Clinical Manifestations
Characteristic manifestations of Diabetes Type I?
Autoimmune, genetic, virus
5-10% of all diabetics
Age 11-13: most common age to diagnose (usually before age 30)
Patients are usually thin (cachectic)
Presentation: 3 P's!! (polyphagia, polydipsia, and polyuria)
Often diagnosed in a state of emergency (DKA) - Diabetic Ketoacidosis
No insulin produced! MUST have exogenous insulin!
What are some common interventions for Diabetic patients?
Blood sugar checks every 4 hours and administer insulin based on sliding scale provided
Urine ketone testing for patients with glycosuria or persistently elevated blood glucose levels (over 240 mg/dL)
IV fluids Normal Saline 0.9%
What is the first line treatment for Diabetes Type I?
Must have exogenous insulin!!
Insulin is given SubQ (45 degree angle)
What are some patient teachings related to insulin administration?
Insulin injections are to be given at a 45 degree angle (if they are injecting at home, injecting at 90 degrees is okay)
Sites for injection include: abdomen (fastest), arm, thigh, and buttock.
Caution the patient about injecting into a site that will be exercised. Ex: injecting into thigh and then going jogging could increase rate of absorption and speed the onset of action, causing hypoglycemia
Teach patients to rotate the injection between sites - this allows for better insulin absorption
What are some common tests ordered to diagnose, and monitor diabetic patients?
CBC (complete blood count)
Comprehensive metabolic panel (COMP) -- for glucose levels and electrolyte levels
Hemoglobin A1C (for an average of 3 months blood glucose level)
Fasting plasma glucose test (FPS) -- measures blood sugar after an overnight fast
Urinalysis -- uncontrolled diabetics will have glucose in urine (glucosuria)
Characteristic manifestations of Diabetes Type II?
Onset: insidious; usually after age 40
Greater than 90% of population is type II
Overweight, obese
Presentation: fatigue, poor wound healing
May have normal or even excessive insulin secretion, but decreased utilization; DKA rare (HHS more common)
may be controlled by PO meds; some need exogenous insulin
There are a couple examinations that are recommended for diabetic patients to get done yearly, what are they?
Diabetic eye exam (to check eye structure and prevent diabetic retinopathy)
Diabetic foot exam (ensuring proper foot hygiene, regular inspection, and addressing any signs of neuropathy or foot ulcers to prevent diabetic foot complications)
What is the first line treatment for Diabetes Type 2 patients?
Can be oral or insulin, typically PO route (oral) is first line of treatment
Most widely used for OA is Metformin (Biguanide)
Action of Metformin: reduce glucose production by the liver; enhancing insulin sensitivity of glucose
Lactic Acidosis can happen with Metformin -- do not use in patients with kidney disease, liver disease, or heart failure!
IV contrast can interact with Metformin (must be discontinued 48 hours before the CT and wait 48 hours after having a CT done)
Other Drugs:
Sulfonylureas such as Glimepiride (Amaryl), Glipizide (Glucotrol) and Glyburide (DiaBeta, Glynase)
For these, the main action is to increase insulin production by the pancreas so hypoglycemia is the major side effect!!
What kind of nutritional recommendations would you provide for patients with diabetes?
Diabetic diet
Carbohydrate counting (45 to 60 grams per meal)
Teach the patients to outline their meal plan (MyPlate method)
ADA recommends 20% to 35% of total calorie intake from fat (including fat-soluble vitamins)
Protein: ADA recommends individualizing protein intake, but to teach patients how to choose lean protein whenever possible
Moderate alcohol use -- alcohol can actually increase glucose levels so must be in moderation
What is the most accurate test used to measure the blood glucose level?
Hemoglobin A1C is the most accurate! Also called "glycosylated hemoglobin"
Measures the average blood glucose level for the previous 3 months
ADA goal is for A1C to be 7% or less
AACE goal is to achieve and maintain A1C of 6.5% or less
Characteristic manifestations of Metabolic Syndrome? HINT: 5 things
1. Waist circumference (greater than or equal to 40 inches (men) OR greater than or equal to 35 inches (women)
2. Triglycerides (greater than 150 mg/dL OR drug treatment for elevated cholesterol)
3. HDL cholesterol (less than 40 for men, less than 50 for women OR drug treatment for elevated cholesterol)
4. Blood pressure (greater than or equal to 130 mmHg systolic or greater than or equal to 85 mmHg diastolic OR drug treatment of hypertension)
5. Fasting glucose (greater than or equal to 110 mg/dL OR drug treatment for elevated glucose)
If a patient is confirmed to have at least 3 of these components, they are diagnosed with metabolic syndrome!
