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147 Cards in this Set
- Front
- Back
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Percentage of ingested protein that converts to glucose
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50-60%. Most is stored as glycogen. Protein consumption directly affects BG levels more for those who have poorly controlled T2DM.
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Does consuming protein w CHO help to lower glycemic response?
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No.
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What are the ADA recommendations for dietary protein?
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-Should not exceed 20% of total daily energy intake.
-microalbuminuria: 0.8-1.0 g/kg bw -nephropathy: 0.8 g/kg bw |
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ADA guideline for alcohol
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-drink in moderation
-consume alcohol w food to reduce risk for nocturnal hypoglycemia -avoid high carb mixers (juice or soda) |
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Nutritional considerations during pregnancy
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-achieve normoglycemia and prevent ketosis
-carbs during pregnancy should be at least 175g/d distributed btw 3 meals and 2-4 snacks. -regular physical activity may be helpful to normalize BGs |
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Effects of exercise on insulin sensitivity
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-post-exercise= increase uptake of glucose by the muscles
-insulin secretion decreases during exercise, but insulin sensitivity significantly increases -meds may need to be reduced -insulin sensitivity post-exercise may last 24-72 hrs |
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Aerobic exercise recommendations for T2DM
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-at least 150 min/wk of moderate aerobic activity
-at least 90 min/wk of vigorous aerobic activity -distribute time over 3 days/wk - no more than 2 consecutive days should lapse w/o activity -greater cardiovascular benefits achieved with 4+ hrs/wk |
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Resistance training recommendations for T2DM
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-safe and beneficial (w regard to lowering A1c)
-3x/wk, targeting all major muscle groups -progress to 3 sets of 8-10 reps |
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Exercise precautions for T1DM w hyperglycemia
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-hyperglycemia + ketosis can worsen if exercising when BG is >250 mg/dL. Advise client to avoid until BG improves.
-If BG is 250-300 mg/dl without ketones, exercise is probably safe. -Delay exercise if BG is >300 mg/dL, regardless of ketones |
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Exercise precautions for T2DM w hyperglycemia
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-if BG is >300 mg/dL, it is NOT necessary to abstain from exercise (especially if in postprandial state).
-advise client to remain well-hydrated -if ketones are present, STRENOUS exercise should be avoided. |
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Exercise and microvascular complications (proliferative retinopathy & peripheral neuropathy)
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Proliferative retinopathy- avoid vigorous or resistance exercises to prevent vitreous hemorrhage and retinal detachment.
Peripheral neuropathy-avoid exercises that increase risk for skin breakdown, joint injury, and charcot fracture. Protective, well-fitting shoes and socks should be worn. In cases of severe loss of sensation, non-weight-bearing activities are preferred. |
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Exercise and microvascular complications (autonomic neuropathy & microalbuminuria)
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Autonomic neuropathy- risk for decreased cardiac response to exercise, postural hypotension, silent angina, and impaired thirst sensation. Thorough cardiac eval should be done.
Microalbuminuria-exercise can increase urinary protein excretion. Presence of microalbuminuria should not limit exercise. Cardiovascular status should be evaluated prior to activity. |
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Exercise recommendations for patients w PVD
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With less severe PVD, a walking program is indicated. It should include low intensity walking intervals, alternating with rest.
With severe PVD, a walking program is NOT indicated. |
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What is intermittent claudication?
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PVD-related ischemic pain resulting from an inadequate oxygen supply to the muscles of the lower extremities. Pain is exacerbated by walking and alleviated by rest (eventhough it is recommended for tx of mild PVD). BUT, when a person has pain at rest or during the night, the PVD is severe and a walking program is contraindicated.
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How to prevent exercise-induced hypogylcemia
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-test BG prior to activity
-if BG is <100 mg/dL, risk for hypoglycemia is high. -if pt uses insulin or a secretagogue, supplemental CHO is needed if BG is <100 mg/dL. Pt should be warned about post-exercise low BG (PEL). |
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Learning needs assessment includes...
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-previous learning/level of knowledge and health beliefs
-patient goals -attitudes and feelings about diabetes education -preferred learning styles (video, read, listen, hands-on) -psych status (depression, stress, anxiety) -social & cultural factors -readiness and willingness (scale of 1-10) |
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Characteristics of an adult learner
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-self-directed
-needs a reason to learn (info should be useful to them) -prefers personalized, relevant info -active-learner (group discussions, demonstrations, role playing) |
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Goals of Diabetes Self Management Education (DSME)
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Goals include enabling people w diabetes to make informed decisions & actively participate in their own care. Objectives are met by programs that provide training in self-care behavior, problem-solving and collaboration w healthcare providers.
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What are components of a DSME program?
