education
define type 1 diabetes
- destruction of beta cells causing complete abscence of insulin.
- glucose cannot enter the cell without insulin
- increased glucose = damage
nursing dx for diabetes
- potential for impaired wound healing, injury, kidney disease, hypoglycemia, DKA, HHS, coma, death,
- pain due to neuropathy
what are macrovascular complications
- accelerated/ abnormal lipid metabolism. Diseases of the large and medium size blood vessels with greater frequency and early onset
- they include cerebrovascular, cardiovascular and peripheral vascular disease (HTN, stroke, low extremity amputation, infection)
what are some on going assessments for long term monitoring of diabetes?
- glycosylated hemoglobin assays (Hgb A1C)
- glycosylated serum proteins and albumin
- kidney function tests
causes of type 1 and type 2 diabetes
type 2: obesity, strong genetic disposition
define diabetes type 2
- decreased insulin production and cellular insulin resistance
- hepatic overproduction of glucose since glucose cannot enter the cell
how to treat potential problems for diabetes
- prevent injury from hyperglycemia: meds (insulin, PO), nutrition, exercise, transplant
- neuropathy: footwear, screenings, mirrors
- pain: prevent injury from reduced vision, reduce risk of kidney disease, prevent hypoglycemia (glucose tabs, monitoring glucose)
- prevent DKA and HHS: managing sick days
earliest indicator of diabetic nephropathy and its risk factors/ tx
- DM is the leading cause of end stage renal disease with earliest indicator being microalbuminuria
- risk factors: uncontrolled BG, HTN, hx of 5-10 years DM
- Tx: control BG and BP, ARBs, ACEs reduce level of albuminuria and rate of progression
what are the diagnostic tests for diabetes
- random: >200 any time of day AND has signs and symptoms of DM
- fasting: 8 hours preferred test >126 on 2 separate tests confirm diabetes (100-125 is pre diabetes)
what is glucose intolerance
- abnormal change in response to elevated glucose of 100-125 fasting level
- insulin resistance "pre diabetes" should test A1C regularly and monitor for symptoms of diabetes such as polyuria, polyphagia, and polydipsia
- hypercholesterolemia, obesity, hypertension
exercise with diabetics
- increases blood glucose, wt. management, decreases stress and BP
- check glucose before and after, carry something that has glucose (10-15 carbs)
- avoid exercise if glucose is >250 or <80 and wear ID bracelet
what makes up carbohydrates
- provide energy, fiber, vitamins and minerals
- sugar, starch and fiber raise blood glucose (alcohol)
- CHO recommended from fruits, non starchy veggies, whole grains, legumes, low fat milk
- must watch total calories (fiber 21-25gm/day, 45-65% total calories from CHO)
what occurs during diabetic retinopathy and which type gets it
- nearly all type 1 diabetics will eventually have this.
- blood vessels to retina are blocked, causing them to leak leading to retinal hypoxia, edema, retinal hemorrhages and hard exudates on the retina
- blurred vision, early cataracts, estimated to be the most common cause of NEW cases of adult blindness
what are other forms of diagnosing diabetes
- urine ketones
- lipid, cholesterol, triglyceride levels
- serum and urine creatine levels
- urine for microalbuminuria/ doppler studies
symptoms of type 1 vs type 2
type 1: 3 Ps, weight loss because the body cannot get glucose and turns to other energy sources such as fat and protein, fatigue, ketonuria, and SOMETIMES blurred vision (symptoms usually acute onset)
type 2: fatigue, recurrent infections/ vaginal yeast/ candida, prolonged wound healing and visual changes
goals of a diabetic diet
type 1: consistency to attain normal levels
type 2: weight loss (5-7% of body weight)
- each patient's individual meal plan should be constructed with their lifestyle and goals in mind
- controls lipids to reduce heart disease, complications, address individual needs
protein in the diet with DM
- 20-35% of daily intake (same as non diabetics)
- protein does not increase blood glucose
- diabetic with kidney disease needs to reduce protein intake
what happens during diabetic neuropathy
- most common complication of diabetes. Nerve fibers damaged due to decreased blood flow
- sensory: pain and loss of sensation
- motor: foot deformities
- autonomic neuropathy (impotence, neurogenic bladder, gastroparesis, cardiovascular)
oral meds used for type 2 diabetics
- sulfonylurea (glipizide, glyburide) stimulates pancreas to produce insulin
- meglitinides (repaglinide) short acting, ^
- biguanides (metformin) decrease production of glucose by liver, increase tissue response to insulin
- alpha glucosidase inhibitor (acarbose) slows carbs digestion and absorption, take w first bite of food
- thiazolidinediones (rosiglitazone) increase tissue sensitivity to insulin, causes fluid retention (caution with cardiac) monitor LFTs
symptoms of absence of insulin
- hyperglycemia, ketone bodies, hemoconcentration, hypovolemia, hyper viscosity, hypoperfusion, hypoxia
- acidosis, 3 Ps
educating patient on stress affecting blood sugar
- ANS stimulates output of cortisol from adrenal cortex and epinephrine from medulla
- epinephrine works quickly to increase HR and BP
- cortisol works slow to increase glucose availability to suppress cell mediated immunity
- chronic stress leads to hyperglycemia, HTN, increased LDL, accelerates atherosclerosis, suppresses immune system
fat in the diet as a diabetic
- dietary fat provides energy, carries fat-soluble vitamins and provides essential fatty acids
- <200mg a day in cholesterol, 20-35% of total calories <7% saturated
- 2 servings of fish per week
wat happens during mixed vascular and neuropathic disease
- foot complications of micro and macro diseases placing patient at risk for injury and serious infection. Smoking makes it worse
- leading cause of hospitalization (annual foot screening, daily inspection, appropriate foot wear)
ways to administer insulin and the types
- needle/vial, pen, pump, bolus, gtt (routines by subq, regular can be given IV when immediate onset of action is needed, insulin cannot be taken orally because it is inactivated by gastric juices)
- rapid acting (lispro/humalog) , short acting (regular), intermediate (NPH), long acting (glargine/lantus), pre-mixed (humulin 70/30)
where is insulin stored
- secreted and stored in the beta cells of the islets of langerhans in the pancreas. It is transformed by the liver into active insulin
- insulin attaches to receptors on target cells where it promotes glucose transport into cells through cell membranes
- insulin is released continuously into blood stream in small increments, with larger amounts released after food