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360 Cards in this Set
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When does Type 2 DM usually occur?
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usually after 30, but can at any age
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Type 2 DM, relationship to insulin replacement?
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not insulin dependent
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Type 2 DM, relationship to Ketosis
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ketosis resistent
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Type 2 DM, percent overweight?
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80%
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Type 2 DM, 3 causative factors:
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obesity, heredity, environmental factors
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Type 2 DM, can you release insulin?
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some, but not enough
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Type 2 DM, can't release enough insulin, why? x2
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may be r/t v insulin production, or
excess CHO intake |
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What type of diabetic can get v sensitivity to insulin?
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pt w Type 2 DM
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v sensitivity to insulin is called...
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insulin resistance
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Type 2 DM, what can obesity do to body's response to insulin?
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reduce insulin binding at receptor sites
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Type 2 DM, obesity reducing insulin binding at receptor sites can lead to what?
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hypersectretion of insulin and
eventual pancreatic cell exhaustion |
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What type of DM sees symptoms r/t fat breakdown?
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Type 1 during DKA
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Type 2 DM, what can you develop?
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hyperosmolar nonketotic syndrome (HNKS)
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HNKS, what signs do you see? x3
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hyperglycemia and hyperosmolarity with alterations in sensorium
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HNKS can prevent what, but not what?
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ketosis doesn't occur, but not enough insulin to prevent hyperglycemia
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HNKS, first two symptoms
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polyuria
polydipsia |
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HNKS, polyuria & polydipsia cause what? with what symptoms? x6
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severe dehydration:
warm flushed skin, ^ temp, v BP, rapid thready pulse, soft sunken eyeballs, v LOC |
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HNKS, severe dehydration can lead to what?
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hypovolemic shock
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When do you seek attention with HNKS? x3
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when neuro signs appear:
altered sensorium, hemiparesis, seizures |
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2 subtle signs of undetected DM
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nocturia
wounds heal slowly |
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What type of DM can go undetected?
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type 2
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When might MD dx DM? x2
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insidious onset of fatigue,
complication of DM ex. poor vision |
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Type 2 DM, treatment x3
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diet, exercise,
oral anti-diabetic agents if needed |
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DM secondary to other conditions x3
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1. Hypersecretion of hormones that antagonize insulin
2. Pancreatic disease 3. Burns |
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What hormones antagonize insulin? x3
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glucocorticoids, epinephrine, growth hormone
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Why do burns cause DM?
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excessive metabolism makes need for insulin exceed supply
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When does gestational DM occur usually?
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2nd or 3rd trimester
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What causes gestational DM?
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insulin antagonizing hormones from placenta
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Treatment for gestational DM? x2
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diet, insulin if needed
*note:not exercise (only do that at same level as pre-preg. |
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previous hx or hyperglycemia (ex illness or pregnancy), but current glucose metabolism is normal
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prediabetes
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Who's at risk for DM? x9
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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"
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Criteria for dx of DM? x3
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1. Symptoms, plus random <200 mg OR
2. FBS (fasting BS) ≥126 3. 2-hr postload glucose ≥200 during oral glucose tolerance test (GTT) |
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FBS (fasting blood sugar) is defined as...
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blood drawn after NPO ≥8 hr
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GTT (glucose tolerance test) procedure?
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pt fasts overnight,
drinks 75 gm CHO (glucola), draw blood Q1Hx3 |
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Normal values of GTT
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1hr. <115
2hr. <200 3hr. <140 |
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ADA guidelines for normal and prediabetic FBS?
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normal FBS = 80-90
prediabetic FBS = 100-125 |
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SMBG
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self monitoring of blood glucose
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Best way to keep BS normal and v complications
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SMBG
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How often monitor glucose: if on insulin? if not on insluin?
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on insulin: 2-4x/day
not on insulin: 2-3x/week |
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What is used to determine if treatment is adequate over a 24 hour period?
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Continuous glucose monitoring system
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When what is happening to pt that you would check for ketones in urine? x2
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when BS staying high, and
during illness |
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What's the blood test that shows BG over 2-3 month period?
