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46 Cards in this Set

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Diabetes Mellitus
a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action or both
OSMOTIC DIURESIS: too much glucose in the body; the kidneys can't filter glucose fast enough so it leaves the body, along w/it k,Na,Ch,and H2O. cells breakdown fat and protein for energy.
Four cardinal signs:
`polyuria
`polydipsia
`polyphasia
`weight loss
Pathophysiology
`beta cells secrete insulin
`alpha cells secrete glucagon

when a person eats- insulin secretion increases & moves glucose(energy) from the blood to the muscles, and fat cells.
In the muscle & fat cells, insulin:
`transports & metabolizes glucose for energy

`stimulates storage of glucose in the liver & muscle(in the form of glycogen)

`signals the liver to stop the release of glucose

`enchances storage of dietary fat in a adipose tissue

`accelerates transport of amino acids(derived from dietary protein) into cells
glucose
primary ENERGY source in most cells
glucagon
hormone secreted by the beta cells of the pancreas that increase the BGL by stimulating the liver to change glycogen to glucose
glycogenolysis
conversion of glycogen to glucose in the liver and muscles
Does the brain store glucose?
No
glycogen
storage for glucose; excess carbohydrate is stored in the liver and muscles
Type 1
characterized by an absence in insulin production and secretion from autoimmune destrution of the beta cells of the isles of Langerhans in the pancreas, formerly called insulin dependent,juvenile
Type 1
causes
`genetics

`immunulogic or
environmental factors(virus)

`often have islet cell
antibodies

`often have antibodies to
insulin even before insulin
treatment

`little or no endogenous
insulin

`ketosis-prone when insulin
absent

`acute complications of
hyperglycemia: diabetic
ketoacidosis
Type 1
characteristics(s/s)
`polyuria
`polydipsia
`polyphasia
`weight loss
`fatigue
`increase frequency in infections
`rapid onset
`insulin dependent
`early onset usually (< 30 yr)
`highest incidence in african
american
`need insulin to preserve life
Type 2
characterized by the relative deficiency of insulin production and a decreased insulin action and increased insulin resistance. formerly called non-insulin dependent, adult onset.
Type 2
characteristics(s/s)
`polyuria
`polydipsia
`obesity
`sedentary lifestyle
`fatigue
`familial tendency
`onset any age(usually>30)
`history of high B/P
`low energy
`recurrent infection
`hispanics, native americans
`usually found accidentally
Type 2
causes
`no islet antibodies

`decrease in endogeous insulin
or increased w/insulin
resistance

`most pts. can control blood
glucose thru weight loss if
obese

`ketosis rare, except in
stress or infection

`acute complication:
hypergycemic hyperosmolar
nonketotic syndrome
Diagnostic Findings
Basic criterion:
High blood glucose
~symptoms & casual plasma
glucose concentration>
200mg/dL(>1test)
(`casual is defined as
anytime of day w/o
regard to time since last meal)

~Fasting plasma glucose- FPD-
>126mg/dL (>1test)
( -fast is defined as no
caloric intake for at
least 8 hours)

~2hour postload glucose
>200mg/dL (1test) during
an oral glucose tolerance
test,
Blood Test
~Glycoslylated hemoglobin:
(HgbAic or AIC)

`blood test reflects average
BGL over a period of
approx. 2-3 months(amt.of
glucose stored in
hemoglobin) RBC's
live for 120 days

`normal results is 4-7%

`anything >8%; glucose not
being controlled

`7%=BGL 150mg/dL

***If a pt. reports mostly
normal SMBG results but the
HgbAic is high, there may
be errors in the methods
used for glucose monitoring.
SMBG's
(self monitoring blood glucose)
`For most pts. requiring
insulin,smbg is recommended
2-4 times daily(usually
before meals and @ bedtime)

`For pts who take insulin
before each meal,SMBG's
required three times daily
to determine each dose

`Pts not recieving insulin,
recommended to assess two to
three times a week,
including a 2-hour post
prandial test.

`for all pts, it is
recommended to test when
hypo or hyper glcemia is
suspected

`pt should increase his
frequency of smbg w/changes
in meds, activity, or
diet,and w/stress or illness
Five components in management
1 nutrition
2 exercise
3 monitoring
4 pharmacologic
5 education
Nutrition
Caloric Distribution
Recommended:
Carbs-50-60%
Fats-20-30%
Protein-10-20%
Carbohydrates
*Carbohydrates-have the
greatest effect on BGL

`digest quickly
`convert to glucose quickly
`once digested, 100% carbs
are converted to glucose
Fats
`recommendations-limit total
intake of dietary
cholesteral to < 300mg/day
protein
`may include some nonanimal
sources of protein to help
reduce saturated fat and
cholesteral intake

`the amount of protein intake
may be reduced in pts.
w/early signs of renal
failure
Fiber
`high carb/high fiber helps
lower total cholesteral &
low density lipoprotein
cholesteral in blood

`High fiber may also improve
BGL and lower the need for
exogenous insulin
Alcohol
`need to be aware of the potential adverse effects of alcohol specific to diabetes