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-diabetes disease process
-food & nutrition -physical activity & exercise -medication -self-monitoring of blood glucose (SMBG) -acute complications (prevention and treatment) -chronic complications (prevention and treatment) -psychological & social adjustment to DM -problem-solving -setting goals -pregnancy planning & preconception care (if applies) |
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What are the strongest predictors for behavior change (think about the health belief model)?
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perceived susceptibility + disease severity are the strongest predictors for behavior change.
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What are components of the health belief model?
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-perceived benefits
-perceived costs -severity of DM & complications -susceptibility |
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Locus of control theory and DM
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People with an internal locus of control are more likely to make health behavior change than those with an external locus of control.
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BG goals in pregnancy
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60-90 mg/dL before each meal and at bedtime
<95 mg/dL fasting <130 mg/dL ONE hour postprandial <120 mg/dL TWO hours postprandial |
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A1c targets recommended for T1DM in children
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0-6 yr old, 7.5-8.5%
6-12 yr old, <8% 13-19 yr old, <7.5% |
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Oral agent that is recommended for the treatment of diabetes during pregnancy
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Glyburide (micronase).
Glyburide is a sulfonyurea. Dosage is 1.25-20 mg. Can take once or twice daily. SE: hypoglycemia & wt gain Eliminated via kidney. |
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Which type of insulin is used during pregnancy?
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The following carry a B (okay) rating:
Rapid-acting (humalog or novolog) Humalog Mix 75/25 Other insulins have a C rating or are not rated. It is not recommended to use them. |
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What are likely causes of fasting HYPERglycemia?
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dawn phenomenon- hormonal changes that cause the hepatic release of stored glucose (gylcogen) into the blood stream in the early morning hours.
somogyi effect- ebound effect d/t hepatic release of glucose in response to nighttime HYPOglycemia. inadequate basal insulin **It is VERY unlikely that excessive CHO intake from the night before will cause high morning BGs. |
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Transtheoretical Model of Behavior Change--what are the stages?
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Precontemplation-not thinking about making changes within the next 6 months.
Contemplation-thinking about making changes within the next 6 months. Preparation- planning to initiate changes within 1 month (may be researching methods, etc). Action- person has started making changes Maintenance- person has made changes and maintained the changes for at least 6 months. Recycling is a term used when a person goes back to a previous stage after relapse. |
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Diabetes Empowerment Scale
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28-item questionnaire that measures self-efficacy. Assessing self-efficacy can help target areas of educational need.
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Presentation of T1DM at diagnosis
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Presentation often includes:
polyuria, polydipsia, extreme hunger, weakness, recent weight loss. If in DKA, symptoms may include: dehydration, tachycardia, orthostatic hypotension, and abdominal pain. They may also have fruity acetone breath. |
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Alcohol and DM meds
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-when taken w a sulfonyurea, alcohol can trigger hypoglycemia.
- when taken w metformin, alcohol can cause lactic acidosis. |
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Puberty and DM
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-puberty can be delayed d/t poor glycemic control
-hormonal changes during puberty make it harder to control BGs. Higher insulin doses are typically required. |
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DSME assessment in older adults should include...
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-functional limitations (hearing, vision, cognition, mobility)
-chronic illness -depression -economic hardship -social support (or lack thereof) |
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Monofilaments to assess lower extremities
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ADA recommends a thorough foot exam by a HCP at least 1x/yr. Exam evaluates for loss of protective sensation (LOPS) w a 10-gram monofilament. If the pt is not able to feel the bristle, they are at higher risk for foot injury and amputation.
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Assessment of the diabetic foot includes...
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-inspection for injury (skin breakdown, fungal infection, blisters, red marks from ill-fitting shoes, deformities, dryness/cracking and toenail issues)
-foot pulses and circulation -testing for loss of protective sensation with 10-gram monofilament -screening for peripheral artery disease (PAD) |
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What is a common testing procedure for peripheral artery disease (PAD)?
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Ankle Brachial Index (ABI) measures bp in the ankle and the arm while the pt is at rest, then bp is repeated 5 min after walking on a treadmill.
