Download Care of the Client with Diabetes Mellitus: Type 1 and Type 2

Chronic Exam I Notes
Diabetes
1
12 Questions on Exam
Wong: 1132-1146
L. Jones
Lecture 9-23-02
Black 1149-64;1164-1172;1180-1191
Smith: pgs.500-05
Care of the Client with Diabetes Mellitus: Type 1 and Type 2
I.
Terminology:
a. glycogenesis: promotion of the storage of glycogen when blood glucose
levels are increased
b. glycogenolysis: breakdown of glycogen (stored carbohydrate) to glucose
c. glycolysis: the metabolism of glucose
d. lipolysis: the metabolism of fats and lipids
e. gluconeogenesis: process by which the liver synthesizes glucose from
noncarbohydrate substances, especially proteins
f. polydipsia: excessive thirst
g. polyphagia: excessive appetite and eating
h. polyuria: excessive excretion of urine
i. hypoglycemia: Blood sugar < 70mg/dL
j. hyperglycemia: Blood sugar > 126 mg/dL
k. Type 1 DM: formerly known as insulin-dependent diabetes. Characterized
by the destruction of pancreatic beta cells, usually leading to absolute
insulin deficiency. Affects approximately 10% of people w/ diabetes and
is usually diagnosed by the age of 30.
l. Type 2 DM: formerly known as noninsulin-dependent diabetes or adultonset diabetes. Most common form of diabetes that affects 90-95% of
people w/ diabetes. Usually diagnosed after the age of 40 yrs, but is
becoming more common in younger people.
m. Impaired fasting glucose: People with Type 1 or 2 DM may be classified
as having impaired glucose tolerance aka impaired fasting glucose: New
diagnostic category defined by fasting glucose levels above 110 mg/dl but
below 126 mg/dl.
II.
Insulin Metabolism
1. Insulin is continuously released at a basal rate with increased rate when
food is ingested.
2. Counterregulatory hormones stimulate glycogen release and breakdown
the effect of insulin-e.g. norepinephrine and epinephrine both break down
insulin. Other hormones that antagonize insulin:
1. growth hormone
2. cortisol
3. glucagon
3. This activity provides a steady but regulated release of glucose for energy
during food intake.
III.
Epidemiology of Diabetes Mellitus
1. Affects 18 million people or 8% of the population in the US
1. 9 million are undiagnosed
2. 9 million are diagnosed
 Diabetes is the 7th leading cause of death in the US
 By 2025, 1 in 3 or 4 Americans will have DM
Chronic Exam I Notes
Diabetes
2
12 Questions on Exam
Wong: 1132-1146
L. Jones
Lecture 9-23-02
Black 1149-64;1164-1172;1180-1191
Smith: pgs.500-05
 Prevalence of DM by Race and Ethnicity
1. Pima Indians have 50% prevalence-causing them to have
the highest rate of amputations and blindness
2. African Americans: have a 1.6 X rate of DM compared to
Caucasians
3. Hispanic Americans are 2 X more likely compared to nonHispanic Caucasians
4. Asians have a higher rate with Filipinos among the highest
of the Asian population.
IV.
Risk Factors for Diabetes Type 2
1. Obese (85%) of all people with Type 2 DM are obese.
2. + family member
3. Member of high risk population-e.g. race
4. Hypertensive
5. Dyslipidemic
6. Hx. of gestational DM or baby > 9 lbs.
7. Previous IGT or IPG: (Impaired glucose tolerance/prediabetes/ BS btw.
110-126 mg/dl) IPG: Impaired plasma glucose
V.
Etiology of Type 1 DM
1. Development of Type 1 DM broken down into 5 stages
1. genetic predisposition
2. environmental trigger
3. active autoimmunity
4. progressive beta cell destruction
5. overt diabetes mellitus
2. Genetic Predisposition:recessive gene + autoimmune response can destroy
islet cells on the pancreas
3. Type 1 DM does not develop in all people who have a genetic
predisposition
4. Autoimmune disorder
VI.
Etiology/Pathophysiology of Type 2 DM
1. Decreased tissue responsiveness to insulin as a result of receptor site
defects: means that very little or not enough insulin is getting into the
cells.
2. Increased/Overproduction of insulin occurs early on but islet/beta cells are
eventually exhausted/worn out. Insulin exhaustion
3. Abnormal hepatic glucose production = liver is releasing glucose at the
wrong times due to unknown etiology
VII.
Classification of DM
1. Type 1:
1. Usually young, thin with abrupt signs and symptoms such
as polyuria, polyphagia, polydipsia
Chronic Exam I Notes
12 Questions on Exam
Lecture 9-23-02
Diabetes
3
Wong: 1132-1146
L. Jones
Black 1149-64;1164-1172;1180-1191
Smith: pgs.500-05
2. Increased genetic susceptibility
3. Multiple islet cell antibodies (ICAs)-test is done to assess
for presence of antibodies