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Glycosylated hemoglobin (HgbA1c or A1C)
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What's normal range for A1C test?
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4-6%
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Define preprandial blood glucose. What range?
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BS taken before meal,
80-120 mg |
Grandma (80y/o) walking through the desert (120 deg) before her meal
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What routes can you take insulin?
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sub q and IV
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What four things does insulin do?
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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. |
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RAPID ACTING INSULIN,
name 'em: |
humalog (Lispro)
novolog (Aspart) Apidra (Glulisine) |
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RAPID ACTING INSULIN,
onset? peak? |
onset: 10-15 min
peak: 40-60 min |
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SHORT ACTING INSULIN,
name 'em: |
Regular
Humalog R Novolin R |
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SHORT ACTING INSULIN,
onset? peak? |
onset: ½ - 1 hr.
peak: 2-3 hrs. |
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INTERMEDIATE ACTING INSULIN,
name 'em: |
NPH
Lente Humulin N Novolin N |
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INTERMEDIATE ACTING INSULIN,
onset? peak? |
onset: 2 - 4 hrs.
peak: 4 -12 hrs. (~8 hrs.) |
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LONG ACTING INSULIN,
name it: |
Ultralente
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LONG ACTING INSULIN,
onset? peak? |
onset: 6 hrs.
peak: 12 - 16 hrs. |
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VERY LONG ACTING INSULIN,
name 'em: |
Lantus (Glargine)
Levemir (Detemir) |
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VERY LONG ACTING INSULIN,
onset? peak? |
onset: 1 hr.
peak: continuous (no peak) |
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What insulin type can you use with an INSULIN PUMP?
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Regular, Humalog, or Aspart
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Insulin sites: x4
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upper arms, upper thighs, abdomen, hips
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Preferred insulin injection site:
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abdomen
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Why is abdomen preferred insulin site?
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easy access for pt, and
absorption is more even and rapid |
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Use how many insulin injection sites in each area?
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6
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Order of speed of insulin absorption for injection sites [fastest to slowest]
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1. abdomen
2. arms 3. thighs 4 hips |
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Use what insulin injection site on gym days?
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abdomen
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Describe local insulin reaction: x3
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redness, swelling, itching at injection site
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What can give for local insulin reaction?
When? |
antihistamine,
1 hr. before insulin |
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Systemic Reaction to insulin,
Rx? |
desensitization with small doses of insulin
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Resistance to replacement insulin, defined as...
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pt needing > 200 units of insulin per day for normal BS
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A disturbance of fat metabolism,
called what? |
lipodystrophy
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Two types of lipodystrophy,
called what? |
1. lipoatrophy
2. lipohypertrophy |
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Define lipoatrophy
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dimpling of sc fat
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Define lipohypertophy
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fibrofatty mass (scar tissue) at injection site
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What does pt do to cause lipohypertrophy?
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prolonged use of same injection site
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Complication from lipohypertrophy
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irregular absorption
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situation in which sudden v in BS is followed by rebound hyperglycemia (stress hormones respond to low BS)
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Somogyi phenomenon
*Sumo wrestler is so big he falls he bounces right up |
a. Somogyi phenomenon
b. Dawn phenomenon c. insulin waning |
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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 |
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situation in which you have:
a progressive ^ in BS from bedtime to am |
Insulin waning
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a. Somogyi phenomenon
b. Dawn phenomenon c. insulin waning |
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Three types of morning hyperglycemia:
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a. Somogyi phenomenon
b. Dawn phenomenon c. insulin waning |
phenomenons
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Somogyi phenomenon: Timeline...
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bedtime: high BS
3am: low morning: high |
when is it normal?
when is it ^? |
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Dawn phenomenon: Timeline...
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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 ^? |
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Insulin waning: Timeline...
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progressive ^ in BS from bedtime to am
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when is it normal?
when is it ^? |
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Somogyi phenomenon: Rx... (2 choices)
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v evening dose of intermediate insulin OR
^ bedtime snack |
either , or
targeted at increasing BS early |
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Dawn phenomenon: Rx...
