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92 Cards in this Set
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Examples of metabolic syndrome, aka Insulin Resistance Syndrome, Syndrome X
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Abdominal Obesity, Hypertension, Dyslipidemia (high triglycerides, low HDL, high LDL); Glucose Intolerance (hyperinsulinemia); Insulin Resistance, Proinflammatory Cytokines (elevated C-reactive protein); Prothrombotic Factors
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Definition of Metabolic Syndrome--can be ANY 3 of the following:
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*Abdominal obesity (waist circumfrence)--MEN>40 inches; WOMEN>35 inches; *Triglycerides > or equal to150 mg/dl;
*HDL cholesterol-MEN<40mg/dl; WOMEN<50 mg/dl *Blood Pressure > or equal to 130/85 mmHg *Fasting glucose > or equal to 100mg/dl (used to be 110) |
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Prevalence of Metabolic Syndrome
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National survey data (NHSNESIII) estimate ~23% of adults >20 years old have metabolic syndrome
-overweight/obese adults 20 yrs and older: overweight: 34% obese: 34% obesity in children: 12-19 yrs: 18% 6-11 yrs: 20% 2-5 yrs: 10% |
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Health consequences of Metabolic Syndrome
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-is associated c 4-fold increase risk for type 2 diabetes.
-associated with 2-fold increase risk for CVD -Stroke |
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ppl with Metabolic Syndrome are also susceptible to...
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fatty liver dz-liver cirrhosis
other liver dz cholesterol gallstones asthma sleep apnea osteoarthiritis pulmonary dz renal dz ocular complications polycystic ovary syndrome colon, endometrial, and breast cancer |
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Medical complications of obesity
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pulm dz
nonalcoholic fatty liver dz gall bladder dz gynecologic abnormalities gout idiopathic intracranial htn stroke coronary heart dz severe pancreatitis cancer phlebitis |
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medical management of metabolic syndrome
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Lifestyle: wt mgmt, increased physical activity, stop smoking
Pharmacology: lipid-lowering drugs, ACE inh, daily aspirin, insulin sensitizers (metformin and/or thiazolidinediones) *ugh* |
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quote from governor Owens from Colorado
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EAT LESS, MOVE MORE, LIVE LONGER
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Diabetes
Management Goals |
1. Return and maintain blood glucose level to normal or near normal.
2. Prevent complications |
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Type I diabetes
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-Body's own T-cells attack and destroy pancreatic beta cells (autoimmune process)
-Genetic predisposition -Exposure to virus -Nonimmune factors of unknown etiologies -Onset of symptom: ketoacidosis, sudden wt loss, polydipsia, polyuria, polyphagia -Honeymoon period may last 3-12 months (whatever that means?) |
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Type 2 Diabetes
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-Metabolic problem
-insulin resistance -early stages: hyperglycemia and hyperinsulinemia -inappropriate glucose production and release by the liver that does not match body's need -adipokines from adipose tissue altar glucose and fat metabolism -onset is gradual (9-12 yrs) -few, if any symptoms -high risk groups: African americans, hispanic americans, asian americans, pacific islanders, american indeans, ppl c metabolic syndrome, ppl age 60 and older, women c hx of gestational diabetes, ppl c a 1st degree relative c type 2 diabetes -kids c Type 2 diabetes r/t inactivity and obesity |
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Most common type of diabetes
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Type 2 (90%+)
16 million in the US have type2 main cause of kidney failure, limb amputations, new onset of blindness in adults and a major cause of heartdz and stroke. -prevalence has tripled in the last 30 yrs, mainly r/t the increase in obesity -Approx 10 million americans are @high risk for type 2 diabetes -to delay the onset of type 2 d: *diet *exercise *wt loss (5-7% of body wt) *metformin (glucophage) |
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Long-term complications of diabetes
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vascular changes (CAD, CVD, PVD)
-retinopathy leading2 blindness -nephropathy leading to kidney failure (using ACE inh can reduce risk) -neuropathy (affects 60-70% of diabetes population) |
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Neuropathy-2 types
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peripheral neuropathy: decreased sensation, diminished or absent deep reflexes, decrease in muscle strength or size
Autonomic neuropathy: N,V, delayed emptying of gastric contents, diarrhea or constipation, urinary retention or incontinence, decreased sweating, ortho hypotnsn, erectile dysfunction, heart rate may be high at rest, but remain fixed c activity |
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NRSG dx's
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impaired sensory perception
impaired mobility impaired circulation risk for infection poor nutrition activity intolerance fatigue pain risk for injury self-care deficit sexual dysfunction impaired skin integrity urinary non compliance |
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the 14 commandments of foot care
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examine feet daily
wash feet daily do not use hot water pat feet thoroughly dry, esp btwn toes apply bland powder if feet perspire apply bland lotion to dry feet cut toenails regularly do not use corn pads or corn plasters do not cut corns/calluses (I think I just threw up in my mouth) !!! Do not wear sox or nylons that restrict blood flow do not use hot water bottles, heatin pads, other heating devices, or ice packs on the feet do not walk barefoot wear appropriate shoes inspect shoes before wearing |
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prevention of diabetic ulcers and infxn
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daily self-exam and foot care could reduce amputations by 85%
Wounds do not heal easily c blood glucose levels above 150 mg/dl |
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diabetes chart
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angiopathy and/or neuropathy
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if angiopathy...