-ankle pressure is measured using a standard cuff, placed around the calf and a doppler. -pressures should be equal if normal |
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Thiazolidinedione (TZD)--points to remember
*Pioglitazone (Actos) |
-functions as an INSULIN SENSITIZER
-does NOT cause hypoglycemia when used alone -take with food for max absorption -may cause ovulation (beware to menopausal women) -weight gain is possible -swelling is likely d/t water retention. Caution w CHF. -contraindicated for pt w liver disease. -liver enzymes should be monitored q2m during 1st yr -takes 4-6 weeks for maximum effectiveness |
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Biguanide--points to remember
*Metformin (Glucophage, Glucophage XR) |
-functions as an INSULIN SENSITIZER and REDUCES HEPATIC GLUCOSE PRODUCTION
-Does NOT cause hypoglycemia when used alone -Take with food to decrease GI side effects -does NOT cause weight gain -helps to improve lipids -contraindicated in pts w renal disease (cr >1.5 mg/dL in males or cr>1.4 mg/dL in females) -contraindicated in pts w alcoholism (could cause lactic acidosis) -contraindicated in pts w MI and CHF -do not take w acarbose (reduces metformin bioavailability) |
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Dosages for Metformin
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Adults: max daily dose 2550 mg/d
Children (10-16 yo): max daily dose 2000 mg/d *may take weeks to titrate proper dose. Typically start w 500 mg bid w food and titrate up in 2 wk intervals (if needed). **2000 mg/d has been found to reduce fasting BG by reducing nocturnal hepatic production |
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Meglitinides
*Repalinide (Prandin) *Nateglinide (Starlix) |
-Both can STIMULATE INSULIN SECRETION
-can cause hypoglycemia -take 15-30 min BEFORE meal to avoid postprandial hyperglycemia. -Nateglinide (Starlix) + sulfonyurea is NOT EFFECTIVE -Nateglinide (Starlix) + metformin IS EFFECTIVE -Nateglinide (Starlix) may be used with mild renal & hepatic disease --Nateglinide (Starlix) may NOT be used with someone who has phenylalanine impairment (i.e. PKU) |
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Which oral anti-diabetic drug has recently been approved for use during pregnancy?
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Glyburide (micronase), which is a sulfonyurea.
Peak is 4 hours, duration is 12-24 hours. |
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Alpha-Glucosidase Inhibitors
*Acarbose (Precose) *Miglitol (Glyset) |
-Does NOT cause hypoglycemia when used alone
-metabolized in the GI tract to decrease glucose absorption rate, which helps to decrease POSTprandial hyperglycemia. -must take w FIRST BITE OF MEAL. -if hypoglycemia occurs, must treat w glucose or lactose to quickly raise BG. -contraindicated for pts w creatinine clearance <25 ml/min (drug accumulates) -contraindicated for pts w GI disorders |
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Gliptins (DPP-4 Inhibitors). Oral agent for T2DM.
*Sitagliptin (Januvia) *Saxagliptin (Onglyza) *Vildagliptin (Galvus) *Tradjenta |
-only used in T2DM (not in T1DM)
-Functions to prolong the action of gut hormones (GLP-1 and GIP) that are necessary to stimulate insulin production. -Also functions to decrease glucagon levels, which decreases hepatic glucose production. -Does NOT cause hypoglycemia when used alone, with metformin, or with Actos. -May cause hypoglycemia when used w sulfonyurea, so sulfonyurea dosage would need to decrease. -weight neutral -contraindicated in pts w GI disease -side effects: runny nose or congestion, upper resp infection, UTI |
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GLP-1 Agonists--injectable
*Exenatide (Byetta) *Liraglutide (Victoza) |
-Difference btw Byetta & Victoza is that Byetta is given 2x/d (1 hr prior to first and last meals) and Victoza is given 1x/d (anytime). Also, Victoze is NOT approved for use w insulin.
-Byetta may be used with sulfonyurea, metformin, TZD, Lantus. -used in pts w T2DM to help stimulate insulin production -May cause hypoglycemia and GI side effects -Fixed dose pens for injection (exp 30 days after open) -Contraindications: GI disorders, renal dysfunction. |
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Which oral anti-hyperglycemic agents can cause weight gain?
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sulfonyureas, TZDs, and meglitinides
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Which oral anti-hyperglycemic agents can cause hypoglycemia?
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sulfonyureas and meglitinides---because they stimulate insulin secretion.
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Latent Autoimmune Disease Adults (LADA)
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After several years on oral agents, some pts develop antibodies to their own insulin producing islet cells. GAD (Glutamic Acid Decarboxylase) reveals autoimmune antibodies and the need for insulin therapy.
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Insulin pump and weight gain
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Some patients may gain weight when starting the pump d/t improved cellular absorption of glucose
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dietary fiber and sugar alcohols
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If total amount of dietary fiber and or sugar alcohol is >5g, the patient is able to subtract half of the amount of fiber or sugar alcohol grams from the total carbohydrates when determining the amount to bolus.
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How often should A1C be tested?
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Depends on the person, their age, and their BG control.
*poor BG control: 4x/yr *good BG control: 2x/yr Generally, children have A1c tested at regular clinic visits, q3m (4x/yr) |
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What does fructosamine measure?