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change pre-dinner intermediate insulin to bedtime
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change the time of intermediate insulin
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Insulin waning: Rx...
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^ dose of pre-dinner or bedtime insulin
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is it changing the dose or
changing the timing |
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what delivers insulin thru skin under pressure
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Jet injector
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Insulin given with this by dialing a dose or pushing a button for every 1 or 2 unit increment given
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Insulin pens
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How often do you change insulin pump dressing?
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Q3 days
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When does an insulin pump administer doses?
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basal dose (ex) q1h
bolus dose before meals |
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Can you use oral antidiabetic agents during pregnancy?
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no
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What can oral antidiabetic agents cause?
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hypoglycemia
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When do you use oral antidiabetic agents?
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when exercise and diet don't work
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Which oral antidiabetic agent stimulates beta cells to produce insulin?
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Sulfonylureas
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Requirement for sulfonylureas?
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functioning pancreas.
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Sulfonylureas, examples...
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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) |
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orinase: drug class?
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sulfonylurea - 1st gen
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diabinese: drug class?
h |
sulfonylurea - 1st gen
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you wear NYLons around your NESE
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micronase: drug class?
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sulfonylurea - 2nd gen
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glucotrol: drug class?
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sulfonylurea - 2nd gen
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amaryl: drug class?
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sulfonylurea - 2nd gen
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Sulfonylurea
side effects: |
1st gen - GI and dermatitis
2nd gen - weight gain *alcohol may cause Antabuse-like reaction |
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Which oral antidiabetic agents in particular may cause disulfurin-like reaction?
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sulfonylureas
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Biguanides: examples x2
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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 |
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Thiazolidinediones: examples x2
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Actos,
Avandia |
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Thaizolidinediones: risk r/t pregnancy
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^ risk of pregnancy if taking oral contraceptives
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Actos: drug class?
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Thiazolidinedione
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Avandia: drug class?
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Thaizolidinedione
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Glucophage (Metformin): drug class?
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Biguanide
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Glucovance (Metformin with glyburide): drug class?
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Biguanide
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Alpha glucosidase inhibitors: example 1
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Precose
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Precose: drug class?
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alpha glucosidase inhibitor
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Meglitinides: example x1
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Prandin
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MEGalomaniacs only shop for PRAND name products
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Prandin: drug class?
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Meglitinides
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Exenatide (Byetta): drug class?
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Oral antidiabetic agent
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Exanatide: brand name?
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Byetta
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Byetta: generic name?
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Exanatide
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What is the one oral antidiabetic agent that someone with Type 1 DM can use?
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Pramlintide (Symlin)
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Pramlintide (Symlin): drug class?
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oral antidiabetic agents
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Pramlintide: brand name?
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Symlin
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Wouldn't it be interesting if you could go to a PROM in SYM City
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Symlin: generic name?
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Pramlintide
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When do you use pramlintide (Symlin)?
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when mealtime insulin is not enough by itself
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What's the optimal wt. to lose per week with DM?
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2 lbs/wk.
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Two goals of DM diet:
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1. maintain optimal weight
2. control BS |
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What condition is important to correct ASAP with DM?
Why? |
obesity
(more resistant to all insulin) |
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It is good to keep what two things CONSISTENT with the DM diet?
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1. number of calories at different meals
2. time between meals |
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DM, re: skipping meals
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don't do it
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DM, re: menu
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should be varied
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Import to include what ingredient in the DM diet?
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fiber
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What does fiber do for the diabetic? x2
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prevents wide variations in BS and minimizes ^ BS after meals
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If on NPH, good to have what? when?
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snack at night
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Preferred calorie distribution:
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50% from CHO (40% complex, 10% simple),
30% from fats, 20% from proteins |
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What are 8 examples of STARCHY VEGETABLES?
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corn, lima beans, parsnips, peas, potato, pumpkin, squash, yam
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cheese, cottage cheese
these count as what exchange? |
meat exchanges
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butter, margarine, cream, cream cheese, mayonnaise, dressings
These count as what exchange? |
fat exchanges
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what's special about peanut butter as an exchange?