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vascular/arteriole dz leading to thrombosis, small areas of gangrene, minor amputation then major amputation.
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if neuropathy...
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autosomic/sensory/motor...loss of sensation/muscle atrophy, change in gait, new pressure points, ulceration, infection, gangrene, amputation
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Charcot's Foot
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caused by neuropathy
muscles lose ablity to support the foot sudden softening of bones in the foot minor trauma to the foot goes undetected c no tx's bones fx and joints dislocate eventually the foot changes shape the arch collapses rocker/bottom appearance |
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Sx's of Charcot's foot
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affected part of the foot warmer than the other foot
swelling, redness, pain or no pain, circulation is okay, can mimic cellulitis or DVT, in most cases only one foot is affected, but both feet and be effected over time. Calluses and diabetic foot ulcers may occur as a result of bony protrusions causing pressure |
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tx of Charcot's foot
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stabilization of affected area
total contact cast non-weightbearing tx can take 6-9 mos after healling, specialized footwear and foot orthoses may be needed surgery can be used to reshape the deformity |
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Other foot problems
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*muscle atrophy
*tendons and ligaments tighten *new prerssure points |
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Sensory Foots Examination
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-the pt should not be able to see where the monofilament is applied.
-apply the monofilament perpendicular to the skin surface -apply sufficient force to cause the filament to bend then lift from skin (about 1.5 seconds) -repeat twice@the same sight but include a 3rd time when the skin is not touched -do not apply the monofilament on ulcer sitte, callus, scar, or necrotic tissue. |
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Dental care and Diabetes
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Increased risk for:
-gum dz (gingivitus) -cavities -tooth loss -dry mouth (xerostomia) -variety of oral infections |
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Dental care and Diabetes
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-Poor oral health can make diabetes more difficult to control
-infections may cause blood glucose to rise -diabetes can diminish ability to taste sweets, which may cause pt to choose more sweets or sweeter foods -may make glucose control more difficult |
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PREVENTION
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visit dentist at least q6 months
infrom dentist about diabetes brush teeth 2x a day floss daily look for early signs of gum dz -bleeding gums, redness, swelling, loose teeth |
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Exercise and Diabetes
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Reduces risk of CAD, decreases plasma cholesterol, triglycerides and LDLs, Increases HDL's
Reduces body fat helpls c wt loss improves insulin sensetivity reduces hyperinsulinemia improves qual. of life and self-esteem can reduce stress |
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Recommendations for Exercise
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Type I
-all levels of activity can be performed by those without complications and are in good glucose control *TYPE 2 diabetics -30-60 mins, up to 5x per week *for wt loss -at least 60 mins/day |
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Exercise and Type I
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-regular exercise has not been shown to consistently improve blood glucose control
-exercise-enduced hypoglycemia is common d/t accelerated absorption of insulin and increased insulin sensetivity--commonly 6-12 hours after exercise |
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TYPE 2 and exercise
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-reduces A1c levels
-decreases or eliminate the need for insulin or oral agents for some pts -improves insulin sensitivity -helps with wt loss |
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Preventing hypoglycemia r/t exercise
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-monitor cgb levels b4 and after exercise
-exercise when cbg is high normal (1-3 hrs after eating) -pre-exercise complex carbs 15-40 grams depending on intensity and duration -try to avoid exercise when insulin is peaking |
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preventing hypoglycemia r't exercise contd...
