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8/3/2019 DM Review Notes
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PEDIA
DIABETES MELLITUS
Type I DM(Insulin Dependent DM)
-partial/complete lack of secretory capacity of thebeta cells of pancreas,insulin deficiency
Normal bld glucose:70-110 mg/dL
Assessment:1.3 Ps,enuresis(more common in type I DM)
2.Wt. loss
3.vaginitis(candida)4.dehydration
5.hypo/hyperkalemia-complication
Diet:
-3 meals/day
-Midafternoon CHO snack-Bedtime CHON snack
Exercise:
-dietary adjustment when exercising-extra food for activity(10-15 g CHO every 30-45
mins of activity)
-monitor bd glucose before exercising
Insulin:
-Diluted insulin for infants to provide small enoughdoses to avoid hypoglycemia.
-Glycosylated Hgb-tests every 3 mos
-should not withheld during stress-hyperglycemiaand ketoacidosis result-Glucagon-IM/SQ if unable to consume P.O.
Bld glucose monitoring:-more accurate than urine testing
-finger prick
Urine testing:
-tests ketones and glucose
-2nd voided urine is most accurate
ACUTE COMPLICATION:
1.Hypoglycemia
-too much insulin-too much oral hypoglycemic agent
-not enough food
-excessive activityIntervention:
-complex CHO and CHON(slice of bread or peanut
butter cracker)
-extra snack,if next meal not planned for >30 mins
or activity is planned.-if become UNCONCIOUS:
>squeeze cake frosting or glucose paste onto the
gums and retest bld glucose level>if does not improve w/in 15-20 mins and if reading
remains low,administer additional sugar:
Carbonated beverage
3-4 hard candies2 or 3 glucose tabs
Life savers
1 tsp honey>if child remains unconscious,administer
GLUCAGON>Hosp setting:dextrose IV.
2.HyperglycemiaNotify physician if child unable to take food or
fluids.Sick day rules:
-always give insulin even if child does not have anappetite
-test bld glucose level at least q 4 hrs.
-test for urinary ketones w/ each voiding-calorie-free liquids to aid in clearing ketones
-rest esp. if ketones are present
3.Diabetic Ketoacidosis
-life-threatening condition
-metabolic acidosis-bld glucose level:>300 mg/dlInterventions:
-correct dehydration:IV 0.9% or 45% saline
-correct hyperglycemia:IV Reg insulin-monitor potassium:potassium replacement
-IV dextrose added when bld glucose reaches
appropriate level.
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ADULT
DIABETES MELLITUS
-chronic disorder of impaired CHO,CHON,and
lipid(fat) metab.caused by deficiency of insulin.
TYPE I:Insulin-dependent diabetes mellitus
-nearly absolute deficiency of insulin
-if insulin not given,fatsmetabolized,=ketonemia(acidosis)
TYPE II:Non-insulin dependent DM-lack of insulin or resistance to action of insulin
-insulin sufficient to stabilize fat and CHON metab
but not to deal with CHO metab.
Microvascular complications:
retinopathy,nephropathy,neuropathy
Assessment:1.3 Ps(more common in type I DM)
2.wt.loss(common in type I DM)3.vaginal infxns
Diet:-food exchange from American Diabetic
Association
-dietary guidelines for Americans(Food GuidePyramid)issued by US Dept. of Agri and Health and
Human Services
Exercise:- blood glucose level
-dietary adjustments when exercising
-monitor bld glucose before exercising-Initially,15 g CHO snack(a fruit exchange) or
complex CHO + CHON before engaging in
moderate exercise to prevent hypoglycemia-if bld glucose >250 mg/dL + urinary ketones(type I
DM)-not to exercise until bld glucose is closer to
normal and urinary ketones are absent
Oral hypoglycemic meds:
-prescribed for DM II
-Type II DM-insulin may be needed duringstress,surgery,or infxn
Insulin:-for Type I DM
-also for Type II DM when diet and weight control
therapy have failed
REGULAR INSULIN-only insulin can be
administered IV in emergency tx of DKA.
-illness,infxn,stress need for insulin and not be
withheld because hypoglycemia and ketoacidosiscan result
Complication of insulin therapy:
1.Local allergic reactions-avoid alcohol to cleanse skin before injxn.
2.Insulin lipodystrophyLipoatrophy-use of HUMAN INSULIN helps to
prevent this complication.
Lipohypertrophy-caused by repeated use of an injxnsite.
3.Insulin resistance-develops immune antibodies that bind
insulin,decreasing insulinTx:Purer Insulin Preparation
4. Dawn Phenomenon
-reduced tissue sensitivity to insulin b/w 5 & 8
AM(prebreakfast hyperglycemia occurs)Tx:evening dose of INTERMEDIATE-ACTING
INSULIN at 10 PM.
