) is the prototype

more effective at decreasing postprandial hyperglycemia

less likely to cause hypoglycemia before the next meal

injection just before a meal

this is the only class of insulin used for insulin pumps

Postprandial Hyperglycemia:

abnormally high blood sugar level that occurs 1 to 2 hours after eating

Short Acting Insulin:

• Regular insulin is the prototype

• give 30 minutes before a meal

• IV and subcutaneous administration

• It’s the ONLY insulin that is ever given IV

• onset of 30 min-1 hour, peak 2-3 hours, duration 5-7 hours

Intermediate Acting Insulins:

• NPH suspension is prototype

• 1-1.5 hours onset, peak in 8-12 hours, duration 18-24 hours

• given sub-q

• must be mixed

  • DO NOT SHAKE - roll gently between palms

Long-Acting Insulins:

Insulin glargine (Lantus) is the prototype

onset 1.5-2 hours, lasts approximately 24 hours, no peak

given sub-q

provides a basal amount of insulin through 24 hours, like normal endogenous insulin secretion

Rapid-Acting Insulin Brand/Generic Names:

• NovoLog (Insulin aspart)

• Apidra (Insulin glulisine)

• Humalog (Insulin lispro)

Short-Acting Insulin Brand/Generic Names:

• Humulin R (Regular)

• Novolin R (Regular)

Intermediate Acting Insulin Brand/Generic Names:

• Humulin N (NPH)

• Novolin N (NPH)

Pre-Mixed NPH w/Regular Insulin Brand/Generic Name:

• Humulin 70/30 (70% NPH and 30% Reg)

• Novolin 70/30 (70% NPH and 30% Reg)

• Humulin 50/50 (50% NPH and 50% Reg)

Long-Acting Insulin Brand/Generic Names:

• Levemir (Detemir)

• Lantus (Glargine)

Onset of Rapid-Acting Insulin:

15 minutes

Onset of Short-Acting Insulin:

30-60 minutes

Onset of Intermediate Acting Insulin:

1-2 hours

Onset of Pre-Mixed NPH w/Regular Insulin:

30-60 minutes

Onset of Levemir Long-Acting Insulin:

3-4 hours

Onset of Lantus Long-Acting Insulin:

varies

Peak of Rapid-Acting Insulin:

30-90 minutes

Peak of Short-Acting Insulin:

2-4 hours

Peak of Intermediate Acting Insulin:

6-14 hours

Peak of Pre-Mixed NPH w/Regular Insulin:

varies

Peak of Levemir Long-Acting Insulin:

6-8 hours

Peak of Lantus Long-Acting Insulin:

1 hour

Duration of Rapid-Acting Insulin:

3-5 hours

Duration of Short-Acting Insulin:

5-8 hours

Duration of Intermediate Acting Insulin:

16-24 hours

Duration of Pre-Mixed NPH w/Regular Insulin:

10-16 hours

Duration of Long-Acting Insulin:

24 hours

Signs and Symptoms of Hypoglycemia:

• dizziness

• sweating

• mood swings

• trembling

• hunger

• blurred vision

• tachycardia

• pallor

• headache

• fatigue

Nursing Implications for Insulin Administration:

• sub-q administration (most common)

  • only rapid-acting is used in insulin pumps, which are inserted into sub-q tissue

• regular insulin may also be given IV

• two nurses always check the dosage

Nursing Implications for Insulin Timing:

• short or intermediate acting given 30-45 minutes before meals

• rapid acting given about 15 minutes before eating

• need food at peak action time of insulin

• know your time of onset and peak to know when to check back on the patient

Nursing Implications for Insulin Site Selection:

• abdomen

• back of arm

• thigh and hip if adequate sub-q tissue

• rotate sites

Nursing Implications for Insulin Regarding Therapeutic Effects:

Hgb A1c levels <7%

Nursing Implications for Insulin Regarding Adverse Effects:

signs and symptoms of hypoglycemia

Nursing Implications for Patient and Family Teaching for Insulin:

• correct technique to administer medication

• how to prevent hypoglycemia (blood glucose <70mg/dl)

• how to treat hypoglycemia when it happens

• signs and symptoms of hyperglycemia