Download Insulin

Symptoms of diabetes + casual plasma glucose level less
than or equal to 200 mg/dL
OR
 Fasting plasma glucose higher than or equal to
126 mg/dL
OR
 2-hour postload glucose level higher than or equal to 200
mg/dL during an oral glucose tolerance test
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Impaired glucose tolerance (IGT)
◦ FPG <110 mg/dL: normal fasting glucose
◦ FPG ≥110 mg/dL but <126 mg/dL: impaired fasting
glucose (IFG)
◦ FPG ≥126 mg/dL: provisional diagnosis of diabetes mellitus
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Preprandial-110 mg/dl
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Postprandial-180 mg/dl
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Of the 16 million Americans – 5 million are probably unaware they

2,000 per day are diagnosed with DM
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Causes 200,000 deaths annually
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6th leading cause of death
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Leading cause of blindness
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Causes >50% of nontraumatic lower-limb amputations
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Leading cause of end stage renal disease
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Two types
◦ Type 1
◦ Type 2
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Lack of insulin production OR
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Production of defective insulin
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Affected patients need exogenous insulin
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Complications
◦ Diabetic ketoacidosis (DKA)
◦ Hyperosmolar nonketotic syndrome
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Oral antidiabetic drugs not effective
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Symptoms
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Polyuria
Polydipsia
Polyphagia
Glycosuria
Unexplained weight loss
Fatigue
Hyperglycemia
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Most common type
Caused by insulin deficiency and insulin
resistance
Many tissues are resistant to insulin
◦ Reduced number insulin receptors
◦ Insulin receptors less responsive
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Several comorbid conditions
• metabolic syndrome OR insulin-resistance syndrome OR
syndrome X
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Obesity
Coronary artery disease
Dyslipidemia
Hypertension
Microalbuminemia (protein in the urine)
Enhanced conditions for embolic events (blood clots)
Insulin Resistance
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Type 1
◦ Exogenous insulin
◦ Dietary control
Type 2
◦ Lifestyle changes
 Dietary control
 Weight reduction
 Exercise
◦ May require oral hypoglycemic therapy or
exogenous insulin
◦ Insulin when oral hypoglycemic medications
can no longer provide glycemic control
◦ Hyperglycemia that develops during pregnancy
◦ Insulin must be given to prevent birth defects
◦ 4% of all pregnancies
◦ Must be reclassified if it persists 6 weeks
post-delivery
◦ Usually subsides after delivery
◦ 30% of patients may develop Type 2 DM within
10 to 15 years
hypertension
Vascular smooth
muscle cell growth
Release of chemokines
Release of cytokines
Expression of cellular
adhesion molecules
Hyper coagulation
Platelet Activation
Decreased Fibrinolysis
◦ Macrovascular (atherosclerotic plaque)
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Coronary arteries
Cerebral arteries
Renal arteries
Peripheral vessels
◦ Microvascular (capillary damage)
 Retinopathy
 Neuropathy
 Nephropathy
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MI
DVT
PE
Stroke
AAA
Retinopathy
Increased Glucose
Decreased Insulin
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Cardiovascular disease, including hypertension
Peripheral vascular disease
◦ Delayed healing
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Visual defects, including blindness
Renal disease
Infection
Neuropathies
Impotence
FIGURE 36-1 Complications of diabetes mellitus.
Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
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Insulins
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Oral hypoglycemic drugs
Both aim to produce normal blood glucose
states
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Substitute for & same effects as endogenous insulin
Restores the diabetic patient’s ability to:
◦ Metabolize carbohydrates, fats, and proteins
◦ Store glucose in the liver
◦ Convert glycogen to fat stores
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Some derived from porcine sources
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Most now human-derived, using recombinant DNA technologies
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Goal: tight glucose control
◦
To reduce the incidence of long-term complications
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Rapid-Acting
 Most rapid onset of action
 Shorter duration
Insulin
Onset
(mins)
Peak (hrs)
Duration (hrs)
aspart (Novolog)
2-33
1-3
3-5
lispro (Humalog)
2-33