5.Somogyi Phenomenon
-normal or elevated bld glucose present at
BEDTIME-hypoglycemia 2-3 AM-hyperglycemic 7 AM
Tx:
a.decreasing evening(predinner or bedtime)dose ofINTERMEDIATE OR LONG ACTING INSULIN
b.increasing BEDTIME SNACK
6.Insulin Waning
-progressive rise in bld glucose level from
BEDTIME to MORNING
Tx:a.increasing evening(predinner or bedtime)dose of
INTERMEDIATE OR LONG ACTING INSULIN
b.instituting dose of INSULIN before evening mealif one is not already prescribed.
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Insulin Pumps
-externally worn device contains syringe attached tolong,thin,narrow-lumen tube w/ needle or Teflon
catheter attached to end.
-inserts needle or Teflon catheter into SQ(abdomen)-worn on a belt or in a pocket
-needle/Teflon catheter changed every 3 days
-delivers bolus of REGULAR INSULIN before
each meal.
Pancreas transplants
-performed on a limited number of clients(mostlyclients receiving kidney transplantations
simultaneously)
-immunosuppressive therapy to treat rejection.
Bld glucose monitoring:
-more accurate than urine testing-finger prick
-caution with diabetic retinopathy and neuropathy
Urine testing:-tests ketones and glucose
-2nd voided urine is most accurate
Urine ketone testing:
-should be performed during illness
-whenever TYPE I DM has glycosuria and with bldglucose level of >240 mg d/L for 2 consecutive
periods.
ACUTE COMPLICATIONS OF DM:1.Hypoglycemia
-too much insulin
-too much oral hypoglycemic agent-not enough food
-excessive activity
*High-fat foods slow absorption of glucose andhypoglycemic symptoms may not resolve quickly.
a.Mild hypoglycemia-10 to 15 g FAST-ACTING SIMPLE CHO:
Glucose tablet
6-10 life savers or hard candy4 tsp sugar
4 sugar cubes
1 tbs honey/syrup cup fruit juice/regular (nondiet softdrink)
6 saltine crackers
3 graham crackers>retest bld glucose in 15 mins.
b.Moderate-15-30 g FAST-ACTING SIMPLE CHO
>low-fat milk or cheese after 10-15 mins.
c.Severe-
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-K level fall rapidly w/in 1st hr of tx as dehydrationand acidosis are treated
-K administered IV in diluted solution(when Kreaches normal to prevent hypokalemia)
Guidelines during illness:
-test bld glucose,test urine for ketones every 3-4 hrs
-if usual meal plan cannot be followed,substitute soft
foods 6-8 x per day-vomiting/diarrhea/fever:consume liquids every to 1
hr. to prevent dehydration and to provide calories.
3.HYPERGLYCEMIC HYPEROSMOLAR
NONKETOTIC SYNDROME(HHNS)
-extreme hyperglycemia w/o ketosis and acidosis-occurs most often with TYPE II DM
Assessment:-bld glucose 600-1200 mg/dL
-low BP,low HR-dehydration
-seizures
Interventions:-Tx similar to DKA
-Insulin plays less critical role in tx of HHNS becauseinsulin is not needed for reversal of acidosis in HHNS.
CHRONIC COMPLICATIONS OF DM
1.Retinopathya.Photocoagulation(laser therapy):removes
hemorrhagic tissue to scarring.
b.Vitrectomy:removes vitreous hemorrhages thus tension on retina,preventing detachmentc.Cataract removal w/ lens implant
2.Nephropathy
-microalbuminuriaInterventions:
-restrict CHON,Na,K-prepare for dialysis
-prepare for kidney transplant
-prepare for pancreas transplant
3. Neuropathy-erectile dysfunction/impotence-loss sensation in CN III,IV,V,VI
-dyspareunia r/t yeast infxnInterventions:
-dont treat corns,blisters, ingrown toenails
-dont wear same pair of shoes 2 days in a row
-estrogen-containing lubricants for female
OPERATIVE CAREPreop care:
-Long-acting oral antidiabetic meds are d/c 24-48 hrs.before surgery.
-Insulin may be adjusted/withheld if IV insulinadministration during surgery is planned.
Postop care:
-IV glucose and Reg.insulin infusion until client cantolerate oral feedings
-supplemental short-acting insulin-monitor bld glucose if client receiving TPN.
MEDICATIONS FOR DIABETES MELLITUS
A.INSULIN
-prescribed for clients with Type I DM- glucose transport into cells and promotes
conversion of glucose to glycogen, serum glucose
levels.
-primarily acts in the liver,muscle,and adiposetissue by attaching to receptors on cellular
membranes and facilitating passage of
glucose,K,and Mg.
