CCBC Nursing 160: Exam Two Prep Questions and Answers [Latest 2025 / 2026 Update] [100% Verified Answers]

CCBC Nursing 160: Exam Two Prep Metabolism: Diabetes Mellitus, Adrenal Disorders, Thyroid Disorders. What is the concept defined as the physical and chemical processes the body uses to maintain itself through catabolism and anabolism (build up versus break down)? Metabolism Do alterations in metabolic function affect every system in the body? YES, it's systemic! Examples: 1. Nutrition: glucose control, how your diet can also affect thyroid. 2. Elimination: diarrhea or constipation with thyroid disorders. 3. Infection: when protein production is disrupted it increases the risk for infection. 4. Mobility: neuropathy with diabetes. 5. Sensory Perception: again, neuropathy and retinopathy with diabetes. Why is the Endocrine System important? The endocrine system is essential to the body's metabolic functioning and its adaptation to the changing environment. Which gland of the endocrine system is considered the "master gland" because of the influence it has on secretions of hormones by OTHER endocrine glands? The pituitary gland! It's located on the inferior aspect of the brain and is divided into two lobes: the anterior and posterior pituitary. What controls the pituitary gland? The hypothalamus. What are the various other anatomic structures involved in metabolic function? 1. Thyroid gland 2. Islets cells of the Pancreas 3. Adrenal Glands 4. Parathyroid Gland 5. Gonads: Testes and Ovaries What are the chemical messengers in the body that cause a specific action? HORMONES! They are always present in varying amounts based on needs that change with changes in the environment What should be included in the nursing assessment in regards to Metabolism? 1. Height and weight: ex, can be affected by growth hormone. 2. Fat distribution: ex, Cushings where fat is moved tp specific areas of the body such as the face and between the shoulders (cause a hump-like appearance). 3. Immunosuppression. 4. Vital Signs. 4. Musculoskeletal anomalies: ex, acromegaly (a long-term condition in which there is too much growth hormone and the body tissues get larger over time). 5. Head, face, neck anomalies. 6. Skin, nail, and hair changes: ex, with Hypothyroidism skin, nail, and hair changes common with women over 40 (30% affected). What system alterations should the nurse expect to see during their assessment in regards to metabolic disorders? 1. Neuro changes: ex, lack of thermoregulation (body temp control). 2. Cardiovascular changes: ex, diabetes can lead to a narrowing of the blood vessels. 3. GI disturbances. 4. GU disturbances. 5. Reproductive problems. What are the risk factors related to metabolic disorders? 1. Age: ex, anyone over 50 is more prone to ALL METABOLIC DISORDERS. 2. Gender: most metabolic disorders more common with FEMALES. 3. Heredity: ex, diabetes and thyroid disorders. 4. Weight: can be a BIG hint that a metabolic disorder is present. 5. Environmental exposures: ex, radiation exposure can damage thyroid function (and also can increase likelihood of thyroid cancer). 6 Autoimmune disruption: ex, Graves Disease (an autoimmune disorder that leads to overactivity of the thyroid gland: hyperthyroidism) or Hashimoto's (chronic thyroiditis that causes swelling/inflammation of the thyroid gland that often results in reduced thyroid function: hypothyroidism). 7. Ethnicity/Race: ex, incidence of certain disorders is increased with particular ethnicities such as African American WOMEN being at a higher risk for diabetes. What are some lifespan considerations that affect an individuals' metabolic functioning? 1. Gerontological Changes: ex, weight gain, fatigue, thinning hair (thyroid and sex hormone issue) and cognition changes (irritability). 2. Changes in Children and Adolescents: ex, "Precocious Puberty" where sexual and physical characteristics happen earlier than normal (indicates something is wrong with the sex hormones: prior to age 8 for girls and 9 for boys), Hyperpituitarism (hypersecretion of pituitary hormones) can lead to gigantism, and increased weight gain with children can lead to an increased occurrence of Type 2 Diabetes (80% of children who are overweight WILL develop Type 2). What is Diabetes Mellitus? A chronic metabolic disease characterized by INCREASED levels of blood glucose as a result of defects in insulin secretion and insulin action. Why has the incidence of diabetes increased in recent years? Because people as a whole are getting larger (for Type 2 diabetes) and less mobile. What is the KEY to decreasing the incidence of Diabetes Mellitus? Prevention (identify symptoms early). What is the key to limiting the cost of treatment for Diabetes Mellitus? Containment of complications! (achieving and maintaining meticulous blood glucose control: the challenging part for both the nurse and the patient) It's time to get in depth about the pancreas! What is the function of the pancreas in regards to blood glucose regulation? How does it work? The pancreas is one of the major organs of the body. It has both exocrine (produces sodium bicarbonate and digestive pancreatic enzyme) and endocrine (produces hormones; insulin, glucagon, somatostatin) function. The endocrine function of the pancreas focuses on its special group of cells known as the Islets of Langerhans. The Islets of Langerhans has three distinct types of cell, the alpha, the beta, and the delta cells: 1. Alpha Cells The alpha cells secrete glucagon. One of the major actions of glucagon is it stimulates the liver to convert glycogen (stored glucose) and amino acids to glucose when blood glucose is LOW. The secretion of glucagon is actually a regulatory mechanism wherein it is released once the body transmits negative feedback in cases of low blood sugar level. This is an automatic response. In cases that blood glucose level is on its desired level or exceeds the normal level, glucagon secretion stops. (Alpha Cells--Glucagon--Increase BG) 2. Beta Cells The beta cells secrete insulin. Insulin has two major functions in response to blood glucose concentration. First, it counters the effects of glucagon by stimulating the liver to convert glucose to glycogen (stimulates the liver to STORE gluocse) and inhibits the conversion of other non-carbohydrates like amino acid to glucose. Second, it facilitates the diffusion of glucose into the cells through insulin receptors. Insulin secretion is also regulated by a negative feedback by the body to respond when the blood glucose is HIGH. (Beta Cells--Insulin--Decrease BG) 3. Delta Cells The delta cells secrete somatostatin. Somatostatin is released by the delta cells to help regulate carbohydrates by inhibiting the secretion of glucagon (Delta Cells--Somatostatin--Decrease BG) In the pancreas, the low blood sugar level in the body is responded by the pancreas by producing glucagon to elevate blood glucose concentration. Once it reaches the desired or above normal level, it releases insulin and somatostatin to counter the effects of glucagon. What is happening in the pancreas with Diabetes Mellitus? With Diabetes Mellitus, the beta cells (those which secrete insulin) fail to release what is required while the alpha cells (those which secrete glucagon in response to low blood sugar) are either normal or hyperactivated. As the insulin production cannot cope up with the production of glucagon, the blood glucose level remains above normal. Also, this is aggravated by constant carbohydrates and protein intake. Therefore with diabetes, the pancreas does not make enough insulin (type 1 diabetes) or the body can't respond normally to the insulin that is made (type 2 diabetes). This causes glucose levels in the blood to rise (hyperglycemia). What are the 3 P's of Hyperglycemia? 