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Fructosamine measures glycosylated serum albumin over the past 2-3 weeks.
*may be ordered to decide upon safety of elective surgery bc hyperglycemia can turn into DKA or HHS during surgery. *always use fructosamine test during pregnancy & if more frequent averages are needed. *use fructosamine in patients with abnormal hemoglobin levels |
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When should patients test for ketones?
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-when BG is >300 mg/dL (T2DM)
-when BG is >250 mg/dL (T1DM) -during illness -during unusual stress -losing weight (abnormally) -pts w T1DM are more likely to develop ketones |
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What are reasons patients should test BG at 3AM (when assessing pattern management)?
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3 AM BG tests are helpful to evaluate fasting BG, nocturnal hypoglycemia, and Somogyi syndrome.
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Less insulin is typically needed during which timeframe?
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midnight-3AM
*although some people react differently, depending on their routines. |
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Pattern management--adjusting insulin doses
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An adjustment is based on 2-3 day trend/pattern
- adjust insulin 10-20% and trial for 2-3 days. -if hypoglycemic, decrease insulin by 10% and trial for 2-3 days. -another method is to add or subtract 1-2 units of insulin q2-3 days until BG is in target range. |
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Fasting and pre-meal BG tests are used to adjust ______ dose.
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basal (lantus, NPH, basal rates for pump)
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Which oral antidiabetic meds stimulate insulin secretion?
*this means they are only appropriate in T2DM and also have more potential to cause hypoglycemia |
SULFONYUREAS
*glyburide (micronase,diabeta) *glipizide (glucotrol) *glimepiride (amaryl) MEGLITINIDES *repaglinide (prandin) *nateglinide (starlix) |
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Oral agents and time needed to reach therapeutic dose
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Metformin: may take weeks. Titrate every 2 wks.
TZDs: may take 6-8 weeks. *2-hr postprandial SMBG analysis is often used for titration (especially for sulfonyurea, meglitinide, and/or alpha-glucosidase inhibitors because these drugs are prescribed specifically to lower postprandial BGs) |
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food and oral agents
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Sulfonyureas: food has minimal affect on absorption
-exception is glipizide, which is taken on empty stomach -take 30-60 min BEFORE food to impact postprandial BG Meglitinides: food has minimal affect on absorption -take 15 min before food to impact postprandial BG Metformin: take w food to avoid GI discomfort TZDs: food has major effect on absorption. Take w largest meal of the day. Alpha-glucosidase inhibitors: take w 1st bite of food |
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If BG is low around noon, which insulin is likely affecting this value? What are recommendations to prevent low BG around noon?
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-AM rapid acting (or regular) insulin.
Solutions: -decrease AM insulin (basal, correction, or I:C ratio) -increase calories at breakfast -add mid-morning snack -change exercise time if done before lunch |
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If BG is low before bed, which insulin is likely affecting this value? What are recommendations to prevent low BG before bed?
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-rapid acting (or regular) insulin before dinner
Solutions: -decrease insulin (basal, correction, or I:C ratio) before dinner -increase carbs at dinner -increase carbs at evening snack -exercise earlier in the day |
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Hypoglycemia
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BG = 70 mg/dL or lower
*severe hypoglycemia does not have a defined BG level. If a pt is not able to self-treat d/t mental confusion or unconsciousness, the event is severe. |
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CNS reactions to hypoglycemia
CNS reaction to low BG = neuroglycopenia |
slurred speech
slow thinking un-coordination mental confusion |
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Autonomic reactions to hypoglycemia
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Autonomic symptoms of hormonal counterregulation d/t hypoglycemia include:
trembling sweating racing pulse heavy breathing |
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Defective autonomic hypoglycemia counterregulation
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For many pts w T1DM, after ~5 yrs, glucagon secretion is diminished to an inactive level that cannot stimulate release of glucose from the liver. EPINEPHRINE secretion will then take over to increase gluconeogenesis. If epinephrine's response is inadequate, growth hormone and cortisol secretion assist to raise BG.
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Pregnancy and hypoglycemia
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-fetal demand for glucose is high during 1st trimester
-frequent vomiting can cause hypoglycemia -postpartum is a time of increased insulin sensitivity (so is breastfeeding). More frequent testing is required to avoid hypoglycemia. Basal insulin may also need to be decreased. |
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How does kidney disease potentially impact pharmacokinetics?
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DURATION of exogenous insulin and oral agents that stimulate insulin production IS INCREASED, so the risk of hypoglycemia is also increased.
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Glucagon emergency kit
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Glucagon kit may only be used in a person with stored glycogen. So, if pt has depleted their glycogen reserves, the glucagon injection will not work.
