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360 Cards in this Set

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When does Type 2 DM usually occur?
usually after 30, but can at any age
Type 2 DM, relationship to insulin replacement?
not insulin dependent
Type 2 DM, relationship to Ketosis
ketosis resistent
Type 2 DM, percent overweight?
80%
Type 2 DM, 3 causative factors:
obesity, heredity, environmental factors
Type 2 DM, can you release insulin?
some, but not enough
Type 2 DM, can't release enough insulin, why? x2
may be r/t v insulin production, or
excess CHO intake
What type of diabetic can get v sensitivity to insulin?
pt w Type 2 DM
v sensitivity to insulin is called...
insulin resistance
Type 2 DM, what can obesity do to body's response to insulin?
reduce insulin binding at receptor sites
Type 2 DM, obesity reducing insulin binding at receptor sites can lead to what?
hypersectretion of insulin and
eventual pancreatic cell exhaustion
What type of DM sees symptoms r/t fat breakdown?
Type 1 during DKA
Type 2 DM, what can you develop?
hyperosmolar nonketotic syndrome (HNKS)
HNKS, what signs do you see? x3
hyperglycemia and hyperosmolarity with alterations in sensorium
HNKS can prevent what, but not what?
ketosis doesn't occur, but not enough insulin to prevent hyperglycemia
HNKS, first two symptoms
polyuria
polydipsia
HNKS, polyuria & polydipsia cause what? with what symptoms? x6
severe dehydration:
warm flushed skin, ^ temp, v BP, rapid thready pulse, soft sunken eyeballs, v LOC
HNKS, severe dehydration can lead to what?
hypovolemic shock
When do you seek attention with HNKS? x3
when neuro signs appear:
altered sensorium, hemiparesis, seizures
2 subtle signs of undetected DM
nocturia
wounds heal slowly
What type of DM can go undetected?
type 2
When might MD dx DM? x2
insidious onset of fatigue,
complication of DM ex. poor vision
Type 2 DM, treatment x3
diet, exercise,
oral anti-diabetic agents if needed
DM secondary to other conditions x3
1. Hypersecretion of hormones that antagonize insulin
2. Pancreatic disease
3. Burns
What hormones antagonize insulin? x3
glucocorticoids, epinephrine, growth hormone
Why do burns cause DM?
excessive metabolism makes need for insulin exceed supply
When does gestational DM occur usually?
2nd or 3rd trimester
What causes gestational DM?
insulin antagonizing hormones from placenta
Treatment for gestational DM? x2
diet, insulin if needed

*note:not exercise (only do that at same level as pre-preg.
previous hx or hyperglycemia (ex illness or pregnancy), but current glucose metabolism is normal
prediabetes
Who's at risk for DM? x9
Family hx, obese, women with large babies, gestational DM, stressed pt, minorities, age 45 or up, hypertension, ^ triglycerides

*only God (Gestational DM)
Family hx
Aage 45 and up
Triglicerides elevated
Hypertension
Obesity
Moms with big babies, Minorities
Stressed pts
"only God FATHOMS"
Criteria for dx of DM? x3
1. Symptoms, plus random <200 mg OR
2. FBS (fasting BS) ≥126
3. 2-hr postload glucose ≥200 during oral glucose tolerance test (GTT)
FBS (fasting blood sugar) is defined as...
blood drawn after NPO ≥8 hr
GTT (glucose tolerance test) procedure?
pt fasts overnight,
drinks 75 gm CHO (glucola),
draw blood Q1Hx3
Normal values of GTT
1hr. <115
2hr. <200
3hr. <140
ADA guidelines for normal and prediabetic FBS?
normal FBS = 80-90
prediabetic FBS = 100-125
SMBG
self monitoring of blood glucose
Best way to keep BS normal and v complications
SMBG
How often monitor glucose: if on insulin? if not on insluin?
on insulin: 2-4x/day
not on insulin: 2-3x/week
What is used to determine if treatment is adequate over a 24 hour period?
Continuous glucose monitoring system
When what is happening to pt that you would check for ketones in urine? x2
when BS staying high, and
during illness
What's the blood test that shows BG over 2-3 month period?
Glycosylated hemoglobin (HgbA1c or A1C)
What's normal range for A1C test?
4-6%
Define preprandial blood glucose. What range?
BS taken before meal,
80-120 mg
Grandma (80y/o) walking through the desert (120 deg) before her meal
What routes can you take insulin?
sub q and IV
What four things does insulin do?
