Certified Diabetes Educator Exam 1

Front 1

Ankle Brachial Index
ABI

Back 1

Test for PAD
Measure BP with standard cuffs at arm and calf
check first at rest then repeat after 5 min of walking
results should be same or approximately the same

Front 2

Acanthosis Nigricans

Back 2

Skin condition occurs in up to 90% of children with type 2 diabetes. Indicator of hyperinsulinemia and insulin resistance. Most common in obese dark-skinned children 25% more frequent in blacks. Dark brownish to black velvety raised patches. Usually resolves when insulin resistance is addressed.

Front 3

Differences in Blood Glucose Monitoring results

Back 3

Whole blood glucose level is lower than plasma
Lab tests measure plasma only. Meters programmed for plasma reading are closer to lab draw. Whole blood meters will be lower

Front 4

Insulin Injection Technique

Back 4

- Washes hands
-Checks insulin vial for type, expiration date and ensures that insulin is free of sediment, frosting or other signs of contamination
-Cleanses top of insulin vial with alcohol
-Injects air into the insulin vial equal to amount of insulin to be injected
-Measures and draws the appropriate amount of insulin
-Selects appropriate injection site and has a site rotation system
-Administers injection sq. lightly grasp fold of skin and inject at 90 deg angle. Very thin people should use 45 deg angle.
-follows appropriate technique for sharps disposal

Front 5

How long does exercise affect BG

Back 5

Blood glucose lowering effects of exercise can be immediate or prolonged, affecting blood glucose for a period of up to 48 or more hours.

Front 6

Why focus on carb intake

Back 6

Carbohydrate is the type of food with the greatest effect on postprandial blood glucose levels.

Front 7

What increments of time are looked at when measuring the effects of lifestyle changes

Back 7

Changes are usually evaluated at 6 weeks to 3 months following implementation

Front 8

What information should be included in a food diary

Back 8

- Foods eaten
-approximate amounts
-time of day food is eaten
-situation inn which eating occurred
-record of exercise

Front 9

Carbohydrate to insulin ratio

Back 9

15:1
for every 15 grams of carbs 1 unit of rapid or short-acting insulin whould be injected

Front 10

Insulin adjustment during exercise:
Rapid or short-acting

Back 10

Reducing by 30-50% effectively decreases risk of hypoglycemia

Front 11

Insulin adjustment during exercise:
Intermediate acting

Back 11

Reducing by 10% is recommended

Front 12

What class of oral medications put patients at a substantial risk to develop hypoglycemia

Back 12

sulfonylureas

Front 13

What is the equation used to estimate age-adjusted HR

Back 13

220 - Client's age = estimated age-adjusted heart rate

Front 14

What is the recommended intensity of exercise for diabetics (percentage of adjusted HR)

Back 14

60-85% of the client's age adjusted heart rate

Front 15

What is the Rating of Perceived Exertion?

Back 15

This is a subjective measure in which the client rates how intense the exercise feels on a scale of 0 - 10
Zero- no effort at all
Ten- extremely strong or maximal feelings of exertion

Front 16

What is the recommended Rating of Perceived Exertion level for a diabetic

Back 16

Ann exertion level of 2 (weak) to 5 (strong) is recommended depending on the fitness level of the individual

Front 17

What is the ADA guideline for home glucometer results total error rate?

Back 17

10% or less for glood glucose levels of 30 to 400 mg/dl 100% of the time

Front 18

What is the procedure for checking home glucose monitor accuracy against lab value results?

Back 18

- Meter accuracy should be checked against lab values, not another meter
-Lab test used for comparison should be fasting plasma glucose test
-Lab test and meter test should be performed at the same time
-test done using the meter should use capillary blood collected from fingertip or alternate puncture site Do NOT use a drop of the venous sample
-venous sample should be centrifuged within 30 min of collection

Front 19

What percentage lower is the blood glucose level results using a whole blood glucose monitor as opposed lab results?

Back 19

Whole blood results from a meter will give a reading of 11-15% lower thn the plasma levels measured in the lab

Front 20

What is the most common source of error in SMBG (Self Monitoring of Blood Glucose?

Back 20

Failure to obtain an adequate blood sample

Front 21

What is the procedure for collecting an adequate capillary sample for home SBGM?

Back 21

-Using WARM water to wash hands
-Dangling or shaking hand below the waist for approximately 30 sec
-Setting the adjustable end cap on the lancing device to an appropriate puncture depth
-Using the "milking" technique to push blood to the fingertip. This involves pushing the blood from the base of the finger to the tip, which is more effective than just squeezing the fingertip.

Front 22

What things need to be assessed to determine cause of user errors in SBGM?

Back 22

- is the sample size adequate?
-are the test strips defective?
-is the meter properly calibrated?
-is the optic window on the meter clean?

Front 23

What should be checked or done to test strips to ensure accuracy?

Back 23

-expiration date
-keep reagent vial tightly capped between uses and perform periodic control tests of strips
-store away from extreme heat, cold or humidity

Front 24

When should home ketone test be done?

Back 24

-When blood glucose is persistently elevated over 300
-When on a weight reduction diet
-When ill, especially if febrile or infection present
-Undergoing severe stress
-Significantly increasing physical activity

Front 25

What does a client need to know about their medication?

Back 25

-The right time of day to take the medication
-When to take the medication in relation to meals
-What to do if a dose is missed
-What is the dose
-What is the required spacing of meals (meals should be no more than 4-5 hours apart to prevent low BS)
-What do they do if they have a hypoglycemic reaction
-What lab tests should the doctor be checking while they are on the med

Front 26

What individual characteristics need to be considered when developing an individualized teaching plan?

Back 26

-Learning styles
-Culture
-Educational level and literacy
-Psychosocial status
-Cognitive status
-Functional limitations
-Readiness to learn and make behavior change
-Baseline knowledge
-Age and developmental level
-Personal and metabolic goals
-Access to resources

Front 27

What is the empowerment approach to diabetes education program?

Back 27

The empowerment approach to diabetes education recognizes that the person with diabetes holds the primary rights and responsibilities for their own self-care.

Front 28

What is one of the first messages that participants in a DSME program should hear?

Back 28

Diabetes is a self-managed condition

Front 29

What should clients who consult internet sites as sources for DM education be cautioned about?

Back 29

That not all sources of information are reliable and that sites hosted by major authoritative bodies, such as the ADA, are usually most appropriate

Front 30

What are the benefits of group DSME sessions?

Back 30

-participants are alllowed to direct the content of education
-participants are able to practice decision-making in a supportive environment
-allows participant to seek and acquire the information that is most important to them
-it is an active, self-directed approach appropriate for adult learners

Front 31

What are the limitations of group sessions?

Back 31

-the educator has less control over the program content
-some group members may monopolize and leave others with unmet needs
-clients with impaired hearing or language barriers may not be appropriate to be included

Front 32

Give three examples of situations where demonstration is an effective instructional method

Back 32

-self glucose monitoring
-drawing insulin
-injecting insulin
-calculating insulin dose
-calculating carbohydrates

Front 33

Benefits of demonstration as instructional method

Back 33

-allows instructor to directly observe behaviors that can indicate learning has taken place
-can help identify areas that require additional instruction

Front 34

Limitations of demonstration as an instructional method

Back 34

-difficult to do effectively in group setting
-can be time consuming

Front 35

Benefits of role-playing as instructional method

Back 35

-appropriate for a variety of age groups
-provides opportunity to practice problem-solving
-allows for exploration of feelings
-allows for practice of new behaviors
-can be equally effective in both individual and group sessions

Front 36

Examples of effective instructional methods for preschool children

Back 36

-simple question and answer session
-Props such as puppets and dolls

Front 37

Examples of effective instructional methods for school-aged children

Back 37

-games
-puzzles
-age appropriate videos
-interactive computer games

Front 38

Examples of effective instructional methods for teens

Back 38

-same-age group classes and discussions
-diabetes camps
-activities that involve peers
-activities geared to allow for decision making
-activities geared to allow for problem solving

Front 39

Examples of effective instructional methods for adults

Back 39

-learning content that is relevant to day-to-day living
-practical content
-self-directed
-collaboration of educational objectives

Front 40

Tools that educator can use to facilitate client goal setting

Back 40

-behavioral change theory
-patient empowerment approach
-patient-centered communication
-self-directed approach to keep client empowered and involved throughout the learning process
-informed decision making
-promote client confidence and self-efficacy
-foster effetive problem-solving
-foster coping skills
-identify strategies to overcome barriers
-COLLABORATION

Front 41

Elements of successful behavioral goal setting

Back 41

-client should select goals they feel will reap benefit
-goals that client is interested in doing
-goals that client believes they are able to do

Front 42

The acronym "SMART" is often used in developing behavior goals. What do the letters in the acronym "SMART" stand for?

