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ALTERATIONS IN GLUCOSE METABOLISM
ALTERATIONS IN GLUCOSE METABOLSM
Assessment of alteration in glucose metabolism (4)
1. polyuria
2. polydipsia
3. polyphagia
4. weight change
How is DM characterized?
by glucose intolerance
Onset of DM-1?
before age 30
Physiology of DM-1?
pancreatic beta cells destroyed by autoimmune process
Give insulin to DM-1?
yes
What are people w/ uncontrolled DM-1 prone to?
ketosis
Onset of DM-2?
older than 30 & obese
physiology of DM-2?
1. insulin resistance

OR

2. decreased insulin production
What is insulin resistance?
decreased sensitivity to insulin
Does ketosis occur w/ DM-2?
no, rare
Give insulin for DM-2?
NO:

tx w:
1. diet & exercise
2. oral hypoglycemic agents
Onset of gestational DM?
during pregnancy (2nd or 3rd trimester)
A mom w/ GDM is considered to have __
a high risk pregnancy
What is impaired fasting glucose? Why is it significant?
above 110 mg/dl and below 126 mg/dl

risk factor for future DM devo
DM-2 Risk Factors (8)
1. parents & sibs w/ DM
2. obesity (20%+ above ideal BW)
3. AA, hispanic, Native Am., Asian
4. 45+
5. previously impaired fasting glucose
6. HTN
7. HDL <35 mg/dL, TG>250 mg/dl
8. hx of GDM or baby 9+lb
3 tests to help detect DM
1. blood glucose monitoring
2. urine ketones
3. glycosylated hgb (HbA1c)
Normal range in FASTING BLOOD GLUCOSE
60-110 mg/dL
Presence of sugar in the urine is a sigh of DM, calls for an immediate __
blood glucose test
What does the presence of urine ketones indicate?
DM control has deteriorated & the body has started to break down stored fat for energy
What is a HbA1c?
a blood sample that can be taken WITHOUT fasting
Normal values for HbA1c?
4-6%
Special considerations that might impact testing for DM? (3)
1. meds
2. illness
3. stress
4 goals for nutrition management in a pt w/ DM
1. provide all essential food constituents (low lipids if elevated)
2. ideal BW
3. meet energy needs
4. achieve normal-range glucose levels
4 methods for nutrition management in a pt w/ DM
1. Food exchange
2. Carb counting
3. Food guide pyramid
4. Glycemic index
What is a food exchange?
foods on list in specified AMOUNTS contain equal number of calories, and G of fat, protein, carbs
How does insulin work?
lowers BG by facilitating uptake and the use of glucose by muscle & fat skills
How does the presence of insulin impact the release of glucose from the liver?
decreases its release
When you mix insulins, which should you draw up first?
REGULAR FIRST
Sites of insulin injections?
1. abdomen
2. posterior arms
3. anterior thighs,
4. hips
What special consideration should you consider for insulin injections?
ROTATE SITES
How many times should one use a self injection syringe?
use a disposable syringe 1x and discard into a hard plastic container w/ a tight-fitting top
"Sick day rules": how should you take DM meds?
take insulin or oral agent as ordered
"Sick day rules": how often should you check blood glucose & urine ketones?
q3-4 hr