1. acts on liver to stimulate formation of glycogen from glucose
2. Allows glucose + protein to get in to cells
3. Stimulates adipose tissue to synthesize and store fat.
4. Stimulates metabolism of CHO.
RAPID ACTING INSULIN,
name 'em:
humalog (Lispro)
novolog (Aspart)
Apidra (Glulisine)
RAPID ACTING INSULIN,
onset?
peak?
onset: 10-15 min
peak: 40-60 min
SHORT ACTING INSULIN,
name 'em:
Regular
Humalog R
Novolin R
SHORT ACTING INSULIN,
onset?
peak?
onset: ½ - 1 hr.
peak: 2-3 hrs.
INTERMEDIATE ACTING INSULIN,
name 'em:
NPH
Lente
Humulin N
Novolin N
INTERMEDIATE ACTING INSULIN,
onset?
peak?
onset: 2 - 4 hrs.
peak: 4 -12 hrs. (~8 hrs.)
LONG ACTING INSULIN,
name it:
Ultralente
LONG ACTING INSULIN,
onset?
peak?
onset: 6 hrs.
peak: 12 - 16 hrs.
VERY LONG ACTING INSULIN,
name 'em:
Lantus (Glargine)
Levemir (Detemir)
VERY LONG ACTING INSULIN,
onset?
peak?
onset: 1 hr.
peak: continuous (no peak)
What insulin type can you use with an INSULIN PUMP?
Regular, Humalog, or Aspart
Insulin sites: x4
upper arms, upper thighs, abdomen, hips
Preferred insulin injection site:
abdomen
Why is abdomen preferred insulin site?
easy access for pt, and
absorption is more even and rapid
Use how many insulin injection sites in each area?
6
Order of speed of insulin absorption for injection sites [fastest to slowest]
1. abdomen
2. arms
3. thighs
4 hips
Use what insulin injection site on gym days?
abdomen
Describe local insulin reaction: x3
redness, swelling, itching at injection site
What can give for local insulin reaction?
When?
antihistamine,
1 hr. before insulin
Systemic Reaction to insulin,
Rx?
desensitization with small doses of insulin
Resistance to replacement insulin, defined as...
pt needing > 200 units of insulin per day for normal BS
A disturbance of fat metabolism,
called what?
lipodystrophy
Two types of lipodystrophy,
called what?
1. lipoatrophy
2. lipohypertrophy
Define lipoatrophy
dimpling of sc fat
Define lipohypertophy
fibrofatty mass (scar tissue) at injection site
What does pt do to cause lipohypertrophy?
prolonged use of same injection site
Complication from lipohypertrophy
irregular absorption
situation in which sudden v in BS is followed by rebound hyperglycemia (stress hormones respond to low BS)
Somogyi phenomenon


*Sumo wrestler is so big he falls he bounces right up
a. Somogyi phenomenon
b. Dawn phenomenon
c. insulin waning
situation in which you have:
normal BS until 3 am, then gradual ^
Dawn phenomenon


*we had Dawn a little bit by 3rd semester, but then she ^ since then
a. Somogyi phenomenon
b. Dawn phenomenon
c. insulin waning
situation in which you have:
a progressive ^ in BS from bedtime to am
Insulin waning
a. Somogyi phenomenon
b. Dawn phenomenon
c. insulin waning
Three types of morning hyperglycemia:
a. Somogyi phenomenon
b. Dawn phenomenon
c. insulin waning
phenomenons
Somogyi phenomenon: Timeline...
bedtime: high BS
3am: low
morning: high
when is it normal?
when is it ^?
Dawn phenomenon: Timeline...
normal BS until 3am, then gradual increase


*like the dawn as the sun starts to come up slowly
when is it normal?
when is it ^?
Insulin waning: Timeline...
progressive ^ in BS from bedtime to am
when is it normal?
when is it ^?
Somogyi phenomenon: Rx... (2 choices)
v evening dose of intermediate insulin OR
^ bedtime snack
either , or
targeted at increasing BS early
Dawn phenomenon: Rx...
change pre-dinner intermediate insulin to bedtime
change the time of intermediate insulin
Insulin waning: Rx...
^ dose of pre-dinner or bedtime insulin
is it changing the dose or
changing the timing
what delivers insulin thru skin under pressure
Jet injector
Insulin given with this by dialing a dose or pushing a button for every 1 or 2 unit increment given
Insulin pens
How often do you change insulin pump dressing?
