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TYPE 1 DIABETES - Coggle Diagram

- - - - MANY HAVE HTN AND HIGH CHOLESTEROL
  - - - red-brown, round or oval patches
      - scaly then flat and indented; skins
    - - velvety light brown to black skin thickening; flexures, axillae, and neck
    - - red-yellow lesions; atrophic skin--> shiny and transparent--UNCOMMON
  - - - recurring or persistent infections: C. albicans, boils, furuncles; cystitis
    - - Hand hygiene, avoid exposure
      - flu and pneumococcal vaccine
  - - - sensory neuropathy and PAD are major risk factors
      - other factors: clotting abnormalities, impaired immune function, autonomic neuropathy
      - SMOKING INCREASES RISK
    - - annual monofilament screening
    - - decreased blood flow= decreased O2, WBCs, and nutrients causes longer wound healing, increased risk for infection
  - - - laser photocoagulation
        
        most common
        
        laser destroys ischemic areas of retina
      - vitrectomy
        
        aspiration of blood, membrane, and fibers inside the eye
      - iluvien
        
        injectable micro-insert that delivers corticosteroids flucinolone acetonide for 36 months
      - Vascular endothelial growth factor (VEGF) blocking drugs--reduce inflammation
  - - - hypertension
      - genetics
      - smoking
      - CHRONIC HYPERGLYCEMIA
    - - If albuminuria present, drugs to delay progression: ACE INHIBITORS and ANGIOTENSIN II RECEPTOR ANTAGONISTS
      - control of hypertension and blood glucose levels in a healthy range: imperative
  - - - reduced nerve conduction and demyelination
      - ischemic damage to peripheral nerves
    - - most common form
      - affects hands and/or feet bilaterally; "stocking-glove neuropathy"
      - loss of sensation, abnormal sensations, pain, and paresthesias
        
        pain--burning, cramping, crushing, tearing; worse or only occurs at night
    - - paresthesias--tingling, burning, itching; "walking on pillows or numb feet"
      - very sensitive
      - complete or partial loss of sensitivity to touch or temperature is common
      - FOOT INJURY AND ULCERATIONS may occur without patient ever having pain
      - SMALL MUSCLES OF HANDS AND FEET MAY BE AFFECTED CAUSING DEFORMITY AND LIMITED FINE MOVEMENT
- - - - intensive or physiologic insulin therapy--most closely mimics endogenous insulin production
      - administer multiple daily injections (or insulin pump) with frequent self-monitoring of blood glucose (or continuous glucose monitoring system
      - Bolus--rapid or short acting insulin before meals
      - Basal--intermediate or long acting (background) insulin once or twice a day
      - GOAL: achieve glucose level as close to normal as possible as much of the time as possible
    - - rapid acting: lispro (humalog), aspart (novolog), and glulisine (Apidra)
      - short acting: regular (humulin R, Novolin R)
      - Intermediate acting: NPH (Humulin N, Novolin N)
      - Long acting: glargine (Lantus), detemir (Levemir), degludec (Tresiba)
      - Inhaled Insulin: Afrezza
  - - - Avoid IM--risk of hypoglycemia!
  - - - roll before use
  - - - rapid acting synthetic (bolus)--mimic natural insulin in response to meals
        
        Aspart, glulisine, and lispro
        
        onset of action: 15 min
        
        injected within 15 min of mealtime
      - Short acting regular (Bolus)
        
        onset of action: 30-60 minutes
        
        injected 30-45 min before meal
        
        more likely to cause hypoglycemia
  - - - long acting (basal)
        
        Degludec (Tresiba), Detemir (Levemir), and glargine (Lantus, Toujeo, Basaglar)
        
        released steadily and continuously with no peak action for many people; onset varies
        
        administered once or twice a day
        
        Do not mix or dilute with any other insulin or solution
      - duration: 12-18 hrs
      - Peak: 4-12 hrs
      - can mix with short and rapid acting insulins
      - cloudy; must agitate to mix
        
        lispro protamine and aspart protamine are also cloudy
      - DON'T HOLD THIS ONE, EVEN WHEN PATIENT IS NPO!!!!
  - - - consider visual, manual, or cognitive skills
  - - - 0.3 and 0.5 mL syringes have 1 U increments
      - 1 mL syringe has 2 U increments
    - - needles are short so no need to pinch the skin
    - - extremely thin or muscular patient--> give at 45 degees
    - - only THE USER recaps syringe
      - no alcohol swab; wash with soap & water
        
        in hospital, follow policy to cleanse site
    - - portable, convenient, compact, discreet
      - various lengths and gauges
      - good option for patients with poor vision
      - patient education and printed instructions
  - - - careful programming and constant monitoring makes it possible because delivery is similar to physiologic patterns
      - more flexibility with meals and activities
    - - infection at insertion site
      - risk for DKA
      - cost of pump and supplies
      - attached to a device
  - - - high dose of insulin causes low glucose during the night
      - release of counterregulatory hormones causes rebound hyperglycemia
        
        concern when glucose checked in the morning and increase insulin is given
        
        determine if Somogyi effect by checking glucose between 2-4 AM
        
        assess patient for headache, night sweats, or nightmares
    - - morning hyperglycemia present on awakening
      - may be due to release of counterregulatory hormones in predawn hours
        
        growth hormone and cortisol
        
        more severe in adolescence and young adulthood-- peak time for growth hormone
- - - - take meds as prescribed on time
      - accurately administer insulin, noninsulin injectables or OAs
      - coordinate eating with meds
      - eat adequate food as needed with exercise
      - recognize and treat symptoms and teach family/caregiver too
      - carry simple carbohydrates
      - wear or carry diabetes ID
  - - - test the 2nd drop--less alcohol mixed!
      - sample must be checked BEFORE patient eats!!!
      - when to test
        
        before meals
        
        two hours after first bite
        
        when hypoglycemia is suspected
        
        every 4 hours during illness
        
        before and after exercise
      - consider impaired vision, cognition, or dexterity; use adaptive devices
    - - flash glucose monitoring-- wave reader over sensor and get reading
      - subcutaneous sensor displays glucose values on pump or pager-like device or smart phone; updates every 1-5 minutes
        
        reads interstitial versus blood glucose; lags behind 5-10min
      - helps identify trends and patterns
      - goal: increase "time in range" with fewer increase and decrease
      - alerts to hypoglycemia or hyperglycemia
      - no need to check finger stick first before making insulin dosing decisions
- - - - Insulin (a hormone) is needed to carry glucose into cells of the body
- - - - have patient or caregiver demonstrate knowledge & skills