*main danger- Hypoglycemia-
esp. for pts. who take
insulin

`to reduce risk, eat while consuming alcohol
Exchange list
`there are 6 main exchange list:
1 bread/starch
2 vegetable
3 milk
4 meat
5 fruit
6 fat
More info can be found thru the ADA (american dietary association)Some manufactures & resturants publish exchange lists
Food guide pyramid
`commomly used for pts w/type 2 who have a difficult time compling w/a calorie-controlled diet (fats toward top)
Carb counting
`fist=1c=2svg pasta or oatmeal

`thumb=1oz=piece cheese

`handful=1oz=handful nuts or
2oz=2 handful pretzels

`palm=3oz=cooked svg meat
Carb counting
`1 carb= 15 grams

`1 svg starch= 15gr carb

`1 svg fruit= 15gr carb

`1 svg milk= 15gr carb

`3 svg veg= 15gr carb
Sick Day Rules
(stress days)
**BGL rises; cells inbody
can't fight sickness; needs
insulin or pt. goes into
HYPERglycemia

`insulin or oral meds as usual

`freq. blood sugar monitoring

`freq. smsll mesls

`liquids q1.5-2h

`report N/V/D
Exercice
(benefits)
`lowers BGL by increasing the
uptake of glucose by muscle
& by improving insulin
utilition

`decreases cario risk factors

`improves circulattion &
muscle tone

`strength training can
increase lean muscle mass,
which increases resting
metabolic rate

***
`alters blood lipid levels

`increases levels of high
density lipoproteins

`decreases total cholesteral

`decreases triglyceride levels
Exercise
(precautions)
`If BGL > 250mg/dL & have
ketones in urine; should
not begin exercising until
their urine test - for
ketones & BGL test is
closer to normal

``15gr carb snack w/protein
(increases uptake of
glucose by muscle cells;
lowers BGL; decreasing
the amt. of insulin
needed;reduce cardio risk
factors)

``exercise @ same time each
day

``proper footwear
15 Grams
1/2 c fruit juice
1 c milk
1 tsp sugar
1/2 c reg soda
5 lifesavers
3-4 glucose tablets
Monitoring Glucose levels
`SMBC

`freq: ac & hs

`wash hands(warmth; bleeds
better)

`lower hand( bleeds better)

`puncture side finger pads
Urine testing
(most common method used for self-testing of ketone bodies)
`testing for ketones

`ketones in urine signal that
control in type 1 is
deteriorating; risk of DKA
is high

`strip turns PURPLE when
ketones present

`
Ketone testing should be performed:
`whenever type 1 pt has
Glucosuria or persistently
elevated glucose levels
in the blood( > 240mm/dL
for two testing periods in
a row)
Pharmacologic Therapy

*one unit of insulin will
affect BS by 30 points
TYPE 1: body losses the ability to produce insulin; exogenous insulin must be administered for life

TYPE 2: insulin may be neccessary on a long term basis to control glucose levels if diet and oral agents fail.

Type 2 may require temporary insulin during illness, infection, pregnancy, surgery,...
Categories insulin

Rapid action
Rapid acting::
( humalog & Novalog)
blood glucose lowering agents-short duration

onset 5-15 min

peak action 1h

*because of their rapid onset,should eat no more than 5-15 min after injection

~used for rapid reduction of
glucose; to prevent
nocturnal HYPOglycemia
Short acting

for emergency situations eg.DKA
(Humalog R & Novolin R)

onset 30m-1h

peak 2-3h

*clear solution; should be admin. 20-30m before a meal

~can be taken w/long acting
insulin
intermediate

often cloudy
NPH (Humulin N, Novilin L,& Novilin N)

onset 3-4h

peak 4-12h

*white &cloudy; not so important to eat 30m before admin.; it is IMPORTANT; however, to eat around time of onset and peak

Dawn Phenomenon, Somogyi,
Insulin waning seen if intermediate or longacting given before dinner; can be moved to bedtime
Long acting
Ultralente(UT)
(often called peakless)


onset6-8h

peak 12-16h

~used primarily to control
fasting glucose level
Very long lasting
"Peakless basal insulins"
Lantus- approved as basal insulin

insulin is absorbed very slowly over 24h and can be given once daily @ hs(not to be mixed w/other insulins.
Storing insulin
vials Not in use should be refrigerated

extreme temps should be avoided

insulin in use room temp(4weeks)

clear then cloudy'

extra dose in fridge
oral antidiabetic agent
may be effective for TYPE2 that can't be tx by diet & exercise alone;

they can't be used during pregnancy

include:

sulfonylureas
biguanides
alpha glucosidase inhibitors
thiazolidinnediones
meglitinides
HYPOglycemia
BGL<50-60mg/dL

too much insulin
oral hypoglycemic agents
too little food
excessive excerise

mid morning may occur when the morming reg.insulin is peaking

late afternoon coincides w/the peak of the morming NOH or Lente insulin.

Middle of the nite may occur because of peaking evening or predinnerNPH or Lente insulins,esp.in pts. who didn't eat bedtime snack.
s/s
(SNS)
sweating
tremors
tachycardia
palpitations
nervousness
hunger
(CNS)
lack of concentration
headache
lightheadedness
confusion
memory lapse
numbness of lips & tongue
slurred speech
impaired coordination