Type 1 DM
What are common presenting symptoms for a type 1 diabetic? (3+)
3 P's- polyuria, polyphagia, polydipsia:
polyphagia because the cells are starved of glucose. When food is ingested, insulin secretion should increase. In type 1- it does not. Insulin is used to metabolize glucose for cell energy and stores the excess in the liver as glycogen and in muscle for later use. Insulin helps store dietary fat in adipose tissue and helps transport amino acids which are essential proteins for the body. Because the body does not produce this insulin that converts glucose into energy, the client's body in effectively metabolizes fat cells for energy which results in muscle wasting, adipose tissue loss, and weight loss. The metabolism of fat creates ketones which are excreted and detected in the urine.
Polydipsia and polyuria go hand in hand. high glucose cells circulating in the vascular system, through osmosis, pull water from the cell into the vascular space to dilute the glucose. That makes the cells starved of water, and so the patient will be more thirty and therefore urinate more. Frequent urination occurs because the cells are not retaining this fluid and it is being excreted out.
The difference between Type 1 and Type 2 diabetics is that type 2 diabetics _________.
Still produce insulin but have reduced insulin sensitivity or decreased insulin production. Has a slower onset of disease. Can be prevented/reversed. Does not lead to DKA. Frequently associated with obesity and sedentary lifestyle.
Name 2 Medications/conditions/therapies that may require additional insulin be administered
Steroids, Phenytoin (Dilantin), TPN, stressful event (surgery), sick day, atypical antipsychotics, thiazide diuretics
What labs would indicate nephropathy/ kidney injury? (2-3)
Elevated creatinine, albuminurea, elevated BUN, decreased GFR,
Describe the pathophysiology of Gestational Diabetes for the mother
Caused by decreased insulin sensitivity as pregnancy progresses (around 24-28 weeks gestation). Failure of the oral glucose tolerance test indicates insulin resistance due to hormones from the placenta inhibiting the action of insulin.
name 4 or more symptoms of a patient with hypoglycemia
Agitation/irritability, 'hangry', tachycardia, diaphoretic, headache, shakiness, fatigue/weakness, double/blurred vision, confusion, dizziness, leg cramps
Cold and clammy, give me some candy
What are the contributing causation factors to developing type 2 diabetes? Name 4 or more
Ethnicity (higher incidence in Hispanics, African Americans, Pacific Islanders, Native Americans, Asians), Obesity, stress, sedentary lifestyle, lack of diet and exercise, polycystic ovarian syndrome, Advanced Age, history of gestational diabetes, elevated cholesterol or triglyceride levels.
What should the patient be educated about as far as diet and exercise? (3)
They should keep a consistent diet and exercise routine, eat a snack of long-lasting carbs before exercising, do not exercise if ill, Check glucose levels before, during, and after exercise, and consume around 130g of carbs a day
3 education points for the patient with neuropathy
Inspect feet daily, wear shoes at all times, do not use heating pads, no lotion between toes, consult podiatry for nail clippings and cut straight across only.
Gestational Diabetes places the mother at higher risk for what?
Type 2 diabetes, LGA baby, C-section, hemorrhage and vaginal lacerations
Explain the pathophysiology of Type 1 DM
Autoimmune illness that occurs in childhood during an acute virus, toxin, or environmental vulnerability where the body attacks beta cells within the pancreas resulting in altered function of pancreas--> unable to produce insulin (insulin dependent). Is genetically linked and has a higher incidence in the Caucasian ethnicity.
List the different types of medication management for a Type 2 Diabetic and include patient education for those medications.
Oral hypoglycemic medication- Metformin (damaging to kidneys- hold for sx)
Insulin: rapid-acting (Humalog onset 15 min; peak 30-90); Short acting (regular), Intermediate (NPH), and Long-acting (Lantus- peakless)
What specialists should be consulted for a newly diagnosed diabetic client? Describe the specialist and what they will do for the client. (3)
Nutritionist: plan meals
Diabetes educator: teach insulin injection sites, not to rub injection site, rotate sites, S&S, ect.
Endocrinologist- prescribes medication and manages SSI
Dietician: can order supplements like glycerin that help with wound healing due to the added protein.