What is DKA? What are some interventions related to this condition?
Diabetic Ketoacidosis (DKA) -- Diabetic emergency!
Manifestations: dehydration (dry mucous membranes), tachycardia, orthostatic hypotension, lethargy, weakness. Abdominal pain may be present (anorexia, nausea, vomiting), acetone (sweet, fruity odor breath), Kussmaul Respirations!
Interventions:
IV fluid administration (Normal Saline 0.45% or Normal Saline 0.9% to help raise BP and restore urine output to 30 to 60 mL/hr. When glucose levels approach 250 mg/dL, 5% to 10% dextrose is added to prevent hypoglycemia
Obtain a serum potassium level before starting insulin!
What are some common medications used for Hypothyroidism?
Levothyroxine (Synthroid)
monitor heart rate and report pulse greater than 100 bpm or an irregular heart beat
promptly report chest pain, weight loss, nervousness, tremors, and/or insomnia
What kind of recommendations would you recommend for health promotion of diabetic patients?
1. Teach the proper way on how to check blood sugar levels with blood glucometer
--- if blood glucose is low, drink 1/2 cup of juice (Orange juice is the best) or take 2-3 glucose tablets and recheck blood glucose level after 15 mins
2. Teach to recognize signs of hypoglycemia: headache, sweating, impaired vision, dizziness, fast heart rate (tachycardia), hunger, shaking, irritability, anxiety, weakness/fatigue
3. Lifestyle Modifications: exercise, cessation of smoking, heart healthy diet (minimal carbs, decrease calories, glucose, fats)
ADA recommends that people with DM engage in at least 150 minutes/week (30 mins, 5 days a week)
ADA also recommends people with DM to perform resistance training 2 to 3 times a week unless contraindicated.
4. Goals: Maintain BG levels as close to 100 mg/dL as possible (A1C 7% or less); achieve lipid levels and BP levels near normal
What tests are used to confirm the diagnosis and management of hypothyroidism?
Thyroid function tests TSH and free T4
Characteristic manifestations of Hyperthyroidism? (excessive thyroid hormone function)
Low TSH level, high T4 level!
Most common cause: Grave's Disease
Exophthalmos (protrusion of the eyeballs from the orbits)
Acropachy (clubbing of the digits)
palpitations, tremors, weight loss, high BP, bounding rapid pulse, increased cardiac output, increased appetite, thirst, increased peristalsis, nervousness, increased respiratory rate, intolerance to heat, increased temp
THYROID STORM -- Acute Thyrotoxicosis -- acute, severe, rare condition that occurs when excess amounts of thyroid hormones are released into the circulation, symptoms are prominent and severe:
severe tachycardia, heart failure, shock, hyperthermia (up to 106 F), agitation, delirium, seizures, abdominal pain, vomiting, diarrhea, and coma
What are some common interventions for patients with hyperthyroidism?
Monitor vitals, including BP and heart rate
Patient most likely on telemetry (tachycardia can indicate stimulation by the thyroid hormone and result in dysrhythmias)
assess respiratory status and auscultate lung sounds (for signs of pulmonary congestion)
Encourage eye protection and eye drops (exophthlamos can make eyes dry and put risk of damage to cornera) - recommend dark sunglasses and isotonic eye drops for lubrication
monitor daily food intake, daily weight!
Educate to avoid foods that cause loose stools or increased peristalsis; incorporate extra calories, protein, carbs and vitamins into 6 small meals throughout the day
What are some common medications used for hyperthyroidism?
Anti-thyroid drugs are first line treatment
such as:
propylthiouracil and methimazole (Tapazole) - these drugs inhibit hormone synthesis
At time, radioactive Iodine therapy can be used (RAI) -- damages or destroys thyroid tissue, thus limiting thyroid hormone secretion, but has a delayed response
What kind of things would you implement for health promotion of hypothyroidism patients?