Back 42

S - SPECIFIC - Tells what the person will do

M- MEASURABLE - tells how mch, how often and/or how many

A- ACHIEVABLE- Is something the person wants to do and can commit to

R- REALISTIC- The person feels confident that they can do what they have planned

T- TIME- specifies the time period after which the behavior will be evaluated

Front 43

Example of a SMART goal

Back 43

I will check my blood sugar twice a day, every day, before breakfast and before dinner for two weeks

Front 44

Characteristics of type 1 DM

Back 44

-Results from autoimmune destruction of the beta cells of the pancreas
-Leads to an absolute deficiency of endogenous insulin
-Usually involves rapid destruction of beta cells in children and slower destruction in adults
-Children and adolescents sometimes present with ketoacidosis as the first sign of the disease
-Absence of endogenous insulin secretion is manifested by low C-peptide levels
-Causes include genetic predisposition and environmental factors
-Patients are usually lean but normal or overweight status does not preclude dx
-Patients are also prone to Hashimoto's thyroiditis, Addisons dz, vitiligo, celiac sprue, autoimmune hepatitis, pernicious anemia and myasthenia gravis

Front 45

Characteristics of type 2 DM

Back 45

-pathophysiology involves insulin resistance and relative insulin deficiency
-treatment with exogenous insulin is not needed for immediate survival
-unlike type 1 there is no autoimmune destruction of pancreatic beta cells
-obesity and increased body fat in the abdominal region increases the risk
-ketoacidosis is rare
-often goes undetected for years
-hyperglycemia develops gradually in earlier stages of disease and is usually asymptomatic
-occurs in higher incidence in people having HTN and dyslipidemia
-risk factors include: increased age, obesity, sedentary lifestyle, positive family history and personal h/o gestational DM
-genetic predisposition is a significant risk factor

Front 46

What diseases, conditions and events can lead to onset of DM

Back 46

- pancreatitis
- trauma
- infection
- cancer
- hemochromatosis
- cystic fibrosis

Front 47

Excessive production of which hormones that are antagonistic to insulin and can cause DM?

Back 47

- growth hormone
- cortisol
- glucagons
- epinephrine

Front 48

What do genetic defects of beta cells lead to?

Back 48

Maturity onset diabetes of the young (MODY) manifested by the onset of hyperglycemia in people usually younger than the age of 25

Front 49

Genetic defects of insulin action result in?

Back 49

abnormalities of the insulin receptors, leading to insulin resistance and hyperglycemia

Front 50

What viral infections have been known to induce DM?

Back 50

-congenital rubella
-coxsackievirus B
-cytomegalovirus
-mumps

Front 51

What genetic syndromes are associated with the onset of DM

Back 51

-Down syndrome
-Klinefelter syndrome
-Turner syndrome

Front 52

What are the categories of increased risk for diabetes collectively known as "Prediabetes"?

Back 52

- Impaired fasting glucose (IFG)
- Impaired glucose tolerance (IGT)

Front 53

What is Prediabetes?

Back 53

When blood glucose levels are elevated above normal but not high enough to be classified as diabetes

Front 54

What conditions are associated with prediabetes?

Back 54

- obesity
- increased abdominal fat
- dyslipidemia
- HTN

Front 55

What lab values indicate Impaired Fasting Glucose (IFG)?

Back 55

Fasting plasma glucose levels of 100 mg/dl to 125 mg/dl

Front 56

What lab values indicate Impaired Glucose Tolerance (IGT)?

Back 56

2 hour oral glucose tolerance test values of 140 mg/dl to 199 mg/dl

Front 57

In 2010 what criteria for an A1C did the ADA recommend be used to identify increased risk for DM (prediabetes)?

Back 57

An A1C level of 5.7 to 6.4%

Front 58

What are the ADA criteria for the diagnosis of DM?

Back 58

- A1C >/= 6.5%
- Fasting plasma glucose (FPG- no caloric intake for at least 8 hrs) >/= 126 mg/dl
- 2 hour plasma glucose >/= 200 mg/dl during an oral glucose tolerance test (OGTT)
- Random plasma glucose >/= 200 mg/dl when client presents with classic symptoms of hyperglycemia

Front 59

What does OGTT stand for?

Back 59

Oral Glucose Tolerance Test

Front 60

What risk factors indicate, according to the ADA, a need to test children who are overweight for type 2 DM?

Back 60

- Family history of type 2 DM in first- or second-degree relatives
- Native american, african american, hispanic/latino, asian american, pacific islander
- signs of insulin resistance such as acanthosis nigricans, HTN, dyslipidemia or polycystic ovary syndrome
- Maternal history of gestational diabetes during child's gestation

Front 61

Overweight is defined as:

Back 61

- BMI > 85th percentile for age and sex
- Weight for height > 85th percentile
- Weight > 12-30% above ideal

Front 62

How often should fasting plasma glucose be done on children at risk for type 2 DM?

Back 62

every 3 years

Front 63

How can dietary intake by modified for diabetes prevention?

Back 63

- decrease calories and total dietary fat
- decrease saturated fats
- increase the intake of dietary fiber and whole grains

Front 64

What percentage of body weight loss was shown by the Diabetes Prevention Program (DPP) to reduce high-risk overweight subjects risk for developing diabetes?

Back 64

A weight loss of 5-7% of their initial body weight reduced the risk of developing DM by 58%

Front 65

What has been found to be the greatest physical predictor for diabetes risk above both BMI and body weight?

Back 65

Waist circumference

Front 66

What number of inches for men and what number for women of waist circumference put them at higher risk for developing DM?

Back 66

Men having waist circumference greater than 40 inches
Women having waist circumference greater than 35 inches

Front 67

How does exercise effect blood sugar?

Back 67

Exercise boosts carbohydrate metabolism and insulin sensitivity

Front 68

What is the ADA recommend in terms of an exercise regimen?

Back 68

150 minutes of moderate intensity exercise per week

Front 69

What role does genetics play in the development of type 1 DM?

Back 69

While there is a genetic predisposition, many people who have the genetic risk do not develop the dz. An environmental or viral trigger is believed necessary for the disease to express itself in predisposed individuals.

Front 70

What islet cell antibody is considered to be the best immunologic predictor for the development of type 1 DM?

Back 70

Glutamic Acid Decarboxylase

Front 71

What type of antibodies appear early in the course of type 1 DM and what do they do?

Back 71

Islet cell antibodies direct their attack against beta cells

Front 72

What are the stages of progression of type 1 DM?

Back 72

1. abrupt onset of illness
2. "honeymoon period" wherein beta cellls are in a compensatory phase and temporary normoglycemia results
3. Continued beta cell destruction leads to acute loss of glycemic control which results in the permanent need for exogenous insulin

Front 73

What is Relative insulin deficiency?

Back 73

Insulin production by the beta cells of the pancreas is insufficient for the body's needs. There is a 50% reduction in beta cell mass in people with type 2 DM

Front 74

What is insulin resistance?

Back 74

Insulin receptors, found mostly on muscle and liver tissue, have developed a resistance to insulin. Insulin resistance is present years before the onset of hyperglycemia.

Front 75

Why is there over production of glucose by the liver in the presence of insulin resistance?

Back 75

Normally increased insulin levels in the blood suppress hepatic glucose production. In type 2 DM, insulin resistance of hepatic receptors results in continued hepatic glucose production despite circulating insulin levels.

Front 76

Why does diabetes usully require increasingly intensive therapy over time?

Back 76

Diabetes is a naturally progressive disorder and requires increasingly intensive therapy due to the proressive loss of beta cell function and/or increasing insulin resistance

Front 77

What are the ADA target glucose goals for self-monitoring for most adults?

Back 77

Fasting 90-130 mg/dl

Postprandial Less than 180 mg/dl

Front 78

What factors should be considered when recommending a goal for glycemic control?

Back 78

- Age
- Pregnancy status
- hypoglycemic awareness
- comorbidities

Front 79

Why would a less stringent goal be set for SBGM and A1C levels?

Back 79

If there is limited life expectancy or in those with reduced hypoglycemic awareness.

Front 80

What are the target blood glucose ranges and A1C for Ages 0-6?

Back 80

100-180 mg/dl before meals

110-120 mg/dl at bedtime

A1C 7.5-8.5%

Front 81

What are the target blood glucose ranges and A1C for Ages 6-12?

Back 81

90-180 mg/dl before meals

100-180 mg/dl at bedtime

A1C <8.0%

Front 82

What are the target blood glucose ranges and A1C for Ages 13-19?

Back 82

90-130 mg/dl before meals

90-150 mg/dl at bedtime

A1C < 7.5 %

Front 83

Why do infants and children have more liberal target BG goals?

Back 83

To prevent undetected hypoglycemia and protect the developing nervous system.

Front 84

What are some reasons to consider more lenient target BG goals for older people?

Back 84

- impaired functional status
- Poor social support or isolated living situation
- Decline in cognitive function
- Hypoglycemic unawareness
- Decreased life expectancy

Front 85

What should be taken into account when choosing medications for elderly clients?