30mins – 2.5
3-6.5
glulisine (Apidra)
2-33
30mins – 1.5
1.-25
May be given SC or via continuous SC infusion
pump (but not IV)
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Short-Acting
◦ regular insulin (Humulin R, Novolin R)
Insulin
Onset (mins)
Peak (hrs)
Duration (hrs)
Humulin R
30 mins to 4 hrs
2.5-5
5-10
Novolin R
30
2.5-5
8
◦ Onset 30 – 60 minutes
 The only insulin product that can be given by IV
bolus, IV infusion, or even IM
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SC rapid or short-acting doses adjusted according to
blood glucose test results
Typically used in hospitalized diabetic patients
◦ Or in patients on TPN / enteral tube feedings or receiving steroids
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Subcutaneous insulin is ordered in an amount that
increases as the blood glucose increases
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Intermediate-Acting
◦ isophane insulin suspension (also called NPH) (Humulin N,
Novolin N)
◦ isophane insulin suspension & insulin injection
(Humulin 50/50 , Humulin 70/30, Novolin 70-30)
◦ Lispro protamine suspension (Humalog 75/25, Novolog Mix
70/30)
◦ insulin zinc suspension (Lente, Novolin L)
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Cloudy appearance
Slower in onset and more prolonged duration
than endogenous insulin
Insulin
Onset (hrs)
Peak (hrs)
Duration (hrs)
Isophane (NPH):
Humulin N
1-4
4-12
16-28
Novolin N
1-5
4-12
24
Humulin 50/50
0.5
4-8
24
Humulin 70/30
0.5
4-12
24
Novolin70/30
0.5
2-12
24
Isophane & Insulin:
Insulin
Onset
(hrs)
Peak (hrs)
Duration (hrs)
lispro protamine & lispro:
Humalog Mix 75/25
0.25-0.5 0.5-1.5
12-24
Novolog Mix 70/30
0.2-0.33 2.4
24
Lente Iletin II
1-1.5
8-12
24
Novolin L
1-4
7-15
20-28
Insulin Zinc Suspension:
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Combination Insulin Products
◦ NPH 70% and regular insulin 30% (Humulin 70/30,
Novolin 70/30)
◦ NPH 50% and regular insulin 50% (Humulin 50/50)
◦ insulin lispro protamine suspension 75% and insulin
lispro 25% (Humalog Mix 75/25)
Insulin
Onset
Peak
Duration
glargine (Lantus
1
No peak
activity
24 (when
administered at hs)
detemir (Levemir)
1
6-8
6-28
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It is a test that allows healthcare providers to
see how diabetics have managed their blood
glucose level over the last 2-3 months….
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Storage:
◦ Neither be allowed to freeze or heated above 98oF
◦ Store in refrigerator until opened
◦ Once opened, store at room temp: 68o to 75oF
◦ Once opened, discard after 30 days
◦ Avoid excess agitation – gently roll in the palms of
hands (not shaken) to warm and resuspend insulin
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Atrophy or hypertrophy
◦ Dermatologic conditions
◦ Hypertrophy more common
 Fat pads become anesthetized
 Results in prolonged & erratic insulin absorption
 Loss of diabetic control
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Used for type 2 diabetes
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Treatment for type 2 diabetes includes
lifestyle modifications
◦ Diet, exercise, smoking cessation, weight loss
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Oral antidiabetic drugs may not be effective
unless the patient also makes behavioral or
lifestyle changes
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HbA1c
◦ Good indicator of the average blood glucose levels.
◦ Shows the average blood glucose level during the previous 120 days
◦ Used to assess long term glycemic control
◦ Performed at diagnosis and at specific intervals to evaluate the treatment
plan
◦ Altered by pregnancy, increased triglycerides & bilirubin
◦ Twice annually for patients with good control
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Quarterly for patients whose therapy has changed
◦ First generation:
 chlorpropamide (Diabinese),
 tolazamide (Tolinase)
 tolbutamide (Orinase)
◦ Second generation:
 glimepiride (Amaryl)
 glipizide (Glucotrol)
 glyburide (DiaBeta, Micronase)
Sulfonylureas
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Stimulate insulin secretion from the beta cells of the
pancreas, thus increasing insulin levels
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Beta cell function must be present
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Improve sensitivity to insulin in tissues
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Result: lower blood glucose levels
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First-generation drugs not used as frequently now
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Sulfonylureas
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Hypoglycemia
hematologic effects
nausea
epigastric fullness
heartburn
many others
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Sulfonylureas
◦ Hypoglycemic effect increases when taken with alcohol, anabolic
steroids, many other drugs
◦ Adrenergics (beta blockers) may mask many of the symptoms of
hypoglycemia
◦ Hyperglycemia: corticosteroids, phenothiazines, diuretics, oral
contraceptives, thyroid replacement hormones, phenytoin,
diazoxide and lithium.