4. Absolutely no insulin production as islet cells have been
destroyed
5. Usually diagnosed/found in ketosis (ketosis: the
accumulation of ketones caused by rapid oxidation of fatty
acids)
 Type 2:
1. Usually >35 years old (although more kids are now
diagnosed with Type 2 DM)
2. Insidious onset (no clear symptoms initially)
3. Obesity, lack of exercise
4. Genetic susceptibility
5. Relative insulin production (some insulin produced by the
pancreas)
6. No islet cell antibodies (islet cells are not being destroyed
by antibodies with Type2)
7. Usually not found in ketosis
 Prediabetes:
1. Fasting glucose levels >100 mg/dl but less than 126 mg/dl
VIII. Clinical Manifestations
Type 1 Diabetes Mellitus Type 2 Diabetes Mellitus
Abrupt Onset
Insidious Onset
S&S:
S&S:
Polyuria
Polyuria
Polyphagia
Polyphagia
Polydipsia
Polydipsia
Fatigue
Fatigue
Weight Loss
Wounds that do not heal (Increased risk
of amputations)
Impotence
Blurred Vision
Vaginal infections/fungal infections of toes
IX.
Diagnostic Studies:
1. Screen should be considered >45 yrs of age and at 3 yr. intervals b/c
incidence increases @ 45 yrs.
2. Symptoms + casual /random glucose >200 mg/dl
random test taken at any time of day without regard to time since last
meal. If >200 mg/dl plus S&S such as polyuria, polydipsia and/or
unexplained weight loss = diagnosis for DM
3. Fasting plasma glucose > 126 mg/dl = diagnosis of DM.
Chronic Exam I Notes
Diabetes
4
12 Questions on Exam
Wong: 1132-1146
L. Jones
Lecture 9-23-02
Black 1149-64;1164-1172;1180-1191
Smith: pgs.500-05
normal value is <110 mg/dl. Values btw. 110-125 mg/dl indicate
impaired fasting glucose. Critical values in adults are those <60
mg/dl or >500 mg/dl
4. 2 hour plasma glucose in OGTT (Oral glucose tolerance test) >140 mg/dl
(according to blackboard slides)
2 hours following a meal, blood is drawn. Glucose levels >200 mg/dl
(according to Text) is an indication to diagnose DM. Glucose levels
btw 140-200= diagnosis of impaired glucose tolerance. Normal levels:
80-140 mg/dl.
5. Glycosylated hemoglobin or A1C <7% or 6.5%
Glucose normally attaches to hemoglobin on RBC, and once attached,
it cannot dissociate. Therefore, the higher the blood glucose levels,
the higher the levels of glycosylated hemoglobin (HbA1C). The results
of this test show the average blood glucose level over the previous 3
months. ***Useful in evaluating long-term glycemic control. Normal
values are 6%-7% (according to text)
6. Microalbuminuria-(protein in urine can be due to kidney failure)
Testing for microalbuminuria shows early nephropathy
7. 24 hour creatinine clearance
8. Doppler studies
Case Study: C.C. is a 55 yr old black male who is the youth minister at a local church. He denies
any complaints but states, “My wife is making me come. She says I can’t see.” His FBS is 135
mg/dl X1 and 145 mg/dl on repeat. His 2 h pp is 210 mg/dl. His A1C is 13%. His cholesterol is
250 mg and HDL is 32 mg/dl and LDL is 165 mg/dl. His BP is 144/92. He is 5’9” tall and
weighs 220 lbs.
 Norm FBS= btw 80-120 mg/dl
Client’s: 135 and 145
 Norm 2 hpp= < 80-140
Client’s: 210
 Good BP for DM: 130/90
Client’s: 144/92
 Norm Chol: <200
Client’s: 250 mg/dl
 HDL: 35+ (good chol)
Client’s: 32 mg/dl
 LDL: <100 (bad chol)
Client’s:165 mg/dl
 AIC Norm: 6.5%-7%
Client’s: 13%
 Vision problems: common in clients with diabetes
 Client is not proportionate for height and weight
X.
Criteria for Good Control: How we tell if the client is able to
manage/control their glucose levels
1. Normal Fasting Blood Sugar btw. 80-120 mg/dl
2. 2 hour PPG <140 mg/dl (postprandial glucose)
3. Hba1C <7 (6.5%)
4. Optimum Weight (means lose weight slow & steady 10-20 lbs/3 mos)
5. Feels Good
Chronic Exam I Notes
Diabetes
5
12 Questions on Exam
Wong: 1132-1146
L. Jones
Lecture 9-23-02
Black 1149-64;1164-1172;1180-1191
Smith: pgs.500-05
XI.
Collaborative Management of DM (monitoring, diet, medications,
exercise and education)
A. Monitoring Blood glucose
 Detects extremes of BG (blood glucose) and establishes glycemic
controls (helps pt. to establish own glycemic goals)
 Educate client on proper technique, record keeping and calibration
 Initially, client should perform AC, HS and occasional 3 am testing of
blood glucose levels. (AC= before meals; HS= hour of sleepespecially important for Type 1 management; Type 2 may get down to
one test/day, but will need to test frequently at first.)
B. Nutritional Therapy Goals:
 Euglycemia: BS between 80-120