If kit is used, SMBG should be done frequently. Effect of increased BG may last 9-27 min. Give carb food and drink ASAP. Basal insulin may also need to be decreased for 24 hrs following glucagon injection. |
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Sick Day Treatment
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-stress hormones are released which raise BG
- high BG + dehydration + ketones = risk for DKA -increase sugar-free fluid intake -maintain electrolyte balance (broth, G2, etc) -test BG + ketones q2-3h and report to MD -eat ~200g carb/d, liquid or soft food -supplemental insulin may be needed |
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What should be included in the "sick day box"?
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insulin, syringes, lancets, ketone strips, meter strips, oral agents, bottles of water, electrolyte drinks, soup, bouillon cubes, saltines, instant oatmeal, jello, juice boxes, MD phone number. Check expiration dates of items in box to ensure safety.
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Blood glucose goals for children <6 yrs
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Before meals: 100-180 mg/dL
Bedtime/overnight: 110-200 mg/dL A1c: 7.6-8.5% |
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Blood glucose goals for children 6-12 yrs
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Before meals: 90-180 mg/dL
Bedtime/overnight: 100-180 mg/dL A1c: <8% |
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Blood glucose goals for teens (13-19 yrs)
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Before meals: 90-130 mg/dL
Bedtime/overnight: 90-150 mg/dL A1c: <7.5% |
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Blood glucose goals for adults
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Before meals: 70-130 mg/dL
Bedtime/overnight: 70-150 mg/dL A1c: <7% |
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Survival Skills: Education focus for the 1st week of diagnosis
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-testing BG
-testing ketones (urine or blood) -measuring and administering insulin -insulin actions -meal planning -prevention, recognition, and treatment of HYPOglycemia |
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This sulfonyurea should be taken on an empty stomach
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glipizide
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Model that uses a percentage score
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PIPE. It is a tool to monitor program effectiveness.
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Aspirin + glipizide (sulfonyurea) _______blood pressure
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lowers
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Pt is taking a sulfonyurea + alpha glucosidase inhibitor. For hypoglycemia, which would be the most preferred source of sugar? 4 oz juice, 4 oz soda, 2 tbsp raisins, 8 oz skim milk
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skim milk because the lactose is preferred source when taking alpha glucosidase inhibitors. Typical fast acting carbs do not act as quickly when taking these meds, but lactose is not as affected.
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Major limiting factor for controlling BG is...
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fear of hypoglycemia
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According to the ADA, normal A1c values for people who DO NOT have diabetes is...
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4-5.6%
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Which study emphasized the result that for every % decrease in A1c, there was a 35% reduction risk of MICROvascular complications?
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DCCT
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How does Phenytoin (anti-seizure med) affect BG?
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increases BG
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People w T1D should always test for ketones when BG is > ______ mg/dL
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250
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What does ketonuria in the presence of NORMAL blood sugar (i.e. euglycemia) indicate?
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weight loss
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When should annual urine screening for protein be initiated in pts with T1D?
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When they have had T1D for 5 years
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Describe RE-AIM
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It is a program tool to monitor effectiveness by determining if the program can be MAINTAINED
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Which type of oral anti-hyperglycemic should be discontinued in pt's with kidney disease?
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Biguanide (glucophage/metformin)
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Meglitinides should NOT be prescribed with which class of oral anti-hyperglycemic agents?
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Sulfonyureas (because they both cause increased insulin production).
Ex: repaglinide (prandin), nateglinide (starlix). Meglitinides are taken before meals, they have a shorter half-life, but act faster than sulfonyureas. |
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A common problem for people w T2DM who still produce insulin, but have difficulty controlling postprandial BGs may be related to...
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delayed first-phase insulin response
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Which hormone activates lipoprotein lipase in order for triglycerides to be deposited into adipose tissue?
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insulin
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What is important about the UKPDS study?
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-followed people with newly diagnosed T2DM for 10 yrs
-results showed that intensive glycemic control (7% A1c) significantly reduced MICROvascular complications. -data also suggests that intensive control can reduce incidence of MI and stroke in people w T2DM |
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What is important about the ACCORD study?
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-compared effects of intensive glycemic control on CV outcomes in people w T2DM.
-one arm of the study was terminated early d/t findings that intensive glycemic control (A1c <6%) was assoc w increased mortality. -the other arms of the study (lipids, BP) continue |
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When BG is high after meals, possible causes include...
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-too much carb at meal
-not enough pre-meal insulin -inadequate oral agent dose |
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Gestational Diabetes--diagnostic criteria using 75g OGTT
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- fasting BG 92 or greater
- 1 hour BG 180 or greater - 2 hour BG 153 or greater **only one of the above values is necessary for diagnosis ** test is done at 24-28 wks gestation |
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RDA for protein (non-pregnant vs pregnant)
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non-pregnant protein requirement: 0.8 g/kg/d
pregnant protein requirement: 1.1 g/kg/d (or 25 extra grams of protein for a singleton and 50 extra grams of protein for twins) |
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When is it NOT appropriate to test for microalbuminuria?