Q3 days
When does an insulin pump administer doses?
basal dose (ex) q1h
bolus dose before meals
Can you use oral antidiabetic agents during pregnancy?
no
What can oral antidiabetic agents cause?
hypoglycemia
When do you use oral antidiabetic agents?
when exercise and diet don't work
Which oral antidiabetic agent stimulates beta cells to produce insulin?
Sulfonylureas
Requirement for sulfonylureas?
functioning pancreas.
Sulfonylureas, examples...
1st gen: Orinase, Diabinese
2nd gen: Micronase, Glucotrol, Amaryl

*King ORIN may be DIABolitical, but MICRO self doesn't LOSE CONTROL (gLUCOTROL) of love (AMOR or amaryl)
orinase: drug class?
sulfonylurea - 1st gen
diabinese: drug class?
h
sulfonylurea - 1st gen
you wear NYLons around your NESE
micronase: drug class?
sulfonylurea - 2nd gen
glucotrol: drug class?
sulfonylurea - 2nd gen
amaryl: drug class?
sulfonylurea - 2nd gen
Sulfonylurea
side effects:
1st gen - GI and dermatitis
2nd gen - weight gain
*alcohol may cause Antabuse-like reaction
Which oral antidiabetic agents in particular may cause disulfurin-like reaction?
sulfonylureas
Biguanides: examples x2
glucophage (Metformin)
glucovance (Metformin with glyburide)
Two BIsexual GUidos (BIGUAnides) named PHAGY and VANCE
go to a performance at the MET... and Vance is very GLYB
Thiazolidinediones: examples x2
Actos,
Avandia
Thaizolidinediones: risk r/t pregnancy
^ risk of pregnancy if taking oral contraceptives
Actos: drug class?
Thiazolidinedione
Avandia: drug class?
Thaizolidinedione
Glucophage (Metformin): drug class?
Biguanide
Glucovance (Metformin with glyburide): drug class?
Biguanide
Alpha glucosidase inhibitors: example 1
Precose
Precose: drug class?
alpha glucosidase inhibitor
Meglitinides: example x1
Prandin
MEGalomaniacs only shop for PRAND name products
Prandin: drug class?
Meglitinides
Exenatide (Byetta): drug class?
Oral antidiabetic agent
Exanatide: brand name?
Byetta
Byetta: generic name?
Exanatide
What is the one oral antidiabetic agent that someone with Type 1 DM can use?
Pramlintide (Symlin)
Pramlintide (Symlin): drug class?
oral antidiabetic agents
Pramlintide: brand name?
Symlin
Wouldn't it be interesting if you could go to a PROM in SYM City
Symlin: generic name?
Pramlintide
When do you use pramlintide (Symlin)?
when mealtime insulin is not enough by itself
What's the optimal wt. to lose per week with DM?
2 lbs/wk.
Two goals of DM diet:
1. maintain optimal weight
2. control BS
What condition is important to correct ASAP with DM?
Why?
obesity
(more resistant to all insulin)
It is good to keep what two things CONSISTENT with the DM diet?
1. number of calories at different meals
2. time between meals
DM, re: skipping meals
don't do it
DM, re: menu
should be varied
Import to include what ingredient in the DM diet?
fiber
What does fiber do for the diabetic? x2
prevents wide variations in BS and minimizes ^ BS after meals
If on NPH, good to have what? when?
snack at night
Preferred calorie distribution:
50% from CHO (40% complex, 10% simple),
30% from fats,
20% from proteins
What are 8 examples of STARCHY VEGETABLES?
corn, lima beans, parsnips, peas, potato, pumpkin, squash, yam
cheese, cottage cheese
these count as what exchange?
meat exchanges
butter, margarine, cream, cream cheese, mayonnaise, dressings
These count as what exchange?
fat exchanges
what's special about peanut butter as an exchange?
it counts as 1 meat and 2 fat exchanges
how do you lower glycemic index of starch and sugars?
eat with fats and proteins
glycemic index, define...
describes how much a given food ^ BS compared to equal amount of glucose
alcohol may cause...
...esp. if...
hypoglycemia...
...esp. if on insulin or oral hypoglycemics
Exercise does what to insulin need?
v need
If taking insulin, it is best to exercise how long after meals?
1-2 hours
When on insulin, if exercising for a long time, when do you check BS?
What do you bring?
before, during, after
bring CHO snacks
What other health problems must you consider before starting exercise with DM?
neuropathy and risk for heart disease
Don't begin exercise if BS is greater than what? What else is an issue?
BS>250
ketones in urine
Stress does what to BS?