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may need to decrease dose of insulin peaking during exercise
-better way to control wt *carry a fast-acting source of carb *carb replacement during exercise and post-exercise (glucose-lowering effects of exercise may last up to 48 hrs) -carry and ID card or wear bracelet identifying wearer as having diabetes |
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carb replacement
if mild mod exercise less than 30 mins--walking 1-2 miles/hr light housework |
none
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moderate exercise 30-60 mins, bowling, walking 3-4 miles/hr, golf, swimming
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15 grams of carbs per hour
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high exercise for more than 1 hour...jogging 5 miles/hr, skiing, playing tennis
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30-50 grams of carbs per hour
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Hyperglycemia and exercise
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if blood glucose is >300 (type 1) or 400 (type 2) check ketones.
-if moderate to large ketones are present, exercise may increase blood glucose (delay exercise until ketones are absent) -If no ketones, exercise may help lower blood glucose *begin exercise and check glucose after 15 mins. If glucose is higher, stop exercise. -for type 1, DKA may result if exercise begins when blood glucose is elevated and ketones are present. |
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diabetic complications and exercise
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Retinopathy: avoid strenuous and high intensity activities, heavy wt lifting, scuba diving, activities that require head to lower than waist; jarring activities, and competetive sports
*walking, cycling, and swimming are best |
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diabetic complications and exercise
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*peripheral vascular disease-non-wt bearing exercises are best.
*peripheral neuropathy-avoid wt bearing activities and jogging. -wear well fitting shoes -range of motion activities, cycling, and swimming are the best. |
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diabetic complications and exercise cont.
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*autonomic neuropathy-avoid strenuous, high-intensity activities and extreme temeratures (decreased ability to sweat)
-water aerobics are good *NEPHROPATHY -exercise tolerance is generally diminished -low intensity aerobic activities--walking, swimming, and cycling. |
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Goals of nutrition therapy for diabetics
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1. maintain near-normal blood glucose levels as possible
2. achieve optimum serum lipid levels 3. provision of adequate calories for: maintaining or attaining reasonalbe wt for adults; normal G&D rates in children and adolescents; increased metabolic needs during pregnancy and lactation, or recovery from illness. 4. prevention of hyper-and hypoglycemia, and long-term complications 5. improvement of overall health |
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nutrition and type 1 diabetes
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-eat @ consisent times synchronized with the time-action of the insulin preparation used
-multiple daily injections or use of an insulin pump to allow more flexibility |
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Nutrition and Type 2 Diabetes
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emphasis on achieving glucose, lipid and blood pressure control
wt loss of 5-7% of body wt c moderate caloric restriction (250-500 calories less than avg daily intake) |
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Diabetic Diet
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Protein: 10-35% if renal fxn ok
Total fat: 20-25%, less than 7% saturated fats Carbs: 45-65% not less than 130g/day *some evidence that the 30/30/40 diet may be helpful in maintaining good glucose control. |
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CARBS
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-carb limit is based on client need
-total carbs are divided among meals and snack throughout the day *bkfst 30-60 grams *lunch 45-60 grams *dinner 45-60 grams *snacks 15-30 grams -priority should be given to the total amt of carbs rather than the source |
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glycemic index
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glycemic index (GI) may be used to rank various carb-rich foods accd to how much they affect blood glucose
-low GI, <55: most fruits and veg's (but not potato), oats, buckwheat, whole barley, all-bran -medium GI (56-69): sucrose, basmati rice -high GI (70 or more): corn flakes, baked potato, jasmine rice, white bread, white rice, mars bar |
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exchange list
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within each list, every food contains about the same # of calories adn the same amt of carb, protein and fat
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list of substitutes
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starch: bread, cerials, grains, starchy vegetables
fruit: fruit and fruit juices milk other carbs: sweets and desserts non-starchy vegetables meat and meat substitutes fat: mono-and polyunsaturated fats and saturated fats free foods: any food or drink that contains less than 20 calories or less than or equal to 5 grams of carbs per serving (limited to 3 servings spaced throughout the day) |