1. Polyuria: frequent urination. 2. Polydipsia: excessive thirst. 3. Polyphagia: excessive hunger. What is a common physical characteristic of a patient with hyperglycemia? "Fruity" breath smell. How does diabetes affect the vessels of the body? Diabetes damages ALL vessels and starts with the smallest ones. Examples: the eye vessels (retinopathy), vessels in the kidneys (nephropathy), and the small nerves (neuropathy). How do the different types of Diabetes classifications vary? They vary by CAUSE, CLINICAL COURSE, and TREATMENT. What are the different classifications of Diabetes Mellitus? 1. Type 1 Diabetes: once known as juvenile diabetes or insulin-dependent diabetes, is a chronic condition in which the pancreas produces little or no insulin, a hormone needed to allow sugar (glucose) to enter cells to produce energy. 2. Type 2 Diabetes: far more common type 2 diabetes occurs when the body becomes resistant to insulin or doesn't make enough insulin 3. Metabolic Syndrome (Diabetic Ketoacidosis): a problem that occurs in people with diabetes, most commonly in those with Type 1 diabetes. It occurs when the body cannot use sugar (glucose) as a fuel source because there is no insulin or not enough insulin. Fat is used for fuel instead. Byproducts of fat breakdown, called ketones, build up in the body. 4. Gestational Diabetes: high blood sugar (diabetes) that starts or is first diagnosed during pregnancy. 5. Impaired Glucose Tolerance or Pre-Diabetes: refers to a condition in which blood glucose concentrations fall between normal levels and those considered diagnostic for diabetes (BG 110-126 while FASTING). What is the NEWEST classification of Diabetes Mellitus? Latent Autoimmune Diabetes (LADA) or Type 1.5. What exactly is LADA or Type 1.5? LADA is thought to be a SLOWLY progressing version of Type 1 Diabetes, though 10% of people with Type 2 Diabetes have LADA. Therefore genetically it has components of both Type 1 & 2. What is the criteria for diagnosing someone with LADA or Type 1.5? 1. Adult onset (usually in their early 20's, late 30's). 2. Presence of auto antibodies in blood. 3. No insulin necessary for the initial 6 months (because they are still producing decreasing amounts of insulin up until that 6 month mark---once past 6 month period, treated as a Type 1 diabetic). This is still being researched. What is the criteria for diagnosing a patient with Diabetes Mellitus? They must have SYMPTOMS consistent with DM plus: 1. Casual Plasma Glucose (PG: usually random, any time of the day/night): GREATER than 200 mg/dL 2. Fasting Plasma Glucose (FPG): GREATER than 126 mg/dL. 3. Hemoglobin A1C (HgbA1C, 3 month average of BG): GREATER than 6.5% indicates Diabetes Mellitus. Think of the hemoglobin as a velcro covered ball that glucose in the blood gets stuck to. What is the range for Normal Blood Glucose? 60-110 mg/dL (this would be at least 2 hours after a meal) What is the range for Hyperglycemia (an elevated blood glucose level)? FASTING BG greater than 110 mg/dL OR 2 hours after a meal BG greater than 140 mg/dL. What is the range for Hypoglycemia (a low blood glucose level)? LESS than 60 mg/dL. Again, what is a Hemoglobin A1C or Glycated Hemoglobin level? It's a blood test that reflects the average blood glucose over a 2-3 month period. How often is a HgbA1C level drawn? Either every 3 months for newly diagnosed diabetes mellitus until control of BG is achieved. OR Every 6 months for controlled diabetes mellitus. What is the goal for the HgbA1C level? To be LESS than 7.0% Should a 70 year old man with a history of 2 MI's have his HgbA1C go as low at 7%? No. Because everyone's levels will respond differently and if this particular patient allows his levels to dip too low it could stress his heart, which with 2 MI's already could be detrimental. Any HgbA1C level greater than 7.0% is considered out of control, but what if the level rises to 10-12%? Then the patient's BG is completely out of control and they WILL develop complications. What is the physiology and pathophysiology associated with Type 2 Diabetes Mellitus? Type 2 diabetes, once known as adult-onset or non insulin-dependent diabetes, is a chronic condition in which your body either resists the effects of insulin — a hormone that regulates the movement of sugar into your cells — or doesn't produce enough insulin to maintain a normal glucose level. - adult onset very common. - strong genetic tendency. - usually uncontrolled for many years before finally diagnosed and therefore can either lead to complications or the damage is already done: ex, wounds that won't heal or numbness/tingling in the fingers. - routine screening for this is key! What is happening in the liver with Type 2 DM? The liver will continue to make glucose even when you don't need it. What is happening in the GI tract with Type 2 DM? Too much glucose is being absorbed in the GI tract. What is happening in the pancreas with Type 2 DM? Insulin secretion is impaired. You have SOME but not enough. In addition, beta cells in the pancreas are chronically exposed to high glucose so eventually they are no longer as sensitive to the higher levels and don't work as effectively. What is happening in the muscles with Type 2 DM? Insulin-stimulated glucose uptake is DECREASED. Too much fat tissue inhibits the muscle's ability to respond. What are some signs and symptoms that would be associated with chronic or recurrent mild hyperglycemia? - polyuria - polyphagia - polydipsia - sleep disturbances - overweight - numbness/tingling (neuropathy/parasthesia) - delayed CRT - poor perfusion leading to sexual dysfunction - chronic fatigue - wounds that won't heal - blurred vision - BG greater than 140 mg/dL - higher risk/occurrence of respiratory infections (definitely recommend flu and pneumovax). - bloods vessels in the body will be stiff, narrow, and weakened - warm extremities (flushed skin) - decreased GI motility and peristalsis over time, leading to Gastroparesis: a condition that reduces the ability of the stomach to empty its contents. It does not involve a blockage (obstruction). - increased risk for ALL infections - vaginal infections and perineal itching for women As you can see, poor blood glucose control can lead to MANY complications. How is exercise beneficial for a patient with an elevated blood glucose? Exercise is key! Because it: • Increases glucose uptake by muscle cells. • Improves insulin utilization (it increases the metabolic rate so it burns glucose longer). • Can reduce need for meds. • Reduces cholesterol & triglycerides. • Improves circulation & muscle tone. • Decreases cardiovascular complications. • Type 2 can decrease insulin resistance (because Type 2's tend to have an increased insulin resistance because of being overweight). It increases perfusion and glucose metabolism! It decreases insulin resistance and increases muscle cell sensitivity to the glucose they DO have. What are the ADA goals for EVERYONE with Diabetes Mellitus? 1. To maintain near normal blood glucose (60-110 normal). 2. To achieve optimum lipid levels (because vessels can become damaged and occluded from poorly controlled lipid and blood glucose levels). 3. To achieve optimum BP control. 4. To prevent and treat complications (continually monitor and intervene EARLY). 5. To improve overall health through optimum nutrition and exercise (making sure to monitor daily protein, fat, carbohydrate AND calorie intake). What is included in the nurse's role when caring for a patient with DM? 1. Assessment and monitoring of their nutritional status. 2. Know the patient's nutritional prescription. 