Hyperglycemia, Hypoglycemia, Type 1 & 2 Diabetes, and Metabolic Syndrome

Hyperglycemia

Pathophysiology

• Pancreas has two main functions:

  • Endocrine: secretes insulin or glucagon to regulate blood glucose levels.

  • Exocrine: secretes enzymes for digestion such as amylase and lipase.

• Glucagon: released in response to low blood glucose levels to prevent hypoglycemia.

• Insulin: key hormone that unlocks the cell to allow absorption of glucose.

• After a meal, the digestive system breaks down carbohydrates into simple sugars called glucose.

• The circulatory system carries the glucose to the brain and muscles for fuel.

• Insulin is produced in the pancreas by the islets of Langerhans in the beta cells.

• Insulin regulates the concentration of circulating blood glucose by binding to receptors on liver, muscle, and fat cells.

• As glucose binds to the cell receptors, glucose enters the cell, and the concentration of circulating glucose decreases.

• When there is a lack of insulin, cells are not able to uptake the glucose that is needed for energy.

• The liver will release glucagon stores and stimulate glucose production through gluconeogenesis and glycogenolysis.

• Gluconeogenesis: generates glucose from non-carbohydrate sources, such as proteins, lipids, pyruvate, or lactate.

• Glycogenolysis: mainly occurs in the hepatocytes of the liver and myocytes of the muscles.

Risk Factors

• Obesity

• Smoking

• Medications

• Illness/Infection

• Genetics

• Chronic stress

• Insomnia

• Sedentary lifestyle

Complications and Comorbidities

• Comorbidities:

  • Autoimmune disorders

  • Hyperlipidemia

  • Hypertension

  • Gestational diabetes

  • Polycystic ovary syndrome

  • Metabolic syndrome

  • Cushing’s syndrome

  • Acromegaly

  • Pheochromocytoma

• Complications:

  • Metabolic syndrome

  • Coma

  • Death

  • Damage to blood vessels

  • Nerve damage

  • Coronary artery disease

  • Stroke

  • Peripheral vascular disease

  • Retinopathy

  • Nephropathy

  • Poor wound healing

  • Depression

Impact on Overall Health

• Polyuria

• Polydipsia

• Polyphagia

Clinical Presentation

• Increased urine output

• Thirst

• Weight loss

• Dry mucous membranes

• Low blood pressure

• Increased heart rate

• Changes in cognition

• Abdominal pain

• Nausea and vomiting

• Fruity breath

• Fast shallow respirations

Lab Testing and Diagnostic Studies

• Blood glucose testing:

  • Fasting: greater than $125$ mg/dL

  • Postprandial: greater than $180$ mg/dL

• Hemoglobin A1c (HbA1c):

  • Average blood glucose level over previous 2 to 3 months

  • Goal: less than $6$

Role of the Nurse

• Glucose monitoring

• Medication administration

• Involve interpreter if necessary

• Connect authentically with the client

• Collaborate with the health care team

• Teaching:

  • How to monitor blood glucose

  • Set goal for target blood glucose level

  • Storage of equipment and supplies

  • Manage and dispose of sharps appropriately

  • Minimize infection risk

  • Obtain medical ID bracelet

  • Monitor urine for ketones

  • Review triggers for hyperglycemia

  • Medication management

The Nursing Process

• Recognize Cues (Assessment):

  • Monitor blood glucose levels (random, fasting, postprandial, HbA1c).

  • Monitor for manifestations of hyperglycemia.

• Analyze Cues and Prioritize Hypotheses (Analysis):

  • Identify blood glucose level.

  • Initiate prompt treatment.

  • Prevent progression to a hyperglycemic crisis.

• Generate Solutions (Planning):

  • Focus on solutions to lower blood glucose level immediately and over the long term.

• Take Action (Implementation):

  • Medication administration

  • Lifestyle changes (diet, exercise)

• Evaluate Outcomes (Evaluation):

  • Improved, worsened, or no change

Treatment and Therapies

• Diet

• Exercise

• Oral medications

• Insulin

• Collaborate with endocrinologist and/or health care provider

Hypoglycemia

Pathophysiology

• Hypoglycemia: blood glucose $70$ mg/dL or less.

