Diabetes Mellitus

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Diabetes Mellitus by Mind Map: Diabetes Mellitus

1. Report BG >300 x2

2. Non-diabetic patients may require insulin while taking the medication.

3. Usually appears 10-20 years after diagnosis

4. Fasting plasma glucose: blood draw after fasting

5. Pancreas Transplantation

5.1. For Type 1 diabetes with kidney transplant

5.2. Eliminates need for exogenous insulin, SMBG, and dietary restrictions

6. 1 drink/day for women, 2 for men

7. Eye problems.

8. Bed wetting.

9. Plasma Glucose Testing

9.1. Oral Glucose Tolerance Test (OGTT)

10. No insulin is produced.

10.1. Autoimmune disease.

11. If unable to swallow: glucagon 1mg IM or SQ

12. Insulin

13. Decreased weight.

14. Limit cholesterol to < 200 mg/day

15. Classification

15.1. Type 1

15.1.1. Juvenile Onset: DM 1 can occur at any stage of life but is most commonly found in young people

15.1.2. Often diagnosed before age 15.

15.1.3. Daily insulin required for life.

15.1.4. 5-10% of diabetes.

15.2. Sedentary Lifestyle

15.2.1. Insufficient insulin production or improper use of insulin..

15.3. Type 2

15.3.1. Most common in adults aged 35 or older.

15.3.2. Obesity

15.3.3. Risk Factors

15.3.3.1. Age greater than 45

15.3.3.2. Positive family history (10x more likely)

15.3.3.3. Ethnicity

15.3.3.4. Hypertension

15.3.4. May need to supplement insulin.

15.3.5. Over 90% of diabetes.

15.3.6. Genetic link.

15.4. Diabetic Ketoacidosis (DKA)

15.4.1. Profound deficiency of insulin

15.4.2. Hyperglycemia (>250), ketosis, acidosis (<7.3), and dehydration

15.4.3. Normal pH range: 7.35-7.45

15.4.4. Most likely to occur in Type 1

15.4.5. Ensure patent airway, administer O2

15.4.6. Establish IV access; begin fluid resuscitation

15.4.7. Clinical Manifestations

15.4.7.1. Dehydration: poor skin turgor, tachycardia, dry membranes

15.4.7.2. Lethargy and weakness

15.4.7.3. Eyes soft and sunken

15.4.7.4. Fruity sweet breath odor

15.4.7.5. Kussmaul respirations

15.4.8. Higher risk of maternal/neonatal complications

15.5. Goes away after pregnancy.

15.6. Impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT)

15.7. Occurs during pregnancy.

15.8. Gestational

15.8.1. May not reoccur.

15.8.2. May have a large baby.

15.8.3. Usually detected 24-28 weeks when OGTT is done.

15.8.4. Nutritional therapy is the first line of treatment!

15.9. Pre-Diabetes

15.9.1. Blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes.

15.10. Secondary Diabetes

15.10.1. Diabetes caused by an outside factor.

15.10.1.1. Stress increases blood glucose levels.

15.10.2. Drug or chemical induced.

15.10.2.1. Dilantin

15.10.2.2. Corticosteroids

15.10.2.3. Antipsychotic meds

16. Signs and Symptoms

16.1. Type 1

16.1.1. Increased thirst.

16.1.2. Rapid onset.

16.2. Duration: 5-8 hours

16.3. Type 2

16.3.1. Increased weight.

16.3.2. Slow onset.

16.3.3. Recurrent infections

16.3.4. Prolonged wound healing

16.3.5. Nerve disruption

16.4. Type 1 and 2

16.4.1. 3-P's

16.4.1.1. Polyphagia

16.4.1.2. Polydipsia

16.4.1.3. Primarily seen in Type 1 but can be seen in Type 2.

16.4.1.4. Polyuria

16.4.2. Fatigue

17. Treatments and Interventions

17.1. Early Diagnosis

17.2. Monitor glucose before, during, after exercise

17.3. Reduces CV risk factors

17.4. Glucose Monitoring

17.5. Routine Exercise

17.5.1. Meal planning

17.5.2. Do not exercise if blood glucose level > 300 mg/dL and if ketones are in urine

17.5.3. Increases insulin sensitivity

17.5.3.1. Saturated fats < 7% of total calories

17.6. Nutritional Therapy

17.6.1. Type 1

17.6.1.1. Consistency

17.6.1.2. More flexibility with rapid acting insulin, multiple daily injections, or insulin pump

17.6.2. Type 2

17.6.2.1. Low fat and carbs

17.6.3. Carbohydrates

17.6.3.1. Spacing meals

17.6.3.2. May decrease need for DM meds for Type 2

17.6.3.3. Minimum of 130 g/day

17.6.3.4. Nonnutritive and nutritive sweeteners can be used in moderation

17.6.4. Exercise 1 hour after meal

17.6.5. Fats

17.6.5.1. Minimize trans fat

17.6.6. 15%-20% of calories

17.6.7. Protein

17.6.7.1. High-protein diets are not recommended

17.6.8. Alcohol

17.6.8.1. Inhibits glucogenesis by liver

17.6.8.2. Can cause severe hypoglycemia

17.6.9. General Guidelines

17.6.9.1. Raw/Whole Foods will lower a glycemic response

17.6.9.1.1. Emphasis on achieving glucose, lipid, and BP goals

17.7. Fewer symptoms lead to higher glucose levels (>600)

17.8. Bariatric Surgery

17.8.1. For DM Type 2

17.8.2. Used when lifestyle/drug therapy management is difficult

17.8.2.1. Combine carbs, protein, and fat to slow down absorption and decrease glycemic response

17.9. BMI >35

17.10. Monitor for Complications

17.10.1. Hyperosmolar Hyperglycemic Syndrome (HHS)

17.10.1.1. Life-threatening syndrome in Type 2 DM

17.10.1.2. Enough insulin to prevent DKA

17.10.1.3. More severe neurologic manifestations

17.10.1.4. Change in LOC? Check BG!

17.10.1.5. High mortality rate

17.10.1.6. Therapy

17.10.1.6.1. IV insulin and NaCl infusions

17.10.1.6.2. Monitor serum potassium, replace if needed

17.10.1.6.3. Cardiac monitoring

18. Complications

18.1. Angiopathy

18.1.1. Damage to blood vessels secondary to chronic hyperglycemia

18.1.2. Leading cause of diabetes-related death

18.1.3. Macrovascular and microvascular

18.1.3.1. Macrovascular Angiopathy

18.1.3.1.1. Diseases of large and medium sized blood vessels

18.1.3.1.2. Higher frequency and earlier onset in patients with DM

18.1.3.1.3. Cerebrovascular Disease

18.1.3.1.4. Cardiovascular Disease

18.1.3.1.5. Peripheral Vascular Disease

18.1.3.1.6. Decrease risk factors

18.1.3.1.7. Screen for and treat hyperlipidemia

18.1.3.2. Microvascular Angiopathy

18.1.3.2.1. Thickening of vessel membranes in capillaries and arterioles

18.1.3.2.2. Specific to diabetes

18.1.3.3. Aspiration of blood, membrane, and fibers inside the eye

18.1.4. Tight glucose levels can help prevent/minimize risks

18.2. Peripheral Vascular Disease (PVD)

18.3. Retinopathy

18.4. Nephropathy

18.5. Neuropathy

18.6. Infections

18.7. Hypertension

18.8. Poorly Controlled Diabetes

18.8.1. Diabetic Ketoacidosis (Type 1)

18.8.2. Fluid and Electrolyte Imbalance

18.9. Nail care

18.10. Chronic Foot Complications

18.10.1. Sensory neuropathy leads to decrease of protective sensation, leading to unawareness injuries

18.10.2. Peripheral artery disease decrease blood flow and wound healing, while increasing the risk of infection

18.10.3. Teach frequent assessment of feet

18.10.4. Proper footwear

18.10.5. Diligent wound care for foot ulcers

18.10.6. Neuropathic arthropod (Charcot's foot)

18.10.6.1. Ankle and foot changes that lead to joint dysfunction and footdrop

18.10.6.2. Increases chance of foot ulcer

18.11. Chronic Skin Problems

18.11.1. Diabetic dermopathy

18.11.1.1. Most common

18.11.1.2. Red-brown, round or oval patches

18.11.2. Acanthosis nigricans

18.11.2.1. Manifestation of insulin resistance

18.11.2.2. Brown-black skin seen on flexures, axillae, and neck

18.11.3. Defect in mobilization of inflammatory cells and impaired phagocytosis

18.11.4. Necrobiosis lipoidica diabeticorum

18.11.4.1. Red-yellow lesions

18.12. Infection

18.12.1. Recurring/persistent infections

18.12.2. Treat promptly and vigorously

18.12.3. Hand hygiene and flu/PNU vaccine

19. Diagnostic Studies

19.1. Hemoglobin A1C

19.1.1. Does not require fasting

19.1.2. Measure glycemic levels over the past 90-120 days

19.1.3. Normal A1C: 4.5%-6.5%

19.2. Fructosamine

19.2.1. Formed by a chemical reaction of glucose with plasma protein

19.2.2. Reflects glycemic in the previous 1-3 weeks.

19.2.3. May show a change in blood glucose levels before A1C does.

19.3. Autoantibodies

19.3.1. Helps distinguish between autoimmune Type 1 diabetes and diabetes due to other causes.

19.4. Urine Studies

19.4.1. Urine testing for glucose

19.4.2. Urine testing for ketone bodies

19.4.3. Tests for renal function

19.4.3.1. Presence of protein such as albumin to detect early onset of nephropathy

19.4.3.2. 24-hour urine test for creatinine clearance to evaluate renal function if albumin is present