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it counts as 1 meat and 2 fat exchanges
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how do you lower glycemic index of starch and sugars?
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eat with fats and proteins
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glycemic index, define...
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describes how much a given food ^ BS compared to equal amount of glucose
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alcohol may cause...
...esp. if... |
hypoglycemia...
...esp. if on insulin or oral hypoglycemics |
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Exercise does what to insulin need?
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v need
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If taking insulin, it is best to exercise how long after meals?
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1-2 hours
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When on insulin, if exercising for a long time, when do you check BS?
What do you bring? |
before, during, after
bring CHO snacks |
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What other health problems must you consider before starting exercise with DM?
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neuropathy and risk for heart disease
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Don't begin exercise if BS is greater than what? What else is an issue?
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BS>250
ketones in urine |
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Stress does what to BS?
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^ BS
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What are examples of types of stress? x3
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px, emotional, infection
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Stress increases production of what BS increasing hormones?
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glucocorticoids and epinephrine
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What does the diabetic pt need more of during stressful times?
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insulin
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Major possible danger before/during/after surgery for DM pt.?
Why? |
hypoglycemia,
CNS sensitive to low BS |
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How do you modify admin. of oral hypoglycemics, intermediate and long-acting insulin, before surgery?
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stop them 1-2 days pre-op and give regular insulin instead
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How often check insulin surrounding surgery?
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Q1H
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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 |
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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. |
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When should you schedule a diabetic for surgery?
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early in the day (so pt. not NPO so long)
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What are two pathological conditions of diabetics that cause problems during surgery?
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1. they have generalized vascularized disease
2. v resistance to infection |
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Major possible danger before/during/after surgery for DM pt.?
Why? |
hypoglycemia,
CNS sensitive to low BS |
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What type of diabetic meds are usu. stopped before surgery?
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oral hypoglycemics, intermediate and long-acting insulin
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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 |
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What's hanging during surgery for DM pt.?
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1 IV of glucose
1 IV of insulin adjusted hourly according levels |
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Post-op for DM pt:
Continue IV glucose and IV insulin until when? |
until pt is taking po
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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. |
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What might BS do right after surgery?
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BS may be elevated (d/t stress)
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It's important to check for what life-threatening complications? 1+2ex
Why? |
CV complications (ex) MI, stroke,
b/c diabetics have atherosclerosis |
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It's important to check for what dermal complications? x2
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wound infection, skin breakdown
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At how many weeks do you check for gestational DM?
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24-28 wks gestation
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What's the criteria for Class A in Whites Classification of Pregnant Diabetics?
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abnormal GTT only
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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
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What hormones does a pregnant lady produce that antagonize insulin? x6
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estrogen, progesterone, HCG, HPL, cortisol, growth hormone
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Why are diabetic pregnant pts more likely to develop ketoacidosis?
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increased amount of insulin antagonizing hormones produced
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What are pregnant diabetics in risk of acquiring?
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ketoacidosis
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What do pregnant diabetics need more of?
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insulin
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Why is insulin depressed in pregnant diabetic?
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placenta breaksdown insulin
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What happens to the need for insulin as pregnancy progresses?
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increased need
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What happens to insulin needs right after placenta delivery?
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need drops abruptly
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what's the most important NI after birth for diabetic mom?
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stop delivery of extra insulin
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What normal birthing s/e is more dangerous for the pregnant diabetic?
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vomiting
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What issue is more common and serious in pregnant diabetic?
What's an ex of what it can cause? |
Infection,
ex. pyelonephritis |
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The chance of what increases for the fetus and/or neonate of diabetic mom?
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death
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What presents the greatest fetal risk if mom has diabetes?
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ketoacidosis
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What problems have a high incidence d/t effects of diabetes on pregnancy? x6
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PIH, hydramnios, congenital anomalies, RDS, dystocia, pp hemorrhage
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With what class might a therapeutic abortion be justified?
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Class F or worse
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Women of what class can usu. have babies with normal weight and low morbidity?
