Diabetes Study Notes

Diabetes Mellitus Management and Complications

• Metabolic disorder resulting in inadequate production of insulin (Type 1) or inability of the
body’s cells to respond to insulin that is present (Type 2).
• Diabetes mellitus is significantly more prevalent in African Americans, American Indians, and
Hispanic populations, possibly due to obesity and inactivity.

Diabetes mellitus can lead to

• cardiovascular disease
• Hypertension
• kidney disease
• Neuropathy
• Retinopathy
• peripheral vascular disease,
• stroke

Type 1 diabetes mellitus

• autoimmune dysfunction involving the destruction of beta cells (produce insulin) in the islets of
Langerhans of the pancreas.
• usually occurs at a young age, and there are no successful interventions to prevent the disease.

Type 2 diabetes mellitus

• progressive condition due to increasing inability of cells to respond to insulin (insulin resistance)
• decreased production of insulin by the beta cells.

Hormones & Organs that Alter Blood Glucose

Glucose

• Fuels cells with energy

Insulin

• Takes glucose into cells for energy

Ketones

• By product of fat breakdown→ fat used as energy

Pancreas

• Produces insulin and glucagon (turns glycogen into glucose to raise blood glucose levels)

Liver and Glycogen

• Uses glucose stored in the liver (glycogen) to increase blood glucose (body thinks blood
glucose is low)
Diabetes Study Notes

Kidneys

• Plays a role in reabsorbing glucose into the tubules, but if too much glucose is present, it
leaks into urine causing osmotic diuresis
• Osmotic diuresis: polyuria and excretion of Na+, K+ and Cl-

Diabetic Complications

Diabetic Ketoacidosis (DKA)--> Type 1

• Acute, life-threatening condition characterized by uncontrolled blood glucose levels

>250mg/dL
• Metabolic acidosis WITH KETONES in blood and urine
• Rapid onset
• High mortality rate (up to 10%)
• NO INSULIN → NO GLUCOSE USE
• Can occur in type 2 if severe illness is present

Hyperglycemic Hyperosmolar State (HHS)→ type 2

• Acute, life threatening, profound hyperglycemia >600mg/dL

• Leads to dehydration
• NO KETONES
• Occurs gradually over several days
• Can cause coma, death

Health Promotion

Type 1 DM: Cannot be prevented

Type 2 DM: Life-style modification and decrease risk of complications

Screening

• BMI > 25 and 1 or more factors

• Mother/ father who is diabetic
• 45 yo or older
• Hx of PCOS, vascular disease, gestational diabetes, infant weighing >9lbs
• Asian, African, Hispanic, American Indian, Pacific Islander heritage
• B/P higher than 140/90 mmgh
• HgA1C > 5.7%
• HDL less than 35 or triglycerides >250
• Fasting blood glucose, oral tolerance test, A1C for confirmation (tests)

Nutrition

• Carbs: 45% of intake

• Protein: 15-20%
• Fat: low saturated fat 20-35%
• Eat 5-6 small meals
Diabetes Study Notes

Exercise

• 150 minutes/ week @ least 3x a week exercise

Risk Factors

Sedentary Lifestyle

Metabolic Syndrome

At least 3 factors that increase risk for cardiovascular events and develop DM type 2

• Central obesity: male >40 in, female >35 in waist circumference

• Hyperlipidemia: triglycerides >150; HDL <50 female, <40 males
• Blood pressure: consistently greater than 130/85 and taking meds for HTN
• Hyperglycemia: fasting glucose >100 or taking meds for hyperglycemia

Insulin Resistance

• Impaired glucose levels (fasting) 100-125

• Impaired glucose tolerance 140 or A1C 5.7-6.4%

Age

• Vision and hearing deficits may interfere with the understanding of teaching, reading of
materials, and preparation of medications.
• Tissue deterioration secondary to aging may impact the client's ability to prepare food, care
for self, perform ADLs, perform foot/wound care, and perform glucose monitoring.
• A fixed income: limited funds for buying diabetic supplies, wound care supplies, insulin, and
medications. This may result in complications.
• May not be able to drive to the provider's office, grocery store, or pharmacy. Assess support
systems available for older adult clients.
• The older adult may have visional alterations (yellowing of lens, decreased depth
perception, cataracts), which can affect ability to read information and attend to medication
administration.

