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DIABETES :warning: 🍭🍰🍦:warning: (Type II (risk factors (obesity, older…

- - - - brain relies heavily on glucose for energy: manifestations of hypoglycemia often present an altered level on consciousness
- - - - minimum of 130g-150mg day or 50%-60% of total daily intake
      - one carb serving is 15g
      - patient should have between 45-60 g per meal
      - fruits, vegetables, grains, legumes, low-fat milk
    - - 15%-20% of total daily intake
      - meats, fish, poultry, dairy, nuts, legumes
    - - should be <7% of total daily intake
      - daily cholesterol should be <200 mg/day
      - two or more servings of fish per week
    - - one drink per day for women; two drinks per day for men
    - - fruits and vegetables should comprise 50% of a person's plate
      - grains and protein should comprise 50% of a person's plate. at least half of the grains should be whole grain
      - meal planning should be based on the patient's usual food intake and preferences
      - food choices should be balanced with glucose-lowering agents (GLAs)(insulin, oral agents, and non-insulin injectable agents) and exercise patterns
      - GLAs should be prescribed and administered with the patient's eating habits and activities in mind
      - education on portion control
  - - - ⬇️ insulin resistance
      - ⬇️ blood glucose levels
      - promote weight loss
      - ⬇️ triglyceride and cholesterol levels
      - ⬇️ blood pressure
      - improve circulation
      - prevent complications (obesity, fatty liver disease)
    - - patient as an elevated blood glucose level >250mg/dL and ketones are present in the urine
        
        it is not necessary to postpone exercise when blood glucose levels are ⬆️in the absence of ketosis
  - - - patients with type 1 need to take insulin because the pancreas is no longer producing insulin
      - in some cases, patients with type 2 diabetes will require insulin if the combination of endogenous insulin produced by the pancreas and glucose-lowering activity provided by OAs is insufficient
      - insulins are classified by the length of time they remain active in the body
      - rapid acting
        
        lispro, aspart, glulisine
        
        aspart (novolog)
        
        peak: 30 min-3 hr
        
        onset: 10-30min
        
        duration: 3-5 hours
      - short-acting
        
        regular
        
        onset: 30 min-1 hour
        
        peak 2- 5 hours
        
        duration 5-8 hours
      - intermediate-acting
        
        NPH
        
        onset: 1.5-4 hours
        
        peak: 4-12 hours
        
        duration 12-18 hours
      - long-acting
        
        (Lantus) glargine, detemir
        
        onset: 0.8-4 hours
        
        peak: no pronounced peak
        
        duration: 24+ hours
      - administration
        
        most are administered subcutaneously but it is packaged and prescribed for different delivery methods
        
        traditional multi-dose vial insulin
        
        many insulins are packaged in multi-dose vials requiring the nurse to withdraw the medication with an insulin syringe
        
        only an insulin syringe can be used to draw up and administer insulin subcutaneously
        
        insulin pen
        
        some insulins are prepackaged by the manufacturer in a pen that contains 300 units of insulin (multiple doses)
        
        patient attaches a disposable needle to the pen to administer the dose
        
        patient will turn the dial to the correct dose, inject the needle into the skin, and push the button on the top of the pen to administer the dose
        
        mixed insulin
        
        patient may receive more than one type of insulin at a time
        
        it is common to administer a long-acting insulin as a "basal" insulin dose and either a rapid-acting insulin with meals to provide an extra bolus to control blood glucose levels
        
        premixed insulins (ex. Novolin 70/30) contain both NPH (a long-acting insulin) and regular (a short-acting insulin) in one vial
        
        insulin pump
        
        delivers insulin via a subcutaneous needle left in the tissue, attached to a small mechanized pump device, worn at the waistline
        
        only delivers rapid-acting insulin
        
        delivers a basal rate so the patient is receiving a continuous amount of insulin throughout the day
        
        the patient can program the pump to administer insulin boluses based on carbohydrates ingested
        
        closely mimics insulin release in a healthy person who does not have diabetes. allows for tighter BG control
        
        inhaled insulin
        
        inhaled insulin is a rapid-acting insulin given when the patient begins to eat or within 20 minutes of eating
        
        not a substitute for long-acting insulin
        
        not recommended for patients who smoke or have chronic obstructive pulmonary disease because it can cause bronchospsms
        
        common side effects include hypoglycemia, cough, and throat pain/irritaiton
        
        patient should determine the blood glucose level before administering insulin
        
        instruct the patient to wash his or her hands first and clean the injection site
        
        when insulin in being administered, most health care facilities require two nurses to verify that the dose and type of insulin in the syringe are correct
        
        bolus dose insulin should be administered around the patient's meal schedule and should be withheld if the blood glucose level is <70 mg/dL
        
        rapid-acting insulin should be given when the patient is eating
        
        short-acting insulin should be given within 30 minutes of a meal
        
        long-acting insulin is given at a scheduled time
        
        insulin administered subcutaneously (either a single injection or continuously with an insulin pump)
        