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Class A-C
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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)
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What do you teach pregnant diabetic r/t what you teach any diabetic?
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teach same stuff, plus
signs of PIH |
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For pregnant diabetic, Rx includes dietary modification EXCEPT what?
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NEVER RESTRICT CALORIES
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In what week do insulin requirements ^ with pregnant diabetics?
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18th-20th week
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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 |
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What diabetic med do you never use with preg diab b/c may be teratogenic?
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oral hypoglycemics
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What's it mean if no ^ in required insulin after 1st trimester?
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possible problem with placenta
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What do you use to monitor a fetus of diab mom? x8
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U/S, AFP, fetal echocardiogram, estriol levels, ST, NST, biophysical profile, L/S ratio
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What do you want to see with L/S ratio for fetus of diab mom?
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3:1 or more
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During which weeks does diab. mom often deliver?
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38-40 weeks
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What 3 criteria do you use determine when to induce diab. mom? x3
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pt. status, tests of placental function, fetal maturity
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NI for laboring diabetic mom? x2
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keep on left side,
continuous monitoring |
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Breastfeeding is good in what ways?
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psychologically,
physically |
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Why is it good to breastfeed for mom's BS?
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v insulin needs
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Typical size of infants of diabetic mom?
For example... |
LGA,
ex. even delivered @37 wks, may weigh 9-10 |
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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
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Why are infants of diabetic moms large?
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Extra glucose stored as fat
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What s/s might you see with infant of diabetic mom r/t excess fat storage? x10
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fat, red-faced, round-faced, lie quietly, move little, seldom cry, cord/placenta larger, hepatosplenomegaly, cardiomegaly, cushingoid-like
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What % of infants of diabetic moms are hypoglycemic?
How many hours old are they? |
50%,
6 hours (esp. 1-4 hrs) old |
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If mom's not well-controlled, what's babies BS?
hypo- OR hyperglycemic? |
Hyperglycemic
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What is the only organ not enlarged in infant of diabetic mom?
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brain
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What can diabetic mom do to make baby less likely to develop hypoglycemia after birth?
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control BS during pregnancy
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What are neonate s/s of hypoglycemia? x6
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twitching, tremors, limp, poor feeding, convulsions, high-pitched cry
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Crying is
High-pitched o Convulsions o Limp a Twitching, Tremors e is POOR FEEDING |
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What are 3 NI to prevent hypoglycemia for neonate of diabetic mom?
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1. check BS frequently
2. give glucose-water 3. feed frequently |
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Is it ok for mom to breastfeed if on insulin?
Why? |
yes, b/c insulin not in breast milk
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What can you do for neonate of diabetic mom if BS very low?
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IV with glucose
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What are the major potential problems for neonate of diabetic mom? x7
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hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia, RDS, birth trauma (ex perinatal asphyxia), congenital anomalies
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BIRTH
P o a C H e R |
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What do you see with neonatal hypocalcemia?
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tremors
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What's an example of a congenital anomaly of neonate of diabetic mom?
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heart defects
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What is hypocalcemia in the neonate r/t? x2
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maternal diabetes,
prematurity |
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What is hyperbilirubinemia in the neonate of diabetic mom r/t?
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prematurity
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What Class of pregnancy diabetes is at risk for RDS?
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Class A-C
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What is unique about the lungs of neonate of diabetic mom of class D-R?
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accelerated lung maturation d/t stress
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What is birth trauma of the neonate of diabetic mom r/t?
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large size
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If young child is uncooperative for an injection or drawing blood, what do you do first?
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let parents help
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How do you help PRESCHOOLERS deal with injections?
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let them give pretend injection to doll
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What is a possible indicating symptom of child with diabetes?
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bed-wetting at night
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How can you help a child if uncooperative at home with insulin injections? x2
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establish routine,
follow with something fun (story) |
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How do you help child work thru feelings about injections, etc.?
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have them draw pictures and talk about them
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What do school age diabetic children often want?
So, what do you do? |
to participate in self care, so teach them ASAP
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Growing diabetic children need more calories, how many meals and snacks do you feed them?