Discuss the importance of thyroid hormone therapy (need for lifelong therapy, taking thyroid hormone in the morning before food (30 mins prior), need for regular follow up care and monitoring of thyroid hormone levels
caution the patient not to switch brands of the hormone since the bioavailability of the thyroid hormones may differ
emphasize the need for a comfortable, warm environment because of cold intolerance
teach ways to prevent skin breakdown (use soap sparingly and apply lotion to skin)
caution the patient, especially if older adult, to avoid sedatives
discuss ways to minimize constipation (gradual increase in activity, increased fiber in diet, use of stool softeners, regular bowel elimination time, avoid using enemas)
What is the RAUI test? (Radioactive Iodine Uptake Test)?
Ordered for patients with hyperthyroidism
This test gives an endocrinologist an idea on how well the thyroid is functioning.
outpatient procedure
Before the scan, the patient is given a small amount of radioactive iodine (pill form) taken by mouth. Thyroid cells absorb iodine, so after the iodine is ingested, measurements are taken by camera after 4 hours and again at 24 hours.
camera takes pictures of the thyroid from different angles, revealing size and shape of the gland.
If the thyroid absorbs none or only a small amount, the patient has thyrotoxicosis which results from inflammation of the thyroid gland
If the thyroid absorbs large amounts of iodine, you may have Grave's Disease
Characteristic manifestations of hypothyroidism? (deficiency of thyroid hormone)
High TSH level, low T4 level!
Fatigue, lethargic, cold and dry skin, hair loss, constipation, cold intolerance
personality and mental changes including impaired memory, slowed speech, decreased initiative, and somnolence; may appear depressed
weight gain as a result of decreased metabolic rate
can cause decreased cardiac contractility and decreased cardiac output; patient may have low exercise tolerance and shortness of breath on exertion
patients with severe, long-standing hypothyroidism may have Myxedema (puffiness, facial and periorbital edema, and a mask-like affect)
What are some common interventions for patients with hypothyroidism?
Give thyroid hormone therapy and all other medications
monitor core temperature for hypothermia that often occurs in myxedema
use gentle soap and moisturize often to prevent skin breakdown
frequent position changes and a low-pressure mattress help maintain skin integrity
monitor patient's progress by assessing vital signs, body weight, intake and output, and edema
cardiac assessment especially important
note energy level and mental alertness
What are the different types of Insulin and their onset, peak, and duration?
Rapid Acting: Lispro (Humalog), aspart (Novolog)
Onset: 10-30 mins; Peak: 30 min-3 hr; Duration: 3-5 hours
Short Acting: Regular (Humulin R, Novolin R)
Onset: 30 min-1 hr; Peak: 2-5 hr; Duration: 5-8 hr
Intermediate Acting: NPH (Humulin N, Novolin N)
Onset: 1.5-4 hr; Peak: 4-12 hr; Duration: 12-18 hr
Long Acting: Glargine (Lantus, Toujeo), Detemir (Levemir), Degludec (Tresiba)
Onset: 12-15 mins; Peak: 60 mins; Duration: 2.5-3 hr
Identify signs and symptoms requiring medical evaluation (fever, sore throat, and skin eruptions)
Teach the importance of regular labs including: CBC, thyroid function tests (medications for hyperthyroidism can increase WBC count)
Instruct to take medications with meals to minimize GI distress
Teach to avoid OTC cough medications because many contain iodine
Identify stressors and discuss precipitating factors to thyroid crisis: these things can cause exacerbation of this disease and throw a patient into thyroid storm
Evaluate the patient's knowledge of the disease
Emphasize the importance of planned rest periods to help reduce fatigue
Stress the importance of regular follow up appointments
What are some other tests that may be ordered for a patient with hypothyroidism in addition to the thyroid function tests?
Lipid panel (can show abnormally high cholesterol)
Anemia panel (CBC, hemoglobin/hematocrit) - can potentially be elevated
Increased CK level (creatine kinase)
Presence of thyroid antibodies suggest an autoimmune origin so these labs could all potentially be elevated