AH1 Exam 3 - DM & HHS

Pathophys of DM 1

• Triggered by autoimmune process

• Insulin-produce beta cells of pancreas destroyed

• Absolute lack of insulin!!

• Can be caused by pancreas resection — RAREEE

3 P’s of DM 1

• Polyuria

• Polydipsia

• Polyphagia

Why does Polyuria occur w/ DM 1?

• Excessive urination

• Osmotic diuresis - taking fluid from body & peeing it out

• Kidneys can’t can’t keep up cuz hyperglycemic - dehydrated pt

Why does Polydipsia occur w/ DM 1?

• Excessive thirst - super dehydrated! Fluid vol deficit

• Dehydration from excessive urination

Why does Polyphagia occur w/ DM 1?

• Cells cannot absorb glucose due to insulin deficiency — cellular starvation & extreme hunger signals

• Excessive hunger!! - cells reach for energy sources

2 other symptoms of DM 1

• Fatigue

• Weight loss

What is Hemoglobin A1c?

Avg blood sugars of a pt - important

Fasting blood glucose DM #

Greater than or equal to 126 mg/dL

2-hr postprandial DM #

Greater than or equal to 200 mg/dL

Hemoglobin A1c #

Greater than or equal to 6.5%

Random blood glucose level #

Greater than or equal to 200 mg/dL

Also accompanied by s/s of hyperglycemia

Med management for DM 1

• Insulin!

• Nutrition management

• Pt edu & self management

• Detection & prevention of complications

What is hypoglycemia?

• BGL <70 mg/dL

• can lead to serious complications if untreated — DEATH

How can hypoglycemia occur?

Dosed inapp insulin, surgery, not eating

Early s/s of hypoglycemia (6)

• Shakiness

• Confusion

• Sweating

• Palpitations

• HA

• Blurred vision

Late signs of hypoglycemia (3)

• Seizures

• Coma

• Loss of consciousness — important to know LOC!!!!

15/15 rule for hypoglycemia

• If conscious = 15g simple carb

• Altered LOC = dextrose 50% (25-50 mL) IVP

• Check blood sugar in 15 mins & if less than 70 = 15 g simple carb (if CONSCIOUS — do this 3x) - if not fixed after 3x give IV dex

What do we give once blood sugar back to norm after hypoglycemia?

• Complex carb & protein

• Investigate cause of hypoglycemia

What is DKA?

Serious & sometimes fatal complication of DM - hyperglycemic emergency

DKA causes (3)

• Intentional or unintentional missed or reduced doses of insulin

• Inadequate insulin due to increased insulin needs secondary to stress or infection

• New onset of type 1 DM - don’t know they’re diabetic!! Most often seen in Type 1 but can occur in Type II esp w/ severe stress like infection

DKA patho

• Can’t move insulin into cell - insulin is the key!

• Body attempts to obtain energy by the rapid breakdown of fat stores - releases fatty acids from adipose tissue

• Liver converts fatty acids into ketone bodies - they have a low pH resulting in METABOLIC ACIDOSISSS

DKA manifestations (11) :(

• Polydipsia

• Polyphagia

• Lethargy/stupor

• Blurred vision

• Fruity breath - ketone breakdown

• Kussmaul breathing - trying to compensate to reg pH

• METABOLIC ACIDOSIS!!

• N/V

• Abd pain

• Polyuria

• Glycosuria - kidneys can’t filter glucose

Blood glucose level for DKA

• Greater than 250 mg/dL

• KETONURIAAA (KETONES IN URINE)

ABG for DKA

• pH less than or equal to 7.30 (acidosis)

• Serum bicarb less than or equal to 18 mEq/L (norm 22-26)

Anion gap of DKA

>10 mEq/L — Positive anion gap, early trigger

DKA treatment (3)

• Fluid replacement w/ isotonic norm saline; PRIORITY; FVD - replace intravascular fluid lost