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3 meals,
3 snacks per day |
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What type of insulin?:
Humalog (Lispro) |
rapid-acting
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What type of insulin?:
novolog (Aspart) |
rapid-acting
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What type of insulin?:
apidra (Glulisine) |
rapid-acting
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What type of insulin?:
regular |
short-acting
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What type of insulin?:
humalog R |
Short-acting
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What type of insulin?:
novolin R |
short-acting
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What type of insulin?:
NPH |
intermediate-acting
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What type of insulin?:
Lente |
intermediate-acting
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What type of insulin?:
Humulin N |
intermediate-acting
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What type of insulin?:
Novolin N |
intermediate-acting
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What type of insulin?:
Ultralente |
long-acting
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What type of insulin?:
lantus (Glargine) |
very long-acting
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What type of insulin?:
levemir (Detemir) |
very long-acting
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Humalog brand name?
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Lispro
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Novolog brand name?
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Aspart
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Apidra brand name
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Glulisine
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Lispro generic name
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Humalog
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Aspart generic name
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Novolog
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Glulisine generic name
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Apidra
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Lantus brand name
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Glargine
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Glargine generic name
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Lantus
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Levemir brand name
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Detemir
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Detemir generic name
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Levemir
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What are the s/s of DIABETIC KETOACIDOSIS?
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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"
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DKA, do s/s appear slowly or quickly?
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slowly
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DKA causes what 3 problems?
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hyperglycemia, dehydration, acidosis
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With DKA, you've been "HAD"
Hyperglycemia Acidosis Dehydration |
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Average BS for DKA:
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300-800 mg (maybe >1000)
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If severity of DKA is not r/t BS, what other two issues might it be r/t?
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low serum bicarb (0-15 mEq/L),
Low pH (6.8-7.3) |
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What does v pCO2 indicate?
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respiratory compensation of acidosis (Kussmaul breathing)
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What changes in the CBC might you see in DKA? x4
Why? |
^ Hct, Hgb, BUN & creatinine,
d/t dehydration |
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What level of care does DKA require?
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ICU,
it's a medical emergency |
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If DKA pt is conscious, how do you position him?
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on side
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If DKA pt has low O2 sat, what can you do?
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nonrebreather mask
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What are 3 parts of Rx for DKA, in order?
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1. Rehydrate
2. Correct acidosis (by giving insulin) 3. Replace electrolytes |
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What are the 3 steps to REHYDRATION of DKA pt?
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1. NS
2. 1/2NS 3. D5W |
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When rehydrating DKA pt, what's the RATE and DURATION of administering NS (NS is first step)?
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NS @ 500-1000 mL/hr
for 2-3 hrs |
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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 |
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What's unique about what insulin does for DKA pt?
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inhibits fat breakdown
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For DKA pt, what are two possible steps for admin of insulin?
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1. may give 5-10 unit regular insulin per IV bolus
2. Give slow continuous IV of reg insulin (5 units/hr) |
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For DKA pt, too rapid a correction w/ insulin may cause...
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cerebral edema
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For DKA pt, how often do you check VS?
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Q1H
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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 |
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For DKA pt, what 2 things have to happen before stopping insulin even after normal BS is reached?
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1. bicarb improves (at least 15-18 mEq/L)
2. pt can eat |
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For DKA pt, how long might insulin be given even after normal BS is attained?
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12-24 hours
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For DKA pt, what do you rarely give to correct acidosis?
Why? |
rarely give bicarb b/c
may cause big drop in K |
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For DKA pt, what electrolyte is most important that they're losing?
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K
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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 |
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For DKA pt, 2 NI after resolution:
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1. find precipitating cause to prevent future DKA
2. teach sick day rules |
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Symptoms of HNKS:
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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) |
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For HNKS pt, what's the BS?
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600-1200 mg
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For HNKS pt, what's the osmolality?
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above 350
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For HNKS pt, what's abnormal w/ CBC?
Why? |
^ BUN & creatinine, b/c of
dehydration |
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3 causes of HNKS:
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1. acute illness
2. drugs that fuck w/ insulin 3. undiagnosed Type II |
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What's the difference in the need for insulin when it comes to DKA vs. HNKS?