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When the patient is ill or has a fever, it is not appropriate to test for microalbuminuria
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Albustix is NOT an appropriate method to test for microalbuminuria because it does not start to read positive until the albumin excretion rate exceeds ___.
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at least 300 mg/24 hours (which is considered to be macroalbuminuria)
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Wound healing is impaired when BG is higher than ____ mg/dL.
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200
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In severe illness including hypotension, which oral medication is usually stopped to avoid lactic acidosis?
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Metformin
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For most people with T1DM, after about five years of diabetes, ________ hormone secretion is deficient and ________ hormone is the counterregulatory hormone to raise BG level.
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glucagon, epinephrine
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When switching a patient from regular short-acting insulin to rapid insulin for the pre-meal bolus, we usually need to ___________ the basal dose.
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increase
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Treating hypogycemia with 15 grams of carbohydrate typically raises BG ________ mg/dL
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30-45
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The counterregulator hormone, epinephrine, can help to raise BG in two ways....what are they?
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1. gylcogenolysis
2. inhibit glucose utilization by insulin |
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Why are patients encouraged to consume food within an hour following hypoglycemia event?
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Because BG level may fall again if food is not eaten
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Recovery of mental and motor function (related to neuroglycopenia) after a low BG episode takes a _____ time period than BG recovery.
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longer
So, after a hypoglycemic episode, BG may return to normal, but the pt could still suffer from slow thinking and dizziness. |
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What is CQI?
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Use timely evaluations to improve program quality
-Plan -Do -Check -Act |
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What is the Re-Aim evaluation tool?
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-Reach (population/potential)
-Effectiveness (outcomes) -Adoption (reach potential) - Implementation (time & cost r/t results) - Maintenance (sustainability) |
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What is the PIPE evaluation program?
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It is very straight-forward.
-Penetration -Implementation -Participation -Effectiveness PxIxPxE = impact score (ability of the program to improve the health of the community) |
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Describe the empowerment model
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1. Define the problem (biggest concern)
2. Identify feelings 3. Identify long-term goals 4. Identify short-term behavior plan change 5. Implement and evaluate plan |
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Target BP for people with diabetes
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130/80
If they have HTN, the first line of treatment is ACE inhibitors (-pril), then ARBs (-sartan) ***ACE inhibitors are absolutely contraindicated in pregnancy--> may lead to fetal death. |
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In the ED, the first line of defense for the pt w DKA is to treat _____ then ______.
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1- dehydration and electrolytes
2- hyperglycemia Fluid deficits are typically 100 mL per kg of body weight. Fluid replacement alone will lower blood glucose. Tracer studies have found that during the first four hours of therapy for DKA, up to 80 percent of the decline in glucose concentration may be caused by rehydration. |
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In DKA and HHS, the pt can present w decreased mentation (lethargy, confusion). Which lab value is likely responsible for this symptom?
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serum osmolality (usually >320 mOsm/kg)
(2 x sodium (mEq/L) + plasma glucose (mg/dL)) /18 |
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What about potassium---with regard to DKA?
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Acidosis increases potassium levels and glucose administered with insulin lowers them. Potassium should be started as soon as adequate urine output is confirmed and the potassium level is less than 5 mEq per L.
Usually 20 to 30 mEq of potassium is given for each liter of fluid replacement. If the potassium level is less than 3.3 mEq per L, potassium replacement should be given immediately and insulin should be started only after the potassium level is above 3.3 mEq per L. |
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Avoiding ________________ and limiting the rate at which the ____________ level drops may reduce the chance of cerebral edema.
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overhydration
blood glucose *cerebral edema is more common in children and the mortality rate is very high (~70%). |
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Lab values to determine that DKA has resolved
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BG <200 mg/dL
bicarbonate at least 18 mEq/L pH at least 7.3 |
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Teaching methods for low literacy
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-limit concepts to 2-3 per session
-ask questions often -use repetition and ask pt to repeat in their own words -do not rush!! -underline for emphasis (don't use all caps) -use simple words -use at least 12 font -teach diabetes terminology (what the words really mean) |
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AADE suggests 3 standardized tools to track, evaluate, and document OUTCOMES of a diabetes program. What are they?
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-CQI (continuous quality improvement)
-RE-AIM (reach, effectiveness, adoption, implementation, maintenance) -PIPE (penetration, implementation, participation, effectiveness) |
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What is iodine contrast contraindicated for patients using metformin (Glucophage)?