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Alcohol and Diabetes
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no more than 2 drinks/day for men and 1 drink/day for women-12 oz beer, 5 oz wine, 1.5 oz distilled spirits
*alcohol is best substituted for fat exchange (1 bev=2 fat exchanges) *alcohol may increase the risk for hypoglycemia in ppl treated c insulin or sulfonylureas -alcohol competes c liver enzymes blocking production of glucose -since glucose is not freely available when needed, the hypoglycemia that follows can be profound and prolonged. |
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sexuality and diabetes
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check blood glucose b4 sexual activity
-if at risk for hypoglycemia, keep simple carbs, or glucose tablets handy -if glucose not well controlledd, may not feel well enuf for sexual activity -men: can change in libido -ED...50-60% of men over 50yrs who are diabetic have some degree of impotence. PREVENTION-good glucose control, avoid smoking, decrease alcohol intake, keep BP c in normal ranges -low semen quality and volume leads to sterility -depression |
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Women
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-frequent yeast infxns
-painful intercourse r/t vag dry -decreased libido -loss of orgasm r/t neuropathy -menstrual disorders -may have difficulty controlling cbg levels the week before and during menstrual period (levels may increase or decrease) -planning a pregnancy: if on oral agents, need to switch to insulin...high infant birth wt, increased risk spontaneous abortions, malformation of fetus, and stillbirths. -wives of men with diabetes...fewer conceptions, more miscarriages |
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hypoglycemia
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-too much insulin
-increased exercise without increased food intake -decreased food intake -drugs -tx: 10-15 grams of fast acting carb (will increase blood glucose 40-50 mg/dl within 10-15 mins)...2 grahm crackers, 2-3 pcs of hard candy, 1/2 cup juice, 2 packets sugar, Glucagon (1/2 to 1 mg subQ). |
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to treat low sugar 15:15 rule
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check blood sugar, eat 15 grams carbs, wait 15 mins for sugar to get into blood
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Hyperglycemia
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too little insulin, eating too much, decreased exercise without decreased food intake, emotional stress, physical stress like infection, trauma, surgery; drugs, sx: weak, increased thirst, frequent urination, dry mouth, n, v, decreased appetite or polyphagia, coma, acetone breath
TX: insulin or oral agents, replace fluids, resolve underlying stressors, return to appropriate diet and exercise plan |
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Self monitoring of blood glucose (smbg)
Issues: |
Issues: adequate peripheral circulation, manual dexterity (tremors, MS, arthiritis); vision, memory, coping ablity (ex: sight of blood)
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Ideal SMBG monitoring-how often to check blood sugar for type 1
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if on insulin: b4 meals, HS, during night, 2 hr pc (after meal), b4 and after exercise, symptoms of low BG, during illness, before driving >100
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ideal SMBG monitoring for Type 2...
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not on insulin: 2x per week or more if not in good control; 2 hr pc; more often if high blood glucose; during illness...as often as they are willing
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continuous glucose monitors (CGM)
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uses a sensor to measure glucose levels in the fluid just under the skin...insert the sensor much like an infusion set for an insulin pump, with a handheld applicator and special adhesive tape
-sensor transmits the result to a handheld receiver or insulin pump every few minutes -wear the sensor for 3-7 days b4 replacing (depends on the brand) -may stand alone as a monitor or fxn as a combo CGM and insulin pump |
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Blood glucose goals
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-fasting 80-100 mg/dl
b4 meals 70-130 2hrs after meals <140 before bedtime 100-140 -target blood glucose: as close to normal w/out severe hypoglycemia |
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Glycosylated hemoglobin (HbA1c)
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-formed as glucose attaches itself to the hemoglobin in the RBC...unaffected by food intake, medication, exercise or stress...can measure glucose cntrol for the past 2-3 months....normal is 4 - 5.6% for ppl w/out diabetes....Goal is less than 7% (avg in US is 9.7)
-Exceptions are the elderly, ppl c chronic illness, CVD, neuropathy, infants and children, severe hypoglycemia, hypoglycemia unawareness, high risk occupations PROBLEMS: a normal level may represent relatively high blood glucose concentrations alternating c hypoglycemia -problem if pt is anemic or has any condition that shortens the life of the RBC |
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Managing sick-days
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report any illness to Dr when it increases blood sugar levels and causes urine ketones.
Test blood sugar and ketones every 2-4 hrs until results are normal |
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When to call MD
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high glucose levels >250 for over 6 hrs, ketones last over 6hrs, fever, illness lasts over 24hrs, dehydration, severe abd pain, other unexplained sx's
-continue taking insulin even if unable to eat solid foods or vomiting -if on oral agents, take usual dose, if unable to keep pills down--call Dr |
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sick days
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cont. eating foods and drinking fluids even if vomiting, having diarhea, or high blood sugar
-take @least 45-50 grams of carb q 3-4 hrs to prevent low blood sugar while insulin clears the ketones -15 grams of carbs 1/2 cup reg. soft drink 1 double popsicle 1/2 cup regular jello 1 cup gatorade 1 cup soup 1/2 cup fruit juice 1 slice toast 6 soda crackers |
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to prevent dehydration
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drink@least 8 oz fluid q hour, limit activity if blood sugar is over 250 and ketones mod-large. Type 2 diab. may need insulin to manage sugar during illness
no oral diabetic meds in hospital...pt needs more insulin than pancreas can provide and some meds can produce side effects such as lactic acid or risk for heart failure |
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HHNS, type 2
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-elevation of blood sugar, hyperosmolarity, little or no ketones
-increased blood sugar increases urine=dehydration -severe dehydration will lead to sz, coma, and eventually death -life-threatening endocrine emergency -reported in all age groups, most frequently affects older pt c type 2 diabetes |
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HHNS causes:
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infxns-pneumonia, uti; poor compliance c diabetic meds; meds that raise serum glucose, inhibit insulin, or cause dehydration-diuretics, beta blockers, dialysis, tpn, fluids that contain sugar
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HHNS warning signs
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cbg over 600, dry parched mouth, extreme thirst, warm dry skin that dosnt sweat, high fever, sleepiness or confusion, visual changes or disturbances, hallucinations, weakenss, hemiparesis
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HHNS Tx's
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IV rehydration, electrolyte replacement, IV insulin, dx and mgmt of precipitating and coexisting probs, prevention-glucose monitoring, compliance c meds, adequate water
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Insulin INJ sites
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absorption rate-abd wall, arms, thighs, buttocks
*give injections in one site-abdomen preferred *increased absorption-exercise and heat *smoking reduces the absorption of insulin in an irregular fashion |
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Storage of insulin
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current bottle in use mayb be stored on counter for up to 4 weeks. avoid temp extremes (below 87 degrees, do not freeze)...unused bottles may be stored in fridge....cold insulin delays the absorption (capillary vasoconstriction)...insulin syringes may be reused up to 7x (cap needle and store in fridge)...when traveling, protect insulin from extreme temps (thermos or cooler)...prefilled syringes are stable for up to 30 days stored in fridge
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INsulin regimens
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1-4 injections per day, maybe more.
the basal-bolus regimen most closely mimics endogenous insulin production |
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Insulin types
rapid acting, short action |
rapid acting: lispro (humalog), aspart (novolog), glulisine (apidra)
ONSET 15 mins PEAK 60-90 mins DURATION 3-4 hrs *short acting: regular (humulin R, Novolin R) ONSET 30min-1hr PEAK 2-3 hrs DURATION 3-6 hrs |
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insulin types cont.
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intermediate-acting: NPH (humulin N, Novolin N)
ONSET 2-4hrs PEAK 4-10 hrs DURATION 10-16 hrs *long acting: glargine (lantus), detemir (levemir) Cannot be mixed c other insulins ONSET 1-2 hrs PEAK no pronounced peak DURATION 24+hrs |
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insulin cont.
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pre-mixed...novolin mix 70/30 <70% NPH, 30% regular>
humulin 50/50 <50%NPH, 50% regular> Timing of insulin varies from person to person and can vary in the same person on different days |
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insulin pump
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delivers thru infusion set
cannula in abdomen, thigh, or buttock using introducer needle site change q 2-3 days pumps use raped-acting insulin -basal insulin 24/7 bolus dose of insulin based on carb content of meal -SMBG 4-6x per day |
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I-port functions
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medication delivery channel directly into subQ tissue....an insertion needle guides a soft cannula under the skin...once applied, insertion needle is removed and only the soft cannula remains below the skin, acting as the gateway into the sub Q tissue
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SOMOGYI effect vs DAWN phenomenon
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Somogyi: hyperglycemia in morning, undetected hypoglycemia, happens in middle of night, most common with insulin using diabatics, c/o nightmares, early morn HA, N.
DAWN phen.: all exhibit some dawn phen; part of circadian rhythms; hyperglycemia in the morning when the diabetic does not have enuf circulating insulin to match the glucose |
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oral agents type 2
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sulfonylureas: stimulates pancreas to produce insulin, increases insulin effects at cellular level, decreases sugar production by liver, helps manage 2hr pc
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oral agents type 2 RX
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2nd generation:glipizide(glucotrol), glyburide (micronase, diabeta, glynase); glimipride (amaryl)
1st generation last up to 72hrs and increase risk of hypoglycemia S/E: wt gain, rash, puritis, sun sensetivity, GI sx, heartburn, n, v, stomach discomfort...over time may become insensetive to meds |
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oral agent type 2
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biguanide: increases isulin sensetivity at the tissue level, decrease hepatic glucose output, decr. glucose absorp by sm intestine, does not stimulate insulin release, decrease triglyseride, chol, and wt.
RX: metformin, glucophage, metformn xr (riomet), glucophage xr, fortamet xr, glumetza xr SE: ha, agitation, metallic taste, anorexia, n, d, cramping -unless combined c another med, hypoglycemia usually not a problem |
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biguanide cont
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contraindications:
kidney probs, liver probs, meds for heart failure, acute MI, copd, sleep apnea, heavy or binge drinkers, over 80 yrs old...(creatinine clearance) -may cause lactic acidosis, severe weakness, unusual muscle pain, trouble breathing, unusual stomach discomf, feeling cold, dizzy, decreased/irregular HR. d/c med if dehydrated, heart attack, severe infxn, having surgery, IVP, dye study |
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alpha-glucosidase inh (starch blockers)
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slow down absorption of carb in sm intestine, must take at beg. of each meal
RX: acarbose (precose), miglitol (glyset) SE: d, flatulence, abd pain, wt loss, no prom c hypoglycemia, c other meds that cause hypoglycemia, must give 3-4 tabs glucose |
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Rx for Diabetic Neuropathy
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-Nonsteroidal anti-inflammatory drugs
-Tricyclic antidepressants -Serotonin reuptake inhibitors (Duloxetine/Cymbalta) -Anticonvulsants (Gabapentin/Neurontin) (Pregabalin/Lyrica) -Topical capsaicin |
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Children and Diabetes:
Children are different than adults |
-Physical growth & development
-Ability to provide care -Neurologic vulnerability to hypoglycemia |
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Challenges in different age groups
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-Preventing lows
-Predicting appetite and activity -Parenting -Psychosocial issues |
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Toddlers
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-Variable activity and meals
-Daycare and preschool issues -Insulin administration (Nph and fast acting insulin Picky eaters,Not wanting to eat) (Basal/bolus regimen Glargine, fast acting,multiple shot regimen) (Insulin pump) |
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Toddlers
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-Extra snacks for highly activity
-Additional blood glucose checks -Dosing after eating with rapid acting insulin |
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School age
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-More routine schedules
-Developing routine palates and meal times -Dealing with school lunches -Variability of activity (PE, recess, after scool sports,supplemental carbs) -Supervision, time away from parents -Developing autonomyetes (Self monitor, self inject) -Getting sick of diabetes, rebelling |
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School age
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-NPH and fast acting insulin
(works well with routine, 3 meals, 3 snacks) -Basal/bolus regimen (Glargine, fast acting, more flexible) -Pump (Not for everyone, issues of pumps at school, locking the pump, using pen or needle for bolus, parent coming to school to deliver bolus) |
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School age
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-Extra snacks for high activity
-Additional blood glucose checks -More adjustments needed in parental emotions and letting go |
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Adolescent (12-15yrs)
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-Body image and weight control
(eating disorders,misuse of insulin) -Fake blood sugars |