20. Criteria for Diabetes

20.1. A1C > 6.5%

20.2. Fasting Plasma Glucose (FPG) > 126 mg/dl

20.3. Symptoms of hyperglycemia and random plasma glucose > 200 mg/dl

20.4. 2 hour plasma glucose > 200 mg/dl during an OGTT

20.5. Pre-Diabetes

20.5.1. A1C of 5.7%-6.4%

20.5.2. Impaired Fasting Glucose: 100-125 mg/dl after an overnight fast

20.5.3. Impaired Glucose Tolerance: 2 hour post-OGTT of 140-199 mg/dl

21. Self-Monitoring of Blood Glucose (SMBG)

21.1. Enables decisions regarding diet, exercise, and medication

21.2. Helps identify hypo/hyperglycemia

21.3. A must for insulin users

21.4. Never share meters!

21.5. Inaccurate BG Readings

21.5.1. Expired test strips

21.5.2. Squeezing the finger

21.5.3. Unclean hands with food/sugar

21.5.4. Not checking control solution regularly

21.5.5. Obtaining sample from alternate sites

21.5.6. Dehydration, elevated hematocrit

21.5.7. Always recheck!

22. Hypoglycemia

22.1. Rapid onset of symptoms

22.1.1. Confusion

22.1.2. Irritability

22.1.3. Diaphoresis - cold and clammy!

22.1.4. Tremors

22.1.5. Hunger

22.2. Symptoms can also occur when high glucose level falls too rapidly

22.3. Quickly reversible

22.4. At the first sign of hypoglycemia, BG should be checked

22.5. Hypoglycemic unawareness: person doesn't experience S/S, dangerous

22.5.1. Related to autonomic neuropathy and lack of counter regulatory hormones

22.5.2. Patients at risk should be BG levels a little higher

22.6. Treatment

22.6.1. Rule of 15

22.6.1.1. Consume 15g os simple carbs

22.6.1.2. Recheck BG in 15 mins

22.6.1.3. Repeat if BG remains <70

22.6.2. Actue Care Setting

22.6.2.1. 50% dextrose, 20-50mL IVP

23. Sick Day Care

23.1. Take meds as prescribed

23.1.1. Get annual flu shot!

23.2. Test BG q. 4 hours

23.3. Eat sick day foods hourly (15 gm carbs)

23.4. Test ketones q. 4 hrs if BG >240

23.5. Report moderate ketones to HCP

24. Intraoperative Management

24.1. Observe clients for S/S of hypoglycemia

24.1.1. Type 2: d/c oral diabetics 48 hours before surgery, treat with insulin during surgery

25. Heat > 86F and freezing temperatures alter the insulin, making it less effective

26. Used in sliding scale

27. Oral Hypoglycemics

28. NPH (cloudy) - must agitate gently to mix

29. Can be mixed with short or rapid acting insulins

30. Glucose Lowering Agents

30.1. Insulin

30.1.1. Categorized according to onset, peak action, and duration.

30.1.1.1. Rapid-Acting

30.1.1.1.1. The -logs: lispro (Humalog), aspart (NovoLog), glulisine (Apidra)

30.1.1.1.2. Onset: 10-30 mins.

30.1.1.1.3. Peak: 30 mins - 3 hours

30.1.1.1.4. Duration: 3-5 hours

30.1.1.2. Short-Acting

30.1.1.2.1. Regular (Humulin R, Novolin R)

30.1.1.2.2. Onset: 30 mins - 1 hour

30.1.1.2.3. Peak: 2-5 hours

30.1.1.3. Intermediate-Acting

30.1.1.3.1. NPH (Humulin N, Novolin N)

30.1.1.3.2. Onset: 1.5-4 hours

30.1.1.3.3. Peak: 4-12 hours

30.1.1.3.4. Duration: 12-18 hours

30.1.1.4. Long-Acting

30.1.1.4.1. glargine (Lantus), detemir (Levemir), degludec (Tresiba)