*report altered levels to MD
"Sick day rules": what should you do if the pt can't follow a normal meal plan?
sub soft foods (soup, custard, gelatin) 6-8x/day
"Sick day rules": if V, D, or fever?
1. report to MD
2. take liquids (cola, broth, Gatorade) every 0.5-1 hour
2 possible actions of oral hypoglycemic agents?
oral hypoglycemic agents:
improve both tissue responsiveness to insulin and/or the ability of the pancreatic cells to secrete insulin
SMBG?
self monitoring of blood glucose
What must we check to assure that it is safe for one to self-monitor their BG?
eyesight to make sure the pt can see directions and read results
If taking insulin, how often should you check the pt's BG?
2-4x/day
If not taking insulin, how often should you check the pt's BG?
2-3x/week
What is the goal time for testing to be performed?
at the peak action time of medication
4 guidelines for skin and foot-care in pt w/ DM?
1. inspect feed DAILY (use mirror if pt is old/has decreased mobility)
2. wear well-fitting shoes
(break in new shoes slowly by wearing 1-2 hr initially w/ gradual increase in time)
3. don't walk barefoot or use a heating pad on feet
4. cut toenails STRAIGHT across w/o rounding corners
When should a pt w/ DM NOT exercise?
1. extreme temperatures
2. when control of DM is poor
6 common complications a/w DM?
1. hypoglycemia (insulin reaction)
2. hyperglycemia (DKA)
3. HHNKS (hyperglycemic hyperosmolar nonketotic syndrome)
4. diabetic retinopathy
5. coronary artery dz
6. cerebrovascular dz
BG of a pt/ w/ hypoglycemia (insulin rxn)
BG: <50-60 mg/DL
S&S of hypoglycemia?
1. CNS: irritability, confusion, tremors, coma, seizures
2. blurring of vision
3. hypOtension
4. tachycardia
5. skin: cool, clammy, diaphoretic
If hypoglycemic pt is conscious, what should you give?
liquids containing sugar,

SKIM MILK is ideal if tolerated
If hypoglycemic pt is UNconscious, what should you give?
Dextrose 50% IV & glucagon 1 mg IM or SQ
After giving a hypoglycemic pt appropriate liquids, what should you give 15 min later?
additional carb
3 main causes for hypoglycemia?
1. too much insulin/oral hypoglycemia agent
2. inadequate food
3. excess exercise
BS of a pt w/ hyperglycemia (DKA)?
BS 300-800 mg/dL
S&S of hyperglycemia (DKA)?
1. CNS: headache, drowsy, weak, stupor, coma
2. hypOtension
3. tachycardia
4. elevated T
5. polyuria-->oliguria-->polydipsia-->polyphagia
6. *fruity odor to breath
What type of breathing does aperson w/ hyperglycemia (DKA) undergo?
KUSSMAUL RESPIRATIONS (rapid & deep)
How does a pt w/ hyperglycemia (DKA)'s skin appear/feel?
skin is warm & dry

w/ dry mucus membranes
What is a major complication a/w hyperglycemia (DKA)?
fluid volume DEFICIT
3 infusions that a hyperglycemic (DKA) pt will receive?
1. first 2-3 hr: 1 L of NS/hr
then, 200-500 ml/hr 1/2NS
then, D5W or D51/2NS
2. REGULAR IV insulin 5 units/hr
3. K replacement
In a hyperglycemic (DKA) pt, what are 2 areas that you should assess q2-4 hr?
q2-4hr:

1. EKG
2. K
If a patient is hyperglycemic (DKA), what are 4 areas that you should check HOURLY?
HOURLY:
1. level of consciousness
2. UO
3. T
4. blood glucose levels
If a pt is hyperglycemic (DKA), how often should you check the VS?
VS: q15min until stable
If a pt is hyperglycemic (DKA), how often should you assess the CVP?
CVP: q30 min
3 major causes of hyperglycemia (DKA)?
hyperglycemia (DKA)

1. decreased/missed insulin
2. illness/infection
3. untx DM
BS level of a pt/ w/ HHNKS?
BG >800 mg/dL
In which age group does HHNKS typically manifest?
>50 y/o
Which type of DM is a/w HHNKS?
DM-2
Does ketosis and acidosis occur w/ DM-2 or HHNKS?
NO
S&S of HHNKS?
1. hypOtension
2. DRY mucus membranes
3. poor skin turgor
4. tachycardia
5. CNS: alteration in sense of awareness, seizures, hemiparesis
Replacement therapy for HHNKS (3)?
1. NS or 1/2NS
2. REGUlAR insulin
3. K
Before replacing a pt w/ K, what must you first assess?
**make sure the UO is satisfactory
3 main causes of HHNKS?
1. acute illness
2. meds (ie thiazides)
3. treatments (dialysis)