BT-Diabetes_Unit5_student

GLUCOSE MANAGEMENT - NSG 3250

UNIT 2 CONTENT OUTLINE

  • Pre-diabetes

  • Diabetes (Type I & Type II)

  • Gestational Diabetes

  • Metabolic Syndrome

  • Hypoglycemia

  • Hyperglycemia

  • Somogyi Effect

  • Dawn Phenomenon

GENERAL DIABETES INFO

  • Definition:

    • Metabolic disorders characterized by hyperglycemia caused by defects in insulin secretion, insulin action, or both.

  • Statistics:

    • Affects nearly 34.1 million people in the United States; one-third of the cases are undiagnosed.

    • Prevalence is increasing with disabling complications which include:

    • Non-traumatic amputation

    • Blindness

    • Kidney failure

    • Death

ENDOGENOUS INSULIN

  • Function:

    • Clears from circulating blood in 10 to 15 minutes.

    • Major role in metabolism converting:

    • Carbohydrates to glucose

    • Fats to lipids

    • Proteins to amino acids

  • Mechanism:

    • Lowers blood glucose levels by:

    • Signaling liver to stop releasing glucose

    • Pushing glucose into fat tissue

RISK FACTORS FOR GLUCOSE RELATED DISORDERS

  • Family history

  • Obesity

  • Race/Ethnicity

  • Metabolic Syndrome

  • Age: 45 years and older

  • Hypertension

  • Elevated triglycerides/cholesterol

  • History of gestational diabetes with an overweight baby

  • Consider both the number and severity of risk factors.

PRE-DIABETES

  • Description:

    • Characterized by a history of hyperglycemia.

    • Involves impaired insulin sensitivity or impaired insulin synthesis/release.

  • Risk Factors:

    • Obesity

  • Symptoms:

    • None; levels typically remain normal or only mildly elevated.

    • Represents the stage between "normal" and "diabetic" levels.

  • Diagnostic Levels:

    • Fasting glucose: 100-125 mg/dL

    • A1C: 5.7-6.4%

  • Care/Education (prevention):

    • Diet, Exercise, Weight management

DIABETES TYPE 1

  • Demographics:

    • Accounts for 5-10% of all patients; formerly known as juvenile diabetes or insulin-dependent diabetes.

  • Pathophysiology:

    • Insulin-producing beta cells in the pancreas are destroyed leading to decreased insulin production, unchecked glucose production by the liver, and fasting hyperglycemia.

  • Onset:

    • Usually occurs at a young age (<30 years), often with abrupt onset.

    • Patients may present thin at diagnosis, having experienced recent weight loss.

  • Causes:

    • Suspected genetic, immunologic, and environmental factors.

  • Insulin Production:

    • Patients have little or no endogenous insulin and require exogenous insulin to preserve life.

  • Complications:

    • Prone to ketosis when insulin is absent.

    • Acute complication includes diabetic ketoacidosis (DKA).

DIABETES TYPE II

  • Demographics:

    • Affects 90-95% of adults with diabetes.

  • Pathophysiology:

    • Characterized by insulin resistance and impaired insulin secretion.

  • Onset:

    • Can occur at any age, usually over 30 years.

    • Has an insidious and slow progressive course of glucose intolerance.

  • Initial Characteristics:

    • Obesity is often present at diagnosis.

    • Patients may experience a decrease in endogenous insulin or increase in insulin resistance.

  • Management:

    • Most patients can control blood glucose through weight loss if they have obesity.

    • Oral antidiabetic agents may improve blood glucose levels if dietary modifications and exercise are unsuccessful.

    • Some may require insulin, either on a short- or long-term basis to prevent hyperglycemia.

  • Complications:

    • Ketosis is uncommon.

    • Acute complication includes hyperglycemic hyperosmolar syndrome (HHS).

