Endocrine Disorder- Diabetes

Diabetes, diabetes management, pain, and safety

pancreatitis can lead to ….

developing diabetes

what is gluconeogenesis?

the production of glucose

what is the pathophysiology of diabetes?

beta cells are destroyed —> they are not functioning or partially firing

what is diabetes mellitus (DM)?

increased glucose, abnormal insulin production in the pancreas

How many classes of diabetes are there?

4

what is DM type 1?

not enough insulin is being produced, idiopathic (unknown cause, just happens), latent autoimmune diabetes in adults

what is DM type 2?

a person who normally has that insulin resistance to the tissues. Sometimes your, pancreas will fire, sometimes it won’t.

when does someone get gestational diabetes?

happens during pregnancy

what kinds of people would we see having gestational diabetes?

overweight, obese, advanced maternal age, family history of diabetes

when do you return to normal functioning with gestational diabetes?

6 weeks, but you are at a higher risk of getting type 2

other specific types of diabetes:

cushings disease, hyperthyroidism, recurrent pancreatitis, people who are on TPN (long term), use steroids or thiazides (diuretic) antipsychotics

What does someone with hyperglycemia look like?

polyuria, polydipsia, polyphagia, dry skin, blurred vision, drowsy, nausea, shaky

what happens with diabetes 1?

beta cells are destroyed → pancreas STOPS making insulin -→ glucose stays into the bloodstream and CANNOT break down

what does the bloodstream look like with type 1 diabetes?

HYPERglycemia

why does the pancreas stop making insulin? (DM1)

autoimmune destruction of beta cells

Why does the pancreas stop producing insulin?

genetics, autoimmune, environment is changing, viruses, (unsure!!) we normally see this with younger children!

Clinical Manifestations of DM1

polyuria, polydipsia, polyphagia, weight loss (on skinny side), weakness, fatigue

potential complications of DM1

diabetic ketoacidosis!!! (DKA)

what happens with DKA?

sugar keeps going UP!

What is DM2?

there is some firing of their pancreas. They are producing some insulin, but it's not enough insulin to control that glucose in the body.

what age are we seeing DM2 with?

adults, but seeing more with kids (they are obese)

type 2 diabets is…

GRADUAL, when 50-80% of the beta cells are destroyed

What factors contribute to DM2?

FAMILY HISTORY!

Clinical manifestations of DM2?

some may or may not show those classic symptoms.

polyuria, polydipsia, polyphagia, fatigue, RECURRENT INFECTION, yeast infection, oral thrust, prolonged wound healing, vision problems

how can you diagnose DM2?

A1C blood draw, and blood sugar, lab draw

pathophysiology for DM2?

defective cells are not producing enough insulin in pancreas → sugar production stored into adipose tissue → liver produces that glucose → muscles can become resistant to insulin uptake (COMBO OF EVERYTHING)

Risk factors of DM2?

overweight, obese, older, family history, ethnicity (black, asian, hispanic) metabolic disorder, insulin resistance

Complications of DM2?

hyperosmolar hyperglycemia syndrome (HHS)

What is Exogenous insulin?

insulin that enters the body from an outside source, such as an injection or pump, rather than being made naturally by the pancreas

can you be allergic to insulin injections?

NO → maybe the latex covering syringes

culture considerations with insulin?

watch pork → some insulin has pork and we would not give to muslim patient

diagnostic testings for DM 1+2

• serum HgbA1C

• fasting plasma glucose

• 2 hr plasma glucose level

• if the person has hyperglycemia or hyperglycemia crisis

How often to we draw an A1C?

every 3-6 months (average of 3 months),

Considerations when taking A1C

• you do not have to fast

• if you have anemia → false reading

• finger poke? → review with blood draw

• steroids,stress can make this go up

reading for A1C?