        regular insulin has traditionally been the only insulin that is administered intravenously and typically only in emergency situations, not as part of routine management. aspart, lispro, and glulisine are also being administered intraveneously
        
        if the nurse is mixing insulins, he or she will inject air into the intermediate-acting insulin first, then into the short-acting insulin and will withdraw the short-acting insulin first and the intermediate-acting insulin second. this prevents contamination of the short-acting insulin with the intermediate-acting insulin
      - storage
        
        pens & vials may be kept at room temperature
        
        insulin should not be stored in hot or freezing cold environmental as temperature changes the molecular structure of the insulin
      - complications
        
        hypoglycemia occurs if insulin dosing is excessive or the patient is not balancing insulin administration with caloric intake
        
        lipodystrophy occurs if the patient repeatedly administers the insulin in the same area. the nurse will instruct to rotate injection sites = improved, more predictable insulin absorption
        
        allergic reactions (local itching, rash, or even full anaphylaxis)
        
        somogyi effect is an overcompensation by the body in response to extremely low blood sugar levels occurring during the night, resulting in early morning hyperglycemia. the body releases stored glucagon in reaction to the untreated nighttime hypoglycemia, managed by instituting a bedtime snack or decreasing the evening insulin dose
        
        dawn phenomenon is also early morning hyperglycemia caused by the release of cortisol and growth hormone during the early morning hours. it tends to happen to younger patients during periods of growth. managed by increasing the evening insulin dose
    - - many patients with type 2 diabetes, under normal or non-acute conditions, are prescribed oral GLAs
      - OAs improve the mechanisms by which the body produces and uses insulin and glucose
      - used in:
        
        the patient's pancreas produces some endogenous insulin but not enough to maintain healthy blood glucose levels
        
        the patient displays insulin resistance at the cellular level
        
        the patient has increased production of glucose in the liver
      - biguanides
        
        most widely used of all of the oral agents
        
        best "first-line" treatment for type 2 diabetes
        
        metformin is the only biguanide available in the united states
        
        reduce glucose production by the liver
        
        used for patients with pre-diabetes and type 2 diabetes who are overweight because it facilitates weight loss
        
        instruct to take with food
        
        instruct to avoid drinking large amounts of alcohol while taking this medication
        
        most common side effects are gastrointestinal upset and diarrhea
      - sulfonylureas
        
        includes glipizide, glyburide, & glimepiride
        
        works to increase pancreatic insulin production
        
        most common side effects are weight gain and hypoglycemia
      - meglitinides
        
        include repaglinide and nateglinide, which increase insulin production
        
        work to increase pancreatic insulin production
        
        fast absorption rates
        
        should be administered within 30 minutes before a meal
        
        should not be taken if the patient skips a meal
        
        most common side effects are weight gain, photosensitivity, and hypoglycemia
      - alpha-glucosidase inhibitors
        
        include acarbose and miglitol
        
        known as starch blockers because they slow down carbohydrate absorption
        
        should be taken with the first bite of each main meal to be most effective
        
        nursing considerations include treating hypoglycemia with 8oz of skim milk or glucose gel or tablets, since both acarbose and miglitol block the action of other fast-acting sources of sugar
      - dipeptidyl peptidase-4 inhibitors
        
        the main drug in this category is sitagliptin
        
        these medications increase insulin production and decrease hepatic glucose production
        
        the nurse should assess baseline renal function before administration
        
        the most commonly reported side effects are rhinitis, headache, and back pain
      - sodium-glucose co-transporter 2 (SGLT2) inhibitors
        
        the main medications in this class are canagliflozin, dapagliflozin, and empagliflozin
        
        these medications block renal reabsorption of glucose and increase glucose excretion
        
        nursing considerations include assessing urinary function before administration
        
        side effects include urinary tract infections and hypoglycemia
    - - noninsulin injectable agents are the third category of GLAs used in the management of diabetes
      - examples include exenatide and liraglutide
      - these medications imitate a hormone found to be decreased in patients with type 2 diabetes
      - administration of these medications results in an increase in the production of endogenous insulin, slower gastric emptying, and creation of a feeling of fullness after meals
      - can be used alone or with an OA but cannot be combined with insulin administration
      - supplied in prefilled pens and administered one to two times daily
      - the nurse should instruct the patient to take any prescribed oral medications 1 hour before injection to facilitate absorption of oral medications
- - - - onset of symptoms
      - nutrition +increased hunger +increased thirst +typical eating habits
      - elimination +frequent urination +constipation
    - - large-for-gestational-age deliveries
      - pancreatitis
      - cushing's syndrome/ acromegaly
      - any recent surgeries
      - family history of diabetes
    - - prescription and over-the-counter medications, vitamin and mineral supplements, herbal products
    - - chest pain + heart palpitations
    - - abnormal breathing patterns
    - - sensation loss (peripheral neuropathy)
    - - skin breakdown
    - - weight loss + appetite + fruity breath, dry mouth + nausea/vomiting
    - - frequency of urination
    - - capillary blood glucose + hemoglobin A1c + electrolytes + blood urea nitrogen + creatinine
  - - - medications
        