3. Reinforce nutritional teaching with patient and family. 4. Answer any questions about nutritional therapy. What is significant about meal planning for a patient with DM? It must be individualized for EACH patient! Must consider: 1. Diet history. 2. Eating habits and preferences. 3. Cultural/religious/ethnic influences. Ex, Muslims that have religious periods of fasting. 4. Special needs. Ex, any problems with access to food. In addition, the relationship between different types of food and insulin needs to be reinforced with the patient. What percentage of carbohydrate intake affects the blood glucose level? What percentage of protein intake? Fat intake? Carbohydrate intake: up to 100% contributes to the blood glucose level. Protein intake: 50% (one half) contributes to the blood glucose level. The other half is stored as protein and fuel in the body. Fat intake: less than 10%. What are the meal plan goals for a patient with Type 2 DM? 1. Improve BG levels to near normal (recommend eating 3-5 smaller meals a day instead of 3 large meals to help avoid blood sugar spikes). 2. Optimal lipid levels. 3. Attain a reasonable body weight. 4. Improve overall health. 5. Prevent or delay complications. What should be taken into consideration when constructing a DM diet plan for an older adult? 1. Ask them their dietary likes and dislikes. 2. Consider who prepares the food. 3. Age related changes in taste perception. 4. Dental health. 5. Transportation to buy food. 6. Available income. What is the difference between a Carbohydrate Counting Meal Plan and a Consistent Carbohydrate DM Meal Plan? 1. Carbohydrate Counting Meal Plan: - CLOSELY monitors carbohydrate intake. - allows for more accurate estimate blood sugar increases after a meal. - a prescribed amount of carbohydrates are divided between each meal. 2. Consistent Carbohydrate DM Meal Plan: - CC focuses on maintaining similar amounts of carbohydrates at each meal. - stabilizes post-prandial (during or relating to the period after dinner or lunch) BG levels. - used frequently in DM ON INSULIN. *Either one of these is chosen depending on the patient. What is the relationship between carbohydrate counting and insulin coverage? 10-15 grams of carb intake requires 1 unit of Regular or Humalog or Lispro Insulin for coverage! *Thanks to Carb-Counting and Consistent-Carb Meal Plans, the amount of CHO intake for a meal can be estimated and then covered with the appropriate amount of insulin. When preparing a meal plan for a patient with DM, what is a recommended breakdown of what types of food and how much of each is recommended (food exchanges)? - 2 starches - 3 meats - 1 vegetable - 1 fat - 1 fruit - "free food" unlimited. How does fiber assist in the metabolism of carbohydrates? Fiber SLOWS the metabolism of carbs! What is the Glycemic Index? Glycemic Index reflects how much a food increases BG compared with equal amounts of glucose. Glycemic Index should be evaluated by monitoring BG after eating specific foods. Then the insulin dose can be adjusted to the food intake. How is the ChooseMyPlate broken down as far as a suggested meal plan? Food plate is divided into 3 sections: - 1/4 grains or starchy veggies: ex, potatoes, rice, pasta. - 1/4 proteins - 1/2 filled with non-starch veggies: salad, spinach, etc. How are alcohol intake and DM related? Alcohol can potentiate (increase the power) hypoglycemic effects of medications. The insulin will continue to work after the blood sugar has already dropped---causing the BS to drop drastically and the patient could die. - signs of hypoglycemia and intoxication are very similar. Can a patient with DM drink alcohol? YES, but alcohol should be consumed with food. In addition, alcohol is counted as part of the meal plan's daily exchanges. ADA recommend max: - 2 drinks for males - 1 drink for females Alcohol = 2 FAT exchanges *for reference: a 12 oz beer, 5 oz of wine, and 1.5 oz of liquor = 15 grams of CHO and 90 calories. The nurse is educating a pregnant client who has gestational diabetes. Which of the following statements should the nurse make to the client? Select all that apply. a. Cakes, candies, cookies, and regular soft drinks should be avoided. b. Gestational diabetes increases the risk that the mother will develop diabetes later in life. c. Gestational diabetes usually resolves after the baby is born. d. Insulin injections may be necessary. e. The baby will likely be born with diabetes f. The mother should strive to gain no more weight during the pregnancy. a, b, c, d Gestational diabetes can occur between the 16th and 28th week of pregnancy. If not responsive to diet and exercise, insulin injections may be necessary. Concentrated sugars should be avoided. Weight gain should continue, but not in excessive amounts. Usually, gestational diabetes disappears after the infant is born. However, diabetes can develop 5 to 10 years after the pregnancy. See an expert-written answer! The guidelines for Carbohydrate Counting as medical nutrition therapy for diabetes mellitus includes all of the following EXCEPT: a. Flexibility in types and amounts of foods consumed. b. Unlimited intake of total fat, saturated fat and cholesterol. c. Including adequate servings of fruits, vegetables and the dairy group. d. Applicable to those with either Type 1 or Type 2 diabetes mellitus. b. Unlimited intake of total fat, saturated fat and cholesterol. When taking a health history, the nurse screens for manifestations suggestive of DM. Which of the following manifestations are considered the primary manifestations of DM and would therefore be most suggestive of DM and require follow-up investigation? a. Excessive intake of calories, rapid weight gain, and difficulty losing weight. b. Poor circulation, wound healing, and leg ulcers. c. Lack of energy, weight gain, and depression. d. An increase in three areas: thirst, intake of fluids, and hunger. d. An increase in three areas: thirst, intake of fluids, and hunger. The primary manifestations of DM are polyuria (increased urine output), polydipsia (increased thirst), polyphagia (increased hunger). Blood sugar is well controlled when Hemoglobin A1C is: a. Below 7% b. Between 12%-15% c. Less than 180 mg/dL d. Between 90 and 130 mg/dL a. Below 7% A1C measures the percentage of hemoglobin that is glycated and determines average blood glucose during the 2 to 3 months prior to testing. Used as a diagnostic tool, A1C levels of 6.5% or higher on two tests indicate diabetes. A1C of 6% to 6.5% is considered pre-diabetes. Which of the following persons would most likely be diagnosed with DM? A 44-year-old: a. Caucasian woman. b. Asian woman. c. African-American woman. d. Hispanic male. c. African-American woman. Age-specific prevalence of diagnosed diabetes mellitus (DM) is higher for African-Americans and Hispanics than for Caucasians. Among those younger than 75, black women had the highest incidence. See an expert-written answer! Which of the following factors are risks for the development of DM? Select all that apply. a. Age over 45 years b. Overweight with a waist/hip ratio >1 c. Having a consistent HDL level above 40 mg/dl d. Maintaining a sedentary lifestyle a. Age over 45 years b. Overweight with a waist/hip ratio >1 d. Maintaining a sedentary lifestyle Aging results in reduced ability of beta cells to respond with insulin effectively. Overweight with waist/hip ratio increase is part of the metabolic syndrome of DM Type 2. There is an increase in atherosclerosis with DM due to the metabolic syndrome and sedentary lifestyle. Of which of the following symptoms might an older woman with DM complain? a. Anorexia b. Pain intolerance c. Weight loss d. Perineal itching d. Perineal itching Which