^ BS
What are examples of types of stress? x3
px, emotional, infection
Stress increases production of what BS increasing hormones?
glucocorticoids and epinephrine
What does the diabetic pt need more of during stressful times?
insulin
Major possible danger before/during/after surgery for DM pt.?
Why?
hypoglycemia,
CNS sensitive to low BS
How do you modify admin. of oral hypoglycemics, intermediate and long-acting insulin, before surgery?
stop them 1-2 days pre-op and give regular insulin instead
How often check insulin surrounding surgery?
Q1H
What IVs are hanging during surgery for DM pt.?
How often and according to what are they adjusted?
1 IV of glucose
1 IV of insulin
adjusted hourly according levels
Post-op for DM pt:
What are the NI of beginning sc insulin post-op? x2
-start prior to stopping IV insulin (d/t shorter DOA)
-may give Regular insulin sc until stable...
...then go back to normal med protocol for pt.
When should you schedule a diabetic for surgery?
early in the day (so pt. not NPO so long)
What are two pathological conditions of diabetics that cause problems during surgery?
1. they have generalized vascularized disease
2. v resistance to infection
Major possible danger before/during/after surgery for DM pt.?
Why?
hypoglycemia,
CNS sensitive to low BS
What type of diabetic meds are usu. stopped before surgery?
oral hypoglycemics, intermediate and long-acting insulin
What is often started for DM pt pre-op?
What if BS is high?
start IV D5W.
give 1/2 usu. dose of regular insulin if high
What's hanging during surgery for DM pt.?
1 IV of glucose
1 IV of insulin
adjusted hourly according levels
Post-op for DM pt:
Continue IV glucose and IV insulin until when?
until pt is taking po
Post-op for DM pt:
What are the NI of beginning sc insulin post-op? x2
-start prior to stopping IV insulin (d/t shorter DOA)
-may give Regular insulin sc until stable...
...then go back to normal med protocol for pt.
What might BS do right after surgery?
BS may be elevated (d/t stress)
It's important to check for what life-threatening complications? 1+2ex
Why?
CV complications (ex) MI, stroke,
b/c diabetics have atherosclerosis
It's important to check for what dermal complications? x2
wound infection, skin breakdown
At how many weeks do you check for gestational DM?
24-28 wks gestation
What's the criteria for Class A in Whites Classification of Pregnant Diabetics?
abnormal GTT only
What are 6 possible indications that might indicate gestational DM?
h
family hx, previous large babies, recurrent preeclampsia, hydramnios, unexplained fetal death or anomaly, obesity

Preeclampsia, recurrent
Relatives had it (family hx)
e
Gorda (obesity)
Nine-pound plus babies (previous LGAs)
a
No life (fetal death/anomaly)
Tide of water (hydramnios)
PREGNANT
What hormones does a pregnant lady produce that antagonize insulin? x6
estrogen, progesterone, HCG, HPL, cortisol, growth hormone
Why are diabetic pregnant pts more likely to develop ketoacidosis?
increased amount of insulin antagonizing hormones produced
What are pregnant diabetics in risk of acquiring?
ketoacidosis
What do pregnant diabetics need more of?
insulin
Why is insulin depressed in pregnant diabetic?
placenta breaksdown insulin
What happens to the need for insulin as pregnancy progresses?
increased need
What happens to insulin needs right after placenta delivery?
need drops abruptly
what's the most important NI after birth for diabetic mom?
stop delivery of extra insulin
What normal birthing s/e is more dangerous for the pregnant diabetic?
vomiting
What issue is more common and serious in pregnant diabetic?
What's an ex of what it can cause?
Infection,
ex. pyelonephritis
The chance of what increases for the fetus and/or neonate of diabetic mom?
death
What presents the greatest fetal risk if mom has diabetes?
ketoacidosis
What problems have a high incidence d/t effects of diabetes on pregnancy? x6
PIH, hydramnios, congenital anomalies, RDS, dystocia, pp hemorrhage
With what class might a therapeutic abortion be justified?
Class F or worse
Women of what class can usu. have babies with normal weight and low morbidity?
Class A-C
What do women in Class A-C have to do to have a baby with normal weight and low morbidity?
What specific level of it?
Keep BS normal (60-110 mg)
What do you teach pregnant diabetic r/t what you teach any diabetic?
teach same stuff, plus
signs of PIH
For pregnant diabetic, Rx includes dietary modification EXCEPT what?
NEVER RESTRICT CALORIES
In what week do insulin requirements ^ with pregnant diabetics?
18th-20th week
Risk of what prior to week 18-20 for preg. diab.:
hypo- OR hyper-glycemia?
Why? x2
fetal drain and
low levels of hormones antagonistic to insulin
What diabetic med do you never use with preg diab b/c may be teratogenic?
oral hypoglycemics
What's it mean if no ^ in required insulin after 1st trimester?
possible problem with placenta
What do you use to monitor a fetus of diab mom? x8
U/S, AFP, fetal echocardiogram, estriol levels, ST, NST, biophysical profile, L/S ratio
What do you want to see with L/S ratio for fetus of diab mom?
3:1 or more
During which weeks does diab. mom often deliver?
38-40 weeks
What 3 criteria do you use determine when to induce diab. mom? x3
pt. status, tests of placental function, fetal maturity
NI for laboring diabetic mom? x2
keep on left side,
continuous monitoring
Breastfeeding is good in what ways?
psychologically,
physically
Why is it good to breastfeed for mom's BS?
v insulin needs
Typical size of infants of diabetic mom?
For example...
LGA,
ex. even delivered @37 wks, may weigh 9-10
Peculiarity of infant size when born to Class D-R moms?
d/t...
r/t...
SGA d/t placental insufficiency r/t maternal vascular disease
Why are infants of diabetic moms large?
Extra glucose stored as fat
What s/s might you see with infant of diabetic mom r/t excess fat storage? x10
fat, red-faced, round-faced, lie quietly, move little, seldom cry, cord/placenta larger, hepatosplenomegaly, cardiomegaly, cushingoid-like
What % of infants of diabetic moms are hypoglycemic?
How many hours old are they?
50%,
6 hours (esp. 1-4 hrs) old
If mom's not well-controlled, what's babies BS?
hypo- OR hyperglycemic?
Hyperglycemic
What is the only organ not enlarged in infant of diabetic mom?
brain
What can diabetic mom do to make baby less likely to develop hypoglycemia after birth?
control BS during pregnancy
What are neonate s/s of hypoglycemia? x6
twitching, tremors, limp, poor feeding, convulsions, high-pitched cry
Crying is
High-pitched
o
Convulsions
o
Limp
a
Twitching, Tremors
e
is
POOR FEEDING
What are 3 NI to prevent hypoglycemia for neonate of diabetic mom?
1. check BS frequently
2. give glucose-water
3. feed frequently
Is it ok for mom to breastfeed if on insulin?
Why?
yes, b/c insulin not in breast milk
What can you do for neonate of diabetic mom if BS very low?
IV with glucose
What are the major potential problems for neonate of diabetic mom? x7
hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia, RDS, birth trauma (ex perinatal asphyxia), congenital anomalies
BIRTH
P
o
a
C
H
e
R
What do you see with neonatal hypocalcemia?
tremors
What's an example of a congenital anomaly of neonate of diabetic mom?
heart defects
What is hypocalcemia in the neonate r/t? x2
maternal diabetes,
prematurity
What is hyperbilirubinemia in the neonate of diabetic mom r/t?
prematurity
What Class of pregnancy diabetes is at risk for RDS?
Class A-C
What is unique about the lungs of neonate of diabetic mom of class D-R?
accelerated lung maturation d/t stress
What is birth trauma of the neonate of diabetic mom r/t?
large size
If young child is uncooperative for an injection or drawing blood, what do you do first?
let parents help
How do you help PRESCHOOLERS deal with injections?
let them give pretend injection to doll
What is a possible indicating symptom of child with diabetes?
bed-wetting at night
How can you help a child if uncooperative at home with insulin injections? x2
establish routine,
follow with something fun (story)
How do you help child work thru feelings about injections, etc.?
have them draw pictures and talk about them
What do school age diabetic children often want?
So, what do you do?
to participate in self care, so teach them ASAP
Growing diabetic children need more calories, how many meals and snacks do you feed them?
3 meals,
3 snacks per day
What type of insulin?:
Humalog (Lispro)
rapid-acting
What type of insulin?:
novolog (Aspart)
rapid-acting
What type of insulin?:
apidra (Glulisine)
rapid-acting
What type of insulin?:
regular
short-acting
What type of insulin?:
humalog R
Short-acting
What type of insulin?:
novolin R
short-acting
What type of insulin?:
NPH
intermediate-acting
What type of insulin?:
Lente
intermediate-acting
What type of insulin?:
Humulin N
intermediate-acting
What type of insulin?:
Novolin N
intermediate-acting
What type of insulin?:
Ultralente
long-acting
What type of insulin?:
lantus (Glargine)
very long-acting
What type of insulin?:
levemir (Detemir)
very long-acting
Humalog brand name?