QUESTION

  • A nurse is preparing to discharge a client with coronary artery disease and hypertension who is at risk for type 2 diabetes. Which information is important to include in the discharge teaching?
    A. How to monitor ketones daily
    B. How to control blood glucose through lifestyle modification with diet and exercise
    C. How to self-inject insulin
    D. How to recognize signs of diabetic ketoacidosis

CLINICAL MANIFESTATIONS OF DIABETES MELLITUS

  • Common Symptoms:

    • Hyperglycemia

    • 3 P's (polyuria, polydipsia, polyphagia)

    • Dehydration

    • Fatigue/weakness

    • Vision changes

    • Paresthesia

    • Dry skin

    • Slow-healing wounds

    • Recurrent infections

  • Timing of Symptoms:

    • When do symptoms typically manifest?

DIAGNOSING DIABETES MELLITUS

  • Diagnostic Criteria:

    • A1C > 6.5%

    • Fasting glucose > 126 mg/dL (requires fasting for at least 8 hours)

    • Glucose tolerance test > 200 mg/dL

    • Casual glucose > 200 mg/dL + symptomatic

QUESTION

  • During a follow-up visit three months after a new diagnosis of type 2 diabetes, a client reports exercising and following a reduced-calorie diet. Assessment reveals that the client has only lost 1 pound and did not bring the glucose-monitoring record. Which value should the nurse measure?
    A. Fasting blood glucose level
    B. Glucose via urine dipstick test
    C. Glucose via an oral glucose tolerance test
    D. Glycosylated hemoglobin level

GOALS OF CARE FOR DIABETES MELLITUS

  • Objectives:

    • Achieve euglycemia without causing hypoglycemia.

    • Complication prevention:

    • Retinopathy

    • Nephropathy

    • Neuropathy

  • Management Strategies:

    • Nutritional therapy

    • Exercise

    • Monitoring

    • Pharmacological therapy

    • Ongoing education

NUTRITIONAL THERAPY

  • Consultation and Planning Thoroughness:

    • Consider preferences, lifestyle, usual eating times, and cultural background.

    • Review diet history and need for weight loss, gain, or maintenance.

    • Determine caloric requirements and appropriate calorie distribution.

    • Nutritional guidelines:

    • Carbohydrates: 50% to 60% with an emphasis on whole grains

    • Fats: 20% to 30%

    • Utilize non-animal sources of protein and increase fiber intake.

    • Employ exchange lists and glycemic index for meal planning.

    • Alcohol should be consumed in moderation due to its risk for hypoglycemia as it can decrease gluconeogenesis.

    • Artificial Sweeteners: Considerations for use.

GLYCEMIC INDEX

  • Influences on Glycemic Response:

    • Combining starchy foods with protein and fat can slow absorption and decrease glycemic response.

    • Raw or whole foods typically elicit lower glycemic responses compared to cooked, chopped, or pureed foods.

    • Whole fruits are preferred over juices to reduce glycemic response due to fiber content.

    • Foods with sugars may produce a lower glycemic response when consumed with slowly absorbed foods.

EXERCISE & REST

  • Benefits of Exercise:

    • Lowers glucose level AND cardiovascular risk.

  • Recommendations for Exercise:

    • Frequency: At least 3 times per week

    • Use proper footwear and conduct daily foot inspections to monitor for injuries.

    • Avoid exercising during insulin peak times, extreme temperatures, or periods when glycemic control is poor.

  • Precautions:

    • Individuals with severely elevated glucose levels (>250) and ketones in their urine should not exercise.

    • Pre- and post-exercise snacks should be consumed to prevent hypoglycemia.

    • Adequate rest should also be considered.

HYGIENE & FOOT CARE

  • Principles:

    • Avoid using moisturizer in already moist areas.

    • Trim nails straight across to prevent ingrown nails.

    • Wash feet daily with lukewarm water and gentle soap; dry thoroughly.

    • Do not soak feet as it can lead to skin breakdown.

    • Inspect feet daily with a mirror.

    • Wear well-fitted shoes to avoid blisters; do not walk barefoot, as 50% of diabetic amputations are avoidable.

    • Risk factors include neuropathy, peripheral vascular disease (PVD), and an increased risk of infections.

DIABETES MONITORING

  • Self-Monitoring Levels:

    • Procedure and frequency of checks must be adhered to.