of the following is accurate pertaining to physical exercise and Type 1 DM? a. Physical exercise can slow the progression of diabetes mellitus. b. Strenuous exercise is beneficial when the blood glucose is high. c. Patients who take insulin and engage in strenuous physical exercise might experience hyperglycemia. d. Adjusting insulin regimen allows for safe participation in all forms of exercise. a. Physical exercise can slow the progression of diabetes mellitus. Physical exercise slows the progression of diabetes mellitus, because exercise has beneficial effects on carbohydrate metabolism and insulin sensitivity. Strenuous exercise can cause retinal damage, and can cause hypoglycemia. Insulin and foods both must be adjusted to allow safe participation in exercise. See an expert-written answer! A patient newly diagnosed with Type I DM is being seen by the home health nurse. The doctors orders include: 1200 calorie ADA diet, 15 units NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the patient at 5 pm, the nurse observes the man performing blood sugar analysis. The result is 50 mg/dL. The nurse would expect the patient to be a. confused with cold, clammy skin an pulse of 110. b. lethargic with hot, dry skin and rapid deep respirations. c. alert and cooperative with BP of 130/80 and respirations of 12. d. short of breath, with distended neck veins and bounding pulse of 96. a. confused with cold, clammy skin an pulse of 110. Signs and symptoms indicative of hypoglycemia. A patient with type 1 diabetes has received diet instruction as part of the treatment plan. The nurse determines a need for additional instruction when the patient says, a. "I may have an occasional alcoholic drink if I include it in my meal plan." b. "I will need a bedtime snack because I take an evening dose of NPH insulin." c. "I will eat meals as scheduled, even if I am not hungry, to prevent hypoglycemia." d. "I may eat whatever I want, as long as I use enough insulin to cover the calories." d. "I may eat whatever I want, as long as I use enough insulin to cover the calories." Rationale: Most patients with Type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction. A patient recovering from DKA asks the nurse how acidosis occurs. The best response by the nurse is that: a. insufficient insulin leads to cellular starvation, and as cells rupture they release organic acids into the blood. b. when an insulin deficit causes hyperglycemia, then proteins are deaminated by the liver, causing acidic by-products. c. excess glucose in the blood is metabolized by the liver into acetone, which is acidic. d. an insulin deficit promotes metabolism of fat stores, which produces large amounts of acidic ketones. d. an insulin deficit promotes metabolism of fat stores, which produces large amounts of acidic ketones. Rationale: Ketoacidosis is caused by the breakdown of fat stores when glucose is not available for intracellular metabolism. The other responses are inaccurate. A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dl (6.7 mmol/L). The nurse will plan to teach the patient about: a. use of low doses of regular insulin. b. self-monitoring of blood glucose. c. oral hypoglycemic medications. d. maintenance of a healthy weight. d. maintenance of a healthy weight. Rationale: The patient's impaired fasting glucose indicates pre-diabetes and the patient should be counseled about LIFESTYLE CHANGES to prevent the development of Type 2 diabetes. The patient with pre-diabetes does not require insulin or the oral hypoglycemics for glucose control and does not need to self-monitor blood glucose. When assessing the patient experiencing the onset of symptoms of Type 1 diabetes, which question should the nurse ask? a. "Have you lost any weight lately?" b. "Do you crave fluids containing sugar?" c. "How long have you felt anorexic?" d. "Is your urine unusually dark-colored?" a. "Have you lost any weight lately?" Rationale: Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar- containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute. See an expert-written answer! When a client learned that the symptoms of diabetes were caused by high levels of blood glucose the client decided to stop eating carbohydrates. In this instance, the nurse would be concerned that the client would develop what complication? a. acidosis b. atherosclerosis c. glycosuria d. retinopathy a. Acidosis When a client's carbohydrate consumption is inadequate ketones are produced from the breakdown of fat. These ketones lower the pH of the blood, potentially causing acidosis that can lead to a diabetic coma. See an expert-written answer! The doctor is interested in how well a client has controlled their blood glucose since their last visit. What lab values could the nurse evaluate to determine how well the client has controlled their blood glucose over the past three months? HgbA1C! This blood test is used to determine how well blood glucose has been controlled over a 3 month period. See an expert-written answer! The lowest fasting plasma glucose level suggestive of a diagnosis of DM is: a. 90mg/dl b. 115mg/dl c. 126mg/dl d. 180mg/dl c. 126mg/dl Glucose is an important molecule in a cell because this molecule is primarily used for: a. Extraction of energy. b. Synthesis of protein. c. Building of genetic material. d. Formation of cell membranes. a. Extraction of energy Glucose catabolism is the main pathway for cellular energy production. The nurse knows that glucagon may be given in the treatment of hypoglycemia because it: a. Inhibits gluconeogenesis. b. Stimulates the release of insulin. c. Increases blood glucose levels. d. Provides more storage of glucose. c. Increases blood glucose levels Glucagon, an insulin antagonist produced by the alpha cells in the Islets of Langerhans, leads to the conversion of glycogen to glucose in the liver. 34. Which of the following chronic complications is associated with diabetes? a. Dizziness, dyspnea on exertion, and coronary artery disease. b. Retinopathy, neuropathy, and coronary artery disease. c. Leg ulcers, cerebral ischemic events, and pulmonary infarcts. d. Fatigue, nausea, vomiting, muscle weakness, and cardiac arrhythmia's. b. Retinopathy, neuropathy, and coronary artery disease. These are all chronic complications of diabetes. Insulin forces which of the following electrolytes out of the plasma and into the cells? a. Calcium b. Magnesium c. Phosphorus d. Potassium d. Potassium Insulin forces potassium out of the plasma, back into the cells, causing Hypokalemia (however, it can also be used to TREAT hyperkalemia). Potassium is needed to help transport glucose and insulin into the cells. Calcium, magnesium, and phosphorus aren't affected by insulin. See an expert-written answer! In educating a client about Type II Diabetes, what would be a proper explanation for poor wound healing? a. High blood glucose damages capillaries. b. Swings in blood sugar prevent proper clotting. c. The pancreas fails to secrete the proper chemicals. d. Ketosis prevents proper healing. a. High blood glucose damages capillaries. High blood glucose damages capillaries which prevent proper healing. A nurse shoud recognize which symptom as a cardinal sign of diabetes mellitus? a. Nausea b. Seizure c. Hyperactivity d. Frequent urination d. Frequent Urination Polyphagia, polyuria, polydipsia, and weight loss are cardinal signs of DM. Other signs include irritability, shortened attention span, lowered frustration tolerance, fatigue, dry skin, blurred vision, sores that are slow to heal, and flushed skin. Which type of diabetes is controlled primarily through diet, exercise, and oral anti-diabetic agents? Diabetes Mellitus Type 2. What are the precautions for Diabetic's when they exercise? 