Glucose Management

Unit 2: Glucose Management

Presentation at GALEN COLLEGE OF NURSING®

List of Glucose Intolerance Disorders

Pre-diabetes —→ possible hx of hyperglycemia
Diabetes
  - Type 1
  - Type 2
  - Gestational Diabetes
Metabolic Syndrome
Hypoglycemia
Hyperglycemia
Somogyi Effect
Dawn Phenomenon

General Diabetes Information

Diabetes is a metabolic disorder characterized by:
  - Hyperglycemia (high blood glucose levels)
  - Insufficient insulin secretion: The body does not produce enough insulin.
  - Ineffective insulin action: The body does not utilize insulin effectively.
It is a common and often underdiagnosed condition.
Clients may transition between categories (e.g., Gestational → Type 2).
Complications = amputation, neuropathy, delayed wound healing, blindness, kidney failure and increased risk of cardiovascular diseases, which can significantly impact overall health.

Endogenous Insulin

Insulin clears from circulating blood within 10 to 15 minutes. Released from the pancrease B cells
Major roles of insulin in metabolism include:
  - Converting carbohydrates to glucose.
  - Converting fats to lipids.
  - Converting proteins to amino acids.
Functions of insulin:
  - Lowers blood glucose levels.
  - Instructs the liver to stop releasing glucose.
  - Facilitates the uptake of glucose into fat tissue.

Risk Factors for Glucose Related Disorders

Notable risk factors include:
  - Family history of diabetes.
  - Obesity.
  - Race / ethnicity. —> African American, Asian, Hispanic, Pacific Islander, Native Americans are at a high risk.
  - Presence of metabolic syndrome.
  - Age. —→ older than 45 should be getting screenings for Type 2 & 5-20 is Type 1
  - Hypertension.
  - Elevated triglycerides and cholesterol levels.
  - History of gestational diabetes with an overweight baby.
It is important to consider the number and severity of these risk factors.

Pre-Diabetes

Defined by a history of hyperglycemia and either:
- Impaired insulin sensitivity
- Impaired insulin synthesis / release.
Symptoms of Pre-diabetes:
- Generally none; blood levels remain normal or mildly elevated.
- Positioned between normal and diabetic levels.
Risk Factors: See diabetes risk factors.
Diagnosis:
- Fasting glucose: 100-125 mg/dL
- A1C: 5.7% - 6.4%
Care recommendations include education focused on:
  - Diet (Healthy)
  - Exercise —→ 30 mins a day 3-5x per week
  - Weight management

Diabetes Type 1 / Type 2

Diabetes characterized by hyperglycemia.
Differences between Type 1 and Type 2 include:
  - Onset / course
  - Pathology
  - Treatment
Type 1 Diabetes:
  - Represents about 5% of diabetic patients.
  - Commonly appears in youth; may involve thinness or unexplained weight loss.
  - Caused by genetic, immunologic, and environmental factors.
  - Little to no endogenous insulin production.
  - Management requires insulin to sustain life.
  - Most acute complication: Diabetic Ketoacidosis (DKA).
Type 2 Diabetes:
  - Comprises 95% of diabetes cases.
  - Can affect any age, but generally manifests in adults.
  - Associated with obesity, heredity, and lifestyle factors.
  - Endogenous insulin is present but decreased in efficacy.
  - Management options include weight loss, dietary changes, oral antidiabetics, and insulin therapy.
  - Most acute complication: Hyperglycemic Hyperosmolar State (HHS).

Clinical Manifestations of Diabetes Mellitus (DM)

Common symptoms of DM include:
  - Hyperglycemia
  - Three P’s: Polydipsia, Polyuria, Polyphagia
  - Dehydration
  - Fatigue and weakness
  - Vision changes —→ blurred vision is a common complaint
  - Paresthesia (tingling or prickling sensation)
  - Dry skin
  - Wounds that are slow to heal
  - Recurrent infections
Important to note when symptoms are expected.