◦ Allergic cross-sensitivity may occur with loop diuretics and
sulfonamide antibiotics
◦ May interact with alcohol/OTC medication containing alcohol) causing a disulfiram (Antabuse) -type reaction (facial flushing,
pounding headache, feeling of breathlessness, and nausea)
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Meglitinides
◦ repaglinide (Prandin)
◦ nateglinide (Starlix)
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Meglitinides
◦ Action similar to sulfonylureas
◦ Increase insulin secretion from the pancreas
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Meglitinides
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Headache
hypoglycemic effects
Dizziness
weight gain
joint pain
upper respiratory infection or flu-like
symptoms
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Biguanides
◦ metformin (Glucophage)
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Biguanides
◦ Decrease production of glucose
◦ Increase uptake of glucose by tissues
◦ Does not increase insulin secretion from the pancreas
(does not cause hypoglycemia)
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Metformin
◦ Primarily affects GI tract: abdominal bloating, nausea,
cramping, diarrhea, feeling of fullness
◦ May also cause metallic taste, reduced vitamin B12 levels
◦ Lactic acidosis is rare but lethal if it occurs
◦ Does not cause hypoglycemia
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Thiazolidinediones
◦ pioglitazone (Actos),
◦ rosiglitazone (Avandia)
◦ Also known as “glitazones”
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Thiazolidinediones
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Decrease insulin resistance
“Insulin sensitizing drugs”
Increase glucose uptake and use in skeletal muscle
Inhibit glucose and triglyceride production in the liver
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Thiazolidinediones
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Moderate weight gain
Edema
Mild anemia
Hepatic toxicity—monitor liver function tests
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Alpha-glucosidase inhibitors
◦ acarbose (Precose)
◦ miglitol (Glyset)
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Alpha-glucosidase inhibitors
◦ Reversibly inhibit the enzyme alpha-glucosidase in the
small intestine
◦ Result: delayed absorption of glucose
◦ Must be taken with meals to prevent excessive
postprandial blood glucose elevations (with the “first
bite” of a meal)
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α-glucosidase inhibitors
◦ Flatulence
◦ diarrhea
◦ abdominal pain
◦ Do not cause hypoglycemia, hyperinsulinemia,
or weight gain
Used alone or in combination with other
drugs and/or diet and lifestyle changes to
lower the blood glucose levels in patients
with type 2 diabetes
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Amylin Mimetic: pramlintide (Symlin)
◦ Mimics the natural hormone amylin
◦ Slows gastric emptying
◦ Suppressed glucagon secretion, reducing hepatic
glucose output
◦ Centrally modulates appetite and satiety
◦ Used when other drugs have not achieved adequate
glucose control
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Incretin Mimetic: exenatide (Byetta)
◦ Mimics the incretin hormones
◦ Enhances glucose-driven insulin secretion from β cells
of the pancreas
◦ Only used for Type 2 diabetes
◦ Injection pen device
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Inhaled Insulin: Exubera
FIGURE 36-2 Mechanisms of action of antidiabetic agents.
Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Early
◦ Confusion, irritability, tremor, sweating
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Later
◦ Hypothermia, seizures
◦ Coma and death will occur if not treated
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Abnormally low blood glucose level (<50 mg/dL)
Mild cases can be treated with diet—higher intake
of protein and lower intake of carbs—to prevent a
rebound postprandial hypoglycemia
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Rapid decrease in blood sugar – during the night
Stimulates the release of hormones that elevate
blood glucose
◦ Epinephrine, cortisol, and glucagon
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Results in elevated early morning blood glucose
Insulin administration may cause a rapid rebound
hypoglycemia
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Oral forms of concentrated glucose
◦ Buccal tablets, semisolid gel
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50% dextrose in water (D50W)
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Glucagon
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diazoxide
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State of hyperglycemia with ketosis
Usually results from infection, environment, or
emotional stressor
◦ As a result of Lack of Insulin, Breakdown:
 Fat – free fatty acids in liver – ketone bodies – ketones in
urine
 Protein – to form new glucose / increased BUN
 Glycogen to glucose (decrease use of glucose because of
decreased insulin)
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Osmotic diuresis
Dehydration / Electrolyte Imbalance
Hyperosmolality Hemoconcentration
Acidosis
Death
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Sudden onset
Factors: infection, stressors, inadequate insulin
Kussmaul respiration / fruity odor to breath, nausea,
abdominal pain
Dehydration, electrolyte imbalance, polyuria, polydipsia,
weight loss, dry skin, sunken eyes, soft eyeballs,
lethargy, coma
Glucose >300 mg/dL
pH <7.35 / Bicarbonate < 15 mEq/L
Na – low / K+ </> / Cr >1.5 mg/dL
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Blood & Urine Ketones - Positive
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Treatment
 Insulin Bolus (0.1U/kg IV) & Infusion (0.1 U/kg/hr)
◦ Regular Insulin
 only insulin that can be given by intravenous infusion
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Restore fluid volume
Potassium Runs
◦ K+ depleted severely with insulin therapy