1. They must inspect their feet DAILY after exercising (due to poor perfusion since the tiny vessels in feet become damaged and can lead to parasthesia). 2. Wear proper shoes! 3. Avoid exercise in extreme heat or cold. WHY? Because it can change their metabolic rate. 4. BG levels should be carefully monitored. WHEN? Before, during, and after exercising! Especially when they are starting a new workout regime. 5. AVOID exerise: if BG is poor. OVER 250 mg/dL. or for Positive ketones in the urine which would mean BG control is extremely poor. Can a consistent exercise routine result in a decreased need for diabetic medication? YES! It can actually decrease the need for oral medications (used by Type 2's) or decrease the need to use as much insulin to control BS. What 3 lab values are most commonly monitored for Diabetic patient's? 1. Blood Glucose 2. Hemoglobin A1C 3. Ketones What are the advantages of BG monitoring? 1. IT'S KEY TO DM MANAGEMENT! 2. Control promotes more normal BG. 3. Normal BG reduces complications. 4. Self-managed BG allows adjustments of treatments. 5. It limits hyperglycemic episodes. Why would it be dangerous for a patient with a history of heart probelms to maintain "too tight" blood glucose control by trying to keep it on the lower range of normal? Keeping the BG lower can actually cause stress on the heart and lead to death. Again, what is the normal range for fasting blood glucose? 60 - 110 mg/dL What fasting level of blood glucose would indicate a diagnosis of diabetes? Any level greater than 126 mg/dL when FASTING. What is the normal range for blood glucose BEFORE a meal (PRE-PRANDIAL)? 70 - 130 mg/dL What is the normal range for blood glucose AFTER a meal (POST-PRANDIAL)? LESS than 180 mg/dL How often are BG levels monitored throughout the day? 2 - 4 times daily. Can monitor routinely and occasionally such as: after fasting, 2 hours after a meal, and before bed. Why would BG levels be checked more than 2 - 4 times a day? 1. If hyper/hypoglycemia are suspected. 2. If the patient is ill. 3. If there have been changes to medications. 4. If the patient has changed their diet or had changes in their activity level, ex: they go on vacation or a cruise. If there is anything different that will affect the person's metabolic rate, then their BG should be checked more often. If a patient is on insulin, how often should their BG levels be checked? At least 3 times daily, before each meal! What HIGHLY acidic substances are formed when the liver breaks down fatty acids for fuel in the absence of insulin? What results from this process? Ketones! Results in diabetic ketoacidosis. What are the implications of positive ketone test results? 1. Tests that have a trace to moderate amount of ketones need to be monitored. 2. Tests that are positive with a large number of ketones need to be treated and correlated with the BG. 3. Large volumes can lead to DKA. How often should a lipid panel (serum triglyceride and cholesterol) be drawn for a diabetic patient? Once a year. What is the normal range for total cholesterol? Less than 200. What is the normal range for triglycerides? Less than 150. What is the normal range for HDL (good cholesterol)? Greater than 40 mg/dL What is the normal range for LDL (bad cholesterol)? Less than or equal to 100. What does the urine test for protein indicate? Proteinuria can indicate early nephropathy (problems with the small vessels in the kidneys); basically the kidneys are letting too large of proteins through into the urine which is NOT good. How often is a kidney function test done? What lab values does this test include? Every 6 months and it includes the BUN/Creatinine levels. How often is a urine microalbumin test done? What will this test show? What is the normal reading for this test? Once a year. This test will show changes in the kidney function prior to blood tests being done. Normal < 30 mg. How often are LFT's done? Every 3-6 months for certain medications. This test is especially important to do for oral meds that can lead to liver toxicity at a certain point. Again, what is the normal range for Hemoglobin A1C and what does this test show? The normal range is 7.0% or less and this test is the average blood glucose over the course of 3 months. How often is an A1C test done? Every 3 months for a newly diagnosed diabetic patient and every 6 months for a controlled diabetic patient. In regards to abnormalities in BG, what is the Dawn Phenomena? Characterized by elevated BG in the morning! This phenomena is caused by the release of either growth hormone, cortisol, and/or endogenous insulin abnormalities (natural insulin abnormalities). How is the diagnosis for the Dawn Phenomena made? Diagnosis is made by checking BG at 2 and 4 AM, and if the levels are high at that time then it's a positive DP. What is the treatment for Dawn Phenomena? Adjustment of insulin doses from dinner to bedtime or increase HS (bedtime) insulin. In regards to BG abnormalities, what is Somogyi's Effect? Characterized by wide differences in early morning BG from 2-4 AM (LOW) and fasting BG from 7-8 AM (HIGH). Basically the glucose is wayyyy too low in the middle of the night and then goes wayyyy too high in the early morning. The blood glucose drops because of too much insulin at bedtime and as a response the blood glucose overcompensates too much and becomes high by 7-8 AM. When should BG be checked to diagnose if Somogyi's Effect is occurring? Checking BG between 2-4 AM is VERY IMPORTANT! BG should also be checked again in the early morning from 7-8 AM. What is the treatment for Somogyi's Effect? If BG is low (60 mg/dL) add more dietary intake at bedtime and give LESS insulin. So essentially, the treatments for DP and Somoygi's are OPPOSITE. For DP= treat high AM BG with more insulin at bedtime or before dinner. For SE= treat low BG from 2-4AM and high BG from 7-8AM with MORE food at bedtime and LESS insulin. How often should BG be checked when a patient is sick? Every 3-4 hours during illness. Should an ill diabetic patient still continue taking their insulin if they aren't eating as much as they usually would be when healthy? YES! If possible, they should still take their long-acting insulin. How else should diabetics manage their nutritional health when ill? 1. They should sip 8-12 ounces of clear fluid HOURLY! Especially if they are experiencing N/V/D. 2. They should substitute any intake to easily digested foods such as toast or jello. When should a healthcare provider be called if a diabetic patient is ill? 1. Call HC provider if not eating for 24 HOURS! 2. Call HC provider if vomiting or diarrhea for 6 HOURS! - If V/D has gone on this long you do not want to wait with a diabetic patient! They can quickly become dehydrated and go into DKA and the situation will go bad very quickly. 3. If BG greater than 300 CALL THE HC PROVIDER! Which type of diabetics usually use oral medications to control their BG? Type 2's, oral meds are used if the pancreas produces insulin. What are the 6 classes of oral medications used by Type 2 diabetics? 1. Sulfonylureas 2. Biguanides 3. Alpha-glucosidase inhibitors 4. Non-sulfonylureas Insulin Secretagogues *Meglitinides 5. Thiazolidinediones 6. DDP-4 *Incretin Mimetics SUck BIG Inhibitors, Not Thiazo Deeply What is the action of (Second Generation) Sulfonylureas? Sulfonylureas: Tell the beta cells of the pancreas to release more insulin and decrease insulin resistance (therefore, this medication class is better for those with a higher BMI. *It's as if insulin is being held captive by the pancreas and the beta cells, so the Sulfonylureas (Amaryl/Glimeperide and Glucotrol/Glipizide and Glyburide) show up and are like, "SUck it pancreas! I'm here to release the insulin! The bloodstream is overloaded with sugar and insulin needs to go clean it up! The body is never able to resist insulin's powers!" How come First Generation Sulfonylureas aren't used? 1st generation sulfo's weren't great because they had significant side effects that resulted. What are examples of Sulfonylureas? Think glipi, glimepiri, glyburi Glucotrol (glipizide) Amaryl (glimepiride) Diabeta, Micronase (glyburide) What are nursing considerations for Sulfonylureas? 