• less the 5.7 (norm)

• 5.7-6.4 (pre-diabetic)

• above 6.5 (diabetes)

fasting glucose levels

• 60-100 (norm)

• 126 (diabetes)

2 hr plasma glucose level

over 200 (diabetic)

reasons for lab results error

• patient had too many carbs

• has acute illness

• on any drugs (contraceptives or steroids)

• if they have a sedentary lifestyle

• they have bad GI absorption

• have they taken APAP (acetaminophen)

Who will you collaborate care with (DM)?

endocrinologist, dietician, social work ($), pharmacist, case workers, mental health professionals, ophthalmologist, podiatrist, cardiologist, PT/OT, obstetricians, nurse practitioners, lab people, PA

diabetes affects…

EVERY system except for brain and lungs

what is the goal for collaborative care?

• symptom management

• make sure patient stays well

• prevent acute complications (skin break -→ slow healers)

• prevent hyper/hypo glycemic episodes (can they see the syringes? → overdose)

• if they are sick, hospitalize them!

Medical treatment trifecta (DM)

exercise, medication, diet (1,800 cal)

rapid acting insulin peak/duration

• peak: 30 min-3 hr

• duration: 3-5 hr

short acting insulin peak/duration

• peak: 2-5 hr

• duration: 5-8 hr

Intermediate acting insulin peak/duration

• peak: 4-12 hr

• duration: 12-18 hr

long acting insulin peak/duration

• peak: no peak

• duration: 16-24 hr

inhaled insulin peak/duration

• peak: 60 mins

• duration: 2.5-3 hr

which drugs should the person be on for DM?

let pharmacy decide, lots of different medication combinations

DM diet?

• INDIVIDUALIZED

• diet tracker on phone

• behavior modification (switch different foods)

• change portions

DM goals?

• FSBS: close to normal

• lipids under control

• BP controlled

• prevent or slow the rate of complications

• behavioral modifications

• maintain the pleasure of eating (dietician, nutritionist)

nutritional therapy for DM

• include carbs (1,800/day)

• protein is individualized

• consume plant fats

• limit alcohol

what is a carb counting diet?

picking what you can have portion wise to limit how many carbs you have a day

what is diet exchange?

exchanging one item they want for another, so they can have something that they want

What does the myplate look like for DM?

1 vegetable, 3 carbs, 2 protein, 4 milk

How often should I diabetic exercise in a week?

150 min/week

Considerations with exercise for a diabetic?

• moderate intensity

• 1 hour after meal (energy reserved and burn off sugar)

• 10-15 g carbs and check sugars BEFORE

• small snack q30 mins during exercise

• carry fast acting sources of carbs

if the diabetics BS is over 250 with urine ketones, should they exercise?

NO

Why is exercise beneficial for diabetic?

decrease insulin resistance, help with weight loss, decrease med need, decrease triglycerides, helps increase good cholesterol, improve circulation, decrease blood sugar

examples of moderate exercise for DM

• housework

• light bicycling

• dancing

• gardening

• roller skating

• brisk walking

Exercise patient teaching

• choose activities you enjoy

• on exercise program

• does not have to be vigorous to be effective

• proper fitting footwear

• monitor glucose

• plan for spontaneous exercise

• candy/sugar on hand for fluctuations

Checking blood sugars frequency depends on..

the person, patients goals, type of DM, med regimen, ability to check BG, access to supplies, patient adherence

checks for BG in acute care?

Ac and hs (7/8, 11/12, 4/5, 8/9)

Surgical manangement for DM

• bariatric (sugars go down from losing weight, normally for type 2)

• pancreas transplant

Nursing assessment for patients with DM?

• eyes that are sunken in

• Kussmaul respirations

• fruity breath

• muscle wasting

• leukocytosis

• dry, warm skin

• hypotension

• weak rapid pulse

• coma

Health promotion for patients with DM?

• ID people who are at risk, monitor, teach

• losing weight (program, daily exercise, low fat)

• screening!!

• ID risk factors

• stop smoking and limit alcohol (1-2 glasses)

• follow treatment plan for HTN

When should we start screening for DM?

age 45 and q3yr

Hyperglycemia mnemonic?

hot and dry? sugar is high!

Hypoglycemia mnemonic?

cold and clammy? need some candy

How should we store insulin for vials and pens?