• Correction of electrolyte imbalances - focus on monitoring K+ level!! Prior to insulin

• Insulin admin, IV delivery - prim line - REGULAR INSULIN

Total body water deficit for a pt in DKA

Up to 6 L..may exceed 9 L w/ HHS

Goal for fluid replacement w/ DKA

Replace half the pt’s water deficit in first 12-24 hr

Recommended admin of fluids for DKA

• 15-20 mL/kg over first hr of treatment - ISOTONICCC (0.9% sodium chloride)

• Should be admin at up to 500 mL/hr for 4 additional hrs

What manifestations need more aggressive fluid therapy?

• Hypotension

• Hypovolemia

What manifestations need less aggressive therapy?

• Renal or heart disease

• Want to AVOID hypovolemia

What do we monitor w/ fluid therapy?

Na+ levels

What do we start IV insulin w/?

• Bolus dose!!

• Followed by cont IV infusion that is titrated based on BGL

How often do we monitor glucose levels when giving IV insulin for DKA?

• hourly!!

• Peripheral sample vs venous sample - if acu check high get accurate reading

What levels should we check/anticipate replacing w/ IV insulin for DKA?

• K+!! Reduces K+ level — drives K+ into cell = hypokalemic (dysrhythmias) ; want baseline K+ prior to insulin

• Check Mg as well

What K+ level do we hold insulin?

• Less than 3.3 mEq/L, hold & replace K+ via IV route

• When K+ reaches 3.3 mEq/L or greater, safe to start insulin & continue to monitor

Nursing clinical steps for treating DKA

1) Anticipate IV access (check K+ first)

2) Draw labs & ABGs as prescribed

3) After IV started, hang ordered NS infusion for hydration

4) K+ may be prescribed to be added or as piggyback

*giving FLUIDS is more IMPORTANT than insulin!!!! (circulation)*

Pathophys of type II DM

• Cell membrane resists transport of glucose into cell

• Increased insulin required

• Pancreas beta cells fail

Type II DM clinical manifestations (9)

• Polyuria

• Polydipsia

• Polyphagia

• Fatigue

• Poor wound healing - vascular changes

• CV disease

• Visual disturbances

• Renal insufficiency

• Recurring infection

dx test for DM II (same as DM I)

• Hemoglobin A1c

• Fasting blood glucose

• 2 hr postprandial blood levels

• Random blood glucose

Treatment for DM II (6)

• Edu

• Monitor glycemic control

• Nutrition

• Exercise

• Monitor for complications

• Meds:

  • Insulin

  • Oral agents (start on it, if uneffective THEN insulin)

Complications of DM II (5)

• Hyperosmolar hyperglycemic state (HHS)

• Decreased immune system

  • Infection

  • Poor wound healing

• Prolonged hyperglycemia

• Vascular effects (peripheral neuropathy)

• Autonomic & peripheral neuropathy

What is HHS?

Serious & sometimes fatal complication of DM — higher mortality rate than DKA

HHS causes (3)

• Infection

• Common in older adults in response to stress or infection

• Occurs in type II DM

Patho behind HHS

• Cells are fed; just not enough to prevent severe hyperglycemia

• Extreme hyperosmolality leads to osmotic diuresis - highly concentrated blood; massive fluid loss

Blood glucose level for HHS

Greater than 600 mg/dL

pH level for HHS/ABGs

• pH Greater than 7.4

• Serum bicarb levels greater than 15 w/ norm pH

Other manifestations of HHS (6)

• Absence of ketones in urine

• Serum osmolality greater than 320 mOsm/kg - higher # is, more concentrated blood is

• Neg anion gap - not acidic

• Profound dehydration

• Altered LOC (pt won’t wake up)

• No metabolic acidosis

Treatment for HHS

• Fluid replacement w/ isotonic norm saline (up to 9L lost)

• Treatment for altered mental stat - airway management

• Insulin admin, by IV - REGULAR INSULIN

• Same rules as DKA!!