Lecture 5 Diabetes M

LECTURE 5 DIABETES M. • definition = an error of glucose metabolism! - causes issues because glucose is the primary fuel ! source and if your body can’t metabolize glucose, ! cells will die • does not include diabetes insipidus = polyuria, polydipsia leading to dehydration due to low ADH! -> it’s just similar with the fluids, not the glucose part ! (similar symptoms)! - opposite syndromes of diabetes i. = SIADH • relationship between amount of urine & specific gravity of urine:! - they are opposites/inverse! - i.e. the less urine out, the higher the specific gravity; ! the more urine out, the lower the specific gravity! * so diabetes = has more urine & low specific ! gravity (opposite with SIADH) TYPE I vs. TYPE II: Differences Names S&S Treatment TYPE 1 DM - Insulin dependent! - Juvenile onset! - Ketosis prone - polyuria! - polydipsia! - polyphagia (increased ! swallowing, but in ! context of DM it also ! relates to eating) D = diet —> least ! important (less ! restrictions than before) I = insulin —> MOST ! IMPORTANT! E = exercise TYPE 2 DM - Non-insulin dependent! - Adult-onset - Non-ketosis prone - same D = diet —> MOST ! IMPORTANT! O = oral hypoglycemic ! (pills) ! A = activity Diet: • primarily Type II • a) It is a calorie restriction.! - tells you that calorie’s are important because the ! diet’s are named (ex. 1500 calorie…)! *** this is the best strategy for them • b) They need 6 small feedings a day. ! - keeps blood sugar levels more normoglycemic ! throughout the day instead of 3 big peaks ! Insulin: • lowers blood glucose • 4 main types you really need to know:! 1. Regular Insulins -> the “R” is important! - ex. Humulin R, Novalin R! - onset = 1 hr.! - peak = 2 hrs.! - duration = 4 hrs.! - is clear (solution) so it can be IV dripped (this is ! the one used if using IV’s)! - short, rapid acting insulin (but Hesi will call it ! intermediate because we now have Lispro which ! acts faster)! 2. N P H! - true intermediate acting insulin! - onset = 6 hrs.! - peak = 8-10 hrs.! - duration = 12 hrs.! - is cloudy (suspension) ! * the issue w/ suspensions is that it precipitates ! -> the particles fall to the bottom over time so ! you CANNOT give via IV (or the PT will ! overdose & the brain will die)! * Hint: general rule => never put anything ! cloudy in an IV bag! 3. Lispro (Humalog)! - fastest acting, rapid! - onset = 15 mins.! - peak = 30 mins.! - duration = 3 hrs.! - you give this as they being to eat so with meals ! (not ac) -> interrupt them while eating!! 4. Lantus (Glargine)! - long acting! - peak = no essential peak because it’s so slowly ! absorbed -> thus, little to no risk for hypoglycemia! - duration = 12-24 hrs.! - only insulin you can safely & routinely give at ! bedtime because it will not cause them to go ! hypoglycemic during the night (YOU CANNOT ! ROUTINELY GIVE THE OTHERS AT BEDTIME)! ** Hint: boards likes to test peaks & tend to test it by ! giving you a time when insulin was given & asking ! when they reach hypoglycemia (which is the peak). • CHECK EXPIRY DATES ON INSULIN!!!! - What action by the nurse invalidates the ! manufacturer’s expiration date? = opening it! -> the minute you open it the date is irrelevant ! because now you have 30 days from opening ! (have to write the date of opening & new expiry) ! - refrigeration is optional in the hospital BUT you ! need to teach PT’s to refrigerate at home! -> though at the hospital the ones that should be ! refrigerated should be the un-opened vials ! - better to give warm, non-expired insulin than cold, ! expired insulin! Exercise: • exercise potentiates insulin! = meaning, it does the same thing as insulin! —> think of exercise as another shot of insulin! - if you have more exercise during the day, you need ! less insulin shots (and bring easily metabolized ! carbs/snacks to sports games) Sick Days: • when a diabetic is sick -> GLUCOSE GOES UP! - need to take their insulin even if they’re not eating • need to take sips of water because diabetics get dehydrated • any sick diabetic is going to have the 2 problems of hyperglycemia & dehydration -> ALWAYS! • stay as active as possible because it helps lower glucose (even if they’re not eating when sick) Complications of Diabetes:! = 3 acute and a boatload of chronics! ACUTE • 1. Low Blood Glucose (in both types)! - a.k.a. insulin shock, insulin reaction, hypoglycemia, ! hypoglycemic shock! - What causes this?! -> not enough food! -> too much insulin/medication (primary cause)! -> too much exercise! - the danger is brain damage which becomes ! permanent (so be careful not overmedicate!)