Lispro
Novolog brand name?
Aspart
Apidra brand name
Glulisine
Lispro generic name
Humalog
Aspart generic name
Novolog
Glulisine generic name
Apidra
Lantus brand name
Glargine
Glargine generic name
Lantus
Levemir brand name
Detemir
Detemir generic name
Levemir
What are the s/s of DIABETIC KETOACIDOSIS?
hyperglycemia, itching, glucosuria, polyuria, polyphagia, polydipsia, wt. loss, weakness, blurred vision, ketones in blood and urine, Kussmaul breathing, ketone breath, n/v, abd. pain, h/a, warm skin, flushed skin, dry skin, ^ T, v BP, rapid thready pulse, v LOC (drowsy or coma)


3Ps
+
Kussmaul, ketone breath, ketones in blood and urine
Elevated BS, glucose in urine & Temp
Trimmed weight
Optical issues (blurred vision)
Abdominal Pain
Crippling weakness
Itching
Dry skin
Obnoxious h/a
Signs of shock (rapid thready pulse, v BP, v LOC)
Indigestion (n/v)
Skin warm & flushed
"3 Ps + KETOACIDOSIS"
DKA, do s/s appear slowly or quickly?
slowly
DKA causes what 3 problems?
hyperglycemia, dehydration, acidosis
With DKA, you've been "HAD"
Hyperglycemia
Acidosis
Dehydration
Average BS for DKA:
300-800 mg (maybe >1000)
If severity of DKA is not r/t BS, what other two issues might it be r/t?
low serum bicarb (0-15 mEq/L),
Low pH (6.8-7.3)
What does v pCO2 indicate?
respiratory compensation of acidosis (Kussmaul breathing)
What changes in the CBC might you see in DKA? x4
Why?
^ Hct, Hgb, BUN & creatinine,
d/t dehydration
What level of care does DKA require?
ICU,
it's a medical emergency
If DKA pt is conscious, how do you position him?
on side
If DKA pt has low O2 sat, what can you do?
nonrebreather mask
What are 3 parts of Rx for DKA, in order?
1. Rehydrate
2. Correct acidosis (by giving insulin)
3. Replace electrolytes
What are the 3 steps to REHYDRATION of DKA pt?
1. NS
2. 1/2NS
3. D5W
When rehydrating DKA pt, what's the RATE and DURATION of administering NS (NS is first step)?
NS @ 500-1000 mL/hr
for 2-3 hrs
When rehydrating DKA pt, what's the RATE of administering 1/2 NS (1/2 NS is 2nd step)?
How much might you use?
When do you d/c it?
-200-500 ml/hr
-may use 6-10L
-d/c when BS is 300 mg or less
What's unique about what insulin does for DKA pt?
inhibits fat breakdown
For DKA pt, what are two possible steps for admin of insulin?
1. may give 5-10 unit regular insulin per IV bolus
2. Give slow continuous IV of reg insulin (5 units/hr)
For DKA pt, too rapid a correction w/ insulin may cause...
cerebral edema
For DKA pt, how often do you check VS?
Q1H
For DKA pt, when they reach BS of 300 mg, what do you do?
and what do you not do?
add glucose to IV,
but don't stop insulin
For DKA pt, what 2 things have to happen before stopping insulin even after normal BS is reached?
1. bicarb improves (at least 15-18 mEq/L)
2. pt can eat
For DKA pt, how long might insulin be given even after normal BS is attained?
12-24 hours
For DKA pt, what do you rarely give to correct acidosis?
Why?
rarely give bicarb b/c
may cause big drop in K
For DKA pt, what electrolyte is most important that they're losing?
K
For DKA pt, 4 steps to K replacement?
(includes admin., checks, leveling off)
1. add K to first few IVs (even if serum K normal)
2. Check OUTPUT
3. Check ECG
4. As DKA resolves, v K
For DKA pt, 2 NI after resolution:
1. find precipitating cause to prevent future DKA
2. teach sick day rules
Symptoms of HNKS:
hyperglycemia, polyuria, polydipsia, warm flushed skin, increased temp and pulse, v BP, soft sunken eyeballs, v LOC, altered sensorium, hemiparesis, seizures

HyPEROSMoLAR
HYperglycemia
Polyuria, polydispsia
Elevate temp & pulse
Red hot skin (warm flushed)
Out cold (v LOC)
Soft sunken eyeballs
Moving difficulties (hemiparesis)
Omit
Lower BP
Altered sensorium
Rumbling or Rocking (seizures)
For HNKS pt, what's the BS?