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In DKA, it's needed to counter acidosis and fat breakdown
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Until when do you continue Rx for HNKS?
How long does that usu. take? |
until neurological signs disappear,
takes ~3-5 days |
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What are two other names for HYPOGLYCEMIA?
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insulin shock
insulin reaction |
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What's the BS for HYPOGLYCEMIA?
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<50 mg
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Who might get HYPOGLYCEMIC reaction, even if BS seems normal?
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pt who's used to BS in 200s
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What are 3 causes of HYPOGLYCEMIA?
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too little food,
too much insulin or oral antidiabetic, or excess px activity |
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Hypoglycemia is most likely to occur at what 2 times?
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when insulin peaks,
before meal time |
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What are symptoms of MILD hypoglycemia? x10
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sweating, cool & clammy skin, tachycardia, palpitations, rapd shallow resp., nervousness, tremors, weakness, pale, hunger
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think 'nervousness'
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What are the symptoms of MODERATE hypoglycemia?
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often irritable, irrational or aggressive behavior, h/a, unable to concentrate, memory
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think drunk
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What causes symtoms of mild hypoglycemia?
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surge of epinephrine
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What causes symtoms of moderate hypoglycemia?
Therefore, what kind of symptoms do you see? |
rain cells deprived of glucose,
CNS symptoms |
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What are the symptoms of SEVERE hypoglycemia?
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very disoriented, seizures, loss of consciousness
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With hypoglycemia, do symptoms come on suddenly or slowly?
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suddenly
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What two types of people might not show milder symptoms of hypoglycemia?
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-If pt had DM for many years (may have v adrenalin response to low BS
-pt taking beta blockers |
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What can happen if BS is too low, too long?
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permanent CNS damage
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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) |
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In hypoglycemic pt, what's 2nd step for CHO replacement?
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eat snack containing protein and complex carb (milk, cheese, hamburger)
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When treating HYPOGLYCEMIA, don't give what to eat?
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hi-cal, hi-fat dessert
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With hypoglycemia, if unconscious at home, what do you tell family to give?
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glucagon IM or sub q
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What's the side effect if giving glucagon?
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nausea
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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 |
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How fast does pt wake up after receiving glucagon?
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20 minutes
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How fast does the pt wake up after receiving D50W?
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minutes
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What might you give to treat pt w/ insulin reaction? (other than CHO)
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epinephrine
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What's the diff between typical person and diabetic in when they get atherosclerosis?
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DM pt gets it younger
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What are three atherosclerotic complications that may happen in DM pt?
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1. PVD
2. CVA 3. CAD |
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What's reason for amputations and gangrene in DM pt.?
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PVD causes occlusions & arterial insufficiency
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What's the most important indicator of severity of PVD?
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presence & severity of intermittent claudication
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What are symptoms of PVD? x8
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taut, shiny, hairless skin, v or absent peripheral pulses, feet cool & pale, loss of hair dorsal foot, thick toenails, intermittent claudication.
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Rx for PVD: x5
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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 |
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What med can you give to help PVD with intermittent claudication exercise?
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Trental
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What do you try to control in pt with PVD with exercise, diet, and meds? x3
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BP, lipids, BS
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What long term complications are unique to DM? x2
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nephropathy,
retinopathy |
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If at risk for microvascular complications, keep what levels normal? x2
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BS, BP
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What is important to stop doing for pt at risk for any vascular complications?
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stop smoking
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What's a symptom of NEPHROPATHY?
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hypoglycemia (b/c insulin not broken down by kidneys)
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What level do you check first to check for NEPHROPATHY?
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albumin in urine
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What % of pt with microalbuminuria develop nephropathy?
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85
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What technique and how often do you check for albumin in DM pt?
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yearly 24 hour urine
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What's unique that you omit from testing a pt with nephropathy?
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no dyes
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What 3 things do you check in pt that develops microalbuminuria?
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BUN, creatinine, HTN
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What med do you use for pt with nephropathy for hypertension?