• Sympathetic nervous system is triggered to release epinephrine and norepinephrine from adrenal glands to increase blood glucose.

• Epinephrine and norepinephrine tap into glucose reserves to release glucose to the blood.

• Pancreas releases glucagon to increase blood glucose.

Risk Factors

• Diabetes

• Changes in schedule

• Travel to different time zones

• Increased exercise

• Fasting

• Unpredictable access to food

• Medications:

  • Beta-blockers

  • Insulin

  • Sulfonylureas

  • Antiarrhythmics

  • Nonsteroidal anti-inflammatory pain relievers

  • Insulin response enhancers

  • Thiazolidinediones

  • Antibiotics

Impact on Overall Health

• Frequent hypoglycemia can change a client’s stress response, leading to hypoglycemia unawareness.

• Older adults are at higher risk for complications such as falls, accidents, injury, bone fractures, heart attack, early onset dementia, seizures, coma, cardiac arrhythmia, and death.

Clinical Presentation

• HE’S TIRED (Mnemonic):

  • He: Headache

  • 'S: Sweating

  • T: Tachycardia

  • I: Irritability

  • R: Restlessness

  • E: Excessive Hunger

  • D: Dizziness

Laboratory and Diagnostic Testing

• Blood glucose testing (random, fasting, HbA1c)

Role of the Nurse

• Monitor blood glucose levels

• Administer medications

• Provide education:

  • Preventing hypoglycemia

  • Treating hypoglycemia

  • Manifestations of hypoglycemia

  • Frequency of blood glucose monitoring

  • Blood glucose targets

  • Diet

  • Exercise

  • Supplies to have on hand

The Nursing Process

• Recognize Cues (Assessment):

  • Identify manifestations.

  • Assess level of consciousness.

  • Determine blood glucose level.

  • Determine client’s ability to recognize and act on hypoglycemia.

• Analyze Cues and Prioritize Hypotheses (Analysis):

  • Prevent complications of severe hypoglycemia.

• Generate Solutions (Planning):

  • Focus on strategies to prevent hypoglycemia.

• Take Action (Implementation):

  • Blood glucose monitoring.

  • Ensure adequate oral intake.

  • Administer oral sources of glucose, glucagon, or IV dextrose.

• Evaluate Outcomes (Evaluation):

  • Improved, worsened, or no change

Treatments and Therapies

• $15$ to $20$ grams of fast-acting carbohydrate by mouth STAT:

  • $4$ ounces of non-diet fruit juice

  • $4$ ounces of non-diet soda

  • $1$ tablespoon of sugar

  • $4$ glucose tablets

• Injectable (IM or SQ) glucagon if client is unable to safely swallow

Type 1 Diabetes

Pathophysiology

• Type 1 diabetes mellitus (DMT1) is an autoimmune disease involving the destruction of beta cells in the pancreatic islets of Langerhans where insulin is produced, leading to loss of insulin production and making glucose absorption impossible.

Risk Factors

• Genetic predisposition

• Possible virus or environmental factor triggering autoimmune response

• Family history

• Age

Complications

• Stroke

• Heart attack

• Peripheral artery disease

• Diabetic neuropathy

• Cataracts

• Glaucoma

• Diabetic foot

• Diabetic nephropathy

• Peripheral neuropathy

Impact on Overall Health

• DMT1 linked to a lower life expectancy and increased risk of having unstable blood glucose levels, weight loss and muscle wasting, anxiety, depression, sleep disturbances, and dermatological conditions.

Clinical Presentation

• Rapid onset of manifestations

• Polyuria

• Polydipsia

• Polyphagia

• Unintentional weight loss

• Visual changes

• Repeated infections

• Delayed wound healing

• Numbness and tingling in hands and feet

Laboratory and Diagnostic Testing

• Non-fasting blood glucose of $200$ mg/dL

• Fasting blood glucose of greater than or equal to $126$ mg/dL

• HbA1c greater than or equal to $7$

• Urinalysis: elevated glucose or acetone levels

• C-peptide levels will be decreased

• Diabetic ketoacidosis (DKA):

  • Blood glucose greater than $250$ mg/dL

  • Blood beta-hydroxybutyrate level is elevated

  • Serum ketones present

  • Blood gas pH less than $7.3$

  • $HCO³$ of less than or equal to $15$ mEq/L

  • Urinalysis: positive for glucose and ketones

Role of the Nurse

• Goal is to manage disease and prevent complications

• Review lab results

• Monitor vital signs

• Medication administration

• Initiate and facilitate referrals to endocrinologists and other services

• Skin and wound care

• Client education

Client Education

• How to monitor blood glucose levels

• Self-administration of insulin

• Recognition and treatment of hypoglycemia

• Recognition of hyperglycemia

• Dietary recommendations

• Screening for complications

• Daily foot care

The Nursing Process

• Recognize Cues (Assessment):

  • Assess glycemic control.