Diagnosing Diabetes Mellitus

Diagnostic criteria for DM include:
  - A1C: Greater than 6.5%
  - Fasting glucose: Greater than 126 mg/dL (after 8 hours fasting)
  - Glucose tolerance test: Greater than 200 mg/dL
  - Random glucose test: Greater than 200 mg/dL with symptoms present

Goals of Care for Diabetes Mellitus

Euglycemia: Maintain normal glucose levels without causing hypoglycemia.
Complication Prevention: Focus on preventing conditions such as:
  - Diabetic Retinopathy —→damage to blood vessels that feed the retina (can see floaters/specks or blurred vision)
  - Diabetic Nephropathy —→ damage to kidney cells
  - Diabetic Neuropathy —→ damage to nerve cells
Cardiovascular Disease —→ increased risk of heart attack and stroke due to atherosclerosis and elevated blood pressure.
Foot Ulcers —→ potential infections and amputations due to poor circulation and nerve damage in the feet.
Skin Complications —→ conditions such as necrobiosis lipoidica and diabetic blisters, which can lead to skin infections and delayed healing.
Gastrointestinal Complications —→ disturbances in digestion and absorption, leading to issues like gastroparesis or diarrhea, which can negatively impact overall health.
Patient Education: Involves planning, assessments, and employing effective educational methods.

Nursing Care for Diabetes Mellitus - Nutrition

Consultations should consider:
  - Timing and cultural preferences.
  - Caloric requirements:
    - Assessment of basic metabolic requirements plus activity level.
    - Caloric distribution should emphasize carbohydrates > fats > proteins.
    - Utilize sources including exchange lists and glycemic index.
Alcohol consumption should be moderate; it can pose risks for hypoglycemia due to decreased gluconeogenesis.
Artificial sweeteners should also be consumed moderately to maintain dietary adherence. —> natural sweeteners may be a better option

Glycemic Index and Food Recommendations

Combining starchy foods with proteins and fats can slow carbohydrate absorption and glycemic response.
Raw or whole foods generally elicit lower glycemic responses compared to cooked or processed foods.
Whole fruits are preferred over juices to lower glycemic response because of natural fiber content.
Consuming sugar alongside foods that have slower absorption properties may reduce glycemic response.

Nursing Care for Diabetes Mellitus: Exercise & Rest

Regular exercise lowers both glucose levels and cardiovascular risks.
Recommendations include:
  - Initiating exercise when glucose levels are between 100-250 mg/dL. —> during a workout you BGL lowers, avoid a hypoglycemic episode
  - Exercise at least 3 times a week.
  - Emphasize consistency and planning.
  - Avoid exercising during insulin peak times.
Precautions for exercise:
- Avoid exercising with severely elevated glucose or ketones in urine.
- Advise clients to have a snack before exercising for backup energy.
Importance of adequate rest, including nighttime and naps.

Nursing Care for Diabetes Mellitus: Hygiene & Foot Care

50% of diabetic amputations are preventable.
Foot care suggestions include:
  - Avoiding moisturizers in already moist skin areas (ex. Between the toes).
  - Trimming nails straight across.
  - Washing feet daily with lukewarm water and gentle soap; ensuring they are dried thoroughly.
  - Avoid soaking feet.
  - Inspect feet daily using a mirror.
  - Wear well-fitted shoes and avoid walking barefoot indoors or outdoors.

Nursing Care for Diabetes Mellitus: Monitoring

Monitoring protocols should include:
  - Procedures and frequency of checks.
  - Responding appropriately to findings.
  - Requirement for self-monitoring of levels and understanding the significance of results.
  - Tracking glycosylated hemoglobin and ketone testing as necessary.

Pharmacological Therapy for Diabetes Mellitus: Insulin

Insulin types may be administered on a schedule, based on intake and glucose levels. Key purposes include:
- Providing insulin that the body cannot produce.
- Often withheld for patients with normal or low glucose levels.
Types of insulin:
- Rapid, Short, Intermediate, Long, Combination.
Lispro- rapid, a short-acting insulin with an onset of action within 15 minutes, peaks in about 1-2 hours, and lasts for 3-5 hours, making it suitable for controlling postprandial blood glucose levels.
Regular Insulin: A short-acting insulin that has an onset of action within 30 minutes, peaks in 2-4 hours, and lasts for 5-8 hours, commonly used to manage glucose levels in both pre- and post-meal situations.
NPH Insulin: An intermediate-acting insulin that begins to work within 1-2 hours, peaks in 4-8 hours, and has a duration of action of about 10-16 hours, often administered to provide basal insulin coverage.
Lantis- long-acting insulin, no peak, onset is 3-6 hours, last about 24hrs