  • Types of monitoring include:

    • Glycosylated hemoglobin testing

    • Ketone testing

PHARMACOLOGICAL THERAPY - INSULIN TYPES

  • Insulin regimens: May be tailored based on intake or sliding scale.

    • Rapid Insulin: (lispro, aspart, glulisine)

    • Onset: 5-15 minutes, Peak: 30-90 minutes

    • Facilitates rapid reduction of glucose/correction.

    • Short-acting Insulin: (regular, insulin-R)

    • Onset: 30-60 minutes, Peak: 2-3 hours

    • Typically used for meal-dose insulin or in combination with longer-acting insulin.

    • Intermediate-acting Insulin: (NPH)

    • Onset: 1-1.5 hours, Peak: 4-12 hours

    • Usually administered in the morning.

    • Long-acting Insulin: (glargine, lantus)

    • Onset: 3-6 hours, NO peak.

    • Used primarily for basal dosing and should not be mixed with other insulins.

QUESTION

  • A client receives a daily injection of glargine insulin at 7:00 a.m. When should the nurse monitor this client for a hypoglycemic reaction?
    A. Between 8:00 and 10:00 a.m.
    B. Between 4:00 and 6:00 p.m.
    C. This insulin has no peak action and does not cause a hypoglycemic reaction.
    D. Between 7:00 and 9:00 p.m.

PHARMACOLOGICAL THERAPY - INSULIN DELIVERY

  • Methods of Administration:

    • Insulin Pump:

    • Continuous delivery, mimicking the pancreas.

    • Requires catheter changes every 3 days.

    • Insulin Pen:

    • Multi-dose application, ease of management; allows for precise dosing.

    • Subcutaneous Injection:

    • Comprehensive management for home care with frequent monitoring.

  • Self-administration:

    • Patient's readiness to learn is crucial.

    • Consider visual aids, such as reading glasses or contact lenses during administration.

PHARMACOLOGICAL THERAPY - SELF INSULIN ADMINISTRATION

  • Storage Recommendations:

    • Insulin should be refrigerated when not in use.

    • Room temperature is acceptable for insulin in use (up to 30 days).

    • Spare vials should be stored under appropriate conditions.

  • Syringes:

    • Commonly have a capacity of 27-29 gauge, 0.5 inches.

    • Administer air into the vial before withdrawing the insulin to prevent pressure issues.

  • Injection Site Guidelines:

    • Preferred sites include the abdomen, upper arm, thigh, or hip.

    • Rotate injection sites to prevent lipodystrophy.

    • 90-degree angle administration is required for effectiveness.

    • Alcohol swabs are not necessarily required unless the site is visibly contaminated.

  • Disposal:

    • Follow local regulations for sharps disposal.

QUESTION

  • A client with type 1 diabetes mellitus is being taught about self-injection of insulin. Which fact about site rotation should the nurse include in the teaching?
    A. Rotate sites from area to area every other day.
    B. Use all available injection sites within one area.
    C. Choose a different site at random for each injection.
    D. Avoid the abdomen because absorption there is irregular.

QUESTION

  • The nurse is teaching a client about self-administration of insulin and about mixing regular and NPH insulin. Which information is important to include in the teaching plan?
    A. There is no need to inject air into the bottle of insulin before withdrawing insulin.
    B. When mixing insulin, the NPH insulin is drawn up into the syringe first.
    C. When mixing insulin, the regular insulin is drawn up into the syringe first.
    D. If two different types of insulin are ordered, they need to be given in separate injections.

COMPLICATIONS OF INSULIN THERAPY

  • Potential Issues:

    • Local allergic reactions

    • Systemic allergic reactions

    • Insulin lipodystrophy

    • Resistance to injected insulin

    • Morning hyperglycemia

ORAL ANTI-DIABETIC AGENTS

  • Purpose:

    • Used for patients with type 2 diabetes who require more than just diet and exercise.

    • May involve combinations of oral medication.

  • Major Side Effect:

    • Hypoglycemia must be closely monitored.

  • Nursing Interventions:

    • Continuous monitoring of blood glucose for hypoglycemia and awareness of additional side effects