Type 1 DM
What are some clinical manifestations of the client with Type I diabetes
3 P's- polyuria, polyphagia, polydipsia, fatigue and weightloss
How would you describe the pathophysiology of Type 2 Diabetes?
It involves defects at the cell membrane that prevent the normal action of insulin. Even though insulin is present, the cell “resists” its effect in transporting glucose into the cell. Because of this, insulin resistance develops that requires increased levels of insulin in order to drive glucose into the cells. Over time, the pancreas cannot keep up with the increased demand for insulin; beta-cell failure appears and progresses. Toward the later stages of type 2 DM, insulin production declines significantly so that approximately 30% of patients with type 2 DM eventually require exogenous insulin delivery to maintain normal blood glucose levels.
Your client has been prescribed insulin for management of their diabetes. Which subcutaneous sites would you advise them to administer their medication?
1. abdomen (best absorption site)
2. upper arm
3. Thigh
4. buttocks
What are the four types of acute complications of either Type I or Type II Diabetes and explain their pathophysiology.
1.The Somogyi effect: This can occur in the client who experiences unrecognized low glucose during the night while sleeping. To combat that, the body responds by releasing growth hormone, cortisol, and catecholamines in an effort to increase blood glucose by releasing glucose stores from the liver therefore causing elevated BG in the a.m.
2. Diabetic Ketoacidosis: Occurs when there is inadequate insulin for cells to obtain adequate glucose for normal metabolism. This causes rapid breakdown of fat stores, releasing fatty acids from adipose tissues. The liver converts the fatty acids into ketone bodies, which can serve as an energy source in the absence of glucose. The ketone bodies, however, have a low pH, resulting in metabolic acidosis.
3. Hypoglycemia: results when there is more circulating insulin than is needed to handle the amount of circulating glucose.
4. Dawn phenomenon: Occurs in relation to release of hormones, such as glucagon, cortisol, and growth hormone, in the early morning. Because the body does not have sufficient insulin to control this glucose surge, blood glucose levels rise.
Describe the pathophysiology of Diabetic Ketoacidosis
Diabetic ketoacidosis (DKA), there is inadequate insulin for cells to obtain adequate glucose for normal metabolism. The body attempts to obtain energy by the rapid breakdown of fat stores, releasing fatty acids from adipose tissues. The liver converts the fatty acids into ketone bodies, which can serve as an energy source in the absence of glucose. The ketone bodies, however, have a low pH, resulting in metabolic acidosis. The absence of insulin also results in an increased release of hormones, such as glucagon and cortisol, in response to inadequate glucose transport into the cells. This leads to gluconeogenesis and glycogenolysis, resulting in severe hyperglycemia leading to hyperosmolality and osmotic diuresis.
It is a serious metabolic condition characterized by hyperglycemia, hyperosmolality, and dehydration without significant ketoacidosis. It occurs when there is sufficient insulin to prevent rapid fat breakdown and ketone release. However, there is not enough insulin to prevent severe hyperglycemia. Blood glucose levels can rise to extremes above 600 mg/dL. The resulting extreme hyperosmolality leads to osmotic diuresis. Dehydration can be profound and electrolyte imbalances severe. Along with dehydration, most patients present with global neurological defects.
What clinical manifestations would you expect to see in the client experiencing a hypoglycemic episode?
Agitation, tachycardic, diaphoretic, headache, shakiness, fatigue, drowsiness, confusion, coma, seizures if severely hypoglycemic
What are some modifiable and non-modifiable risk factors for the development of Type 2 Diabetes?
1. Modifiable- bmi >26kg/m2; increased risk with bmi >30 kg/m2, physical inactivity, HDL </=35mg/dL, Triglyceride level >/=250mg/dL, metabolic syndrome
2. Non-modifiable- 1st degree relative w/ DM, high-risk ethnic populations (i.e., AA, latino, native american, asian, pacific islander), HTN, PCOC, A1c >/=5.7%, h/o cardiovascular disease.
Your client newly diagnosed with Type II Diabetes is scared and asks what changes can they make in their life to improve their health?
1. Tight glycemic control
2. Carbohydrate counting
3. Weight control
4. Physical activity recommendations (150 minutes/week of moderate intensity training)
State at least 3 educational points for the client with diabetic associated neuropathy and their associated rationales
1.Inspect feet daily
2. Wear flat shoes do
3. Cut nails straight across, etc.
What are some known causes of Diabetic Ketoacidosis?
1. Intentional or unintentional missed or reduced doses of insulin
2. Inadequate insulin due to increased insulin needs secondary to stress or infection
3. New onset of type 1 DM
How is HHA diagnosed?
The client will have:
1. Blood glucose level of 600 mg/dL or greater
2. Serum osmolality of 320 mOsm/kg or greater
3. Profound dehydration
4. Serum pH greater than 7.4
5. Bicarbonate concentration greater than 15 mEq/L
6. Low ketonuria and absent to low ketonemia
7. Alteration in level of consciousness
Describe the pathophysiology of Type I Diabetes
Type 1 diabetes is an idiopathic autoimmune disorder in which the body destroys it’s own beta cells in the pancreas which means less insulin is produced and excreted.
What are some clinical manifestations of Type II Diabetes?
Polyuria, polydipsia, polyphagia, fatigue, poor wound healing, cardiovascular disease, visual disturbance, renal insufficiency, recurring infections
Describe what foot care education should cover for the diabetic client
1. Wash feet daily and dry thoroughly, including between the toes.
2. Do not soak feet unless specified by a healthcare provider; soaking can unduly dry skin, break down the skin, and make it prone to damage.