What indications would indicate the client was developing DKA?
Type 1 diabetes
sugars over 250
Kussmuals breathing
acetone breath/ sweet smell
Keytones in the urine
Organ damage
What risks do the infants have who are born from a mother with gestational diabetes?
For the infant, macrosomia increases the risk of shoulder dystocia, clavicle fractures and brachial plexus injury and increases the rate of admissions to the neonatal intensive care unit.
Once born, the infant loses the excess glucose from the mother, but continues to secrete insulin and may result in hypoglycemia.
The Type 1 patient is at home ill with a viral infection. What 3 pieces of nursing education might the clinic nurse provide to the client for SICK DAY management?
Check BG every 2-4 hours, consume fluids without added sugar, administer ordered insulin, avoid strenuous exercise, monitor for s/s of DKA
An adult client reports having dry mucous membranes and skin, blurred vision, and poor wound healing; what are the different types of glucose tests we can use to determine the clients risk for having Type 2 diabetes? Describe these tests (3)
A1C:average glucose level over the last 90 days; 5 and below is normal; pre-dm 5.7-6.4; 6.5 or higher is DM
Fasting glucose: 75-100 normal; 100-125 prediabetic; 126 or higher is DM
Oral Glucose tolerance test: above 140- recheck; fail if levels don't decrease
A Type 2 patient comes to the clinic with an A1C reading of 8.4. What lifestyle modification/education is needed? Name 4 items.
Aerobic exercise 150 min/week, Goal for blood glucose 80-110, Consistent carb diet 130g, low glycemic foods, eat consistent foods, check blood glucose as recommended by MD, lower stress levels, educate of infection prevention/immune compromise
Name 2 macrovascular complications resulting from uncontrolled diabetes
Cardiovascular disease
Peripheral vascular disease: non-traumatic ulcers
Cerebrovascular disease
Patho: large, rough glucose cells cause damage to the endothelial tissues and cells leading to vessel damage, scarring, and narrowing.
Describe the pathophysiology of gestational diabetes of the infant.
Higher glucose levels from the mother pass through the placenta into fetal circulation causing the fetal pancreas to secrete more insulin.
In what ways can we treat a patient with hypoglycemia? Consider different options for a patient who is conscious, unconscious, IV access, no IV access (4)
15-15 rule: give 15g of carbs and recheck glucose in 15 minutes.
D50 IV push
IM glucagon
Glucose Gel
When might a patient need to check their glucose levels- name 4
Prior to administering insulin, prior to meals, if they feel 'low'- hypoglycemic, if they feel 'high'- hyperglycemic, before, during, and after exercising, and before bed
Describe Dawn Phenomenon, Somogyi effect and Insulin Waning.
Dawn:Dawn Phenomenon results from an nighttime release of adrenal hormones that cause blood glucose elevations around 5-6am. Like cortisol, growth hormone counterbalances the effect of insulin on muscle and fat cells. High levels of growth hormone cause resistance to the action of insulin. To manage this, give insulin later in the evening or more insulin to cover the timeframe between 5-6 am.
Somogyi:During the stress of a hypoglycemic event, counterregulatory hormones (including growth hormone, cortisol, epinephrine, and norepinephrine) are released, all of which promote glycogenolysis and gluconeogenesis, resulting in elevated glucose levels after a hypoglycemic episode. To manage this, decrease the amount of insulin given to prevent the drop of glucose or give a snack at bedtime.
Insulin Waning: Insulin waning is the wearing off of insulin and the natural increase of glucose levels in the morning leading to morning hyperglycemia. This can be managed by giving insulin later in the evening, giving a longer acting insulin, or increasing the dose of insulin.
Name 3 microvascular complications resulting from uncontrolled diabetes
nephropathy (ESRD), neuropathy (numbness and tingling), retinopathy (leading cause of blindness), erectile dysfunction/impotence
Patho: the narrowing of the vascular lumens leads to tissue ischemia and destruction of the neurons causing altered sensation and decreased blood flow.
What are the signs and symptoms of a newborn presenting with macrosomia?
low blood glucose in the newborn, resulting in jitteriness or tremors, and sometimes rapid respirations, low temperature and poor muscle tone, excess brown fat, >4000g