1. Due to the decrease in insulin resistance and then release of insulin from the beta cells of the pancreas, this med class can cause HYPOglycemia. Therefore it's important to give this med 30 minutes BEFORE a meal because it takes time for the body to metabolize. 2. Sulfonylureas interact with NSAIDS, warfarin, and sulfonamides. (Therefore this med wouldn't be good for pt's with a DVT and on long term warfarin). 3. Use caution with sulfa allergies. 4. Side effects: GI disturbances (such as diarrhea & cramping but those s/s usually subside after a couple weeks), neuro disturbances, skin rash and weight gain. 5. Contraindicated with pregnancy. ORAL DIABETIC MEDS WOULD NOT BE GIVEN TO A PREGNANT PATIENT! What is the action of Biguanides? Biguanides REDUCE the liver from making more glucose! That way the patient won't have strong spikes or releases of glucose when they are fasting. They also increase tissue sensitivity to insulin (so this is also a good med to give to an overweight diabetic patient). Think: the liver is a BIG organ, Biguanides reduce BIG amounts of glucose from the liver. What are examples of Biguanides? Think: Glucophase, Glucophage 1. METFORMIN is the most common! (glucophase, glucophage XL, fortament) 2. Combination: Metformin with GLYBURIDE (remember, glyburide is a sulfonylurea) = Glucovance What are nursing considerations for Biguanides? 1. This drug minimizes weight gain! Woo hoo! 2. It causes Lactic Acidosis in dehydrated patients. S/S of lactic acidosis: weakness, fatigue, systemic muscle pain, stomach discomfort. This can be FATAL. 3. This should be taken WITH meals. 4. DO NOT USE IN IMPAIRED RENAL FUNCTION! 5. Side effects: GI disturbances, lactic acidosis, and headache. What is the action of Alpha-glucosidase Inhibitors? Alpha-glucosidase is an enzyme that cuts big sugars into little sugars that float around in the blood---these small sugars can be a big problem for BG levels. If Alpha-glucosidase is inhibited, then there are less little sugars floating around! THEREFORE, AG Inhibitors delays absorption of carbs by the intestine to minimize glucose spikes post-prandial (post-meal). This med peaks at 3 hours, so it should be taken WITH food. Literally, your first bite of food should be right after you take this medication. What are examples of Alpha-glucosidase Inhibitors? Remember, this med delays the absorption of carbs by the intestines to minimize BG spikes post-mealtime. 1. Acarbose (Precose) 2. Miglitol (Glyset) What are the nursing considerations for Alpha-glucosidase Inhibitors? 1. Give before meals with the first bite of food. 2. It is MOST effective when taken with a high fiber diet. Because fiber is not absorbed from the intestines. 3. Contraindicated: GI dysfunction! (if no functional GI tract, then the delay in carb absorption would not be effective). 4. HOLD dose if patient is NPO or fasting! (This med is supposed to effect the absorption of carbs in the food you eat, but if you're not eating any food then this med should not be taken) 5. Side effects: GI disturbances, rash, NO weight gain (woo hoo!), NO hypogylcemia because it binds to carbohydrates (unlike sulfonylureas which DO cause hypogylcemia). Remember, alpha-glucosidase inhibitors PREVENT spikes, it doesn't correct an already high blood glucose. Ok, so Sulfonylureas release insulin from the pancreas to decrease BG---what is the action of Non-Sulfonylurea Insulin Secretagogues? Non-Sulfo's IMPROVE insulin action! They make insulin work better~ What are some examples of Non-Sulfonylurea Insulin Secretagogues? 1. Meglitinides: Prandin (repaglinide) 2. Starlix (neteglide) What are the nursing considerations for Non-Sulfonylureas Insulin Secretagogues? 1. This medication is metabolized by the liver so renal and liver function should be monitored. 2. Side effects: GI disturbances, HYPOglycemia (JUST like Sulfonylureas) and cardio effects (no one is sure why this happens but a patient with a history of an MI should NOT take this med). Even though Type 2's only really take oral diabetic medications, why would a Non-Sulfonylurea Insulin Secretagogue not be a good med choice for a Type 1 diabetic? Because Non-Sulfo's make insulin work better! Type 1's don't have any insulin to improve. What is the action of Thiazolidinediones? Thanks to Thiazolidinediones, the body is unable to resist the seductive powers of insulin! Thiazolidinediones lowers insulin resistance. What are some examples of Thiazolidinediones? 1. Actos (pioglitazone) 2. Avandia (rosiglitazone) What are the nursing considerations for Thiazolidinediones? 1. LFT's should be done every 3 months since this med (like Non-Sulfo's) is metabolized in the liver. 2. Warning: Avandia increases risk of MI's (so again, like Non-Sulfo's this med should not be given to patient's with history of heart problems). 3. Side effects: possible liver toxicity, weight gain, hypoglycemia (like Sulfo's and Non-Sulfo's), hyperlipidemia (from damaging cardiac arteries), and increases fractures. What is the action of DPP-4 Inhibitors? 1. Like, Biguanides (Metformin) DPP- 4 inhibitors decrease liver glucose production. 2. INCREASES INSULIN! What are examples of DPP-4 Inhibitors? 1. Januvia (sitagliptin) MOST COMMON! 2. Tradjental (linagliptin) 3. Onglyza (saxagliptin) What are the nursing considerations for DPP-4 Inhibitors? 1. S/S of HYPOglycemia! (because it increases insulin which decreases BG). 2. Side effects: HA, N/V, hypoglycemia! What is the action of Human Amylin (these mimic insulin)? Human amylin lowers post-prandial BG (like the alpha-glucosidase inhibitors) and is an adjunct (added) to insulin. - it decreases the appetite and lowers BG spikes after meals. - it's used WITH insulin but injected SEPARATELY. How is Human Amylin given? As a SQ injection. When it's working well, it can decrease the amount of pre-meal insulin needed by as much as 50%! What is an example of Human Amylin? Symlin (pramlintide) - SQ ONLY What are the nursing considerations for Human Amylin Injections? 1. It must be a separate SQ injection from insulin (meaning multiple injections at that point). 2. Side effects: N/V, anorexia (decreases the appetite), HA, hypoglycemia. What is the action of Incretin Mimetics (these mimic insulin)? Fun fact: this med was developed from the saliva of gila monsters. 1. They enhance insulin secretion in the presence of high BG. 2. They decrease glucose from the liver. 3. They are used with Sulfonylureas (remember they release the insulin from pancreatic jail and make it so that the body is unable to resist the insulin being released). Those two used together allows for REALLY GOOD CONTROL of BG. 4. And like Human Amylin, this prevents hypoglycemic spikes after meals. How are Incretin Mimetics given? Also by injection! What are examples of Incretin Mimetics? 1. Baraclude, Byetta (exenatidine) - SQ only 2. Victoza (luraglutide) -injection What are the nursing considerations for Incretin Mimetics? 1. Refrigerate!!!!!! 2. Give BEFOREEEE MEALLLLSSS!!! 3. This is NOT a substitute for insulin!!! 4. Side effects: N/V, weight loss, anorexia (decreased appetite), NO hypoglycemia (unlike Human Amylin which does cause hypoglycemia). What is the alternative use oral medication that is actually given for Parkinson's Disease and happens to have anti-diabetic effects? Cycloset (bromocriptine) 1. It's FDA approved. 2. An old med used to treat Parkinson's. 3. Help control BG (Type 2's) through brain chemistry. 4. It's a low dose, quick acting, given once daily in the morning. 5. Helps lower post-meal BG all day! What are examples of combination anti-diabetic drugs? 1. Glucovance (remember, this is a Biguanide): metformin with glyburide. 2. Metaglip: glipizide with metformin. 3. Avandamet: Avandia (rosiglitazone) with metformin. What are the advantages of combination drug therapy? 1. Increases compliance: only one pill to take. 2. Cost is less. 3. Multiple actions of the agents at the same time. 4. Drug companies prefer--increases charges for generic medications. What are the hyperglycemic medications used to treat HYPOglycemia? Glucagon!! Glucagon: 1. Increases blood glucose--stimulates glycogen from liver. 2. Treats insulin induced hypoglycemia (BG <60 mg/dL). 3. BG increases 5-20 minutes after administration (therefore the nurse might still have to give D50 depending on how low the BG is). What are the side effects of Glucagon? N/V, low BP, allergy What are the nursing considerations for Glucagon? 1. Administer SQ, IV, IM 2. Use insulin shock. 3. Emergency kit. 4. Monitor BG. Time to talk about Type 1 diabetes! When is the onset for Type 1? Type 1 has a juvenile onset, under the age of 30. Is Type 1 more or less common than Type 2? Type 1 is LESS common than Type 2. 5-10% of DM patients are Type 1. How do Type 1's differ from Type 2's? Type 1's do not have ANY insulin production so they are completely dependent on insulin injections. Type 1 is: -genetic - immunologic - environmental -involves a loss of beta cells -total lack of insulin What are the signs and symptoms associated with Type 1 DM? 1. Onset under 30 y/o. 2. Weight loss. 3. N/V. 4. Syncope. 5. 3 P's: Polyuria, Polydipsia, Polyphagia. 6. Glucosuria. 7. Ketosis. 8. DKA. 9. Hyperglycemia. Again, how is Type 1 DM managed if they do not produce any insulin? Insulin is required for them to survive! They have to do SMBG (self-managed blood glucose), nutritional therapy, and exercise. What is insulin? Insulin is a hormone and a protein. It's the drug of choice to control gestational diabetes and Type 1 DM. What are the 4 type of Insulin? 1. Rapid acting. 2. Short acting (Regular insulin). 3. Intermediate acting. 4. Very long acting (basal insulins). Ok, let's talk about Rapid acting! Rapid acting insulin is normally given RIGHT BEFORE meals to correct hyperglycemia. What are examples of rapid acting insulin? 1. Humalog 2. Lispro 3. Aspart 4. Novolog Think of how rapid a(s)part of a log rolls down a hill like a (lis)pro. What is the route of Rapid acting insulin? Given ONLY SQ, never IV. What is the Onset, Peak and Duration of Rapid acting insulin? Onset: 5 - 15 minutes. Peak: 60 minutes. Duration: 2-4 hours. Ok, let's talk about Short acting insulin! Short acting or Regular insulin is used also for sliding scale coverage as well as for emergency coverage (given as infusions). If that's the case, what is the route for Short acting or Regular insulin? Given SQ AND IV. Short-acting is the only insulin to be given IV. What are examples of Short acting (Regular) insulin? 1. Regular Insulin. 2. Humulin R 3. Novalin R 4. Velosulin BR The regular insulin always have an R on the bottle and they will be a clear solution. What is the Onset, Peak, and Duration of Short acting (Regular) insulin? Onset: 30 - 60 minutes. Peak: 2 - 4 hours. Duration: 4 - 6 hours. Ok, let's talk about Intermediate acting Insulin! Intermediate acting has a protein derivative in the product that prolongs the insulin. This solution is therefore cloudy and must be gently rotated to mix. What is the route of administration for Intermediate acting insulin? SQ ONLY! This type of insulin is not used very often What are examples of Intermediate acting insulin? 1. Humulin N 2. Iletin NPH Look for N or NPH on the label and again, the solution will be cloudy. What is the Onset, Peak, and Duration of Intermediate acting insulin? Onset: 2 - 4 hours. Peak: 4 - 12 hours. Duration: 16 - 20 hours. Alright last one, time to talk about VERY long acting or Basal insulins! Unlike Intermediate insulin these do not have a protein derivative in them to make them cloudy, so these are clear and usually given at bedtime. Can very long acting insulin be mixed with other types of insulin? NOOOOOO! Long acting CANNOT be mixed with any other insulin! What is the route of administration of long acting insulin? SQ ONLY! This insulin is NEVER given for emergency situations. What are examples of long acting or basal insulin? 1. Lantus (glargine) 2. Detremir (Levemir) When should BG be checked when administering long acting? AC/HS What is the Onset, Peak, and duration of long acting insulin? Onset: 1 hour! Peak: There is NO PEAK! This agent is sustained over 24 hours. Duration: 24 hours. What 2 types of insulin make up combination insulin? Combination insulins are two types of insulin that are pre-mixed in the same container. They always contain regular (short-acting) or rapid acting plus intermediate acting insulin. They include 50/50, 70/30, and 75/25. All are cloudy and need rotating prior to SQ injection (only). How should combination insulin be drawn up into the one syringe? Draw up the rapid acting or short acting FIRST (clear solutions) and then the intermediate acting (cloudy solution). Remember: clear, cloudy, cloudy, clear. How quickly should insulin be given once it's been mixed? Within 5 minutes after mixing to maintain action time (basically give it right away). Does insulin need to be refrigerated? No (remember only incretin mimetic injections need to be) NOT insulin injections. They can be kept at room temperature for up to 28 days. When insulin is given SQ, why should the sites be "rotated"? To avoid lipodystrophy a build up of scar tissue at the site. When this happens, the insulin will not be absorbed there as a result. It take about 6 months for that site to recover. What is the best way to evaluate if a patient understands how to give themselves an insulin injection correctly? Reverse demonstration. What kind of insulin is used in an insulin pump? Rapid acting insulin, like Humalog or Novolog. How does an insulin pump work? The pump is worn externally and connects to an indwelling SQ needle. The pumps require ongoing follow-ups and can be used for both Type 1 and 2 diabetics. For the insulin pump, a basal rate is set that is unique to each individual based on how much insulin they need. Patients can give bolus doses associated with their CHO intake. What is the advantage of using an insulin pump? Advantage of the pump over SQ injections is that because of continuous infusion of insulin BG levels are more stable. The pump makes it so that there is a lesser chance to have BG highs and lows. There are several complications that can result from Diabetes. What is the complication of hypoglycemia? Hypoglycemia is a BG less than 60 mg/dL. What are some predisposing factors for hypoglycemia? 1. Too much insulin. 2. Erratic absorption of insulin (such as with lipodystrophy). 3. Sudden increase in activity. 4. Failure to eat on time. 5. Alcohol ingestion (remember if a patient is on insulin and drinks alcohol it can potentiate the effects of the insulin and drastically drop the BG level). 