 Insure urine output >30mL/hr
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Correct acidosis
◦ Bicarbonate is used rarely
 arterial pH < 7.0 or bicarbonate level < 5 mEq/L
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State of hyperglycemia without ketosis
Little breakdown of fat (little or no ketone bodies)
Breakdown
◦ Glycogen– formation of new glucose – hyperglycemia
 Very high levels of glucose >800mg dL
◦ Osmotic diuresis – extracellular dehydration
◦ Renal insufficiency – hyperosmolality – intracellular
dehydration
◦ Hypokalemia – shock – tissue hypoxia - Coma
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Gradual onset
Factors: infection, other stressors, poor fluid intake
Altered CNS function – neurologic symptoms
Dehydration / electrolyte loss
Glucose > 800 mg/dL
pH >7.4 / Bicarbonate >20 mEq/L
Na & K+ normal or low
Bun & Cr – elevated
Blood & Urine Ketones - negative
Treatment
 Rehydrate with NS (if severe) or ½ NS
◦ Use CVP or PCWP / UO / blood pressure monitoring
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IV insulin 10U/hr
◦ Reduce hyperglycemia by 10% /hr
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Replace Potassium (will not be as severe as DKA)
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Before giving any drugs that alter glucose
levels, obtain and document:
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A thorough history
Vital signs
Blood glucose level, HbA1c level
Potential complications and drug interactions
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Before giving any drugs that alter glucose levels:
◦ Assess the patient’s ability to consume food
◦ Assess blood glucose level
◦ Assess for nausea or vomiting
◦ Hypoglycemia may be a problem if antidiabetic drugs are
given and the patient does not eat
◦ If a patient is NPO for a test or procedure, consult physician
to clarify orders for antidiabetic drug therapy
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Keep in mind that overall concerns for any
diabetic patient increase when the patient:
◦ Is under stress
◦ Has an infection
◦ Has an illness or trauma
◦ Is pregnant or lactating
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Thorough patient education is essential regarding:
◦ Disease process
◦ Other Risk Factors:
 Smoking
 HTN
 CAD
◦ Self-Care:
 Medication
 Psychological adjustment
 Nutrition
 Activity and Exercise
 Blood-glucose testing
 Self-administration of insulin or oral drugs
◦ Potential complications
 How to recognize and treat hypoglycemia and hyperglycemia
FIGURE 36-3 Diabetes health care plan.
Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

When insulin is ordered, ensure:
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Correct route
Correct type of insulin
Timing of the dose
Correct dosage
Insulin order and prepared dosages are secondchecked with another nurse
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Check blood glucose level before giving insulin
Roll vials between hands them to mix suspensions – no shaking!
Ensure correct storage of insulin vials
ONLY insulin syringes, calibrated in units, to administer insulin
Ensure correct timing of insulin dose with meals
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Insulin
◦ When drawing up two types of insulin in one syringe:
 Always withdraw the regular or rapid-acting insulin first
◦ Provide thorough patient education regarding selfadministration of insulin injections, including timing of
doses, monitoring blood glucoses, and injection site
rotations
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Always check blood glucose levels before giving
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Usually given 30 minutes before meals
◦ Administer the medication at exact time – with meal or
when food is in sight*
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Alpha-glucosidase inhibitors are given with the
first bite of each main meal
Metformin is taken with meals to reduce GI effects
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Assess for signs of hypoglycemia
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If hypoglycemia occurs:
◦ Give glucagon or
◦ Have the patient eat glucose tablets or gel, corn
syrup, honey, fruit juice, or nondiet soft drink or
◦ Have the patient eat a small snack such as crackers
or half a sandwich
◦ Monitor blood glucose levels
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Monitor for therapeutic response
◦ Decrease in blood glucose levels to the level
prescribed by physician
◦ Measure hemoglobin A1c to monitor long-term
compliance to diet and drug therapy
◦ Watch for hypoglycemia and hyperglycemia
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1.
Neuropathies are:
low blood sugar.
2. degenerations in the central nervous
system.
3. degeneration of peripheral nerves.
4. a numbness and tingling of the extremities

A dose of long acting insulin has been ordered for
bedtime for a diabetic patient. The nurse expects
to give which type of insulin?
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A: Regular
B: Lente
C: NPH
D: Glargine (Lantus)
Diabetic ketoacidosis is:
1. an abnormality in the metabolism of fats.
2. an accumulation of ketones associated with poor control of diabetes
mellitus.
3. an abnormal increase in hydrogen ion concentration.
4. abnormal deposits of fat caused by repeated injection of insulin at
the same site.
The biguanide oral antidiabetic metformin
(Glucophage) has the expected side effect of:
1. hepatotoxicity.
2. blood dyscrasias.
3. hypotension.
4. abdominal cramping and flatulence.

A dose of long acting insulin has been ordered for
bedtime for a diabetic patient. The nurse expects
to give which type of insulin?
◦
◦
◦
◦
A: Regular
B: Lente
C: NPH
D: Glargine (Lantus)
The order reads 10 units of U-100 Regular insulin.
U-100 means there is/are:
1. 10 units of insulin in 1 mL of solution.
2. 1 mL solution/unit of insulin.
3. 100 units of Regular insulin in 1 mL of solution
4. 10 units of insulin in each bottle.