Manifestations of Hyperglycemia/ DKA (HOT and DRY= SUGAR HIGH!)

• Hyperglycemia: blood glucose level usually greater than 250 mg/dL

• Polyuria: (excess urine production and frequency) from osmotic diuresis
• Polydipsia: (excessive thirst) due to dehydration- more thirsty than usual
o Loss of skin turgor, skin warm and dry
o Dry mucous membranes
o Weakness and malaise
o Rapid weak pulse and hypotension
• Polyphagia (excessive hunger and eating) caused from inability of cells to receive glucose (cells
are starving)
o Client may display weight loss.
o Ketones accumulate in the blood due to breakdown of fatty acids when insulin is not
available, resulting in metabolic acidosis.
Diabetes Study Notes

• Kussmaul respirations: increased respiratory rate and depth in attempt to excrete carbon
dioxide and acid due to metabolic acidosis.
• Other manifestations can include acetone/fruity breath odor due to accumulation of ketones,
headache, nausea, vomiting, abdominal pain, inability to concentrate, decreased level of
consciousness, and seizures leading to coma.

Labs Tests

Fasting blood glucose

• >126 mg/dL (no food/ caloric intake 8 hrs prior to test)

Oral glucose tolerance test

• Fasting blood glucose level is drawn at the start of the test.

• consume a specified amount of glucose. Blood glucose levels are obtained at 1 and 2 hrs.
• The clients must be assessed for hypoglycemia throughout the procedure.
• Blood glucose should be <110 overall; <180 @ 1hr; <140 @ 2hrs

Client Education

• Instruct the client to consume a balanced diet for 3 days prior to the test. Then instruct the
client to fast for 10 to 12 hr prior to the test.

Glycosylated hemoglobin (HbA1c)

• The expected reference range is 5.5 to 7%, but an acceptable target for clients who have
diabetes may be 6.5% to 8%, with a target goal of less than 7%.
• HbA1c is the best indicator of the average blood glucose level for the past 120 days. It assists in
evaluating treatment effectiveness and compliance.

Client Education

• Instruct the client that the test evaluates treatment effectiveness and compliance.
• Recommended quarterly or twice yearly depending on the glycemic levels.

Urine Ketones

• High ketones in the urine associated with hyperglycemia (exceed 300 mg/dL) is a medical
emergency.

Diagnostic Procedures: Self-monitored blood glucose (SMBG)

Nursing Action

• Ensure that the client follows the proper procedure for blood sample collection and use of a
glucose meter. Supplemental short-acting insulin may be prescribed for elevated pre-meal
glucose levels.

Client Education

• Instruct the client to check the accuracy of the strips with the control solution provided.
Diabetes Study Notes

• Instruct the client to use the correct code number in the meter to match the strip bottle
number.
• Instruct the client to store strips in the closed container in a dry location.
• Instruct the client to obtain an adequate amount of blood sample when preforming the test.
• Encourage appropriate hand hygiene.
• Encourage use of fresh lancets and avoid sharing glucose monitoring equipment to prevent
infection.
• Advise the client to keep a record of the SMBG that includes time, date, serum glucose level,
insulin dose, food intake, and other events that may alter glucose metabolism, such as activity
level or illness.

Medications for DM

More than 1 type of insulin (rapid, short, intermediate, and long-acting).

• Given one or more times a day based on blood glucose results.

• Insulin may be required by some clients who have type 2 diabetes or women who have
gestational diabetes if glycemic control is not obtained with diet, exercise, and oral
hypoglycemic agents.
• Continuous infusion: insulin may be accomplished using a small pump that is worn
externally. The pump is programmed to deliver insulin through a needle in subcutaneous
tissue. The needle should be changed at least every 2 to 3 days to prevent infection.
• Complications of the insulin pump: accidental cessation of insulin administration,
obstruction of the tubing/needle, pump failure
• Insulin pens: prefilled cartridges of 150 to 300 units of insulin in a programmable device with
disposable needles.
• Used if only one insulin is given at a time
• Convenient for travel
• Oral hypoglycemics: used by clients who have type 2 diabetes, along with diet and exercise,
to regulate their blood glucose.

Types of Insulin: Rapid and Short

Rapid-acting insulin

Lispro insulin (Humalog), aspart insulin (Novolog), glulisine insulin (Apidra)

• Administer before meals- have food tray at bedside

• Onset is rapid, 10 to 30 min
• Given with intermediate or long-acting insulin to provide glycemic control between meals
and at night.

Short-acting insulin

Regular insulin (Humulin R, Novolin R)

• Administer 30 to 60 min before meals to control postprandial hyperglycemia.

Available in two concentrations:

Diabetes Study Notes

• U-500 is reserved for the client who has insulin resistance and is never administered IV.
• U-100 is prescribed for most clients and may be administered IV.

Intermediate and Long insulin

Intermediate-acting insulin

NPH insulin (Humulin N), detemir insulin (Levemir)

• Administered for glycemic control between meals and at night.

• Not administered before meals to control postprandial rise in blood glucose.
• Contains protamine (a protein), which causes a delay in the insulin absorption or onset and
extends the duration of action of the insulin.
• Administer NPH insulin subcutaneous only and as the only insulin to mix with short-acting
insulin.
• Administer detemir insulin subcutaneous only and is never mixed with other insulin.

Long-acting insulin

Glargine insulin (Lantus)

• Administered once daily, anytime during the day but always at the same time each day.
• Glargine insulin forms micro-precipitates that dissolve slowly over 24 hr and maintains a steady
blood sugar level with no peaks or troughs.
• Administer glargine insulin subcutaneous only and never administer IV.
• Nursing Considerations: Observe the client perform self-administration of insulin and offer
additional instruction as indicated.

Client Education: Insulin

• Provide information regarding self-administration of insulin.

• Rotate injection sites (prevent lipohypertrophy) within one anatomic site (prevent day-to-day
changes in absorption rates).
• Inject at a 90° angle (45° angle if thin). Aspiration for blood is not necessary.
• When mixing a rapid or short-acting insulin with a longer-acting insulin, draw up the shorter-
acting insulin into the syringe first and then the longer-acting insulin (this reduces the risk of
introducing the longer-acting insulin into the shorter-acting insulin vial).
• Advise the client to eat at regular intervals, avoid alcohol intake, and adjust insulin to exercise
and diet to avoid hypoglycemia.
• Keep unopened vials of insulin in the refrigerator

Oral Antidiabetics

Biguanides: Metformin

• Reduces production of glucose by the liver (glucogenesis)

• Increases tissue sensitivity to insulin
• Decrease carb absorption in intestines
• Causes GI effects: gas, n/v, diarrhea, anorexia
Diabetes Study Notes

• Stop med 4 days before radiologic test with dye. Restart 48 hrs later (can cause lactic acidosis
due to kidney injury)
• Pt should take B12 and folic acid supplements (med depletes these levels)

Second Generation Sulfonylureas: Glipizide, glyburide, glimepiride

• Stimulates insulin release from pancreas causing decrease in blood sugar levels
• Increases tissue sensitivity to insulin
• Beta blockers can mask tachycardia, typically seen in hypoglycemia
• Take 30 minutes before meals
• Avoid alcohol

Meglitinides: Repaglinide (Prandin), nateglinide (Starlix)

• Stimulates insulin release from pancreas.

• Administered for post meal hyperglycemia.

Nursing Considerations

• Monitor for hypoglycemia.

• Monitor HbA1c every 3 months to determine effectiveness.

Client Education

• Administer 15 to 30 min before a meal.

• Omit the dose if skipped a meal to prevent hypoglycemic crisis.

Thiazolidinediones: Pioglitazone (Actos)

• Reduces the production of glucose by the liver (gluconeogenesis).

• Increases tissue sensitivity to insulin.

Nursing Considerations

• Monitor for fluid retention, especially in clients who have a history of heart failure.
• Monitor for elevation of the client's LDL and triglycerides levels.

Client Education

• Report rapid weight gain, shortness of breath, decreased exercise tolerance.

• Use additional contraception methods because the medication reduces the blood levels of oral
contraceptives and stimulate ovulation.
• Have liver function tests every 2 months the first year.

Alpha-Glucosidase Inhibitors: Acarbose (Precose), miglitol (Glyset)

Diabetes Study Notes

• Slow carbohydrate absorption from the intestinal tract.

• Reduces post meal hyperglycemia.

Nursing Considerations

• Alert the client that GI discomfort (abdominal distention, cramps, excessive gas, diarrhea) is
common with these medications.
• Monitor liver function every 3 months.
• Treat hypoglycemia with dextrose, not table sugar (prevents table sugar from breaking down).

Client Education

• Instruct the client to have liver function tests performed every 3 months or as prescribed.
• Take the medication with the first bite of each meal in order for the medication to be effective.
• Have available dextrose paste to treat hypoglycemia.

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors: Sitagliptin (Januvia), saxagliptin (Onglyza)

• promote release of insulin and decrease secretion of glucagon

• Lowers fasting and postprandial glucose levels

Nursing Considerations

• Few side effects, but upper respiratory symptoms (nasal and throat inflammation) may be
present.
• Alert the client of GI discomforts (nausea, vomiting, and diarrhea).

Client Education

• Instruct the client to report persistent upper respiratory symptoms.

• Medication only works when blood sugar is rising.

Incretin Mimetic: Exenatide (Byetta)

• Decreases glucagon secretion and gastric emptying.

• Decrease insulin demand by reducing fasting and postprandial hyperglycemia.

Nursing Considerations

• Administer subcutaneously 60 min before morning and evening meal.

• Monitor for gastrointestinal distress.

Client Education

• Do not administer after a meal.

• Oral antibiotic, oral contraceptive, or acetaminophen (Tylenol) should never be given within 1 hr
of oral exenatide or 2 hr after an injection of exenatide.
• May have decreased appetite and weight loss.
Diabetes Study Notes

• Wait for next scheduled dose if the scheduled medication is missed.

Amylin Mimetic: Pramlintide (Symlin)

• A synthetic amylin hormone found in the beta cells of the pancreas

• it suppresses glucagon secretion and controls postprandial blood glucose levels.

Nursing Considerations

• Administer subcutaneously immediately before each major meal.

• Do not administer if HbA1c is greater than 9%.
• May administered with insulin therapy or oral hypoglycemic agent.

Client Education

• Monitor and report frequent periods of hypoglycemia.

• Monitor for injection site reactions.

Nursing Actions

Monitor:

• Blood glucose levels (signs of hyper and hypoglycemia) and factors affecting levels (other
medications)
• I&O (urine frequency/ polyuria) and weight
• Skin integrity and healing status of any wounds for presence of recurrent infections
• Feet and folds of the skin should be monitored.
• Sensory alterations in hands and feet (tingling, numbness)
• Visual alterations
• Dietary practices
• Exercise patterns
• The client's SMBG skill proficiency
• The client's self-medication administration proficiency

Client Education

• Restrict exercise when blood glucose levels are greater than 250 mg/dL.
• Test urine for ketones and report if outside of expected reference range.
• Only exercise when glucose levels are between 80-250; do not exercise if ketones are present
• Check blood glucose more often; change in med dose may be needed
• exercise- avoid injecting insulin into thighs if going running (increases absorption rate)
• prevent complications- maintain stable blood sugar levels
• Reinforce teaching the client manifestations of hyperglycemia (hot, dry skin and fruity breath)
and measures to take in response to hyperglycemia.
• Encourage oral fluid intake of sugar-free fluids to prevent dehydration.
• Administer insulin as prescribed.
• Consult the provider if manifestations progress.
Diabetes Study Notes

Sick Day Rules

• Monitor blood glucose every 2 to 4 hr.

• Continue to take insulin or oral hypoglycemic agents.
• Consume 4 oz of sugar-free, noncaffeinated liquid every 30 min to prevent dehydration.
• Meet carbohydrate needs through soft food (custard, cream soup, gelatin, graham crackers) six
to eight times per day, if possible. If not, consume liquids equal to usual carbohydrate content.
• Test urine for ketones and report to provider if they are outside the expected reference range.
(The level should be negative to small.)
• Rest.

Call the provider if:

• Blood glucose is greater than 240 mg/dL. Test urine for ketones, if prescribed.
• Fever is greater than 38.6° C (101.5° F), does not respond to acetaminophen, or lasts more
than 24 hr.
• Feeling disoriented or confused.
• Experiencing rapid breathing.
• Vomiting occurs more than once.
• Diarrhea occurs more than five times or for longer than 24 hr.
• Unable to tolerate liquids.
• Illness lasts longer than 2 days.

Foot Care

• Inspect feet daily for sores and bruises. Wash feet daily with mild soap and warm water. Test
water temperature with hands before washing feet.
• Pat feet dry gently, especially between the toes, and avoid lotions between toes to decrease
excess moisture and prevent infection.
• Do not use commercial remedies for the removal of calluses or corns, which may increase the
risk for tissue injury and infection.
• Consult a podiatrist.
• The best time to perform nail care is after a bath/shower, when toenails are soft and easier to
trim.
• Separate overlapping toes with cotton or lamb's wool.
• Avoid open-toe, open-heel shoes. Leather shoes are preferred to plastic. Wear shoes that fit
correctly. Wear slippers with soles. Do not go barefoot.
• Wear clean, absorbent socks or stockings that are made of cotton or wool and have not been
mended.
• Do not use hot water bottles or heating pads to warm feet. Wear socks for warmth.
• Avoid prolonged sitting, standing, and crossing of legs.
• Teach the client to cleanse cuts with warm water and mild soap, gently dry, and apply a dry
dressing. Instruct the clients to monitor healing and to seek intervention promptly.

Hypoglycemia (COLD and CLAMMY… GIVE SOME CANDY!!!)

Hypoglycemia manifestations
Diabetes Study Notes

• confusion
• Irritability
• sweating
• palpitations
• mild shakes
• lack coordination
• headache/ lightheaded
• tachycardia
• blurred vision
• seizures
• coma

• Hypoglycemia preventive measures are to avoid excess insulin, exercise, and alcohol
consumption
• A decrease in food intake or delay in food absorption can also cause hypoglycemia
• Check blood glucose level.
• if unconscious: place lateral to prevent aspiration. Admin glucagon or D50%. Rpt in 10 minutes if
still unresponsive
• If blood sugar <70 and awake: 15 to 20 g of a readily absorbable carbohydrate (4 to 6 oz of fruit
juice or regular soft drink, 3 to 4 glucose tablets, 8 to 10 hard candies, or 1 tbsp of honey) and
recheck blood glucose in 15 min. Retreat if glucose not above 70.
• If blood glucose is within normal limits, have a snack containing a carbohydrate and protein (if
the next meal is more than 1 hr away).
• Blood glucose increases approximately 40 mg/dL over 30 min following ingestion of 10 g of
absorbable carbohydrate

Complications: Cardiovascular and cerebrovascular disease

• Hypertension, myocardial infarction, and stroke

Nursing Action

• Monitor blood pressure.

Client Education

• Encourage checks of cholesterol (HDL, LDL, and triglycerides) yearly and monitoring of blood
pressure (below 130/80 mm Hg), and HbA1c every 3 months.
• Encourage participation in regular activity for weight loss and control.
• Encourage a diet of low-fat meals that are high in fruits, vegetables, and whole-grain foods.
• Teach the client to report shortness of breath, headaches (persistent and transient),
numbness in distal extremities, swelling of feet, infrequent urination, and changes in vision.
• Encourage a dietary consult.

Complications: Diabetic conditions

Diabetic Retinopathy
Diabetes Study Notes

• Impaired vision and blindness

Client Education

• Encourage yearly eye exams to ensure the health of the eyes and to protect vision.
• Encourage management of blood glucose levels.

Diabetic neuropathy

• Caused from damage to sensory nerve fibers resulting in numbness and pain.
• Is progressive, may affect every aspect of the body, and can lead to ischemia and infection.

Nursing Actions

• Monitor blood glucose levels to keep within an acceptable range to slow progression.
• Provide foot care.

Client Education

• Encourage annual exams by a podiatrist.

• Encourage regular follow-up with provider to assess and treat neuropathy.

Complications: Diabetic nephropathy

• Damage to the kidneys from prolonged elevated blood glucose levels and dehydration

Nursing Actions

• Monitor hydration and kidney function (I&O, serum creatinine).

• Report an hourly output of less than 30 mL/hr.
• Monitor blood pressure.

Client Education

• Encourage yearly urine analysis, BUN, and serum creatinine.

• Encourage the client to avoid soda, alcohol, and toxic levels of acetaminophen or NSAIDS.
• Teach the client to consume 2 to 3 L of fluid per day from food and beverage sources, and to
drink an adequate amount of water.
• Tell the client to report decrease in output to the provider.