Back 85

- Hypoglycemic unawareness
- Declining kidney function
- Declining liver function

Front 86

What are some therapeutic lifestyle modifications that can be made to reduce the cardiovascular risk for diabetics with hypertension?

Back 86

- Weight loss
- Exercise
- Tobacco cessation
- Limitation of sodium intake

Front 87

At what point is an antihypertensive medication usually added to therapeutic lifestyle interventions?

Back 87

When the BP is greater than 140/90 mmHg

Front 88

What BP range is addressed by recommending therapeutic lifestyle interventions?

Back 88

130/80 through 139/89 mmHg

Front 89

Why is LDL cholesterol a factor for type 2 diabetics?

Back 89

While elevated LDL cholesterol is not specifically associated with type 2 DM these particles are atherogenic and their presence increases cardiovascular risk.

Front 90

What is the ADA recommended target goal for LDL cholesterol for those with low to moderate risk?

Back 90

Less than 100 mg/dl

Front 91

What is the ADA recommended target goal for LDL cholesterol for people with very high risk?

Back 91

Less than 70 mg/dl

Front 92

What lifestyle modifications are recommended in the treatment of dyslipidemia?

Back 92

- increased physical activity
- diet low in saturated fat

Front 93

What is the Diabetes Prevention Program (DPP)?

Back 93

A large multicenter study which demonstrated that the onset of diabetes can be prevented or delayed in high-risk subjects when certain lifestyle modifications are implemented. The high risk population was identified as having glucose intolerance.

Front 94

By what percentage is the risk for developing diabetes reduced through weight loss that is achieved by healthy eating an increasing physical activity?

Back 94

58%

Front 95

What are the recommendations for lifestyle modification to prevent or delay the onset of type 2 diabetes that were established by the Diabetes Prevention Program (DPP)?

Back 95

- Weight loss of 5-7%
- Diet low in fat and calories but high in fiber
- Moderate exercise for 150 min per week

Front 96

What are the diabetes-specific tools for measuring quality of life?

Back 96

- Diabetes Quality of Life Measure (DQOL)
- Diabetes Treatment Satisfaction Questionnaire
- Diabetes-Specific Quality of Life Scale (DSQOLS)

Front 97

What domains are measured by diabetes quality of life tools?

Back 97

- Satisfaction with diabetes treatment
- Impact of treatment, such as experience with hypoglycemia and adherence to dietary guidelines
- Impact of diabetes on social, physical and vocational functioning
- Psychological aspects, such as worry about future health

Front 98

What is the gold standard test for measuring glycemic control in people with diabetes?

Back 98

The glycated hemoglobin A1C test

Front 99

How is the A1C measured?

Back 99

By measuring the amount of glucose in the blood that attaches to the hemoglobin molecule.

Front 100

What A1C value has been established by the ADA in 2010 to be an accepted diagnostic criteria?

Back 100

An A1C >/= 6.5%

Front 101

At how many times greater risk are diabetics to have cardiovascular disease than non-diabetics?

Back 101

People with diabetes has a risk for cardiovascular disease that is 2-4 times greater than that of the non-diabetic population

Front 102

What are the elements of the metabolic syndrome associated with type 2 DM?

Back 102

- Insulin resistance
- dyslipidemia
- HTN

Front 103

How often should fasting lipids be tested in patients with DM?

Back 103

At least annually or every two years it the patient is low risk

Front 104

What are the renal function tests typically performed for diabetics?

Back 104

- Microalbuminuria
- Creatinine clearance to estimate GFR directly
- Serum creatinine to estimate GFR indirectly
- BUN to estimate GFR indirectly

Front 105

Microalbuminuria (MAU) Test for Kidney function

Back 105

Purpose- to detect early microalbuminuria so that further decline in kidney function can be prevented or delayed
Values:
Normal less than 30 mcg/mg
Microalbuminuria is defined as 30-299 mcg/mg
Clinical albuminuria is >/= 300 mcg/mg

Front 106

What factors can influence the results of Microalbuminuria (MAU) testing?

Back 106

- Exercise within 24 hrs of the test
- Infection
- Fever
- Inflammatory processes
- Hyperglycemia
- HTN

Front 107

How is a microalbuminuria definitively diagnosed?

Back 107

At least two of three tests performed within a 6-month period are elevated

Front 108

Why are liver function tests performed on diabetics?

Back 108

Liver function tests are necessary to evaluate the safety of initiating medications and to monitor the effects of ongoing medication therapy. Use of multiple medications increases the risk for drug interactions that cause inadequate clearance of byproducts from the liver.

Front 109

What patients are especially prone to impaired liver function?

Back 109

- Elderly patients
- Patients who abuse ETOH

Front 110

What is a common liver function test for medication hepatotoxicity and what is its normal reference range?

Back 110

Alanine aminotransferase (ALT)
Reference range: 8-20 U/L

Front 111

What are some strategies for the educator that can help a client deal with diabetes burnout?

Back 111

- Acknowledging that living with DM is challenging and that many people with the dz have feelings of burnout
- Developing a supportive and collaborative relationship with the client
- Helping the client identify areas where they have been successful
- Helping the client set reasonable, attainable goals
- Encouraging the client to seek help andsupport from others and to optimize available resources
- Helping the client develop effective problem-solving skills

Front 112

How much higher is the rate of depression in those with DM as opposed to the non-diabetic population?

Back 112

The rate of depression in people with diabetes is approximately three times that of people without DM

Front 113

What percentage of the diabetic population is afflicted with depression?

Back 113

15-20% of patients with diabetes are depressed

Front 114

Why is depression a concern for diabetic educators?

Back 114

- Depression has a negative impact on diabetes self-management
- Studies show that depression is directly related to poor glycemic control and subsequent complications
- Depression has a direct association with diabetes complications such as: retinopathy, neuropathic symptoms, nephropathy, HTN and sexual dysfunction
- Depression is associated with maladaptive coping methods such as substance abuse
- Depression increases the risk for cardiovascular dz

Front 115

What are some atypical symptoms of depression?

Back 115

- Sx of hypoglycemia or hyperglycemia despite objective findings of glycemic control
- Physical symptoms that are out of proportion with objective data
- Sexual dysfunction
- Chronic pain
- Worsening of glycemic control
- Decline in self-care behavior
- Poor adaptation to diabetes

Front 116

What are some diabetes-related anxieties?

Back 116

- fear of hypoglycemia
- fear of complications
- fear of using insulin
- fear of performing fingersticks

Front 117

How many calories are in a gram of fat?
In a gram of carbohydrate?
In a gram of protein?

Back 117

9 calories in a gram of fat
4 calories in a gram of carbs
4 calories in a gram of protein

Front 118

How many calories are in one pound of body fat?

Back 118

A pound of body fat equates to approximately 3500 calories

Front 119

How many calories are there per gram of alcohol?

Back 119

There are 7 calories per gram of alcohol

Front 120

Rapid or fast-acting insulin facts

Back 120

• Lispro (Humalog®),
-Aspart (NovoLog®),
- Glulisine (Apidra®),
It is the fastest working of all insulins. Once you inject it, it starts to work (onsets) in about 5 minutes and works hardest (peaks) about an hour after injection. These insulin last (have a duration of) about 4 to 5 hours. It is taken right before meals. Rapid-acting insulin looks clear in the bottle.

Front 121

Short acting or Regular insulin facts

Back 121

•Short-acting insulin like "Regular" insulin is sometimes used around mealtime. It takes longer to work than rapid-acting insulin does. It's taken about 30-45 minutes before you plan to eat and it peaks about three to four hours later. It can keep working for as long as 6 hours after injection. It also looks clear in the bottle

Front 122

NPH or intermediate-acting insulin facts

Back 122

•Intermediate-acting insulin like "NPH" is insulin mixed with something that makes the body absorb the insulin more slowly. That's why this type of insulin looks cloudy and has to be mixed before it's injected. It takes longer (1/2-1 hour) to start working, peaks 4-10 hours after injection, and keeps working for 10-16 hours.

Front 123

Long-acting insulin facts

Back 123

•Long-acting insulin like Glargine (Lantus®) or detemir (Levemir®) is like a marathon runner – lasting the longest. These insulins start working in 2-4 hours and can stay in the body for 24 hours with little or no peak. These insulins are clear and usually taken before bed.

Front 124

What is glycogenolysis?

Back 124

The process by which glycogen, the primary carbohydrate stored in the liver and muscle cells of animals, is broken down into glucose to provide immediate energy and to maintain blood glucose levels during fasting. Glycogenolysis occurs primarily in the liver and is stimulated by the hormones glucagon and epinephrine (adrenaline).

Front 125

Strategies for working with teens

Back 125

- focus on peer relationships
- be aware of body image
- collaborate and compromise with goals set by teen
- Enhance feelings of normalcy
- involve teen in peer support groups/diabetes camp
- Maintain open lines of communication
- explore perceived barriers
- establish primary relationship with teen but keep parents involved- parental involvement is essential in prevention of ketoacidosis
- provide positive reinforcement

Front 126

What is reframing?