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ACE inhibitor
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What's the s/e of flourescein test for retinopathy?
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nausea during, then
hives, bright yellow skin and urine for 12-24 hrs |
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Rx for retinopathy?
|
laser - photocoagulation
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How much does photocoagulation v rate of visual loss to macular edema?
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50%
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What is the pathophysiology of non-proliferative on pre-proliferative retinopathy?
|
macular edema causing central vision loss
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What is the pathophysiology of proliferative retinopathy? x2 paths
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-Bleeding in vitreous makes cloudy vision
-Blood reabsorption causes scar tissue and possible v vision or detached retina |
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What are two other potential vision complications for DM pt besides retinopathy?
|
glaucoma,
cataracts |
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What causes neuropathies in DM pt?
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nerves damaged by BS
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In peripheral neuropathy, does it affect extremities unilaterally or symmetrically?
|
symmetrically
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Two first symptoms of peripheral neuropathy:
Two next possible symtoms: |
1. paresthesia (pricking, tingling), burning (esp. at night)
2. numbness, crawling sensation |
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What's the unique med for peripheral neuropathy?
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Cymbalta
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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 |
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RE: autonomic neuropathy:
what's happens with urinary tract? |
urinary retention, prone to UTI
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RE: autonomic neuropathy:
what's happens with sudomotor neuropathy? |
feet dry, body sweats
prone to foot ulcers |
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RE: autonomic neuropathy:
what's happens with adrenal medulla? |
v sensitivity to low BS
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RE: autonomic neuropathy:
what's happens with cardiovascular system? x3 |
silent MI, slight tachycardia, orthostatic hypotension
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RE: autonomic neuropathy:
what's happens with GI tract? |
delayed GI emptying,
causes bloating, n/v, wide BS swings, diarrhea at night |
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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 |
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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 |
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RE: autonomic neuropathy:
what's happens with retrograde ejaculation? What can it cause |
normal erection & orgasm,
but semen shot into bladder, causes impotence |
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What does increased BS do to immune system in foot & leg problems?
|
impairs leukocytes
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Rx for foot & leg problems: x4
|
antibiotics, bedrest, debridement, may amputate
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Two important NI to teach pt if foot ulcer occurs:
|
1. no walking
2. keep dry |
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With foot ulcers, what do you use to debride?
|
Bakin sol.
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RE: foot ulcers, what happens with insulin (with all infections)?
What bad thing might happen? |
^ need for insulin,
can lead to DKA |
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What are three things that ^ BS?
|
food, illness, stress
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What are two things that v BS?
|
insulin,
exercise, not eating |
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Teach to eat how often for DM pt?
|
Q4-5H while awake
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Teach "tie", what's it mean?
|
Test
Insulin Eat |
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Teach 5 symptoms of hypoglycemia?
|
strange sensation, hunger, sweating, tremors, nervousness
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What do you teach to do to feet after daily washing?
|
massage lotion into feet,
powder between toes |
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When do you teach to buy shoes?
|
afternoon
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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 |
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SICK DAY RULES:
how do take insulin or oral antidiabetics? |
as usual
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SICK DAY RULES:
What do you test? How freq? What levels? |
1. test BS & ketones
2. Q4H 3. any ketones, BS above 300 |
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SICK DAY RULES:
What do you do if ketones in urine? |
take extra insulin
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SICK DAY RULES:
If can't eat normally, what do you do? |
eat freq small amounts of CHO 6-8 x per day
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SICK DAY RULES:
If vomiting or fever, what do you do? |
drink calorie-containing liquids Q 1/2-1H,
if not, call doc |
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What do you teach to report that may indicate ^ BS?
|
itching
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What's the most common cause of DKA?
|
infection
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What do ketones in blood and urine indicate?
|
cells starving
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When do you admin glucagon?
|
insulin-induced hypoglycemia
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What type of insulin is coverage?
|
rapid- or short-acting, only
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What's the best indicator of BS control?
|
A1C
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What's the first part of teaching?
|
find out what they know
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Temp of water when bathing feet?
|
warm, not hot
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