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It can cause lactic acidosis---especially in pts w impaired renal status.
Intravascular contrast studies with iodinated materials can lead to acute alteration of renal function and have been associated with lactic acidosis in patients receiving Glucophage. Therefore, in patients in whom any such study is planned, Glucophage should be discontinued at the time of or prior to the procedure and withheld for 48 hours subsequent to the procedure and reinstituted only after renal function has been re-evaluated and found to be normal. |
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Describe how HYPERthyroidism affects blood glucose in people with diabetes.
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When your metabolism quickens, your medicines go through your body quicker. Your blood glucose level may rise because your usual dosage does not stay in your body long enough to control it.
Hyperthyroidism and low blood glucose can be hard to tell apart. If you are sweating and having tremors from hyperthyroidism, you may think you have low blood glucose and eat extra food, causing your blood glucose to rise. Using your glucose meter to verify low blood glucose levels can help you avoid this problem. |
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Describe how HYPOthyroidism affects blood glucose in people with diabetes.
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When your metabolism slows, your blood glucose level may drop because your diabetes medicine doesn’t pass through your body as quickly as usual and so stays active longer. In hypothyroidism, it is often necessary to reduce your dose of diabetes medicines to prevent low blood glucose.
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What were the findings of the Diabetes Prevention Program (DPP)?
--study done in people with "prediabetes" looking at effects of diet & exercise vs metformin. |
The DPP's results indicate that millions of high-risk people can delay or avoid developing type 2 diabetes by losing weight through regular physical activity and a diet low in fat and calories.
Weight loss and physical activity lower the risk of diabetes by improving the body's ability to use insulin and process glucose. The DPP also suggests that metformin can help delay the onset of diabetes, but lifestyle improvements actually proved to be more effective. |
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Goals for treatment in elderly patients with diabetes
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- Maintain quality of life by minimizing impacts of this disease
- Preserve functional capacity by preventing complications - Minimize risk of hypoglycemia - Meet realistic weight goals - Avoid glucose readings > 200mg/dl - For frail elderly, aim for fasting or bedtime glucose > 100mg/dl - Safety precautions are imperative to prevent falls |
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Drugs that may exacerbate HYPERglycemia
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-Glucocorticoids
- Thiazide diuretics - Phenytoin - Lithium and Phenothiazines - Estrogens - Growth Hormone - Isoniazid and Sympathomimetic agents - Sugar-containing medications |
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Altered perception of HYPOglycemia in elderly
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-Adrenergic symptoms: sweating, nervousness, tremor
- Neuroglycopenic symptoms: confusion - Elderly lose the adrenergic symptoms (loss of autonomic nerve function) and have more profound neuroglycopenic symptoms than the young: reversible hemiparesis (weakness on one side of body). |
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How many carbs in 1 tbsp honey?
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about 17 g
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Why is it important to be aware of the effect of alcohol in people with diabetes?
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- hypoglycemia can be mistaken for drunkness... AND
- If you're on insulin, or certain oral diabetes medications, such as a sulfonylurea (glipizide, glyburide) or meglitinide (Prandin) that stimulate the pancreas to produce more insulin, drinking alcohol can cause a dangerous low blood sugar because your liver has to work to remove the alcohol from your blood instead of its main job to regulate your blood sugar. Alcohol metabolism shuts of gluconeogenesis, so the liver isn't making glucose to keep BGs within normal limits. |
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Which pregnancy hormone is responsible for causing insulin resistance in patients with GDM?
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Human Placental Lactogen (HPL)
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What is autonomic neuropathy?
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Autonomic neuropathy is a nerve disorder that affects involuntary body functions, including heart rate, blood pressure, perspiration and digestion.
Examples: erectile dysfunction, overactive bladder or incontinence, gastroparesis, constipation, vaginal dryness, abnormal HR and BP (usually hypotension), excessive sweating |
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How many hours for DSMT does Medicare cover?
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The number of hours of DSMT coverage depends on whether it is the initial year of DSMT coverage or follow-up training.
Patients are eligible for 10 hours of DSMT during the initial year for DSMT which is the 12 month period following the initial date. If more than 10 hours of DSMT is provided in the initial year, the claim will be denied. |
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When are patients with diabetes advised NOT to exercise?
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- if BG is >300 mg/dL
- if they have ketones (even if BG is <300 mg/dL) |
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Which counterregulatory hormones stimulate a rise in BG?
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epinephrine, norepinephrine, glucagon, growth hormone, cortisol.