Back 126

where clients learn to identify thoughts and attitudes that trigger maladptive behavior in challenging situations and then learn to restructure thoughts, feelings and attitudes in a more positive and productive way.

Front 127

What is the client's role in DSME in the empowerment approach?

Back 127

- identify goals and set agenda for education
- utilize knowledge gained from education to make informed healthcare decisions
- Take active role in identifying problems and learning to problem solve
- participate in contracts with educators and healthcare providers
- identify support system and specify help needed

Front 128

What is the educator's role in the empowerment approach?

Back 128

- Assist client to make informed decisions
- Approach education from the client's perspective and offer info relevant to the individual
- identify client readiness to change ad provide stage-appropriate interventions
- assist client to identify problems and teach problem solving skills
- help clients indentify thoughts, feelings and attitudes that hae an effect on DSME
- Assist with goal setting

Front 129

What are the two major variablesthat affect the decision to make change according to the transtheoretical model?

Back 129

1. Decisional balance involves weighing the pros and cons of making the change. If the person perceives that the benefits and rewards of a behvior outweigh the costs and disadvantages, he or she is more likely to make the change.
2. Self-efficacy is the person's self-confidence that he or she can actually initiate and maintain the proposed behavior change. The higher the self-efficacy, the greater the chance the person will make the change. Studies have indicated that self-efficacy is an important variable in diabetes self-management behaviors.

Front 130

What medications need special instruction in relation to driving?

Back 130

Insulin and sulfonylureas can both cause hypoglycemia and these patients need to be educated to keep a quick source of carbs within arms reach in the car and to test their BS before driving and not to drive if BS is below 70

Front 131

How much higher is the risk of caries, periodontal disease and tooth loss in diabetics?

Back 131

Diabetics have a three-fold risk for dental problems

Front 132

What are common issues related to diabetes and dental problems?

Back 132

- Poor wound healing
- hyperglycemia
- susceptibility to infection
- vascular changes
- neuropathy

Front 133

Why are diabetics at risk for post-dental procedure complications?

Back 133

Tooth loss or dental pain can lead to a change in dietary habits due to need to change to softer foods which tend to cause a sharper rise in blood glucose and they may need to have an adjustment in oral meds and insulin

Front 134

What things should be included in providing education on promoting good dental health?

Back 134

- There is an interrelationship between dental health and glycemic control. A decline in one can lead to a decline in the other
- maintain glycemic control and healthy eating habits.
- maintain good routine brushing and flossing habits
- see the dentist every 6 month and more often if there is periodontal disease
- notify the dentist that you have dibetes and know your most recent A1C
- don't smoke, as it increases the risk for periodontal disease
- dry mouth, common in diabetes, promotes the formation of dental caries. maintain good hydration and use fluoride mouth rinses and salivary substitues as needed
- be prepared to make adjustments in food, oral medication and insulin for dental procedures

Front 135

What are some s/sx of periodontal disease in relation to diabetes?

Back 135

- History of poor glycemic control
- current and persistet poor glycemic control with no obvious reason
- red, inflamed, tender gums
- bleeding gums
- foul breath
- change in eating habits to soft foods

Front 136

What are some interventions when periodontal disease is suspected?

Back 136

- educating the client the gum disease can negatively affect control of blood glucose
- referring to a dentist
- continuing to work with the client to lower blood glucose levels
- anticipating dietary changes, such as consuming more soft foods, that can have an influence on blood glucose control.

Front 137

What are some safety teaching points related to dental care?

Back 137

- Notify dentist about being diabetic and know A1C result
- prevent hypoglycemia during exams and procedures by having appropriate food intake before visit
- if fasting is required before a procedure, be aware that a reduction in med or insulin may be necessary
- avoid scheduling a dental appt during the hours when insulin action will be peaking
- if at risk for hypoglycemia, have a least 15 grams of fast acting carbs readily available.
- avoid dental surgeries during periods of severe hyperglycemia as this will affect healing and increase the risk for infection

Front 138

What is anhidrosis?

Back 138

An autonomic neuropathic condition which leads to little or no production of perspiration in the feet and lower legs resulting in severely dry and cracked skin

Front 139

What is diabetic dermopathy?

Back 139

Pigmented spots on the shins, usually asymptomatic but can be painful if they ulcerate. Most likely due to poor skin perfusion associated with diabetes

Front 140

What is acanthosis nigricans?

Back 140

Velvety brown or black lesions found in the skin folds, most commonly the folds of the neck and axillae. The conditiona is associated with obesity and insulin resistance. in the young, it is a marker of glucose intolerance and when present should prompt providers to screen for type 2 dm

Front 141

What are some common skin infections with DM

Back 141

Staph, beta-hemolytic strep, fungal and candida infections

Front 142

What are some teaching points for skin care?

Back 142

- maintain glycemic control
- maintain healthy eating habits and adequate hydration status
- inspect skin qd and report infections promptly
- pay attention to skinfold areas where fungus and yeast tend to grow.
- dry well in all skinfolds, including between the toes, after each bath or shower
- antifungal skin powders may be used in skinfolds and shoes
- avoid trauma to the skin
- wear protective footwear
- avoid overexposure to the sun, especially if taking sulfonylureas
- use mild soap to bathe and avoid harsh or drying skin care products such as those that contain alcohol

Front 143

What are some special circumstances that may alter a client's ability to perform good foot care?

Back 143

- homelessness
- blindness
- obesity

Front 144

What are the steps to self foot checks?

Back 144

1. carefully inspect all suraces of the feets, including top, bottom and between toes
2. Note any areas of skin breakdown or irritation. Report infection or slow healing promptly
3. Note areas that indicate poorly fitting shoes, such as callus formation or red pressure areas upon removing shoes.
4. Use a mirror if needed to visually access all areas of the feets. Enlist the help of a support person if necessary.

Front 145

What are the teaching points for foot care?

Back 145

- inspect feet qd
- inspect shoes for irregularities that may cause pressre or irritate skin.
- shake out shoes before putting them on
- always wear well-fitting, protective shoes and socks
- wash feet qd with mild soap and warm water as part of the bath or shower
- foot soaks are not recommended
- dry the feet after the bath or shower, especially between the toes
- use moisturizer for dry skin but AVOID getting it between the toes
-avoid highly scented moisturizers and those containing alcohol which may irritate or dry the skin
- cut toenails straight across
- do NOT use heating pads or hot water bottles to warm feet
- promptly report problems such as cuts, scrapes or blisters that do not heal or appear to be infected

Front 146

What is the proper procedure for self-care for calluses?

Back 146

1. gently rub with a pumice stone after the bath or shower
2. apply moisturizing cream or lotion
3. do NOT use sharp instruments to cut a callus and do not use OTC treatments with harsh chemicals that may burn the skin

Front 147

What are a few tips regarding obtaining an adequate blood sample when using a site other than the finger tip for SMBG?

Back 147

- allow more time for the blood drop to form
- hold the lancing device firmly on the site for several seconds before and after the puncture
- gently rub the site for 30-60 seconds before testing
- instruct client to read the manufacturer's instructions for how to place and hold the lancing device.

Front 148

What is continuous glucose montioring (CGM) and special instructions regarding its use?

Back 148

It is a device that uses a sensor to measure the glucose of interstitial tissue on a continuous basis. It is most appropriate for those on intensive insulin regimens as it allows for close real-time monitoring for on-the-spot insulin adjustments. There is a 2-3 minute lag between interstitial glucose and capillary blood glucose so alarms for hypoglycemia should be set to go off at a higher-than-usual target to allow for prompt detection of hypoglycemia.

Front 149

What is an estimated average glucose (eAG)?

Back 149

It is a refined formula for correlating blood glucose and A1C values

Front 150

A1C values as they correlate to SMBG values

Back 150

A1C = BS in mg/dl

6%.............126 mg/dl

6.5%...........140 mg/dl

7.0%...........154 mg/dl

7.5%...........169 mg/dl

8.0%............183 mg/dl

Front 151

What is the leading cause of death among diabetics?

Back 151

cardiovascular disease

Front 152

Other than monitoring BP and lipids what is another important marker for cardiovascular risk?

Back 152

Microalbuminuria

Front 153

What are the target goals set by the ADA for fasting lipid levels?

Back 153

These should be monitored at least annually
- LDL-C < 100 mg/dl
- HDL-C Men > 40 mg/dl
-HDL-C Women > 50 mg/dl
- Triglycerides < 150 mg/dl

Front 154

How often should urine microalbumin be measured?

Back 154

Urine microalbumin should be measured annually, starting at 5 years after diagnosis in type 1 dm and upon diagnosis in type 2. The normal value for spot urine collection is < 30 mcg/mg

Front 155

What does pattern management involve?

Back 155

- Normally, pattern management involves observing and recording blood glucose for 2-3 days and making insulin adjustments based upon a pattern of high or low blood glucose at a given time of day.
- changes are made in 10-20 % increments

Front 156

What are some examples of insulin adjustments in response to patterns?

Back 156

- Glucose high or low before breakfast >>> adjust bedtime intermediate (NPH) or long-acting (glargine, determir) insulin
- Glucose high after breakfast >>> adjust pre-breakfast rapid-acting insulin
- Glucose high after lunch >>> adjust pre-lunch rapid-acting insulin
- Glucose high after dinner >>> adjust pre-dinner rapid-acting insulin

Front 157

According to the ADA what are the goals for Medical Nutritional Therapy (MNT) for diabetes?

Back 157

- Achieve and maintain glycemic control
- Achieve and maintain a lipid profile that will reduce the risk for CVD
- Achieve and maintain blood pressure at target level
- Prevent or delay long-term complications of diabetes
- Individualize nutritional needs based on personal and cultural preferences and willingness to change eating habits
- Integrate the meal plan with the insulin regimen
- Maintin eating as a pleasurable activity with limitations based on scientific evidence
- Meet the concurrent nutritional needs of people with diabetes at different times in the lifecycle, such as youth, pregnancy, old age and lactation
- Safely coordinate nutritional recommendations with risk for hypoglycemia

Front 158

What are the nutrition recommendations and interventions for the prevention of type 2 DM?

Back 158

- Moderate weight loss of 7% of body weight
- 150 minutes of moderate physical activity per week
- Dietary reduction of fat and calories
- Dietary fiber intake of 1 gm/1,000kcal with one-half of grain intake coming from whole grains

Front 159

What are the general principles of the meal plan for diabetes?

Back 159

- If overweighter, start by losing 5-7% of body weight. Even modest weight loss can produce significant results in glucose and lipid results. For overweight client, achieving weight loss shares priority status with achieving glycemic control.
- Eat consistent amounts of cargs from day to day and distribue evenly throughout the day. While eating sugar is not forbidden, the daily intake of carbs should be monitored and controlled.
- Practice portion control
- Limit fats in the diet, especially saturated fats and trans fats
- engage in 150 minuts of moderate intensity physical activity every week

Front 160

How many calories should be eaten for maintenance of ideal body weight?

Back 160

11 kcal/pound (more for those who are more physically active and less for weight loss)

Front 161

What percentage of protein should be in the daily caloric intake?

Back 161

15-20% of daily caloric intake- there are 7 grams of protein per ounce.

Front 162

What percentage of daily calories should be from fat?

Back 162

While total intake is individualized, usually it is recommended that fat be restricted to 25-30% of the daily caloric intake. Less than 7% of calories should come from saturated fat. For individual food, the goal is to have <1 gram of saturated fat per 100 calories. Daily intake of transf fats should be 0.

Front 163

How many mg of sodium is considered moderate?

Back 163

Moderate sodium intake is considered 2300-2400 mg/day

Front 164

What is the recommended daily alottment of sodium for someone with HTN?

Back 164

1500 mg/day

Front 165

How many mg of sodium is there in a teaspoon of salt?

Back 165

2300 mg

Front 166

How much fiber should one eat per day and why?

Back 166

At least 14 gm of fiber per 1000 calories because some studies show greater amounts have a beneficial effect on glycemic control.

Front 167

What is the ADA recommendation regarding carbohydrates in DM management?

Back 167

- A balanced diet including carbohydrate from fruit, vegetables, whole grains, legumes and low-fat milk is encouraged
- People with DM should monitor carbohydre intake by a method such as carbohydrate counting, food exchanges or visual estimation
- Use of the glycemic index may be an appropriate supplement to monitoring total carb intake
- Sugar such as sucrose can be substituted for other carbohydrate in the meal plan. If sugar is added additional insulin or exercise may be indicated
- Although a specific value for fiber intake has not been deermined for people with diabetes, a diet rich in fiber is recommended
- Non-nutritive sugar substitutes and sugar alcohols are safe when used within guidelines established by the FDA

Front 168

What should a client be advised to look for on food labels in regard to sodium per meal?

Back 168

- for single serving foods 400 mg or less of sodium is recommended
- for an entree less than 800 mg of sodium is recommended

Front 169

How much sodium is in a food labeled "low sodium"?

Back 169

140 mg or less of sodium per serving

Front 170

What factors influence the postprandial glucose response to carbohydrate ingestion?

Back 170

- Type of starch (amylase vs amylopectin)
- degree of processing
- the composition of the meal
- method of cooking
- ripeness of the plant
- insulin availability
- sensitivity of the individual

Front 171

What does the glycemic index do?

Back 171

It compares the postprandial response of carbohydrate containing foods. The glycemic response of a food is compared to the glucose response of a reference food, such as white bread or rice. The glycemic index is the rise in blood glucose at 2 hours following ingestion of a 50 gram carbohydrate portion.

Front 172

What are some examples of low glycemic index foods?

Back 172

- Oats
- legumes
- pumpernickel bread
- apples
- oranges

Front 173

What does research indicate about a high fiber diet (approximately 50 grams of fiber per day)?

Back 173

High-fiber diet is associated with reduced glycemia in people with type 1 DM and reduced glycemia and lipemia in people with type 2 DM

Front 174

How many grams of fiber identifies a food as being "high in fiber"?

Back 174

Foods containing >/= 5 grams of fiber are considered rich in fiber and should be encouraged

Front 175

What are some examples of high fiber foods?

Back 175

- legumes
- fiber rich cereals
- whole grain products
- nuts
-vegetables
- fruit

Front 176

What are some examples of a 15 gram carbohydrate servings?

Back 176

- 1 small piece of fruit
- 1/3 cup of rice, cooked
- 1/3 cup of pasta, cooke
- 1 cup milk
- 3/4 cup of yogurt
- 1 slice of bread
- 1 small potato

Front 177

How should a foods carbohydrate count be adjusted if it is considered a high fiber food (at least 5 grams of fiber per serving)?

Back 177

Because fiber is not digested like other carbohydrates, for carbohydrate counting purposes, if a serving of a food contains more than or equal to 5 grams of dietary fiber, you can subtract half the grams of dietary fiber from the total carbohydrate serving of that food

Front 178

What are examples of "free foods" which contin less than 20 calories and fewer than 5 grams of carbs per serving?

Back 178

- pickles
- salsa
- many condiments
- sugar-free gelatin

Front 179

How many servings of carbohydrates are typically allowed per meal when on a carb counting meal plan?

Back 179

3-4 carb choices per meal. Each carb choice equals 15 gm of carbs. usually have an additional allowance of 1-2 carb choices for snacks. Should limit carbs choices that are high in fat and calories

Front 180

Does Sucrose (table sugar) increase blood glucose more that starches?

Back 180

There is strong evidence that, in equal caloric amounts, dietary sucrose does not increase blood glucose more than starch. Therefore, the intake of sugar and sweet foods is not forbidden to people with diabetes. Sucrose can be substituted for equivalent amounts of starch without a significant difference in effect on glycemia.

Front 181

Is the glycemic index of fructose higher or lower than those of sugar and starch?

Back 181

Fructose has a lower glycemic index than either sucrose or starch. Adding fructose as a sweetening agent is not recommended because of the adverse effect on plasma lipids. Naturally occurring fructose in fruits and other foods does not need to be eliminated fro the diet if these foods account for only 3-4% of total energy intake

Front 182

What are some sources of saturated fats and what percentage of daily calories should come from them?

Back 182

Less than 7% of the daily calories should come from them. Sources include animal fat and coconut, palm and hydrogenated vegetable oils.

Front 183

What effect do polyunsaturated fats have on total cholesterol and what are some sources?

Back 183

Polyunsaturated fats lower total cholesterol but have a mixed effet on HDL levels. Sources are corn and sunflower oils and walnuts. Intake should be less than 10% of daily calories

Front 184

What effect do monounsaturated fats have on total cholesterol and what are some sources?

Back 184

monounsaturated fats lower total cholesterol but do not lower HDL They are more beneficial to the lipid panel than polyunsaturated oils. Sources include nuts and canola, olive and peanut oils.

Front 185

What type of fat is Omega 3 and what effect do they have on serum triglycerides and what are some sources

Back 185

Omega 3 re polyunsaturated fats that lower serum triglycerides and have an antiplatelet clotting effect. Sources include fatty fish such as salmon, herring and sardines as well as flaxseed and walnuts.

Front 186

What effect does dietary cholesterol have on cholesterol levels, what should the daily intake be and what are some sources?

Back 186

Dietary cholesterol raises cholesterol levels in some people more than others. Intake should be less than 200-300 mg/day. Sources are egg olks, organ mets and dairy fat.

Front 187

What are the ADA recommendations for protein in the management of DM?

Back 187

- Protein intake should be similar to that of the general population in the person with DM having normal renal function
Protein is not effective in treating hypoglycemia and should not be used to prevent nighttime hypoglycemia since it can increase insulin response without increasing plasma glucose
- High-protein diets are not recommended for weight loss even in patients with normal renal function

Front 188

What relationship is there between the progression of microvascular complications and protein consumption?

Back 188

The progression of the microvascular complications of DM ma be moderated b decreasing protein in the diet, along with attaining glycemic control and lowering BP.

Front 189

What are the ADA guidelines for alcohol use?

Back 189

- People with Dm who choose to use alcohol should do so in moderation ( less than one alcholoic beverage per day for women and less than 2 per day for men)
- Alcohol should be consumed with food to reduce the risk for nocturnal hypoglycemia in people using insulin and glucose lowering oral agents
- Drinks mixed with carbs should be avoided to prevent hyperglycemia

Front 190

What are the BMI classifications?

Back 190

- Normal 8.5- 24.9
- Overweight increase risk for disease 25-29.9
- Obese, high risk 30-34.9
Very high risk 3.50-39.9
- Extremely high risk >40

Front 191

What waist circumference is associated with health risk in relation to type 2 DM, HTN, dyslipids and CVD?

Back 191

- Men > 40 inches
- women >35

Front 192

What are the ADA guidelines for weight loss?

Back 192

- Moderate weight loss for overweight or obese people who have DM or who are at risk for DM
- Weight loss can be achieved through either low-carb or low-fat, calorie-restricted diets followed for up to one year
- Exercise and behavior modification are essential components of any weight loss plan
- Weight loss medications may be appropriate for some overweight or obese people with DM if combined with lifestyle modification
-Bariatric surgery may be appropriate for some obese people with DM and a BMI >/= 35

Front 193

What should be monitored when on a low-carb diet?

Back 193

- Lipid profiles and renal function
- protein intake should be monitored in patients with nephropathy on a low carb diet

Front 194

What are the components of successful weight loss programs and long-term weight management?

Back 194

- Structured and intensive lifestyle modification
- participant education
- individualized counseling
- calorie restriction (50- 1,000 fewer calories than estimated as necessary for weight maintenance
- regular physical activity
- frequent participant contact

Front 195

What is the recommended daily allowance for digestible carbohydrate?

Back 195

130 gm/day.

Front 196

What is the daily carbohdrate allowance during pregnany and how should it be distributed?

Back 196

Carb allowance should be at least 175 grams distributed throughout the day in 3 small to moderate-sized meals and 2-4 snacks. Evening snacks are somtimes required to prevent ketosis overnight.

Front 197

What are the specific benefits of exercise?

Back 197

- Decrease insulin resistance
- Lowers fasting and postprandial glucose concentrations
- Improves uptake of glucose by muscle tissue
- increases fat metabolism
- increases cardiac output
- helps with weight loss and maintenance of weight loss
- reduces BMI
- decreases blood pressure by 5-10 mmHg
- modestly increases HDL cholesterol
- modestly decreases triglyceride levels
- helps alleviate stress, depression and anxiety

Front 198

What are the effects of exercise on insulin sensitivity?

Back 198

During the post-exercise period, there is increased uptake of glucose by the muscles medicated by increased insulin sensitivity of the muscular receptors. While insulin secretion decreases during exercise, the increasedd insulin sensitivity more than compensates for this, resulting in lowering of the blood glucose concentration.

Front 199

How long do the insulin-sensitizing effect last?

Back 199

Depending upon the duration and intensity of the activity, the insulin-sensitizing effect lasts for 24-72 hours following an exercise session. Therefore to optimize the benefits of exercise it is recommended that no more than 2 days pass between sessions

Front 200

What patients should have cardiac stress testing prior to beginning exercise regimen?

Back 200

- previously sedentary individuals with moderate to high risk for CVD
- those with concurrent autonomic neuropathy, PVD or microvascular dz
- those with type 2 D for longer than 10 years
- those with type 1 DM for longer than 15 yrs if age 35 years or older

Front 201

When is exercise not safe for a type 1 diabetic?

Back 201

Hyperglycemia and ketosis can worsen if a person with type 1 DM initites exercise while blood glucose is greater than 250 mg/dl and ketones are present. These clients should be advised to avoid exercise until blood glucose improves and ketones are absent

If BG is greater than 300 mg/dl it is prudent to delay exercise even in the absence of ketones

Front 202

Should insulin be given to a type 1 diabetic who experiences an acute rise in BG following intense exercise?

Back 202

Additional insulin should not be administered becuse its action will coincide with the increased insulin sensitivity that follows exercise.

Front 203

When is exercise not safe for a type 2 diabetic?

Back 203

If ketones are present in the hyperglycemic client with type 2 D, strenuous exercise should be avoided. If BG is > 300 mg/dl it is not necessary to advise them to abstain from exercise at that time, especially is they are postprandial as increasing physical activity is likely to decrease BG levels

Front 204

What are the exercise restrictions for those with proliferative or severe nonproliferative retinopathy?

Back 204

Clients should be instructed to avoid vigorous aerobic or resistance exercises to prevent vitreous hemorrhage and retinal detachment

Front 205

What are the exercise restrictions for those with peripheral neuropathy?

Back 205

clients who have lost protective sensation in the LE should be advised to avoid exercises that increase the risk for skin breakdown, joint injury and charcot fx. Potective and well-fitting shoes and socks should be worn at all times. in cases of severe loss of protective sensation non weight bearing activities such as cyclingor swimming are recommended

Front 206

What are the exercise restrictions for those with autonomic neuropathy?

Back 206

This poses risk for decreased cardiac response to exercise, postural hypotension, silent angina and impaired thirst sensation. A thorough cardiac evaluation needs to be done before being recommended an exercise program

Front 207

What are the exercise restrictions for those with microalbuminuria?

Back 207

Exercise can increase urinry protein excretion but studies have not confirmed that exercise accelerates decline in kidney function. Therefore, the presence of microalbuminuric individuals hould be considered since microalbuminuria and nephropathy are associated with increased cardiovascular risk.

Front 208

What BS level indicates need for carbohydrate intake prior to exercise for patients on insulin or a secretagogue?

Back 208

A blood glucose < 100mg/dl requires a supplemental carbohydrate would be needed prior to exercise.

Front 209

What is post-exercise, late-onset hypoglycemia (PEL)

Back 209

PEL is exercise-induced low blood glucose that occurs 4 or more hours after exercise. It happens most commonly to people having type 1 DM but anyone using insulin or insulin secretaogues is at risk. The risk is increased after exercising at moderate to intense levels for more than 30 minutes.

Front 210

What are some preventative measures for preventing hypoglycemia during exercise?

Back 210

- avoid exercise during peak insulin action
- carb supplementation may be needed to prevent hypoglycemia when exercise is unplanned or insulin adjustments are not possible.
- check BG before, during and afer exercise to hel determine the individual's glycemic response to exercise and the need for supplementation.
- for moderate exercise of 30-60 minutes duration, 15 extra grams of carbs is often appropriate
- for high-intensity exercise or exercise lasting for more than an hour 30-50 grams of additional carbs may be needed for each hour of activity

Front 211

What medication does the ADA recommend starting type 2 diabetics on?

Back 211

Metformin.

Front 212

What are the considerations for a patient taking metformin?

Back 212

- Liver and kidney function must be tested prior to starting
- metformin is not used when GFR is less than 30 and/or serum crt is > 1.5 mg/dl in men or > 1.4 mg/dl in women
- when renal fx is decreased the risk for hypoglycemia is greater with the use of insulin secretagogues
- when the alanine aminotransferase (ALT) level is elevated above 2.5 times normal, the use of metformin and thiazolidinediones is contraindicated
- metformin is containdicated in clients who drink alcohol excessively or engage in binge drinking
- thiazolidinediones are contraindicated in people with heart failure and severe cardiac dz
- metformin should be used with caution with people with heart failure and severe cardiac dz

Front 213

What are the signs of glucose toxicity?

Back 213

Signs of glucose toxicity include prolonged hyperglycemia, A1C >9% and possibly ketones

Front 214

What are the actions of insulin?

Back 214

- Augments protein synthesis by promoting the entry of amino acids into the cells
- promotes utlization of glucose for energy by stimulating its entry into the cells
- enhances storage of unused glucose as glycogen in muscle and liver cells
- enhances the storage of fat and prevents the use of fat breakdown for energy
- impedes glycogenolysis, the making of glucose from glycogen stored in muscle and liver cells
- impedes the formation of glucose from amino acids and other non carbohydrate sources

Front 215

What counter-regulatory hormones antagonize the hypoglycemic effects of insulin?

Back 215

- glucagon
- epinephrine
- norepinephrine
- growth hormone
- cortisol

Front 216

What is the onset, peak and duration times of rapid-acting insulins?

Back 216

ONSET- 5-15 minutes
PEAK- 30-90 min
DURATION- Less than 5 hours

TEACHING- Inject less than 15 minutes before eating. Injecting too early can cause profound hypoglycemia. Compared with regular insulin, both lispro and aspart havea lower overall risk for hypoglycemia.

EXAMPLES- Lispro, Aspart (injection into the abdominal sq tissue has been shown to shorten the duration)

Front 217

What are the onset, peak and duration times of short-acting insulins?

Back 217

ONSET- 30 min
PEAK- 2-4 hours
DURATION- 5-8 hours

TEACHING- Like rapid-acting is used as a bolues insulin to provide postprandial glucose control

Examples- Regular, Novolin R, Humulin R

Front 218

What are the onset, peak and duration times of Intermediate-acting insulins?

Back 218

ONSET- 1-2 HRS
PEAK- 4-10 HRS
DURATION- 10-18 HRS

TEACHING- Cloudy insulin, gently roll and rotate vial prior to filling syringe to resuspend

Examples- NPH, Novolin N, Humulin N

Front 219

What are the onset, peak and duration times of Long-acting insulins?

Back 219

ONSET- 1-2 HRS
PEAK- NONE
DURATION- UP TO 24 HRS

TEACHING- Do NOT mix in same syringe with other insulins

Examples- Glargine, Lantus, Detemir, Levemir

Front 220

What percentage of daily insulin requirement should be provided by long-acting insulin and what time of day should it be administered?

Back 220

When used for basal therapy long-acting insulin should provide about 50% of the daily insulin requirement continuously over 24 hrs. When administered once daily the dose is usually given at bedtime and should always be given at the same time each day/

Front 221

What is the recommended starting dose of insulin for a type 1 diabetic?

Back 221

usually between 0.5 and 1.0 u per kg but during the "honeymoon phase" when some endogenous insulin is still being produced it is usually decreased to 0.2 to 0.6 u per kg

Front 222

What are the criteria for single daily insulin injections?

Back 222

- Contraindicated for type 1 diabetics
- used when dose requireent is less than 30 u/day
- administered in the morning or at bedtime using intermediate or long-acting insulin
- intermediate-acting insulin could be mixed with rapid or short-acting
- often administered at bedtime to improve fasting BG or to suppress nocturnal glucose production by the liver

Front 223

What are the criteria for bid insulin injections?

Back 223

- administered before breakfast and in the evening either before dinner or at bedtime
- may include 2 doses of intermedicate or long-acting insulin onl or mixed intermediate and rapid or short acting insulin at either or both injections
- typically two-thirds of the total daily dose is given at the morning injection and1/3 in the evening

Front 224

What is intensive insulin therapy and why is it used?

Back 224

Intensive insulin therapy includes 3 or more injections per day and glycemic control is optimized when a basal bolus regimen mimics he physiologc profile of insulin secretion as closely as possible. Basal insulin is intermediate or long acting and bolus insulin is given to control postprandial BG.

Front 225

What are some examples of 3-4 daily injection regimens?

Back 225

- bolus given before each meal
- bolus insulin before each meal and basal insulin at bedtime
- bolus regimen with intermediate acting insulin before breakfast + bolus insuling before the evening meal + intermediate acting insulin at bedtime

Front 226

When intermediate insulin is given in the morning what time of the day should bolus not be given?

Back 226

when intermediate acting insulin is given in the morning bolus insulin should NOT be given at lunchtime as the peak action for both insulins would coincide and could cause profound hypoglycemia

Front 227

How should insulin be stored?

Back 227

Insulin vials that are currently in use can be stored at room temp for the nuber of days that the manufacturer specifies as long as room temp remains between 36 and 86 deg F. Vials not in use should be stored in the fridge and used by the printed expiration date. A SPARE BOTTLE OF EACH TYPE OF INSULIN SHOULD ALWAYS BE ON HAND.
Care should be taken to avoid vigorous agitation of the vial as this can cause loss of potency.

Front 228

What should the vial of insulin be inspected for prior to injection?

Back 228

- clumping
- frosting
- precipitation
- change in clarity or color
Rapid and fast acting as well as glargine should remain clear
Intermediate should remain uniformly cloudy without clumping

Front 229

What sequence should be used when drawing up a mixture of regular and intermediate insulins?

Back 229

Rapid acting and regular insulin are drawn into the syringe before intermediate to avoid protamine contamination of the clear insulin. GLARGINE should never be mied with another type of insulin

Front 230

When should premixed insulins be used and what is the disadvantage to using them?

Back 230

They are most appropriately used with clients who need a simple regimen or who have cognitive or functional issues that impair their ability to mix insulin. The disadvantge is that it decreases flexibility and fine-tuning of the regimen.

Front 231

How should prefilled syringes be stored?

Back 231

Regular and NPH insulins can be mixed and stored in the fridge for 1 month. Syringes should be stored vertically with the needle pointing up to prevent the suspended insulin particles from clogging the needle

Front 232

What are the different size options for insulin, what increments are they measured in and how many units of insulin are they able to hold?

Back 232

0.3 cc can hold up to 30 u and are in 1 u increments
0.5 cc can hold up to 50 u and are in 1 u increments
1.0 cc can hold up to 100 u and are in 2 u increments

Front 233

What are the guidelines for needle reuse?

Back 233

- immunocompromised patients should not reuse needles
- discard needle when it is visibly dull or damaged
- discard needle if it comes into contact with any environmental surface
- cap the needle to be reused after each use
- store the syringe at room temp
- do NOT clean the needle with alcohol or any other disinfectant as this will remove the silicone coating that makes the injection more comfortable
- inspect injection ssites for signs of infection or lipodystrophy

Front 234

How should prefilled syringe insulin be given?

Back 234

Needle should remain embedded within the tissue for at least 5 seconds to ensure complete delivery of insulin from the device.

Front 235

What should be done if clear fluid escapes after insulin is injected?

Back 235

Pressure should be applied for 5-8 seconds. Rubbing the site is not advised. If it is suspected that a significant portion of the insulin has been lost due to leakage, blood glucose should be monitored within a few hours.

Front 236

Metformin

Back 236

- Metformin prevents high BG primarily by decreasing glucose dumping from the liver. A secondary efect is that it decreases insulin resistance.
- common side effects are GI such as nausea, bloating, gas, diarrhea, and metallic taste in the mouth. They are more common with higher doses and in the first 2 wks of therapy.
- contraindicated in patients with decreased renal function ie GFR < 30, crt 1.5 in men or 1.4 in women
- should not be used in people who drink more than 2 alcoholic drinks per day or who engage in binge drinking
- caution advised in presence of CHF, dehydration, acidosis, NPO status or pending iodine contrast studies
-The dosage range is 500 to 2550 mg/day.
PATIENT EDUCATION
Take with food to decrease GI effects
Medication takes up to 1 mo to reach max effectiveness
Drinking in excess can lead to lactic acidosis
Stop taking if unable to eat and drink or if dehydrated
Stop taking day of sx or when getting contrast dye
Increases chances for becoming pregnant when rx to tx polycystic ovary syndrome

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Sulfonylureas

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Examples: Glipizide, glyburide and tolazamide
Action: stimulates the pancreas to produce more insulin, only effective if there is still some beta cell production
Common side effects:
- Hypoglycemia with risk greatest in the first few months of starting med. Can be prevented with regular SBGM, avoid delay or missing meals and avoid drinking ETOH. -- weight gain
- sun sensitivity
- HA
- nausea.
Liver and kidney fx should be tested prior to start of med. If either are low the risk for hypoglycemia is increased thus use with caution in elderly who are prone to both of these issues and are at higher risk for hypoglycemia unawareness.
- use with caution in presence of adrenal or pituitary insufficiency
- those with severe sulfa allergies may not be able to take

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Thiazolidinedione (TZD)

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Examples- pioglitazone and rosiglitazone
Action: Increasing the insulin sensitivity of liver and skeletal tissues and by suppressing glucose production by the liver
Side effects:
- weight gain
- mild to moderate anemia
- bone fractures in women
- upper respiratory symptoms
- alone doesnt cause hypoglycemia but when used with sulfonylureas or insulin risk may be increased
- BLACK BOX WARNING- May cause or exacerbate CHF and are contraindicated in those with class 3 or 4 CHF. If taking rosiglitazone advised against using with nitrates or insulin as this combination has been associated with increased risk for cardiac patients
- associated with rare cases of idiosyncratic hepatocellular damage so use with caution in those with hepatic dysfunction. serum transaminase should be checked q 2 mo during the first year of tx and periodically thereafter
PATIENT EDUCATION
Call MD immediately if edema, sudden weight gain, SOB or other signs of fluid retention develop
May induce ovulation in premenopausal women with insulin resistance
May take several weeks of tx to realize optimal effect
May take with or without food
If taking with sulfonylurea or insulin watch for s/sx of hypoglycemia
Do NOT take if pregnant or breastfeeding

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Dipeptidyl Peptidase-4 Inhibitors (DPP-4)

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Examples: Sitagliptin and saxagliptin
Action: An enzyme that rapidly inactivates the incretin hormones. Incretins are digestive hormones that are released fro the small intestine after eating in response to postprandial rise in BG. They lower BG by stimulating release and by decreasing glucagon production in the pancreas. They prolong active incretin levels allowing for increased insulin action following the post-meal rise in BG.
Side effects:
- URI
- UTI
- HA
Unlikely to cause hypoglycemia b/c they do not work well when BG is low
May be used in patients with renal issues when dosage adjustment guidelines are followed.