600-1200 mg
For HNKS pt, what's the osmolality?
above 350
For HNKS pt, what's abnormal w/ CBC?
Why?
^ BUN & creatinine, b/c of
dehydration
3 causes of HNKS:
1. acute illness
2. drugs that fuck w/ insulin
3. undiagnosed Type II
What's the difference in the need for insulin when it comes to DKA vs. HNKS?
In DKA, it's needed to counter acidosis and fat breakdown
Until when do you continue Rx for HNKS?
How long does that usu. take?
until neurological signs disappear,
takes ~3-5 days
What are two other names for HYPOGLYCEMIA?
insulin shock
insulin reaction
What's the BS for HYPOGLYCEMIA?
<50 mg
Who might get HYPOGLYCEMIC reaction, even if BS seems normal?
pt who's used to BS in 200s
What are 3 causes of HYPOGLYCEMIA?
too little food,
too much insulin or oral antidiabetic, or
excess px activity
Hypoglycemia is most likely to occur at what 2 times?
when insulin peaks,
before meal time
What are symptoms of MILD hypoglycemia? x10
sweating, cool & clammy skin, tachycardia, palpitations, rapd shallow resp., nervousness, tremors, weakness, pale, hunger
think 'nervousness'
What are the symptoms of MODERATE hypoglycemia?
often irritable, irrational or aggressive behavior, h/a, unable to concentrate, memory
think drunk
What causes symtoms of mild hypoglycemia?
surge of epinephrine
What causes symtoms of moderate hypoglycemia?
Therefore, what kind of symptoms do you see?
rain cells deprived of glucose,
CNS symptoms
What are the symptoms of SEVERE hypoglycemia?
very disoriented, seizures, loss of consciousness
With hypoglycemia, do symptoms come on suddenly or slowly?
suddenly
What two types of people might not show milder symptoms of hypoglycemia?
-If pt had DM for many years (may have v adrenalin response to low BS
-pt taking beta blockers
What can happen if BS is too low, too long?
permanent CNS damage
First step to treat hypoglycemia when symptoms first occur?
What if it doesn't work? (what BS do you look for?)
take rapid acting simple sugar
(OJ, soda, sugar, hard candy, etc.)
Repeat in 10-15 min (or if BS <70)
In hypoglycemic pt, what's 2nd step for CHO replacement?
eat snack containing protein and complex carb (milk, cheese, hamburger)
When treating HYPOGLYCEMIA, don't give what to eat?
hi-cal, hi-fat dessert
With hypoglycemia, if unconscious at home, what do you tell family to give?
glucagon IM or sub q
What's the side effect if giving glucagon?
nausea
With hypoglycemic pt, if uncoscious in hospital, give what?
What's a potential s/e?
25-50 cc D50W IV push
may get h/a
How fast does pt wake up after receiving glucagon?
20 minutes
How fast does the pt wake up after receiving D50W?
minutes
What might you give to treat pt w/ insulin reaction? (other than CHO)
epinephrine
What's the diff between typical person and diabetic in when they get atherosclerosis?
DM pt gets it younger
What are three atherosclerotic complications that may happen in DM pt?
1. PVD
2. CVA
3. CAD
What's reason for amputations and gangrene in DM pt.?
PVD causes occlusions & arterial insufficiency
What's the most important indicator of severity of PVD?
presence & severity of intermittent claudication
What are symptoms of PVD? x8
taut, shiny, hairless skin, v or absent peripheral pulses, feet cool & pale, loss of hair dorsal foot, thick toenails, intermittent claudication.
Rx for PVD: x5
1. sox - keep socks on at all times
2. HOB - elevate 6-12 in.
3. Whiskey - BID for pink legs
4. Check CMSTP
5. Blankets - Keep weight of blankets off legs
What med can you give to help PVD with intermittent claudication exercise?
Trental
What do you try to control in pt with PVD with exercise, diet, and meds? x3
BP, lipids, BS
What long term complications are unique to DM? x2
nephropathy,
retinopathy
If at risk for microvascular complications, keep what levels normal? x2
BS, BP
What is important to stop doing for pt at risk for any vascular complications?
stop smoking
What's a symptom of NEPHROPATHY?
hypoglycemia (b/c insulin not broken down by kidneys)
What level do you check first to check for NEPHROPATHY?
albumin in urine
What % of pt with microalbuminuria develop nephropathy?
