Diabetes Mellitus

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Diabetes Mellitus by Mind Map: Diabetes Mellitus

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

2. Report BG >300 x2

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

4. Used in sliding scale

5. Usually appears 10-20 years after diagnosis

6. Oral Hypoglycemics

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

8. Fasting plasma glucose: blood draw after fasting

9. Pancreas Transplantation

9.1. For Type 1 diabetes with kidney transplant

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

10. 1 drink/day for women, 2 for men

11. Eye problems.

12. Bed wetting.

13. Plasma Glucose Testing

13.1. Oral Glucose Tolerance Test (OGTT)

14. No insulin is produced.

14.1. Autoimmune disease.

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

16. Can be mixed with short or rapid acting insulins

17. Insulin

18. Decreased weight.

19. Limit cholesterol to < 200 mg/day

20. Classification

20.1. Type 1

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

20.1.2. Often diagnosed before age 15.

20.1.3. Daily insulin required for life.

20.1.4. 5-10% of diabetes.

20.2. Sedentary Lifestyle

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

20.3. Type 2

20.3.1. Most common in adults aged 35 or older.

20.3.2. Obesity

20.3.3. Risk Factors Age greater than 45 Positive family history (10x more likely) Ethnicity Hypertension

20.3.4. May need to supplement insulin.

20.3.5. Over 90% of diabetes.

20.3.6. Genetic link.

20.4. Diabetic Ketoacidosis (DKA)

20.4.1. Profound deficiency of insulin

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

20.4.3. Normal pH range: 7.35-7.45

20.4.4. Most likely to occur in Type 1

20.4.5. Ensure patent airway, administer O2

20.4.6. Establish IV access; begin fluid resuscitation

20.4.7. Clinical Manifestations Dehydration: poor skin turgor, tachycardia, dry membranes Lethargy and weakness Eyes soft and sunken Fruity sweet breath odor Kussmaul respirations

20.4.8. Higher risk of maternal/neonatal complications

20.5. Goes away after pregnancy.

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

20.7. Occurs during pregnancy.

20.8. Gestational

20.8.1. May not reoccur.

20.8.2. May have a large baby.

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

20.8.4. Nutritional therapy is the first line of treatment!

20.9. Pre-Diabetes

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

20.10. Secondary Diabetes

20.10.1. Diabetes caused by an outside factor. Stress increases blood glucose levels.

20.10.2. Drug or chemical induced. Dilantin Corticosteroids Antipsychotic meds

21. Signs and Symptoms

21.1. Type 1

21.1.1. Increased thirst.

21.1.2. Rapid onset.

21.2. Duration: 5-8 hours

21.3. Type 2

21.3.1. Increased weight.

21.3.2. Slow onset.

21.3.3. Recurrent infections

21.3.4. Prolonged wound healing

21.3.5. Nerve disruption

21.4. Type 1 and 2

21.4.1. 3-P's Polyphagia Polydipsia Primarily seen in Type 1 but can be seen in Type 2. Polyuria

21.4.2. Fatigue

22. Treatments and Interventions

22.1. Early Diagnosis

22.2. Monitor glucose before, during, after exercise

22.3. Reduces CV risk factors

22.4. Glucose Monitoring

22.5. Routine Exercise

22.5.1. Meal planning

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

22.5.3. Increases insulin sensitivity Saturated fats < 7% of total calories

22.6. Nutritional Therapy

22.6.1. Type 1 Consistency More flexibility with rapid acting insulin, multiple daily injections, or insulin pump

22.6.2. Type 2 Low fat and carbs

22.6.3. Carbohydrates Spacing meals May decrease need for DM meds for Type 2 Minimum of 130 g/day Nonnutritive and nutritive sweeteners can be used in moderation

22.6.4. Exercise 1 hour after meal

22.6.5. Fats Minimize trans fat

22.6.6. 15%-20% of calories

22.6.7. Protein High-protein diets are not recommended

22.6.8. Alcohol Inhibits glucogenesis by liver Can cause severe hypoglycemia

22.6.9. General Guidelines Raw/Whole Foods will lower a glycemic response Emphasis on achieving glucose, lipid, and BP goals

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

22.8. Bariatric Surgery

22.8.1. For DM Type 2

22.8.2. Used when lifestyle/drug therapy management is difficult Combine carbs, protein, and fat to slow down absorption and decrease glycemic response

22.9. BMI >35

22.10. Monitor for Complications

22.10.1. Hyperosmolar Hyperglycemic Syndrome (HHS) Life-threatening syndrome in Type 2 DM Enough insulin to prevent DKA More severe neurologic manifestations Change in LOC? Check BG! High mortality rate Therapy IV insulin and NaCl infusions Monitor serum potassium, replace if needed Cardiac monitoring

23. Complications

23.1. Angiopathy

23.1.1. Damage to blood vessels secondary to chronic hyperglycemia

23.1.2. Leading cause of diabetes-related death

23.1.3. Macrovascular and microvascular Macrovascular Angiopathy Diseases of large and medium sized blood vessels Higher frequency and earlier onset in patients with DM Cerebrovascular Disease Cardiovascular Disease Peripheral Vascular Disease Decrease risk factors Screen for and treat hyperlipidemia Microvascular Angiopathy Thickening of vessel membranes in capillaries and arterioles Specific to diabetes Aspiration of blood, membrane, and fibers inside the eye

23.1.4. Tight glucose levels can help prevent/minimize risks

23.2. Peripheral Vascular Disease (PVD)

23.3. