Understanding Diabetes

Diabetes Overview

• Diabetes is when blood glucose is either too high or too low.
• When blood glucose is high, the pancreas releases insulin.
• Insulin allows cells to take up glucose from blood.
• The liver produces glycogen.
• Blood glucose levels fall.
• When blood glucose is low, the pancreas releases glucagon.
• The liver breaks down glycogen.
• Blood glucose levels rise.
• Diabetes is the leading cause of kidney failure.
• It is also a leading cause of adult-onset blindness and lower limb amputations.
• Diabetes is a significant contributor to heart disease, stroke, high blood pressure, and nerve damage.
• It is the seventh leading cause of death.
• American Indians, Alaskan Natives, African Americans, and Hispanics have the highest incidence.
• Smoking increases risk and progression of disease.
• Annually, 1.5 million Americans are diagnosed with diabetes.
• It kills more women than men.
• Women with diabetes have a 40% higher risk of heart disease.
• They also have a 25% higher risk of stroke than men with diabetes.
• Hospitalization rates for diabetics are 2.4 times greater for adults.
• Hospitalization rates for diabetics are 5.3 times greater for children than the general population.

Symptoms and Diagnosis

• The three "P's" of diabetes include: polyuria, polydipsia, and polyphagia.
• Other symptoms of diabetes include: fatigue, weakness, sudden vision changes, and dryness.
• Changes in vision can include blurred vision.
• Other symptoms include tingling or numbness in the hands or feet.
• Additional symptoms can include recurrent infections and skin wounds that are hard to heal.
• Main signs and symptoms of diabetes are polyphagia, polydipsia, lethargy or stupor.
• Systemic symptoms include weight loss.
• Respiratory symptoms include kussmaul breathing (hyperventilation).
• Eyesight can be blurry.
• Breath smells of acetone.
• Gastric symptoms can include nausea, vomiting and abdominal pain.
• Diagnosis requires symptoms of diabetes plus a random plasma glucose concentration greater than 200 mg/dL.
• Diagnosis can also be achieved with fasting plasma glucose greater than 126 mg/dL on two separate occasions.
• A fasting plasma glucose level between 100-126 mg/dL is considered prediabetes.
• Diagnosis can also be achieved with a two hour post-glucose load higher than 200 mg/dL during an oral glucose tolerance test.

Types of Diabetes

• Classification of diabetes includes type I, type II, gestational, and pre-diabetes.
• Type 1 diabetes is characterized by an acute onset usually before age 30.
• Type 1 is an autoimmune disease with a genetic predisposition.
• It is characterized by destruction of pancreatic beta cells.
• There is a lack of insulin production by the pancreas.
• Type 1 is associated with weight loss and ketoacidosis.
• Ttreatment of type 1 includes insulin replacement.
• Type 2 diabetes accounts for 90%-95% of all DM cases.
• Type 2 occurs more frequently in people older than 30 years of age.
• The incidence of Type 2 is increasing in younger people.
• Over 80% of cases are obese.
• This type involves cellular insulin resistance.
• It can include impaired insulin secretion.
• Type 2 is non-insulin dependent initially, but may become insulin dependent

Nursing Interventions

• If a patient with pneumonia and respiratory distress is diabetic and solumedrol is given, blood sugar will increase..
• If a patient is placed on tube feeding and does not have a diagnosis of diabetes, check glucose every 6 hours.
• If a patient has urinalysis findings of positive glucose and an Hgb A1C of 8.2, these are indicative of diabetes
• In urine, normal is no glucose.
• If BG is > 180, glucose spills over into the urine.
• With glycosuria, urine will be dilute due to osmotic diuresis.
• Normal FS or serum blood draw is 70-100mg/dl.
• Hgb slowly becomes glucose-bound (glycosylated) over the 90-120-day lifespan of the RBC.
• HbA1C reflects the average level of blood glucose to which the cell has been exposed.
• Normal HbA1C is 4-6%.
• HbA1C > 10% = DM out of control.
• HbA1C is a good indicator of a diabetic's blood glucose control.

Hypoglycemia & Insulin Shock

• Hypoglycemia manifests as confusion, dizziness, shakiness and sweating.
• It can include irritability and headache.
• A patient can experience tingling, a fast heartbeat, and low glucose.
• Blood sugar drops (50-70mg/dL) are signs of hypoglycemia.
• Too little food, too much exercise, or too much insulin/oral agent( peak) can cause a drop in blood sugar.
• Symptoms of hypoglycemia include diaphoresis, tachycardia, palpitations, tremor, hunger.
• CNS responses can include headache, confusion, memory loss, drowsiness, and behavioral changes.
• A client may become unresponsive.
• Mild signs include increased hunger, feeling shaky, dizzy or nervous. May also have diaphoresis and numbness/tingling around the mouth.
• Moderate signs include sudden moodiness, changes in personality, slurred speech and poor coordination.
• Altered LOC is a moderate symptom of hypoglycemia.
• Hypoglycemia may be treated with 10-15 grams of a fast-acting sugar/carb by mouth.
• Additional interventions include 3-4 glucose tablets or 4-6 ounces of fruit juice, or 6 saltines
• Treatment should be followed with a protein and starch snack if the next meal is more than an hour away like cheese and crackers.
• If a client is diaphoretic, drowsy, confused, and has slurred speech and tremors with poor coordination, this can indicate hypoglycemia.
• If the client takes a beta blocker the symptoms may be masked.
• The treatment is glucose.
• Insulin shock involves a blood glucose level that is usually between 20-50mg/dL.
• Insulin shock can occur with insulin overdose.
• CNS depression is very pronounced that self-treatment is impossible.
• There may be severe disorientation, difficulty awakening, seizures, coma, death.
• If patient is unconscious, combative, or unable to swallow, give glucagon injection SQ or IM.
• A glucagon injection initiates conversion of stored glycogen to glucose by the liver.
• Turn patient on side after administration of glucagon.
• Healthcare provider should be notified.
• The 15/15/15 rule: Give 15 grams of carbs, wait 15 minutes and then give another 15 grams of carbs.
• In the hospital, one may give 50% Dextrose IV slowly (repeat as necessary).
• The EMS would administer D50W, with contraindications including closed head injury, CVA, intracranial hemorrhage.

Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Syndrome

• Diabetic Ketoacidosis involves a prolonged decrease or absence of insulin.
• It usually affects Type 1 diabetics but can affect Type 2 diabetics.
• It happens because cells can't use glucose without insulin, so they resort to alternative fuels: protein, fats, stored glycogen.
• Byproduct of amino and fatty acid metabolism = highly acidic ketone bodies.
• Results in sustained hyperglycemia, fluid shifts from IC to EC space causing dehydration,
• Decreased blood pH (acidosis) results from ketones.
• K+ shifts from IC to EC and is eliminated by kidneys, causing hypokalemia.
• Hyperglycemia is when serum glucose exceeds 250mg/dl or greater.
• Ketosis involves ketonemia and ketonuria.
• Acidosis results in a pH less than 7.3.
• Acidosis indicates a serum bicarbonate less than 18 mEq/L.
• DKA is characterized by a combination of hyperglycemia, ketosis, acidemia.
• DKA clinical presentation includes fruity breath odor, Kussmaul's respiration and hyperglycemia.
• Assess also for dehydration, GI issues, and GU complaints.
• Dehydration involves signs and symptoms of tachycardia, weak or impalpable peripheral pulse.
• GI indications include abdominal pain, N&V without diarrhea, polyphagia, polydipsia.
• GU indications include polyuria, ketonuria and glycosuria.
• Also watch for fatigue/weakness.
• The severity of DKA is based on the extent of acidosis, not the level of blood sugar.
• DKA will feature a rapid onset.
• For DKA, follow "sick day” rules should be followed for prevention .
• DKA requires hydration, restoring electrolytes & reversing acidosis.
• HHS occurs in type 2 diabetes.
• Minimal or absent ketosis happens because these patients do produce some insulin.
• Persistent hyperglycemia causes osmotic diuresis, resulting in loss of H2O & electrolytes.
• HHS can lead to altered mental status, decreased LOC and seizures.
• In HHS, clinical symptoms include hypotension and tachycardia.
• HHS is defined by no acidosis nor ketones.
• HHS is treated by replacing fluids, insulin drip to restore normal insulin regimen.
• Manage electrolytes.
• Once glucose is down to 250mg/dL switch IVF to include dextrose 5%, while treating precipitating cause . This is usually infection.
• Glucose will drop faster than in DKA with smaller amounts of insulin and fluid replacement because there are no ketones and acidosis to correct..
• Compare HHS and DKA. They share polyuria, polydipsia, polyphagia, blurred vision. HHS includes mental status change, seizures and paralysis, and DKA includes fruity breath, Kussmaul breathing and metabolic acidosis.

Insulin

• Watch out for side effects with insulin and know the action to take: sliding scale address.
• Always check for prandial hyperglycemia.
• Regular insulin is given with sliding scale.
• Locate the sliding scale.
• Is it on MD Orders, MAR? The MAR, Diabetic Flow Sheet?
• Always know the MOST RECENT blood sugar before giving ANY insulin!!!
• Be aware of the onset, peak, and duration of insulins
• Rapid-acting insulin examples are Humalog, Apidra, Novalog.
• Its onset is 10-30 min, peeks in 0.5-3 hrs and lasts 3-5 hours.
• Short-acting can be Regular, Humulin R, Novolin R.
• Its onset is 30-60 minutes, peaks in 1-5 hours and lasts 6-10 Hours.
• Hypoglycemic reactions are most likely to occur at peak!
• Intermediate acting can be NPH, Humulin N, Novolin N, Novolin Lente, Isophane.
• The onset is 1-2 hrs, peaks in 4-12 hours and lasts 16 hrs.
• Long acting include Lantus, Levemir, Tresiba.
• The onset is 3-4 hrs and lasts 24 hours.

Insulin Pumps and Education

• A patient with Type II diabetes and on metformin, monitor creatinine after contrast, to prevent lactic acidosis
• Insulin Pump is a battery operated and programmable device that delivers constant amount of fast acting insulin
• A catheter implanted SQ delivers insulin, replaced q 3 days.
• A carb counting client can utilize the pump to inject insulin, as needed.
• The major advantage is better control of insulin levels,

Diabetes long-term and Education

• Long-term complications of diabetes include stroke and neuropathy.
• Neuropathy is present in the form of peripheral neuropathy and eurogenic bladder.
• Also, patients are at risk for retinopathy, cataracts and glaucoma.
• Atherosclerosis increases coronary artery disease.
• Other long-term issues can include gastroparesis, infections, and Islet cell loss.
• Wound healing slows down in diabetics and prevention of wounds is key!
• Meal Planning includes Carbohydrates, fat and protein.
• 50% to 60% of calories should be carbohydrates.
• Emphasize whole grains.
• Fat should be around 20% to 30% of calories, , with < 10% from saturated fat.
• Limit cholesterol to < 300mg cholesterol per day.
• Protein should take up 10-20% of calories in diet.
• Non-animal sources (legumes & whole grains) may be emphasized to decrease fat and cholesterol.
• Include 25g per day of fiber Fiber slows stomach emptying and upper GI tract movement of food.
• This provides slower glucose absorption increases sense of fullness.
• Exercise lowers blood glucose and reduces cardiovascular risk factors.
• Snack prior to moderate exercise if on insulin.
• Avoid exercise when insulin is at peak.
• In sick days, patients should assess BG frequently for ketones.
• Adjust treatment accordingly and push PO liquids to prevent dehydration.
• When a patient must undergo surgery, remember NPO status requires routine withholding of insulin.
• Anesthesia will monitor BG closely and treat it.