85
What technique and how often do you check for albumin in DM pt?
yearly 24 hour urine
What's unique that you omit from testing a pt with nephropathy?
no dyes
What 3 things do you check in pt that develops microalbuminuria?
BUN, creatinine, HTN
What med do you use for pt with nephropathy for hypertension?
ACE inhibitor
What's the s/e of flourescein test for retinopathy?
nausea during, then
hives, bright yellow skin and urine for 12-24 hrs
Rx for retinopathy?
laser - photocoagulation
How much does photocoagulation v rate of visual loss to macular edema?
50%
What is the pathophysiology of non-proliferative on pre-proliferative retinopathy?
macular edema causing central vision loss
What is the pathophysiology of proliferative retinopathy? x2 paths
-Bleeding in vitreous makes cloudy vision
-Blood reabsorption causes scar tissue and possible v vision or detached retina
What are two other potential vision complications for DM pt besides retinopathy?
glaucoma,
cataracts
What causes neuropathies in DM pt?
nerves damaged by BS
In peripheral neuropathy, does it affect extremities unilaterally or symmetrically?
symmetrically
Two first symptoms of peripheral neuropathy:
Two next possible symtoms:
1. paresthesia (pricking, tingling), burning (esp. at night)
2. numbness, crawling sensation
What's the unique med for peripheral neuropathy?
Cymbalta
How do you make pain go away from peripheral neuropathy (behavior, not meds or other applications?
How long might it take to go away?
control BS
months to years
RE: autonomic neuropathy:
what's happens with urinary tract?
urinary retention, prone to UTI
RE: autonomic neuropathy:
what's happens with sudomotor neuropathy?
feet dry, body sweats
prone to foot ulcers
RE: autonomic neuropathy:
what's happens with adrenal medulla?
v sensitivity to low BS
RE: autonomic neuropathy:
what's happens with cardiovascular system? x3
silent MI, slight tachycardia, orthostatic hypotension
RE: autonomic neuropathy:
what's happens with GI tract?
delayed GI emptying,
causes bloating, n/v,
wide BS swings,
diarrhea at night
RE: autonomic neuropathy:
what's happens with sexual dysfunction in men?
What med can men admin and how?
diminished erection
papaverine (vasodilator) injected into penis
RE: autonomic neuropathy:
what's happens with sexual dysfunction?
What can you use?
What happens to period?
painful sex,
use estrogen lube,
possible menstrual irregularities
RE: autonomic neuropathy:
what's happens with retrograde ejaculation?
What can it cause
normal erection & orgasm,
but semen shot into bladder,
causes impotence
What does increased BS do to immune system in foot & leg problems?
impairs leukocytes
Rx for foot & leg problems: x4
antibiotics, bedrest, debridement, may amputate
Two important NI to teach pt if foot ulcer occurs:
1. no walking
2. keep dry
With foot ulcers, what do you use to debride?
Bakin sol.
RE: foot ulcers, what happens with insulin (with all infections)?
What bad thing might happen?
^ need for insulin,
can lead to DKA
What are three things that ^ BS?
food, illness, stress
What are two things that v BS?
insulin,
exercise,
not eating
Teach to eat how often for DM pt?
Q4-5H while awake
Teach "tie", what's it mean?
Test
Insulin
Eat
Teach 5 symptoms of hypoglycemia?
strange sensation, hunger, sweating, tremors, nervousness
What do you teach to do to feet after daily washing?
massage lotion into feet,
powder between toes
When do you teach to buy shoes?
afternoon
If foot injury occurs, what do you teach to do?
1. wash w/ soap/water
2. cover w/ DSD, NO ADHESIVE
3. white sox
4. call dr
SICK DAY RULES:
how do take insulin or oral antidiabetics?
as usual
SICK DAY RULES:
What do you test?
How freq?
What levels?
1. test BS & ketones
2. Q4H
3. any ketones, BS above 300
SICK DAY RULES:
What do you do if ketones in urine?
take extra insulin
SICK DAY RULES:
If can't eat normally, what do you do?
eat freq small amounts of CHO 6-8 x per day
SICK DAY RULES:
If vomiting or fever, what do you do?
drink calorie-containing liquids Q 1/2-1H,
if not, call doc
What do you teach to report that may indicate ^ BS?
itching
What's the most common cause of DKA?
infection
What do ketones in blood and urine indicate?
cells starving
When do you admin glucagon?
insulin-induced hypoglycemia
What type of insulin is coverage?
rapid- or short-acting, only
What's the best indicator of BS control?
A1C
What's the first part of teaching?
find out what they know
Temp of water when bathing feet?
warm, not hot