6. Some medications. What are the signs and symptoms associated with hypoglycemia? Systemic: shaky, irritable, nervous, increased HR, palpitations, tremor (they lose muscular control since there isn't enough glucose to control the muscles), hunger, diaphoresis, and pallor. Neurological: HA, slurred speech, blurred vision, confusion, behavior changes, lethargy, loss of consciousness, coma, and death. Depending on how low the BG level is, the s/s and the treatment can vary. If the BG level is mild down to 50-70 what symptoms would you expect and what is the treatment? S/S: tremors, anxious, tachy, sweaty, hunger, shaky, pallor. Treatment: Give the patient 10-15 g of carbs (1 serving) such as a simple carb like orange juice and then follow with a complex carb like cheese and crackers or 2% milk. Could also give glucose tabs or glucagon injection, or try a thick syrup. If the BG level is moderately hypoglycemic at 30-50 what symptoms would you expect and what is the treatment? S/S: HA, irritable, drowsy, slurred speech, blurred vision, and double vision. Treatment: Give the patient 20-30 g of carbs if they're awake enough to swallow or if they're not awake enough to swallow give Glucagon 1 mg SQ or IM; Dextrose 50% 50 cc IV push. If the BG level is severely hypoglycemic less than 30 what symptoms would you expect and what is the treatment? If their BG is that low you have only minutes to intervene: S/S: decreased LOC, coma, seizures, and death. Treatment: administer 50% dextrose IV push IMMEDIATELY. Moving on from hypoglycemia, what is the complication of diabetes referred to as diabetic ketoacidosis? DKA occurs when there is insufficient insulin in the body so it starts to break down fats and proteins for energy (which is why type 1's have weight loss, they are losing tissue and fat for fuel). During this breakdown of fatty acids, highly acidic ketone bodies build up (which are the waste products of fat breakdown). This causes a systemic acidosis or Diabetic Ketoacidosis that requires hospitalization to correct. Which type of diabetic is affected by DKA? Type 1 Diabetics. What kind of onset does DKA have? A rapid onset, this condition occurs suddenly. What are the precipitating factors of DKA? 1. Infection 2. Illness 3. Stress 4. Inadequate insulin What are the signs and symptoms of DKA? 1. 3 P's: polyuria, polydipsia, polyphagia. 2. Elevated ketones 3. Abdominal cramps. 4. N/V 5. Fatigue 6. Dehydration 7. Weight loss. 8. HA 9. Tachycardia 10. Hypotension 11. Fruity breath 12. Kussmaul respirations With DKA there is massive osmotic diuresis: they lose fluids so quickly the body can compensate and they could die. What diagnostic parameters are indicative of DKA? 1. Serum glucose > 250 2. Positive ketones in both urine and the blood. 3. Serum osmolality is increased. 4. Presence of metabolic acidosis so the ph is less than 7.35, the HCO3 is less than 15. 5. Serum Na is initially low and Serum K is low in severe DKA because all of the K is being peed out. 6. BUN > 20. This will be elevated due to the dehydration. What is the treatment for DKA? The key is to stabilize the fluids lost fast and to give them insulin! Initial treatment: 1. Check BG every hour. 2. Insulin: IV drip, SQ regular insulin prn. 3. IV NS fluids: 500 cc hr + with K. After 2-3 hours or when the BG normalizes, the IV is changed to 0.45 NS at 200-300 cc/hr with K. Dextrose: BG reaches 250 mg/dL dextrose is added to avoid drop in glucose (causes cerebral edema). With DKA, dehydration and K loss is what kills them so you'd want to hydrate them based on their BP but not too much because it could over replace). Once stable: 1. Frequent BG monitoring. 2. Insulin admin: SQ or IV. 3. ICU: monitored bed required due to cardiac dysrhythmias from electrolyte imabalance (hypokalemia). 4. ABG's: monitoring acidosis level (for pH). What is the diabetic complication referred to as HHS or Hyperglycemic Hyperosmolar Syndrome? HHS is similar to DKA but more severe. It has a mortality rate of 10-40% while DKA has one that is 1-5%. There is an intense increase of solute in the body, hence hyperosmolar. Does HHS affect Type 1 or Type 2 Diabetics? Type 2's. What are the precipitating factors of HHS? Does it occur rapid like DKA or gradually? It occurs gradually, this can go on for weeks before the patient notices. Due to: 1. Infection 2. Stress: stressors exacerbate the already increased BG level thanks to cortisol and catccholamines (therefore the BG increases but none is being used). 3. Illness 4. Poor fluid intake. What are the signs and symptoms associated with HHS? 1. Severe osmotic diuresis. 2. Dehydrated- poor skin turgor 3. Dry skin 4. Dry mucous membranes 5. Tachycardia 6. Hypotension 7. Electrolyte loss- low sodium, potassium, and phosphorus 8. Neuro: lethargy, change LOC, seizures, and coma. What are the diagnostic levels associated with HHS? 1. Serum glucose 600 - 1200 2. Negative ketones in both urine and the blood. 3. Serum osmolality is increased (will be higher than in DKA become more BG). 4. pH is near normal < 7.40 and HCO3 is near normal < 20, because Type 2's have some insulin so they are not as acidic. 5. Serum Na is normal to low and Serum K is normal to low. 6. BUN > 20. This will be elevated due to the dehydration. What is the treatment for HHS? It's similar to that of DKA. 1. Blood glucose is maintained around 250 until the fluid deficit is corrected. (The BG has to be brought down gradually). 2. Electrolytes are replaced. 3. Rapid fluid replacement. 4. Insulin IV to tx BG. 5. TREAT THE UNDERLYING CAUSE! What are some cradiovascular complications of diabetes? 1. CAD. 2. Cerebrovascular disease. 3. Atherosclerosis (2X more likely to have MI and CVA/stroke if Diabetic). DM accelerates atherosclerosis from hyperlipidemia. 4. HTN 5. Peripheral vascular disease: 50-70% of people who have lower extremity amputations are diabetic. This is preventable! *Also more prone to cavities, mouth infections, and ulcers. Why do diabetics have issues with their feet? It's a perfusion problem. What is involved in the prevention of foot problems? 1. Inspection of feet: Daily! And daily foot hygiene! 2. Protection: correct size shoes and fit, always wear socks, and never go barefoot. 3. Intervention: podiatry- careful toenail maintenance and routine MD visits that include foot evaluation. What is diabetic nephropathy? Compromised perfusion to the kidneys. S/S: urine albumin, changes in output, HTN, proteinuria, hypoglycemia because the kidneys are having trouble metabolizing glucose properly. Diagnostic Tests: 24 hour urine, and increased BUN/ CR (BUN is a product of protein metabolism). How is diabetic nephropathy managed? PREVENTION! -Low protein diet -Control HTN What is diabetic retinopathy? Damage to the capillaries of the retina. S/S: microaneurysms in retinal capillaries, retinal edema, vision changes (red/black lines or spots), retinal detachment. Diagnostic Tests: opthalmic exam every 6 months How is diabetic retinopathy managed? PREVENTION! - control BG - control HTN - laser photocoagulation - ASA (aspirin): anticoagulant What is diabetic neuropathy? Diabetic neuropathy is damage to nerves in the body that occurs due to high blood sugar levels from diabetes. S/S: affects every system, parasthesia, hyperesthesia, joint deformities, muscle atrophy (muscles shrink over time), decreased reflexes, and progressive tissue destruction. Diagnostic Test: physical assessment specific to system How is diabetic neuropathy managed? PREVENTION! -Control BG How long until Diabetic develop autonomic neuropathies? VERY long term: 20+ years to develop. A result of long term hyperglycemia. S/S: Hypoglycemic unawareness (they don't have any feeling or sensation to warn them of hypoglycemia so patient could just pass out because the nerves that detect hypoglycemia are shot). GU: neurogenic bladder, incontinence GI: gastroparesis, diarrhea, constipation CV: postural hypotension