3. Be careful of hot water.
4. Use creams, lotions, or moisturizer but not between the toes to avoid a fungal infection from too much moisture.
5. To avoid injury, do not walk barefoot.
6. Use caution in cutting nails. Ingrown toenails or other nail problems may require podiatry consultation. If you cannot cut your toenails, see a podiatrist.
7. Properly fitting footwear is essential. Check shoes each day for objects that may have fallen inside, excessive wetness, or areas that may cause irritation
What is the best way to prevent diabetes associated complications
Excellent glycemic control/ good blood glucose control!
What are the clinical manifestations which would be demonstrated in the client in DKA
Initial presentation of polyuria, polydipsia, and polyphagia, dehydrated, and an electrolyte disturbances such as hyperkalemia or hypokalemia and hyponatremia related to the increased serum osmolality also results in a shift of fluid from the intracellular to the extracellular space, causing dilutional hyponatremia. Hypovolemia secondary to the osmotic diuresis.
Late signs of DKA client would demonstrate hypotension, tachycardia, Kussmaul respirations, fruity, acetone smell to the breath because of the ketone bodies. The patient may complain of abdominal pain and/or nausea and vomiting. Lethargy and coma may ensue without prompt treatment.
What is the most common cause of HHS?
Hyperosmolar hyperglycemic state most commonly occurs in patients who have some concomitant illness that leads to reduced fluid intake. Infection is the most common preceding illness. Once HHS has developed, it may be difficult to differentiate it from the preceding illness.
How is Type I diabetes diagnosed?
1. Hgb A1C
2.Fasting blood glucose level
3. 2-hour post-prandial (oral glucose tolerance test)
4. Random blood glucose level
How is Type II Diabetes diagnosed?
Hgb A1C levels, fasting blood glucose levels, 2-hr postprandial blood levels, and random blood glucose levels
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 low carb diet, low glycemic foods, eat consistently, check blood glucose as recommended by MD
What are some long-term macrovascular complications associated with uncontrolled diabetes?
Cardiovascular, Cerebrovascular disease, and suppressed/reduced immunity to infections
What are the nursing priority interventions for the client in DKA?
1. Fluid replacement with isotonic normal saline
2. Electrolyte repletion (I.e., potassium, sodium)
3. Insulin administration, most effective by intravenous delivery (ensure potassium levels are WNL prior)
4. Hourly BG checks
What are the priority nursing interventions for a client with HHS?
Treatment priorities include standard care for dehydration with IV fluid and treatment for altered mental status, including airway management as appropriate. Patients may respond to fluids alone, but IV insulin may be necessary to correct hyperglycemia
Your client in room 221 is a diabetic and upon entering the room he has the following presentation: unresponsive to voice or touch, is tachycardic, and diaphoretic. What is your priority nursing intervention at this time?
Check BG and administer 50% dextrose IV per protocol
What is the initial pharmacological intervention for treatment of Type II Diabetes at diagnosis?
oral medications such as glucophage (metformin) that increase the production of insulin, lower insulin resistance, slow the absorption of carbohydrates, or help lower blood glucose These medications are typically used in combination because of their different mechanisms of action. The combination used depends on the patient’s response, with the goal of achieving and maintaining glycemic targets. in combination with lifestyle changes such as diet and exercise, is common
State the sick day rules for clients with Diabetes
1. Have the contact numbers for your healthcare providers and know your glucose targets. Discuss a plan with your provider ahead of time for when you get sick. The plan should include when to call the provider, how often to check glucose, and how to adjust insulin or other oral/injectable medications. Also ask if it is appropriate to check for ketones and when. Also ask what over-the-counter (OTC) medications might be helpful and not negatively affect glucose.
2. Hydrate with lots of water.
3. Check glucose regularly
4 Be prepared for low glucose as well. Follow the rule of 15 grams of carbohydrates such as glucose tablets, hard candy, juice, or soda in the event of low glucose. If glucose has not risen in 15 minutes, repeat the 15 grams of carbohydrates.
5. Have supplies on hand such as a glucose monitoring device, ketone strips, extra batteries, glucose tablets, any appropriate OTC medications, light foods, and low-carbohydrate beverages. It is recommended you have at least 2 weeks of medications on hand.
6. Monitor for signs of DKA: elevated ketones with elevated glucose, nausea/vomiting, abdominal pain, lethargy, confusion, thirst, frequent urination, difficulty breathing, dry or flushed skin, and/or fruity odor to the breath. If you experience any of these, contact your provider and seek medical help.
Name some chronic, long-term microvascular complications of uncontrolled diabetes.
Angiopathy, nephropathy, neuropathy, retinopathy, wound healing complications, cognitive, sexual dysfunction
Name some factors which would confirm a diagnosis for Diabetic Ketoacidosis (DKA)
1. Blood glucose level greater than 250 mg/dL (however, rarely a person may develop DKA at glucose levels lower than 250 mg/dL)
2. Ketonuria (ketones in the urine)
3. Arterial pH of less than or equal to 7.3 (metabolic acidosis)
4. Serum bicarbonate level of less than or equal to 18 mEq/L
5. Positive anion gap
Which patient population is affected more by HHA?
older clients with Type II Diabetes and carries a higher mortality rate than DKA