30.1.1.4.2. Onset: 0.8-4 hours

30.1.1.4.3. Peak: Less defined, or no pronounced peak

30.1.1.4.4. Duration: 16-24 hours

30.1.2. Basal-Bolus Regimen

30.1.2.1. Most closely mimics endogenous insulin production

30.1.2.2. Rapid or short acting (bolus) insulin before meals

30.1.2.2.1. Rapid Acting Insulin (Bolus)

30.1.2.2.2. Short Acting Insulin (Bolus)

30.1.2.3. Intermediate or long acting (basal) background insulin once or twice daily

30.1.2.3.1. Intermediate Acting Insulin (Basal)

30.1.2.3.2. No prolonged exposure to sunlight

30.1.2.3.3. Long Acting Insulin (Basal)

30.1.2.4. Combination Insulin (premixed)

30.1.2.4.1. Provides both mealtime and basal coverage but not as effective as basal-bolus regimen

30.1.2.4.2. Decreases the number of injections

30.1.2.4.3. NPH/regular 70/30

30.1.2.4.4. Good for patients unable to draw up two types of insulin

30.1.3. Administration

30.1.3.1. Subcutaneous injection

30.1.3.1.1. Allow no air bubble in the syringe

30.1.3.1.2. Don't mix insulin of different manufactures

30.1.3.1.3. Abdomen is the fastest absorption area

30.1.3.2. IV: Regular only

30.1.3.3. Never oral

30.1.3.4. Storage

30.1.3.4.1. Unopened: refrigerator

30.1.3.4.2. Opened: room-temperature

30.1.3.4.3. Pre-filled syringes: store upright for 1 week if mixed, 30 days if not

30.1.3.4.4. Open vials and pens can be stored at room-temp for 4 weeks

30.1.3.5. Insulin Pump

30.1.3.5.1. Continuous subcutaneous infusion

30.1.3.5.2. Program basal and bolus douses that can vary throughout the day

30.1.3.5.3. Keep glucose levels in a tighter range

30.1.3.6. Inhaled Insulin

30.1.3.6.1. Afrezza

30.1.3.6.2. Rapid-acting inhaled insulin

30.1.3.6.3. Administered at beginning of each meal or within 20 mins of starting

30.1.3.6.4. Not a substitute for long-acting insulin

30.1.4. Hyperglycemia in the morning

30.1.5. Adverse Effects

30.1.5.1. Hypoglycemia

30.1.5.2. Somogyi Effect

30.1.5.2.1. High evening dose of insulin causes low glucose in the night, body reacts causing hyperglycemia

30.1.5.2.2. Treatment: less insulin in the evening

30.1.5.3. Carry rapidly absorbed carbs with you!

30.1.5.3.1. Decreased insulin production

30.1.5.4. Dawn Phenomenon

30.1.5.4.1. Hyperglycemia on awakening

30.1.5.4.2. Growth hormones and cortisol are secreted by the body during the early morning, causing an increase in blood sugar

30.1.5.4.3. More common in children

30.1.5.4.4. Treatment: increase insulin or adjust insulin administration time

30.1.5.5. Allergic Reaction

30.1.5.6. Systemic Response