  • Assess for complications.

  • Assess for manifestations of DKA.

• Analyze Cues and Prioritize Hypotheses (Analysis):

  • Glycemic emergencies are high-priority problems (hyperglycemia, hypoglycemia).

  • Organize care around problems that are most dangerous in the short term.

• Generate Solutions (Planning):

  • Optimize glycemic control.

  • Prevent long-term complications.

• Take Actions (Implementation):

  • Administer insulin.

  • Provide education on self-administration of insulin.

  • Provide education on how to monitor glucose levels.

  • Provide education on identifying complications.

• Evaluate Outcomes (Evaluation):

  • Improved, worsened, or no change

Treatments and Therapies

• Monitor blood glucose

• Administer injectable insulin (vial, pen, pump)

• Monitor HbA1c

• Eye exams

• Daily foot care/inspection

• Proper nutrition

Insulin Safety

• Precise dosing with correct strength (U-100 or U-500) and syringe size.

• Understanding which insulins can be mixed together.

• Understanding the duration of action (rapid, short, intermediate, long).

• Safe storage: Insulin stored in the refrigerator will have prolonged stability.

• Understand the action, peak, and duration of effect.

• Insulin administration (pump, pen, syringe) at appropriate sites.

Type 2 Diabetes

Pathophysiology

• Healthy Pancreas: Produces sufficient insulin, and receptors allow insulin to enter the cell for energy.

• Type 1 Diabetes: Pancreas does not produce insulin.

• Type 2 Diabetes: Pancreas may produce some insulin but not sufficient to maintain blood glucose levels; the cell receptors become insulin resistant.

Risk Factors

• Age

• Genetics

• Obesity

• Sedentary lifestyle

• Smoking

• Hypertension

Comorbidities and Complications

• Stroke

• Heart attack

• Peripheral artery disease

• Diabetic retinopathy

• Cataracts

• Glaucoma

• Diabetic foot

• Diabetic nephropathy

• Peripheral neuropathy

Impact on Overall Health

• Quality of Life

• Mental Health (Depression, Stress, Fear)

• Family

• Environment

Clinical Presentation

• Manifestations have a slow onset

• Fatigue

• Visual changes

• Skin changes

• Frequent infections

• Gangrene

• Dry skin

• Polyuria

• Polydipsia

• Weight change

• Heart disease

• Neuropathy

• Renal impairment

• Urinary dysfunction

• Bowel dysfunction

Lab and Diagnostic Testing

• To confirm diagnosis, need two abnormal results on 2 different days:

  • Fasting blood glucose: greater than or equal to $126$ mg/dL

  • 2-hr post-prandial blood glucose: greater than or equal to $200$ mg/dL

  • Random blood glucose: greater than or equal to $200$ mg/dL

  • HbA1c: greater than or equal to $6.5$

Role of the Nurse

• Stabilize blood glucose levels

• Prevent disease progression

• Support client with implementation of lifestyle changes

• Review lab results

• Monitor vital signs

• Administer medications

• Assess and treat for hypoglycemia as needed

• Client education

The Nursing Process

• Recognize Cues (Assessment):

  • Review blood glucose and HbA1c levels.

  • Inquire about the manifestations of polyuria, polydipsia, and polyphagia.

  • Inquire about weight change.

  • Assess for visual impairment, renal dysfunction, neuropathy, and abnormal wound healing.

• Analyze Cues and Prioritize Hypotheses (Analysis):

  • The priority is glycemic control.

• Generate Solutions (Planning):

  • Strategies to optimize glycemic control.

• Take Actions (Implementation):

  • Improve glycemic control.

  • Administer medications.