Pharmacological Therapy for Diabetes Mellitus: Insulin Delivery

Delivery methods include:
  - Insulin pumps
    - Continuous delivery mimicking pancreatic activity.
    - Catheter changes every 3 days.—> never disconnect, turn off, abruptly stop using
  - Insulin pens —> multidose, dial, ease of equipment management
  - Subcutaneous injections
    - Requires frequent checks and scheduled administration. —> important to rotate sites
    - Multi-dose vials may be cumbersome compared to pens.
Self-administration considerations include:
- Patients should be ready to learn proper techniques.
- Vision correction (glasses or contacts) if necessary.

Pharmacological Therapy for Diabetes Mellitus: Insulin Self-Administration

Storage guidelines for insulin:
- Refrigerated when unopened and at room temperature for up to 30 days when in use/opened.
Syringe specifications include:
- Capacity and increments must be considered (27-29g needles are typical, ~0.5 in long).
- Air must be injected into the vial before drawing up insulin. —> prefilled syringes must be stored in a upright position and kept at room temperature, avoiding exposure to direct sunlight or extreme temperatures.
Mixing insulins (if necessary) should follow: No River Runs North
- Clear (regular) insulin drawn up first before cloudy (NPH).
Preferred injection sites include:
- Abdomen, upper arm, thigh, or hip; rotation of sites is encouraged.
- Avoid injecting into areas that will be exercised immediately post-injection to prevent variations in absorption.
Education —> check BGL, inject at 45–90-degree angle, stabilize skin, properly clean injection site and dispose of syringes in a sharps container after use to ensure safety.
Monitor for signs of hypoglycemia or hyperglycemia, and be prepared to manage these conditions as needed, including having fast-acting glucose sources available.

Complications of Insulin Therapy

Complications that arise from insulin therapy include:
  - Local allergic reactions
  - Systemic allergic reactions
  - Insulin lipodystrophy—→ when injection site is overused
  - Resistance to injected insulin
  - Morning hyperglycemia——→ may need to increase dose or adjust time of nightly insulin
Hypoglycemia unawareness—→ patients may not recognize low blood sugar symptoms
Weight gain—→ due to increased appetite or reduced glucose utilization
Diabetic ketoacidosis—→ in cases of prolonged insufficient insulin levels
Injection site complications—→ including infections or abscesses if not properly managed.

Oral Anti-Diabetic Agents

Used for Clients with Type 2 diabetes who need more than just diet and exercise for glucose control.
Combination therapies may be warranted.
Major side effect: Hypoglycemia.

Pharmacological Therapy for Diabetes Mellitus: Oral Antidiabetics

Classes of oral agents include: know how these medications work
  - Sulfonylureas (e.g. glipizide, glyburide) ——→ tells pancreas to increase insulin production, increase insulin sensitivity
  - Alpha Glucosidase Inhibitors (e.g. acarbose) ——→ works very fast, make sure pt eat prior to administration
  - Biguanides (e.g. metformin) ——→ can be very damaging to the kidneys & can negatively interact with contrast dye, works by lower BGL by taking glucose directly into the liver to be absorbed
  - Incretin mimetics (e.g. exenatide) ——→ glucagon agonist, stops liver from producing glucagon
  - Thiazolidinediones (e.g. rosiglitazone) ——→ don’t give to HF pts, can cause fluid retention
  - Dipeptidyl peptidase-4 inhibitors (e.g. sitagliptin) ——→ increase in prolonged reaction to incretin, decreasing glucagon levels
  - Meglitinides (e.g. repaglinide)
Oral diabetic medications should be taken on a schedule and administered unless glucose levels are low.
These medications assist the body in releasing insulin already being produced.

Hospitalization of the Diabetic Client

Principles of management during hospitalization:
  - Aim for blood glucose levels between 140-180 mg/dL.
  - Insulin (subcutaneous/intravenous) must be used according to protocols.
  - Intensive management and adjustments of oral antidiabetics may be required.
  - Standard hypoglycemia treatment must be considered. ——→ make sure that an order is in place
  - More frequent blood sugar checks are necessary.
Special considerations based on:
  - Self-care evaluations.
  - Managing hyperglycemia responses.
  - Stress-related hormonal effects impacting blood glucose levels. (may need supplemental insulin)
  - Medication adjustments for optimal control.
  - Nutritional provisions ——→ NPO, clear diets, both parenteral and enteral nutrients.
  - Hypoglycemia management for patients who are NPO requires careful monitoring of blood glucose levels and may include administering glucose tablets, gels, or IV dextrose as appropriate.
- Hygiene is important to keep the cleanliness of wounds, etc.

Gestational Diabetes

Defined as pregnancy-related glucose intolerance.
Condition arises as placental hormones inhibit insulin action.
Diagnosed through:
- Glucose Tolerance Test (GTT) which includes an oral glucose test and glucose challenge test.
Higher risk factors include:
  - Obesity
  - History of gestational diabetes
  - Race / ethnicity considerations.
- and previous pregnancy that resulted in a >9lb baby
Complications include:
  - Perinatal complications
  - Macrosomia (large baby or growth)
  - Increased risk of future diabetes.
Medical management involves:
  - Dietary modifications
  - Regular blood glucose monitoring
  - Insulin management (to be further discussed in maternal health courses).

Latent Autoimmune Disease of Adults (LADA)

A subtype of diabetes characterized by a slower progression of autoimmune beta-cell destruction in the pancreas
Displays similar manifestations and treatment as Type 1 Diabetes but often with a delayed need for insulin therapy.
Risk = hx of auto immune disorders or family history of autoimmune diseases, which increases the likelihood of developing LADA in adults. & BMI >25. Ages 30-50.
Activated by something stressful or traumatic happening to the body

Metabolic Syndrome

Defined as a "cluster of metabolic abnormalities" characterized by:
  - Insulin resistance
  - Increased fasting glucose levels
  - Dyslipidemia / elevated cholesterol levels
  - Abdominal obesity
  - Hypertension
Majorly associated with increased cardiovascular disease risk.
Prevention of diabetes (Type 2 particularly) via:
  - Diet ——→ healthy diet
  - Exercise ——→ 30 mins a day, 3-5x a wk
  - Adequate rest.

Hyperglycemia

Hyperglycemia (BGL >160) occurs due to an excess of extracellular glucose resulting in elevated serum glucose levels, commonly found in:
  - Known diabetes clients
  - Pre-diabetes patients
  - Potentially in others ——→ ex. some pt that may be under stress
Management includes lifestyle changes and insulin as needed. Frequent BGL checks

Hyperglycemic Emergencies (DKA, HHS)

Hyperglycemic emergencies occur as an abnormal body response to total insulin deficiency, particularly during infections, injuries, or illnesses.
Key indicators: Blood sugar greater than 300 mg/dL, changes in level of consciousness (LOC), severe dehydration, hypotension, and gastrointestinal symptoms.
Specific to DKA:
- Kussmaul’s breathing and presence of acetone. (Rapid deep breathing w/ fruity breath smell)

Client Education for DM / Hyperglycemia

Client readiness is vital, incorporating:
  - Acknowledging stages of grief processes. ——→ typically the acceptance stage of grief
  - Inviting discussion of fears and concerns regarding their condition.
  - Addressing literacy levels to ensure understanding. ——→ what type of materials to give for best comprehensions
  - Providing resources for financial or insurance support.
  - Encouraging family support / education.
  - Scheduling follow-up education to reinforce learned information.

Hypoglycemia

Defined as too little glucose available for cells to function effectively.
Common causes include:
  - Excessive medication
  - Inadequate food intake
  - Excessive physical activity.
Diagnostic criteria:
- Glucose levels of less than or equal to 70 mg/dL. (can depend on the individual)
Manifestations may include:
  - Sweating
  - Tremors or shakiness
  - Tachycardia
  - Nervousness
  - Confusion or difficulty in organization of thoughts (LOC)
  - Slurred speech.
Treatment must be timely and may involve:
  - Simple carbohydrates or sugars taken orally (easily broken down). ——→ able to swallow
  - Administration of Glucagon (subcutaneous or intramuscular). ——→ must be reconstituted both the pt and family/caregiver need to know how to prepare it & for pts that are unable to swallow
  - Intravenous push of D50 (50% dextrose). ——→ needs to be pushed slow!

Dawn Phenomenon

A phenomenon commonly seen in Type 1 DM:
  - Defined as “morning hyperglycemia” resulting from a nocturnal surge of growth hormone secretion.
  - This results in an increased demand for insulin in the morning.
  - Typically, normal glucose readings until 3 AM, followed by elevated glucose levels upon waking.
Dawn Never Dips = norm at 3AM——→ Cortisol release upon waking shoots up BGL
Diagnosis involves checking glucose levels at:
  - Bedtime
  - 03:00 AM
  - Upon waking in the morning.
Care strategies may include:
- Additional intermediate acting insulin at bedtime
- Adjusting the timing of evening meals or insulin administration.

Somogyi Effect

Also referred to as “hypoglycemia overnight”:
- Characterized by normal or elevated blood glucose levels at bedtime, followed by hypoglycemia occurring between 2-3 AM.
- This triggers the production of counter-regulatory hormones that lead to morning hyperglycemia.
Somogyi Never Slips = Low at 3AM——→ pancreases release Glucagon shoots up BLG by the time of waking
Diagnosis is challenging, as the patient is typically sleeping and unaware of hypoglycemia.
Signs include:
- Normal or elevated glucose readings before bed
- Hypoglycemia detected at 02:00 - 03:00 AM and hyperglycemia in the morning.
Care strategies include:
- Provision of a nighttime snack.
- Adjusting any intermediate insulin dosages taken at bedtime.

Gerontology and Diabetes

Symptoms of diabetes in the elderly may be decreased or absent, complicating diagnosis, or pt may not be fully aware.
Blood testing is more reliable than urine testing in geriatric populations.
Considerations for exercise include:
  - Overall physical capacity and involvement of physical therapy.
  - Awareness of hypoglycemia risks (decreased appetite), particularly as patients may live alone (don’t cook as much)
  - Renal function issues may delay excretion of glucose and insulin. (decreased kidney function and longer time to metabolize meds)
  - Patients may skip meals due to decreased appetite or have decreased visual acuity that can affect self-management. (Can the effectively see syringe #s for correct dose)
  - Awareness of hypoglycemia unawareness in many elderly patients.

SICK DAY RULES (CALL YOUR DOCTOR)

Guidelines for managing diabetes during illness include:
  - S: Check blood sugar levels every 4 hours.
  - I: Continue taking insulin and diabetes medications as instructed. (body is stressed = increased BGL)
  - C: Maintain regular meal times and drink approximately 8-12oz of fluid every hour:
    - For high blood sugar levels, consume sugar-free options.
    - For low blood sugar levels, consume sugary options.
  - K: Test urine for ketones when blood sugar exceeds 240 mg/dL. (At home ketone dipsticks available)

Long-Term Complications of Diabetes

Macrovascular Complications (Big Veins):
- Include accelerated atherosclerotic (plaque build-up) changes, coronary artery disease, cerebrovascular disease, and peripheral vascular disease.
Microvascular Complications (Tiny Veins):
- Include diabetic retinopathy (eyes) and nephropathy (kidneys).
Neuropathic Complications:
  - Peripheral neuropathy ——→ tingling, numbness
  - Autonomic neuropathies
  - Hypoglycemic unawareness
  - General neuropathies
  - Sexual dysfunction.

Nursing Diagnosis for the Diabetic Client

Possible nursing diagnoses may include:
  - Risk for injury due to decreased sensation or other complications.
  - Self-care deficit regarding blood glucose management.
  - Knowledge deficit about diabetes management and education practices.

Class Summary Prompts

What are three things you already knew about today’s lecture content?
What are two things you learned today?
What is one question you still have?

Reference

Hinkle, J. L., Cheever, K. H., & Overbaugh, K. (2026). Brunner & Suddarth’s textbook of medical-surgical nursing (16th ed.). Wolters Kluwer.