30.1.5.7. Lipodystrophy

30.2. Oral Agents

30.2.1. Work on three defects of Type 2 diabetes

30.2.1.1. Insulin resistance

30.2.1.2. Increased hepatic glucose production

30.3. Connected to a catheter inserted into abdominal tissue

30.4. Non-insulin Drug Therapy

30.4.1. Biguanides

30.4.1.1. metformin (Glucophage)

30.4.1.2. Reduces glucose production by liver

30.4.1.3. Withhold if patient is undergoing surgery or radiologic procedure with contrast medium (dyes)

30.4.1.3.1. Increase insulin production from pancreas

30.4.1.4. Does not increase insulin production

30.4.1.5. Does not cause hypoglycemia

30.4.1.6. Used in prevention of Type 2 diabetes

30.4.1.7. BIGuanides = BIGgest oral antidiabetic

30.4.1.8. Monitor serum creatinine

30.4.1.9. SE: diarrhea, flatuelence

30.4.2. Sulfonylureas

30.4.2.1. Increases insulin production from pancreas

30.4.2.2. Major SE: hypoglycemia, weight gain

30.4.2.3. Contraindications: renal, liver, or cardiac disease

30.4.2.4. Not for patients with sulfa allergy

30.4.3. Increases insulin, lowers glucagon

30.4.4. Meglitinides

30.4.5. Alpha-glucosidase inhibitors

30.4.5.1. "Starch blockers"

30.4.5.2. SE: gas, abdominal pain, diarrhea

30.4.6. Can be used in combination with agents from other classes or insulin

30.4.7. Thiazolidinediones

30.4.7.1. Rarely used because of adverse effects

30.4.7.2. Discontinued

30.4.7.3. Doubled risk of bone fractures in women with DM Type 2

30.4.8. Depeptidyl Peptidase-4 (DDP-4) Inhibitor

30.4.8.1. SE: pancreatitis, lowered potential for hypoglycemia

30.4.9. Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors

30.4.9.1. Increases glucose excretion

30.4.9.2. SE: increased genital tract infections and UTI's, hypoglycemia

30.4.10. Dopamine Receptor Agonist

30.4.10.1. Increases dopamine receptor activity

30.4.10.2. SE: orthostatic hypotension

30.4.11. Glucagonlike Peptide-1 Receptor Agonists

30.4.11.1. non-insulin injection

30.4.11.2. Not usually used for Type 1 DM

30.4.11.3. SE: N/V, hypoglycemia, diarrhea, headache, acute pancreatitis, and kidney problems

30.4.12. Amylin Analog

30.4.12.1. Injection used in addition to mealtime insulin

30.4.12.2. Type 1 or 2 DM

30.4.12.3. Not a replacement for insulin

30.4.12.4. Combination Therapy

30.4.12.4.1. Blend two different drug classes together

30.4.12.4.2. Less pills for a patient to take

30.4.12.4.3. Patient and HCP must be aware of drug interactions that could cause hypo/hyperglycemia

30.4.12.5. SE: hypoglycemia

30.5. SE: hypoglycemia, weight gain