        GLAs: injectable medications, such as insulin
        
        demonstration of proper technique for drawing insulin from a vial or using an insulin pen
        
        identification of appropriate sites for insulin administration
        
        preparation of the site for insulin administation
        
        demonstration of correct subcutaneous administration of the dose
        
        OAs
        
        administration timing (when to take the prescribed dose)
        
        anticipatory guidance regarding side effects and medication interactions
        
        precautions to take regarding skipped, missed, or withheld doses
      - diet and exercise
        
        involve the dietician when educating the patient about dietary needs, restrictions, and the role of food (especially carbohydrates) in managing the blood glucose level
        
        highlight the importance of a well-balanced diet and the practice of portion control
        
        educate the patient about the importance of incorporating regular, moderate exercise into daily life
        
        information regarding how much to exercise, safety measures to take during exercise, and when not to exercise should be included
      - signs/symptoms to report
        
        hypo- and hyperglycemia often result in preventable complications
        
        chronic, persistent illness
        
        impairment in skin integrity
        
        loss of sensation to feet
        
        change in vision
        
        unexplained changes in weight
        
        teach patients hot to use a blood glucose monitor, instruct them NOT to milk their finger (false high blood glucose level) ++ sample can be obtained from arm, fingertip
      - blood glucose monitoring
        
        instruct how to use a lancet to obtain blood for sampling and how to apply it to the strip for the glucometer
        
        cleaning the finger with alcohol or soap and water
        
        use the side of the finger, not the pad
        
        teach how to use and care for his or her blood glucose meter (glucometer)
        
        teach patient to keep a record of blood glucose levels to assess trends and triggers that increase or decrease the patient's blood glucose level
        
        foods eaten
        
        illness
        
        stress
        
        instruct the patient to keep a fasting blood glucose level within normal range to minimize diabetes-related complications
        
        instructing patients with type 1 diabetes to check their blood glucose level before meals and at bedtime
        
        instructing patients with type 2 diabetes to check the blood glucose level one to two times daily and more often if they are ill or have symptoms of hypo- or hyperglycemia
      - preventing hypo- and hyperglycemia
        
        the nurse should instruct the patient regarding the importance of recognizing the early symptoms of both hypo- and hyperglycemia and treating them
        
        most common symptoms
        
        hypoglycemia
        
        shakiness
        
        hunger
        
        irritability
        
        sweating
        
        hyperglycemia
        
        headache
        
        trouble concentrating
        
        thirst
        
        weakness
        
        at-home management
        
        checking a capillary glucose level
        
        supplementing with a 15-g carbohydrate snack (hypoglycemia)
        
        decreasing carbohydrate intake at the next meal, increasing the next insulin dose (patients with an insulin pump) increasing exercise that day (hyperglycemia)
      - foot care
        
        foot care is extremely important for the patient with diabetes because decreased peripheral sensation (neuropathy) prevents the patient from feeling injury or sores on the feet
        
        teach
        
        inspect feet every day for any sores or ulcers. advise patients to use a mirror for this
        
        see a podiatrist regularly for clipping/trimming of toenails
        
        wear well-fitting shoes that do not rub against the toes or soles of the feet
        
        avoid walking barefoot at any time
        
        avoid soaking the feet
        
        thoroughly dry between the toes after bathing or showering
      - sick-day rules
        
        when a patient with diabetes becomes ill, it is important to monitor their diabetes even more closely because illness and infection will raise the blood glucose level
        
        continue taking OAs and/or insulin, even when not taking in as much food. supplement with juices and other carbohydrate-containing liquids
        
        check the blood glucose level every 4 hours when sick and report a blood glucose level consistently above 240 mg/dL
        
        check urine for ketones every 3 to 4 hours (patients with type 1 diabetes)
        
        increase overall fluid intake, especially water
        
        call health care provider if undable to keep down any food or fluid
- - - - occurs in patients with or without diabetes but progresses more rapidly in the setting of diabetes
      - damage to large and medium-sized vessels leads to cardiovascular, cerebrovascular, and peripheral vascular disease
    - - results from a thickening/narrowing of capillary and arteriole cell membranes
      - specific to patients with diabetes
      - found throughout the body but primarily affects the eyes, kidneys, and lower limbs
- - - - perform telemetry monitoring when hyper- or hypokalemia is present
        
        monitor intake and output to check fluid balance and kidney function
        
        monitor blood glucose hourly to determine effectiveness of treatment
        
        contact the health care provider if any abnormalities are detected
- - - - administer regular insulin intravenously to lower blood glucose level
        
        perform telemetry monitoring when hyper- or hypokalemia are present
        
        monitor intake and output to check fluid balance and kidney function
        
        monitor electrolytes to identify electrolyte excesses or deficits
        
        monitor urine for ketones to determine fat breakdown
        
        contact the health care provider if any abnormalities are detected