  • Provide education on signs and symptoms of low and high blood glucose levels, exercise targets and diet.

  • Supervise blood glucose monitoring and self-administration of insulin.

  • Minimize risk of complications.

• Evaluate Outcomes (Evaluation):

  • Improve, worsen, or no change

Treatments and Therapies

• First-line treatment:

  • Nutritional changes

  • Exercise

  • Weight loss

• Strategies to improve glycemic control:

  • Medication (oral medications, insulin)

Metformin

• Oral hypoglycemic medication (Biguanide).

• Contraindicated in clients with severe kidney impairment, metabolic acidosis, or known hypersensitivity to metformin.

• Lowers the amount of glucose the liver makes and the amount of glucose absorbed from food.

• May cause lactic acidosis in clients with kidney disease.

• Client Education:

  • Administration

  • Frequency of blood glucose monitoring

  • Signs of potential overdose

  • Adverse effects (indigestion, bloating, abdominal pain, constipation, headache, metallic taste).

Canagliflozin

• Sodium-glucose cotransporter 2 inhibitor.

• Lowers blood glucose by increasing the amount of glucose excreted in the urine.

• Adverse effects: genital fungal infections, increased urine output, thirst, urinary tract infection, constipation, vulvovaginal itching, nausea.

• Contraindications: Renal failure, known sensitivity to canagliflozin.

• Client teaching:

  • Medication administration: Take with the first meal of the day.

  • Side effects

  • Signs of infection

  • Risk of lower limb amputation

Metabolic Syndrome

Pathophysiology

• Cluster of health conditions:

  • Visceral obesity

  • Hypertension

  • Insulin resistance

  • High triglycerides

  • Low HDL cholesterol

• Systemic stress that promotes inflammation leads to obesity, increased adipose tissue (secreting adipokines), excess lipids in the liver and skeletal muscle, insulin resistance, impaired insulin release and transport, and increased glucose production with impaired insulin action due to tissue inflammation, leading to cardiovascular disease, type 2 diabetes, hypertension, stroke, polycystic ovary syndrome, nonalcoholic fatty liver disease, retinopathy, neuropathy, and nephropathy.

Risk Factors

• Central obesity

• Family history

• Increased age

• Sedentary lifestyle

• Unbalanced diet

• Sleep apnea

• Stress

• Low HDL levels

• Hypertension

• Inflammation

Complications and Comorbidities

• Insulin resistance

• Hyperglycemia

• Neuropathy

• Blindness

• Cardiac arrhythmia

• Neurological disorder

• Polycystic ovary syndrome

• Cancer

• Cardiovascular disease

• Type 2 diabetes

• Stroke

Impact on Overall Health

• Hyperglycemia, hypertension, and hyperlipidemia lead to damage to vasculature and nerves, cardiovascular disease, and strained renal and neurological systems.

Clinical Presentation

• Clients may not present with specific symptoms; metabolic syndrome is often discovered on routine lab tests.

• Diagnosis requires at least 3 of 5 criteria to be met:

  • Hyperglycemia: Fasting blood glucose greater than or equal to $100$ mg/dL

  • Hypertension: Greater than or equal to $130/85$ mm Hg

  • Hypertriglyceridemia: Greater than or equal to $150$ mg/dL

  • Decreased HDL: Less than or equal to $50$ mg/dL (females), Less than or equal to $40$mg/dL (males)

  • Waist Measurement: Greater than or equal to $35$ inches (females), Greater than or equal to $40$ inches (males)

Role of the Nurse

• Identify the presence of risk factors

• Review lab results

• Medication administration (dyslipidemia, hypertension, diabetes)

• Education on lifestyle changes (diet, exercise)

The Nursing Process

• Recognize Cues (Assessment):

  • Labs, vital signs, physical assessment.

• Analyze Cues and Prioritize Hypotheses (Analysis):

  • Blood pressure management and glycemic control.

• Generate Solutions (Planning):

  • Optimize glycemic control, manage hypertension, increase physical activity, improve nutritional status, smoking cessation, and decrease alcohol intake.

• Take Action (Implementation):

  • Medication administration and lifestyle changes.

• Evaluate Outcomes (Evaluation):

  • Improve, worsen, or no change

Treatment

• Treat and prevent obesity through lifestyle changes and medications.