! - S & S:! -> drunk in shock! = think of how people look while drunk -> slurring, ! staggering, impaired judgement, delayed ! reaction time, labile (emotions all over) ! ** from cerebrocortical compromise! = shock -> low BP, tachycardia, tachypnea, cold/! pale/clammy skin, mottled extremities! ** from vasomotor compromise! - Treatment:! a) Administer rapidly metabolizable carbohydrate ! (i.e. sugars)! -> ex. any juice, reg. pop, chewable candy, milk, ! honey, icing, jam! b) BUT combine/follow w/ a starch or protein! -> ex. cracker, slice of turkey! *** skim milk is great because it gives both! - bad combo is too much simple sugars (like pop & candy)! - if unconscious give Glucagon (IM) or IV Dextrose ! (D10, D50) -> how do you determine which to give?! = the setting (i.e. family calling from home, tell ! them to give IM but if in ER give IV)! ** hard to get a vein because of vasoconstriction! • 2. High Blood Glucose in TYPE I = Diabetic Coma/! DKA (Diabetic Keto-acidosis)! -> Hint: Type I is also called “ketosis-prone”! - What causes this?! -> too much food! -> not enough medication! -> not enough exercise! *** none of these are the #1 cause because it is ! acute viral upper respiratory infections (w/in the ! last 2 weeks)! - PT contracts upper resp. infection -> recovers ! w/in 3-5 days like everyone BUT after initial ! recovery, they start going downhill & getting ! more lethargic! * so, if they come into the ER you should ask ! if they’ve had a viral upper resp. infection in ! the last 2 weeks! -> what causes the high glucose is the stress of the ! illness that was not “shut off” and they start ! burning fats for fuel -> ketosis! - S & S:! -> spell out D K A! - D = dehydration! - K = ketones (in blood), kussmaul’s, high K+ ! * you can have ketones in your urine & not ! have DKA! - A = acidotic (metabolic), acetone breath, ! anorexia (due to nausea)! -> hot & flushed, dry = water is a coolant! if you ! lose water (as in dehydrate) you loose coolant! - Treatment:! -> fast rate IV fluids (ex. 200/hr.), w/ reg. insulin in ! the bag ! • 3. High Blood Glucose in TYPE II = HHNK/HHS ! (Hyperglycemic Hyperosmolar Non-Ketotic ! Syndrome)! = this is dehydration (for any HHNK/HHS question ! just call it DEHYDRATION)! - so think of the S&S of dehydration (low water, hot ! temp, flushed, dry)! - nursing diagnosis = fluid volume deficit! - #1 intervention -> giving fluids!! - outcomes you want to see = increased output, BP ! coming up, moist mucus membranes etc.! ** so all the outcomes of a PT coming out of ! dehydration! - Why do these PT’s only get the D (& not the K & A)?! -> they don’t burn fats (which make the ketones)! • Which one is insulin the most essential in treating?! = DKA! -> you don’t have to use insulin w/ HHNK because ! you mostly need to re-hydrate them • Which has a higher mortality rate?! = HHNK! -> DKA’s tend to be a higher priority and symptoms ! are much more acute; HHNK’s tend to come in to ! ER later than they should because symptoms are ! not as visible & they end up getting worse (so by ! the time they come in it might be too far gone) • Who would die first if didn’t treat them? (more lifethreatening)! = DKA! -> but they tend to get treated in time Long-term Complications: • related to 2 problems:! a) poor tissue perfusion! b) peripheral neuropathy • ex. Diabetics have renal failure. What would this be due to? ! -> poor tissue perfusion! ex. Diabetic PT has lost control of their bladder and are now ! incontinent. -> peripheral neuropathy! ex. PT can’t feel it when he injures himself. -> peripheral ! neuropathy.! ex. PT doesn’t heal well when he injures himself. -> poor ! tissue perfusion Which lab test is the best indicator of long-term blood glucose control? • the hemoglobin A1C (HA1C), the glycosated/ glycosylated hemoglobin (all the same) • numbers:! - 6 & lower is what you want to see! - 8 & above means you’re out of control! ** what about 7? = border! -> so they need to work done, evaluation, may ! have to go to hospital, may have an infection ! somewhere • Hint: Boards doesn’t test units so just remember the numbers! !