• can be room temperature for 4 weeks

• avoid sunlight

• store in cooler when traveling

• store unopened in fridge

• store UPRIGHT with the needle upwards

how long is the syringe good for if you draw up 2 different insulins in the syringe?

1 week

if you draw up 1 type of insulin into a syringe how long is it good for?

30 days

what are we looking for when assessing the insulin injection sites?

itching, hives erythema, burning in area of injection

if the person has a true allergic reaction to insulin injection, what happens?

anaphylaxis! (latex around rubber stopper or preservatives causing this)

what is lipodystrophy?

body’s fat tissue wastes away

What is Lipohypertrophy?

buildup of fatty tissue and scar tissue under the skin that forms firm, rubbery lumps

how do we avoid lipohypertrophy and lipodystrophy?

ROTATE SITES

have HgbA1C drawn…

routinely, and follow insulin sliding scale

what is the Somogyi effect?

a rebound high blood sugar level in the morning caused by the body reacting to low blood sugar during the night (give a snack)

What is the dawn phanomenon effect?

a natural, early-morning rise in blood sugar, common in adolescents

What to monitor with our patient with DM?

• monitor for s/s of hypoglycemia, DKA, HHS

• wear medical alert bracelet

• obtain order to change IVF

• abide by diet recommendations

stress, illness, trauma, and steroids ______ blood sugar

INCREASE

S/S of HYPOglycemia

• tachycardia

• irritable

• restless

• excessive hunger

• diaphoresis

• depression (change in LOC)

• confused

• blurred vision

• anxious

• shaking

• pallor

• (T.I.R.E.D)

how to quickly raise blood sugar?

orange juice, put in the sugar packets (cause big drop)

what options raise blood sugar but add protein?

milk, peanut butter on crackers (up to at least 70)

Glucose machine considerations

• monitor patient’s use

• make sure it is calibrated appropriately

oral hygeine with DM

• brush/floss daily

• see dentist q6 months

• let dentist know you have diabetes

What OTC drugs to avoid with DM?

aloe, ginger, cinnamon, St John’s wort, garlic, ginseng

how to provide foot care for pt? (diabetic neuropathy)

• inspect daily

• treat cuts, scrapes, burns right away

• wash area and apply nonabrasive (do not apply anything irritating)

• cover and dry area

• CHANGE DAILY

• cut toe nails straight across

• socks

• no moisture between toes

• wear shoes always

• cotton, wool, silk for socks

what is DKA?

it is a hyperglycemia event where the person has a profound deficiency in insulin, person becomes dehydrated

Who gets DKA?

people with type 1 diabetes

What are the precipitating factors to getting DKA?

people who are sick, infection, cannot control insulin dosage appropriately, person lacks education, person neglects that they have it

patho of DKA

pancreas does not have glucose → liver still making glucose → pouring more into bloodstream → breaking down fat → see polyphagia → glucose into urine → find glucose in bladder/urine → polyuria

S/S of DKA

• dry mouth

• dehydration

• tachycardia

• orthostatic hypertension

• lethargic

• weakness

• sunken eyes

• abdominal pain

• FRUITY BREATHHHHH

• Kussemal respirations

Blood glucose for DKA

>250

ABG for DKA

• pH: <7.3 (acidic)

• HCO3: <16 (acidic)

• metabolic acidosis

where will you see ketones and glucose in DKA?

in the urine

can we wait to treat DKA

NO, treat immediately

How do we treat DKA?

• 0.9% NS (FIRST)

• start insulin drip

• ensure patent airway

• O2 if needed

• monitor stats, urine output (q2)

• breath sounds

• monitor glucose and potassium

• add dextrose to IV fluid when <250

Potassium shift with Hyperglycemia

Potassium starts coming out of the cells and moving to ECF → hyperglycemic state → add in insulin → forces the potassium BACK into the cell → makes person hypoglycemic AND hypokalemic -→ need potassium replacement

Potassium shift in ICU considerations

• sliding scale

• insulin drip

• check every hour

• adjust dose according to the sugar

• lower sugar SLOWLY (careful of potassium shift)

• Add in dextrose (<250)

• prevent cerebral edema

• need potassium replacement