Clinical Management of Diabetes and Glucose Regulation Notes
Managing Glucose Issues in Diabetes
Goals of Insulin Therapy
Prevent & treat hyperglycemia: Address both fasting and postprandial (after eating) hyperglycemia.
Utilization of glucose: Facilitate appropriate use of glucose and nutrients by tissues.
Suppress hepatic glucose production: Inhibit glucose release from the liver.
Mimic normal pancreatic function: Strive to replicate the body's natural insulin release pattern.
Injectable Hypoglycemic Drugs
Regular Insulin
Prototype drug for diabetes management.
Mimics endogenous insulin: Originally derived from animal sources (beef/pork), currently produced via human DNA technology to reduce allergic reactions.
Insulin analogs: Engineered for modified actions (rapid onset/duration).
Dosage Form: Parenteral
Indications: Control of hyperglycemia in diabetes.
Contraindications: Hypoglycemia, allergy to insulin.
Adverse Effects: Hypoglycemia, anaphylaxis.
Monitoring:
Symptoms of hypoglycemia/hyperglycemia
Blood glucose levels
A1C levels
Body weight
Mechanism of Action: Lowers blood glucose by stimulating uptake in muscles and fat, inhibiting hepatic glucose production.
Other Insulin Types
Rapid-acting Insulin:
Lispro (Humalog): Onset <15 min, Peak 30-60 min, Duration 3-4 hrs.
Aspart (Novolog): Onset 15 min, Peak 1-3 hrs, Duration 3-5 hrs.
Glulisine (Apidra): Onset 15-30 min, Peak 60 min, Duration 3-4 hrs.
Short-acting Insulin:
Regular (Humulin-R): Onset 30-60 min, Peak 2-3 hrs, Duration 5-7 hrs.
Intermediate-acting Insulin:
NPH (Humulin-N): Onset 1-2 hrs, Peak 4-12 hrs, Duration 18-24 hrs.
Long-acting Insulin:
Glargine (Lantus): Onset 60 min, No peak, Duration 24 hrs.
Detemir (Levemir): Gradual onset, No peak, Duration 24 hrs.
Limitations of Regular Insulin
Slow onset if given right before meals, risk of hypoglycemia if meal is delayed.
Prolonged duration of action can lead to hypoglycemia when eating patterns vary.
Basal/Bolus Insulin Concept
Basal Insulin:
Suppresses glucose production, meeting approximately 50% of daily needs.
Bolus Insulin:
Limits hyperglycemia post-meal, administered based on food intake.
Insulin Management: Quick-acting insulins better match mealtime insulin release patterns.
Sliding Scale Insulin
Insulin dosage adjusted based on blood glucose levels measured before meals.
Dosing Guide:
BS < 150: No insulin
BS 151-200: 2 units regular
BS 201-250: 4 units regular
BS 251-300: 6 units regular
BS 301-350: 8 units regular
BS 351-400: 10 units regular
> 400: Notify provider.
Oral Hypoglycemic Drugs
Work by decreasing insulin resistance or stimulating insulin production, ineffective for Type 1 DM.
Sulfonylureas
Glipizide (Glucotrol): Common OHA, stimulates insulin release, monitor for hypoglycemia, educate on adherence and signs of hypo/hyperglycemia.
Biguanides
Metformin (Glucophage): Reduces hepatic glucose production, low risk of hypoglycemia.
Other OHAs
Various new agents that stimulate insulin receptors or modify glucose absorption.
Glucose Regulation
Insulin Dynamics
Insulin promotes anabolic processes, regulated by feeding patterns, autonomic nervous system activity, and serum nutrient levels.
Homeostasis and Hormonal Balance
Insulin: Reduces serum glucose, stores nutrients in tissues.
Glucagon: Raises blood glucose levels, promotes glycogen breakdown and gluconeogenesis in the liver.
Diabetes Mellitus Overview
Type 1 vs. Type 2 Diabetes:
Type 1: Autoimmune destruction of beta cells, low insulin.
Type 2: Insulin resistance, with eventual beta cell burnout.
Epidemiology
Rising incidence, notably in certain demographics (racial/ethnic groups, young adults).
Diagnosis Criteria
Diabetes: HbA1c > 6.5%, fasting glucose > 126 mg/dL, random glucose > 200 mg/dL.
Pre-diabetes: A1C 5.7-6.4%, fasting glucose 100-125 mg/dL.
Pathogenesis
Autoimmune destruction in Type 1, combination of overweight and genetic influences in Type 2.
Clinical Consequences
Complications from both types include poor glucose uptake, osmotic diuresis leading to dehydration, electrolyte imbalances, and metabolic derangements.
A patient with diabetes is prescribed regular insulin. What is the most important action for the nurse to take prior to administering the insulin?
A) Assess the patient's blood glucose level
B) Check the patient's weight
C) Confirm the patient's identity
D) Review the patient's dietary orders
Correct Answer: A) Assess the patient's blood glucose level
A nurse is teaching a patient with type 2 diabetes about the use of metformin. Which of the following statements made by the patient indicates a need for further teaching?
A) "I should take this medication with meals to help reduce gastrointestinal side effects."
B) "This medication can help decrease hepatic glucose production."
C) "I can use this medication alone to manage my blood sugar levels."
D) "I need to monitor my blood glucose regularly while on this medication."
Correct Answer: C) "I can use this medication alone to manage my blood sugar levels."
The nurse is providing education on sliding scale insulin. Which of the following is an appropriate guideline for adjusting insulin dosage based on blood glucose levels?
A) Insulin should not be given if the blood glucose is below 150 mg/dL.
B) 2 units of insulin should be given if the blood glucose is between 151 and 200 mg/dL.
C) Insulin should be increased if the blood glucose is consistently above 400 mg/dL.
D) Insulin should be given regardless of blood glucose levels.
Correct Answer: A) Insulin should not be given if the blood glucose is below 150 mg/dL.
A patient with type 1 diabetes reports feeling lightheaded and shaky. What should the nurse do first?
A) Administer a dose of insulin
B) Instruct the patient to eat a snack
C) Check the patient's blood glucose level
D) Call for help
Correct Answer: C) Check the patient's blood glucose level
Which of the following is a long-acting insulin?
A) Lispro (Humalog)
B) NPH (Humulin-N)
C) Glargine (Lantus)
D) Regular insulin (Humulin-R)
Correct Answer: C) Glargine (Lantus)