 Optimal lipid levels Chol,200
 Reasonable weight
 Avoid long term and short term complications
Nutritional Therapy for Type 1 DM
Step One: Integrate Insulin with Eating and Exercise
Conventional Therapy:
Intensive Therapy:
Synchronize food with insulin
Integrate insulin into lifestyle
Eat consistently & adjust insulin Adjust insulin to compensate for lifestyle
**Integrate insulin with eating/diet and exercise plan. Check peak times of insulin and
plan meals around that—need food with insulin! The intensive therapy is especially
good for children with irregular lifestyles—e.g. get/give an insulin the child can take after
a meal instead of at a set time of day.
Case Study: Client with Type 2 Diabetes: C.C. states, “now that I have type 2 diabetes,
give me a list of foods I can eat.” Nurse: You can eat any food that you want, but
control portions and eat a consistent amount—distributing carbohydrates evenly. For a
patient with diabetes, total carbohydrates is the most important part of the label to read!
Normal Carb Serving: Women: 45 g carbs/meal
Men: 60 g carbs/meal
3 carb servings/meal (15 gm ea) 4 carb servings/meal (15 g ea)
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Nutritional Therapy in Children with DM
Individualized meal plans
>6 yrs, 3 meals + 2 snacks
<6 yrs, 3 meals + 3 snacks
Adolescents may awaken hypoglycemic
Infants eat predictably
Toddlers eat unpredictably
Chronic Exam I Notes
12 Questions on Exam
Lecture 9-23-02
Diabetes
6
Wong: 1132-1146
L. Jones
Black 1149-64;1164-1172;1180-1191
Smith: pgs.500-05
Nutritional Therapy for Type 2 DM
Goal is Glucose Control
1. Lean new behaviors of diet, exercise, coping skills
2. Monitor BG and medications
3. Increase physical activity
4. Modify Fat intake
5. Space meals and improve food choices (e.g. use more veggies to help
satiate the hunger. Use fiber-dense foods.
6. Restrict calories for moderate weight loss
**Above steps combined together will help client maintain control of glucose
levels!!
C. Medications: Pharmacological Therapy in Diabetes Mellitus
4 types for Treatment of Type 2 DM
Target
Organ(s)
Drug
Names
Mech. of
Action
Side
Effects:
Liver Level:
Hepatic Glucose
Production
Biguanides,
Metformin, aka
glucophage
GI Tract
Muscle
Pancreas
Precose, Clyset
Insulin,
Sulfonylureas,
Prandin, Starlix
Tells liver to stop
releasing glucose.
Inhibits
breakdown/absorption
of carbs
Biguanides,
Triglitizones
aka Avandia &
Actose
Tells muscle
cells to take in
glucose
#1 prescribed oral
hypoglycemic in
Tx.
Flatus
Flatus
Liver failurehave to check
liver toxicity
with these drugs
**Discontinue
drug for 24 hrs
prior to
angiogram or dye
studies—can go
into kidney
failure!!
Does not cause
hypoglycemia
Does not cause
hypoglycemia
Does not cause
hypoglycemia
Insulin Therapy Indications:
 All individuals with Type 1
 Individuals with Type 2 not controlled by other therapies
 Individuals on TPN
 Sometimes, pts. on steroids
Stimulates insulin
production
Prandin: Short
acting pill taken
with each meal
Glyposide/Amaril/
Glucotrol- work for
24 hours
Can cause
hypoglycemia!
Chronic Exam I Notes
Diabetes
7
12 Questions on Exam
Wong: 1132-1146
L. Jones
Lecture 9-23-02
Black 1149-64;1164-1172;1180-1191
Smith: pgs.500-05
Case Study: N.Y. and his mom are to be taught insulin injections. He says, “me do it!”
Nurse: Let patient give the teddy bear a “shot” while you give him a shot.
Comparison of Human Insulin and Analogues
Insulin
Onset
Peak
Lispro;
Aspart
(Rapid
Acting)
5-15
minutes
11½
hr
Duration Other
Considerations
3-4 hr
Must have food
w/in 5-15
minutes of
injection or risk
hypoglycemia
Human
regular (short
acting)
Humalin N;
Lente
(Intermediate
acting)
Human
Ultralente
(Long acting)
½-1 hr
2 hr
4-6 hr.
2 hr
6-8
hr
12-16
hr.
2 hr
1620
hr
24+
Glargine;
Lantus
1-2hr
Flat
24 hr
Clear
solutions.
May be given
IV. Lispro
may cover
postprandial
glycemic
highs; Lispro
injected
immediately
before eating.
Clear solution.
May be given
IV
May take 1 inj
in a.m. and 1 inj
in p.m.
No prescribed a
lot-can last 2436 hoursunpredictable
New longacting-No peak.
Should not have
hypoglycemia.
Maintains
constant insulin
level.
Clear solution.
When given
SC it
crystallizes
and is released
at a slow,
predictable
rate.
Do not mix
with other
solutions!
Usually given
1x/day at
night-b/c don’t
want pt’s to
mix up or
accidentally
give Lantus
with Regular
or Lispro
insulin. (all
clear
solutions).
Chronic Exam I Notes
12 Questions on Exam
Lecture 9-23-02

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

Diabetes
Wong: 1132-1146
Black 1149-64;1164-1172;1180-1191
Insulin Administration and Storage
Roll cool insulin to avoid irritation
May be stored at room temperature for 1 month
Rotate sites or rate within sites
Do not massage
Do not aspirate
Needle length varies.
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Injection Recommendations for Children
School age and above: abdomen site recommended
Abdomen not recommended with little SC fat
Rotate site
30 g needle!
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Insulin Regimens
Single daily dose-e.g. Lantus
Two injections-e.g. Humulin
Three injections
Four injections
Continuous SC infusion-e.g. insulin pump
8
L. Jones
Smith: pgs.500-05
Acute Complications of Insulin
 Somogyi effect:
o The BG drops below normal in response to too much insulin at night
o Counterregulatory hormones are released which cause rebound
hyperglycemia
o The BG is usually high upon awakening and low around 3 AM
o Treat with less insulin at hs (hour of sleep) or adjusting time at which the
p.m. dose is administered. Steps in the Process:
1. Insulin given h.s.
2. resulting hypoglycemia
3. release of ACTH, GH, FFA, proteins, epinephrine
4. Release of glycogen due to #3
5. Rebound hyperglycemia found in a.m.
D. Exercise:
1. Type 1 Diabetes
 Clients must plan dose and timing of insulin with exercise.
 Strenuous exercise without adequate food may lead to
hypoglycemia
 Vigorous exercise can speed the rate of insulin absorption
 If BG<100 take 15 gm of carbohydrates- e.g. a fruit or a glass of
juice
 If BG >225 regular insulin administration
 Clients with retinopathy must avoid jarring exercise
Chronic Exam I Notes
12 Questions on Exam
Lecture 9-23-02
Diabetes
Wong: 1132-1146
Black 1149-64;1164-1172;1180-1191
9
L. Jones
Smith: pgs.500-05
2. Type 2 Diabetes
 Need medical clearance
 Monitor pre and post exercise BG
 With 10-15 pound weight loss, medication regimen will need to
be adjusted. (might be able to get off the pills altogether!)
Case Study: Client with Type 2: C.C. confided in the nurse that his blood sugar in the
morning was 200 on Monday, 240 on Wednesday and 330 on Thursday. He says, “I’m
not cheating.” (Didn’t go over this in class, but I would check what time and type of
insulin/medications he was on and then discuss diet with him. If he’s eating all his carbs
at one time rather than spreading them throughout the day, that may cause an increase in
his BG levels. I would also check for Somogyi effect. May need to reduce amount of
insulin taken at h.s.) ? 
Case Study:N.Y. is at day camp. It is lunch time. He has been swimming for the past
hour and refuses to come out of the water. He says, “no!” His mother says, “he usually is
so cooperative. He’s my little angel.” Nurse: Behavioral changes can be an indicator of
hypoglycemia. N.Y. has been exercising/swimming for one hour and it is now time for his
food—may need some quick carbs.
XII. Hypoglycemia
 Causes:
o Too much insulin
o Too little food
o Unusual amount of exercise
o Delayed eating
 BG is usually <70 mg/dl with symptoms appearing at <50 mg/dl
 Management
o Acute Interventions
 Stat BG if possible
 First 15 minutes