Ex: growth hormone and cortisol increase insulin resistance in early morning, causing many people with T1DM to experience the "dawn phenomenon". |
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NCEP definition of metabolic syndrome
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Must have 3 or more of the following:
-waist circumference >40" in men and >35" in women -triglycerides >/= 150 -SBP 130 or greater; DBP 80 or greater -HDL <40 in men and <50 in women -Fasting BG 110 or greater |
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What are evaluation tools for measuring healthy coping?
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-Depression scores (Beck Depression Scale)
-QOL measures -Self-efficacy measures (Diabetes Empowerment Scale) -Self-report of constucts (i.e. self-efficacy, feeling of empowerment, and stress management) -also, simply asking pt how they would handle sample situations |
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Describe the approach to treating diabetic foot ulcers
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-wound debridement (chemically or mechanically removing necrotic, callused, and any other physiologically impaired tissue).
-"offloading" the injured foot - meticulous documentation is necessary to track the progression of wound healing. |
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Describe adaptive equipment for visually impaired people with diabetes
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-syringe magnifiers
-preset dose gauges -devices to measure w audible clicks (i.e. insulin pens) -insulin pump w auditory cues -talking meters -blood drop guides for meters |
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Which DM-related meds are contraindicated during pregnancy?
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-statins
-ACE inhibitors -most oral antidiabetic agents |
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In persons with diabetes, the symptoms of serious
psychological depression may resemble A. the “dawn phenomenon”. B. the onset of nephropathy. C. symptoms of chronic hypoglycemic episodes. D. symptoms of chronic high blood glucose levels. |
D
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According to the most recent ADA Guidelines, a diagnosis of diabetes mellitus may be confirmed by the findings of
A. weight loss. B. polydipsia and polyuria. C. two random plasma glucose levels of 145 mg/dL. D. two fasting plasma glucose levels of 135 mg/dL. |
D
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3. According to the most recent American Diabetes
Association Nutrition Guidelines, the recommended fat content for a diabetes meal plan is A. individualized. B. 10% of calorie intake. C. 30% of calorie intake. D. dependent on patient’s age. |
A
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According to DCCT participants striving for good control, some adverse effects of intensive treatment were
A. multiple injections causing lipohypertrophy. B. marked hormonal changes requiring more insulin. C. weight gain and risk of severe hypoglycemia. D. insulin resistance caused by hyperinsulinemia. |
C
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Metformin is an oral antidiabetic agent different than that of sulfonylurea drugs. Some features of the drug are that it
A. stimulates insulin secretion and increases hepatic glucose production. B. causes hypoglycemia. C. reduces hyperglycemia in persons with diabetes, but does not lower blood glucose levels in persons who do not have diabetes. D. results in weight gain and increase in plasma insulin levels. |
C
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6. Which of the following is a major clinical feature of
hyperosmolar hyperglycemic nonketotic syndrome? A. large ketones B. profound dehydration C. nausea and vomiting D. severe acidosis |
B
All other options are clinical features of DKA (but there is also dehydration in DKA). No ketones in HHS. |
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A 25 year-old female is on a basal/bolus regimen using
Lantus® (insulin glargine) at bedtime and Humalog® (insulin lispro) before meals. For the past 5 days, her morning fasting blood glucose tests have been consistently high, but all other blood glucose tests during the day have remained in her suggested target range. Which of the following changes in insulin regime would MOST likely be recommended? A. increase the evening meal Humalog® (insulin lispro) dose B. increase the bedtime Lantus® (insulin glargine) dose C. decrease the evening meal Humalog® (insulin lispro) dose D. decrease the bedtime Lantus® (insulin glargine) dose |
B
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One of the most important keys to successful management of type 2 diabetes is teaching the person
A. meal planning. B. regular urine testing. C. signs and treatment of hypoglycemia. D. selection and use of over-the-counter medications. |
A
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A 48-year-old man with type 2 diabetes wants to begin an exercise program. He has had diabetes for 8 years, takes no medication, monitors blood glucose twice a day, has no complications from diabetes, is 130% of ideal body weight, and follows a 1500 calorie diet. What adjustments to food intake, if any, should be suggested to him?
A. He should carry a fast-acting carbohydrate with him. B. He should increase his diet by 300 calories to prevent hunger during exercise. C. He should increase his carbohydrate intake before exercising. D. There should be no change in diet. |
D
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A 14 year-old female is currently on insulin pump therapy. It is noted that her hemoglobin A1C is 14%. She insists that she boluses for her insulin based on suggested insulin/carbohydrate ratios and insulin sensitivity factors. What is the MOST likely reason for her high A1C?
A. The insulin/carbohydrate ratios for meals need to be increased. B. The insulin sensitivity factor needs to be decreased. C. Her infusion sets need to be changed more frequently. D. She forgets to bolus for meals and snacks. |
D
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