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Alpha-Glucosidase Inhibitors (AGIs)

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Examples: Acarbose and miglitol
Action: Work by reducing the rate of starch digestion and slowing its absorption through the small intestine thus lowering postprandial BG
Side Effects:
- abdominal pain
- diarrhea
- flatulence
may be minimized by starting with low dose and titrating upward
When used alone do not cause hypoglycemia but when taking with insulin or sulfonylureas only glucose and lactose are effective in treating hypoglycemia.
Administration: must be taken with first bite of food
Contraindications:
- inflammatory bowel dz
- cirrhosis
- malabsorption d/o
- pregnancy and breastfeeding
- creatinine > 2.0 mg/dl or crt clearance of less than 25 ml/min
PATIENT EDUCATION
Take with first bite of food
May sometimes be started only once a day to minimize GI side effects. If initial dose is tolerated it will be titrated up until desired effect reached. Usually then given with all three meals.
If hypoglycemia occurs will have to be treated with glucose tablets or milk.

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Meglitinide Medications

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Examples: Repaglinide and nateglinide
Action: Stimulat the pancreas to promptly release insulin in a glucose-dependent fashion with a shorter duration of action than sulfonylureas
Side effects:
- hypoglycemia but risk is significantly lower than sulfonylureas
- GI upset
- upper respiratory symptoms
- back pain
- arthralgia
Administration: Must be taken between 0 to 30 minutes of the meal. If a meal is skipped dose is held. This may make this med a good choice for those with erratic eating habits. Normally started at a low dose and titrated up
Caution: in any patient with increase risk for hypoglycemia such as the elderly, impaired renal fx, adrenal or pituitary impairment.

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Incretin Mimetic Medications

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Examples: Exenatide and liraglutide
Action: Mimic the action of the incretin hormones glucagon-like peptide-1 (GLP-1) and gastric inhibitory polypeptide (GIP) causing an increase in insulin secretion from the pancreas. Delay gastric emptying increasing satiety and promoting weight loss
Administration: Distributed as prefilled pens to be given sq.
Exenatide is given within 30-60 minutes prior to the morning and evening meals. Missed doses should not be given after the meal. It is not labeled for use with insulin and is contraindicated in type 1 DM. Has been associated with pancreatitis so should not be used in patients with a h/o this.
Side Effects:
- nausea
- vomiting
- diarrhea
- hypoglycemia when used in conjunction with sulfonylureas
Liraglutide carries BLACK BOX warning cautioning that thyroid tumors were observed in rodent tests. Not approved as a first-line med and is delivered as a qd sq injection.
PATIENT EDUCATION
Take within 30-60 min of the meal, usually bid with exenatide and qd with liraglutide.
Do NOT take after the meal
If meal is skipped do not take
Store in refrigerator and remove needle from pen after each use
GI side effects can be minimized by injecting med closer to mealtime. Nausea frequently subsides with continued use
Report possible s/sx of pancreatitis
Oral abx and contraceptives should be taken 1 hr apart from these meds

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What are the current criteria for the dx of DM?

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- A1C >/= 6.5
- FPG >/= 126 mg/dl
- 2 hr plasma glucose >/= 200 during an OGTT. uses a glucose load of 75 gm of anhydrous glucose
- in the presence of classic signs of DM a random plasma glucose of >/= 200 mg/dl
- In the absence of unequivocal hyperglycemia the result should be confirmed by repeat testing

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When do you test if the patient is asymptomatic?

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- For type 2 and to assess risk for future DM whould be considered in adults of any age with BMI >= 25 and who have one or more additional risk factors , if without other risk should begin at age 45 with that BMI
- If above was normal then recheck at least every 3 years
- use tests A1C, FPG or 2 hr 75 gm OGTT
- those identified with inc risk for future DM identify and treat other CVD risk factors

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Detection and dx of gestational DM

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- screen for udx type 2 at first prenatal visit in those with risk factors
- In pregnant women not previously dx screen for GDM at 24-28 weeks using 75 gm OGTT and the dx cutpoints- FPG is measured at 1 and 2 hours. Should be performed in am after fasting.
DX OF GDM: FPG >= 92
1h >=180
2h.= 153
Screen those with GDM at 6-12 weeks postpartum to check for persistent DM.
Those with GDM need to be screened every 3 years for DM or preDM
Those with GDM found to have preDM should receive lifestyle interventions or metformin to prevent DM

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Metformin

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decrease hepatic production of glucose
decrease intestinal absorption of glucose
increase insulin sensitivity

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Sulfonylureas
Glipizide
Glyburide
Gliclazide
Glimepiride

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increase insulin secretion
risk hypoglycemia d/t independent of BG
weight gain

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Meglitinides
Repaglinide
Nateglinide

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increase insulin secretion
hypoglycemia
weight gain

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Thiazolidinediones
Pioglitazone
Rosiglitazone

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increase insulin sensitivity
weight gin
edema
CHF
bone fx
increase LDL

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alpha glucosidase inhibitors
Acarbose
Miglitol

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slowed intestinal carb digestion
decrease postprandial glucose

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Neuropathy screening

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screen at dx for type 2 and 5 yrs after dx with type 1 and then at least annually
EP testing rarely needed
screening for s/sx of cardiovascular autonomic neuropathy at dx type 2 and 5 yrs after dx with type 1
meds to relieve sx are recommended to improve QOL

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Distal symmetric polyneuropathy (DPN)

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Should screen annually
test pinprick, vibration, monofilament pressure sensation

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Diabetic autonomic neuropathy (DAN)

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Clinical manifestations: resting tachycardia, exercise intolerance, orthostatic hypotension, constipation, gastroparesis, erectile disfx, sudomotor dysfx, impaired neurovascular fx and potentially autonomic failure in response to hypoglycemia

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Cardiovascular autonomic neuropathy (CAN)

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most clinically important form of DAN
may be indicated by resting HR >100 or orthostasis
associated with increased cardiac events

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Gastroparesis

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should be suspected when there is erratic glucose control or with UGI sx.
constipation

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Examples of serving of carbs

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4 oz juice
7-8 lifesavers
8 0z fat free milk
1 tbsp sugar, jelly or honey

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Retinopathy

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results from damage to the microvasculature supplying the part of the eye responsible for focusing and light
hyperglycemia causes small hemorrhages and blood leakage
to compensate for the loss of normal blood flow from damaged vessles new vessels develop (neovascularization)
new vessels friable and leak causing adhesions between the retina and the vitreous which leads to retinal traction and detachment and macular edema

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Nonproliferative retinopathy

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microaneurysms and other evidence of leakage are seen on fundus exam
no change in vision
staged from mild to very severe

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Proliferative retinopathy

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indicates that neovascularization has started and there is vision impairment
can range from mild blurring to large blind spots
laser photocoagulation therapy

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microalbuminuria

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persistent presence of albumin in the urine of 30 - 299 mg/24 hr
used s marker for inc cardiovasc risk and associated with retinopathy

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Macrovascular dz

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both arteriosclerosis (walls of arteries and veins ecome thicker and lose elasticity) and atherosclerosis (process of plaque formation within blood vessels)
causes CAD at earlier age and more aggressive and is responsible for 50-60 % of deaths of diabetics
CVD with 3-5 times greater risk for death from CVA
PVD

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Charcot foot

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complication of dm r/t peripheral and autonomic neuropathy
repeated trauma to insensitive, neuropathic joints leads to joint destruction and severe deformities of foot structure
unilateral edema and warm foot looks like infection without signs of skin breakdown
loss of arch procuding rocker bottom shape of sole
immediate referral to ortho
NWB status

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Footware

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oxford style or velcro so fit can be modified when edema occurs naturally later in day
plenty of toe room
wide enough to accommodate bunions
made of leather or breathable material
avoid plastic or man made material
adequate cushioning and support of soles
socks of material that can wick moisture away

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Honeymoon period

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a remission phase that occurs early in type 1. characterized by temporary improvement in endogenous insulin production and decreased need for insulin injection. Due to decreased inflammation of the islets of langerhans caused by original autoimmune assault
when exogenous insulin is started the inflammation subsides and the beta cells resume production
typically lasts from 3-12 mo and is more common in young adults with type 1

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Sick days

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continue oral meds and insulin even if not eating normally
stop taking metformin if dehydrated
follow regular meal plan if able with 1 cup of noncaloric fluid/hr
if npo drink 1/2 to 1 cup sugar containing fld per hr
check BG q 2-4 hrs while awake
Call MD for persistent vomiting/diarrhea, BG consistently >300, temp >101, ketonuria

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GDM plasma glucose target goals

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premeal, bedtime and overnight 60-99 mg/dl
peak postprandial 100-129

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Sleep apnea

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as many as 50% of people with type 2 have OSA
it worsens insulin resistance and increases the risk for cardiovascular events, HTN and erectile dysfx