Ingest 15 gm of fast acting carbohydrates (NO fat with
sugar consumption b/c fat slows sugar absorption)

½ OJ, apple juice or grape juice

5-6 lifesavers

½ can of cola
 Second 15 minutes

Check BG

Ingest 15 gm of fast acting carbohydrates

Follow with peanut butter crackers, cheese, milk within
the hour.
 If there is little improvement

Glucagon 1 mg IM in deltoid for at home tx. (breaks
down into glucose.
Chronic Exam I Notes
12 Questions on Exam
Lecture 9-23-02
Diabetes
10
Wong: 1132-1146
L. Jones
Black 1149-64;1164-1172;1180-1191
Smith: pgs.500-05

Administration of 50 ml D50% IV in hospital or
glucose push D50-50cc/ml NOT D5, but D50
**We were told in class that we were not responsible for Acute Metabolic Complications
of HHNK or DKA for testing purposes, so they are not on this outline! 
XIII. Chronic Complications of Diabetes Mellitus
 Macrovascular Complications
o Early onset arteriosclerosis
o Coronary artery disease
o CVA
o PVD
 INTERVENTIONS:
 Maintain euglycemia (btw. 80-120 mg/dl)
 Foot care
 Exercise
 Diet
 Microvascular Complications
o Retinopathy
o Nephropathy
o Neuropathy
 INTERVENTIONS
 Maintain euglycemia (80-120 mg/dl)
 Foot care
 Exercise
 Diet
 Annual eye exam
 Annual albuminuria screen-protein in urine is a sign of
nephropathy
 HTN screening
 ***#1 cause of blindness in adults in the US = DIABETES!
 Infection/ Periodontal disease
o INTERVENTIONS
o Maintain euglycemia (80-120 mg/dl)
o Foot care
o Exercise
o Diet
o Handwashing
o TB screening (b/c of decreased immune response)
o Q 6 month dental exams
o *at increased risk for infection and for periodontal disease
XIV. Sick Day Rules: What to do when the diabetic becomes ill with diarrhea,
nausea and/or vomiting
 Prevent dehydration-force fluids
 Monitor BG q 4-6 hr
Chronic Exam I Notes
Diabetes
11
12 Questions on Exam
Wong: 1132-1146
L. Jones
Lecture 9-23-02
Black 1149-64;1164-1172;1180-1191
Smith: pgs.500-05
 Test blood or urine for ketones to check for acidosis
 Continue intermediate acting insulin, but may have to adjust short acting
insulin
 Call HCP or seek immediate attention for persistent symptoms especially for
young kids. Call day of if they’re 3 yrs or younger.
XV.
Some Developmental Considerations in Children with Type 1 DM
 Adequate growth and pubertal development (delayed height)-usually catch up
 Fluctuating food intake-periods of hyperglycemia and hypoglycemia
 Insulin management-can be difficult especially with non-cooperative school
districts
 Self care for school age children-fingersticks, injections, carb choices
 Adolescents engage in risk taking-may (especially girls) reduce insulin to lose
weight
Case Study: C.C. states, “I can’t test my blood sugar. I don’t have time. Everyone is
going to know. Besides, I hate blood, it makes me sick.” Nurse: Get the patient a
monitor that works for him/her. There are testing/monitoring devices that look just like a
wrist watch that may be effective in obtaining compliance.
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Guidelines for Surgery
Schedule early in morning
Stabilize BG
Maintain BG 90-140 mg/dl postoperatively
Resume meal plan ASAP
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Barriers to Learning for Adults with Diabetes
Shock with diagnosis
Fear and anxiety
Denial
Anger and guilt
Depression
Confusion
Somatization
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Barriers to Adherence for Adults with Diabetes
Grief
Health beliefs
Family dynamics
Limited support system
Poor self image
Language barrier
Insufficient financial resources
Lack of education
Chronic Exam I Notes
Diabetes
12 Questions on Exam
Wong: 1132-1146
Lecture 9-23-02
Black 1149-64;1164-1172;1180-1191
 Multicultural issues
 Interference with lifestyle
12
L. Jones
Smith: pgs.500-05