Storing insulin:
-avoid exposing insulin to extremes in temp.-shoud not be frozen or kept in direct sunlight.
-before injxn,should be at room temp.
-if vial of insulin will be used up in a month,may bekept at room temp;otherwise,vial should be
refrigerated.
Insulin injxn site:a.abdomen-may absorb more evenly and rapidly
than the other sites.
b.arms(posterior surface)c.thighs(anterior surface)
d.hips
-systematic rotation w/in 1 anatomical area isrecommended to prevent lipodystrophy
-dont use same site more than once in a 2-3 wk
period.
-injxns should be 1.5 inches apart within theanatomical area.
-heat,massage,&exercise of injected area can
absorption rates and may result in hypoglycemia.
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Administering insulin:
Usual concentration:U 100(100 units/mL)-most insulin syringes have 27-29 gauge needle,0.5
inch long.
-before use,roll bottle to ensure ingredients aremixed.
-dont shake may cause bubbles.
-premixed insulin:Humulin 70/30-most commonly
used.-mixtures of insulin in prefilled syringes should be
kept in the refrigerator,stable for 1 wk.
-prefilled syringes should be kept flat or with needlein upright position to avoid clogging of needle.
-inject air into the insulin bottle(vacuum makes it
difficult to draw up the insulin)-when mixing,Regular(short-acting)insulin first.
-Regular insulin may be mixed with any other type
of insulin.-Insulin zinc suspension only mixed with each other
and regular insulin.-administer mixed dose of insulin w/in 5-15 mins of
prep,after this time regular insulin binds with NPHand action is reduced.
-aspiration is not recommended with self-injxn.
-administer at 45-90 degree/45-60 degree in thinpersons.
Remember:Regualr insulin is the only type of
insulin that can be administered IV.
B.ORAL HYPOGLYCEMIC MEDICATIONS
-Prescribed for Type 2 DM-stimulate pancreas to produce more insulin- sensitivity of peripheral receptors to insulin
- hepatic glucose output or delay intestinal
absorption of glucose ,thus serum glucose levels.
1.Sulfonylureas
-stimulate beta cells to produce more insulin-can affect cardiac function and 02
consumption=cardiac dysrhythmias.
Side effects:GI sx & dermatological rxns
Ex:a.Chlorpropamide(Diabenese)-can cause
disulfiram(Antabuse) type of rxn wen alcohol is
ingested.b.Tolbutamide(Orinase)
2.Nonsulfonylureas-affect hepatic & GI production of glucose
-used alone or with sulfonylurea
Ex:
Acarbose(Precose)Metformin(Glucophage)
Rosiglitazone(Avandia)
Contraindications and concerns:
*Hypoglycemic meds+-adrenergic blocking
agents=masks s/sx of hypoglycemia
Meds that cause of hypoglycemia:
Anticoagulants
ChloramphenicolSalicylates
Propranolol(Inderal)
MAOIPantamidine(pentam 300)
Sulfonamides
Meds that cause hyperglycemia:
CorticosteroidsThiazide diuretics
Phenytoin(Dilantin)Throid preps
Oral contraceptives
Estrogen compounds
C.GLUCAGON
-hormone secreted by alpha cells of the islets ofLangerhans in pancreas
- bld glucose by stimulating glycogenolysis in
liver.-by SQ,IM,IV-used to treat insulin-induced hypoglycemia when
client is semiconscious or unconscious and unable
to ingest liquids.-bld glucose level begins to w/in 5-20 mins after
admin.
D.DIAZOXIDE(Proglycem)
- bld glucose by inhibiting insulin release from
beta cells and stimulating release of epinephrine
from adrenal medulla-used to treat chronic hypoglycemia caused by
hyperinsulinism resulting from islet cell cancer or
hyperplasia.-not used for hypoglycemic rxns from insulin.
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GLUCOSE STUDIES
1.Fasting Blood Glucose
>70-110 mg/dL
Int:-fast for 8-12 hrs before the test
-DM patient:withhold morning insulin or oral hypoglycemic med.
2.Glucose tolerance test>70-110 mg/dL
-if glucose levels peak at higher than normal at 1 and 2 hrs after injxn or ingestion of glucose,and slower than
normal to return to fasting level,DM is confirmed.Int:
-eat high-CHO(200-300g)diet for 3 days before test
-fast for 10-16 hrs before the test-avoid strenuous exercise for 8 hrs before and after test.
-DM patient:withhold morning insulin or oral hypoglycemic med
-test takes 3-5 hrs-IV or oral admin of glucose,and multiple bld samples
3.Glycosylated hemoglobin
Hemoglobin A1c-reflection of how well bld glucose levels have been controlled for up to the prior 4 mos.-fasting not required before the test.
>good control:7.5% or less
4.Glucose,2hr postprandial
Value: