nurs320 - diabetes

normal range of glucose

70-100 mg/dL

fasting plasma glucose

• no caloric intake for at least 8 hours

• impaired fasting glucose = 100-126

• critical values

  • <60 mg/dL or >500 mg/dL

random glucose

• can be drawn any time

• meals, drugs, stress can cause increase

• critical values

  • >180 mg/dL on two occasions

  • >200 mg/dL with s/s of hyperglycemia

two hour oral glucose tolerance test (OGTT)

• Fasting and then consuming sugary drink

• Multiple blood draws over 2 hours after a glucose load of 75 g

• Critical values

  • 200 mg/dL or more = diabetes

  • >140 and <199 = prediabetes

glycosylated hemoglobin A1c (HbA1c)

• tests to see blood glucose in last 3 months

• glycosylated hemoglobin is glucose that has attached to the hemoglobin protein

• normal range: 4 - 5.6%

• pre-diabetes: 5.7 - 6.4%

• diabetes: 6.5% or higher

other diagnostic testings

• urine - protein and ketones

• kidney function test

• BMI - concern with >25

• lipid levels - metabolic syndrome

• C-reactive protein (CVD)

hypoglycemia

• cause: alcohol stops releasing glucose

• collaborative care:

  • conscious - rule of 15

  • unconscious - glucagon 1 mg IM or Sc or 50% dextrose (D50) 25-50 mL IV push

  • have nothing but patient is unconscious - put sugar under their tongue

diabetes mellitus causes

• obesity

• not enough insulin

• steroids

• hormones

type 1.5

• LADA - latent autoimmune diabetes in adults

• slow-progressing form of autoimmune diabetes

• body destroys cells that produce insulin

type 3

• alzheimer’s disease

• insulin deficiency and insulin resistance as mediators of AD

MODY

• maturity onset diabetes of the young

• autosomal dominant

• leads to beta cell dysfunction

• occurs before age of 25

• not associated with obesity or hypertension

• treatment depends on genetic mutation

pre-diabetes

• hbA1c = 5.7 - 6.4%

• fasting plasma glucose level is above 100

• studies show prevention with lifestyle change of weight loss and regular exercise

• studies show long-term damage of CV system already may be occurring

type 1 diabetes

• progressive destruction of pancreatic B cells

• risk of DKA

• manifestations - 3 P’s, and weight loss

type 2 diabetes

• insulin resistance

• can result in HHNK - hyperosmolar hyperglycemia nonketotic state

• manifestations - gradual 3 P’s, fatigure, recurrent infections, visual changes, prolonged healing times

metabolic syndrome

• cluster of abnormalities working together to increase risk for CV disease and DM

• elevated insulin levels

• decreased HDL (good cholesterol)

• increased LDL (bad cholesterol)

• hypertension

• obesity

• sedentary lifestyle

• treated with weight loss and exercise

hyperglycemia short and long-term consequences

• short term - inadequate glucose reaching cells, dehydration

• long term - end organ disease, macrovascular angiopathy (atherosclerosis)

why cant’t exogenous insulin be taken orally?

insulin can’t be absorbed and broken down in stomach if taken orally

hyperglycemia collaborative care nutritional therapy

• CHO - includes fruits, veggies, whole grains and low fat milk

• high protein diets for weight loss not recommended

• eliminate fats

• limit alcohol, if consumed then with food!

hyperglycemia collaborative care exercise

• best done after meals

• if BS <100 mg/dL - delay exercise

• if BS >250 mg/dL and with ketones in urine - postpone exercising

hyperglycemia collaborative care while patient is ill

• regular diabetic diet

• increase non-caloric fluids

• continue with oral agents and/or insulin

• monitor BS every 4 hours

• if >240 check urine for ketones and report

hyperglycemia collaborative care foot care

• risk of amputation up to 40x higher in diabetics

• foot care/assessment

• proper footwear

• podiatrist

somogyi effect

• overdose of insulin causes low BS in middle of night and morning hyperglycemia

• treatment:

  • check BS between 2 AM and 4 AM, if low then reduce PM dose of insulin OR eat a bedtime snack

dawn phenomenon

• hyperglycemia at night in the AM due to release of hormones in predawn hours

• GH, cortisol, glucagon are factors

• affects majority of diabetics but most severe in adolescence and young adulthood

• high BS after 3 AM

• treatment: if BS is high between 2AM and 4AM then increase insulin and eat bedtime snack

DKA

• inadequate insulin for cells does not allow body to obtain energy

• body attempt to obtain energy by rapid breakdown of fat in liver and form ketone bodies (acidic)

• caused by:

  • missed insulin dose, inadequate insulin, increased insulin needs

  • new diagnosis of type 1 DM

  • stress/illness

HHNK

• hyperglycemia hyperosmolar non-ketotic state

• produce enough insulin to prevent DKA

• not enough insulin to prevent osmotic diuresis, hyperglycemia, or ECF depletion

• increase in serum osmolarity

• BS >400 mg/dL

• ketones ABSENT

treatment of DKA and HHNK

• med emergency

• IV administration of NSS or ½ NSS (first thing you do)

• regular insulin IV

• when glucose falls <250 add IV glucose

• electrolyte replacement

• bicarbonate for pH <7.10 (FOR DKA)

• cardiac monitoring - dysrhythmias - worried about hypokalemia

  • monitor potassium levels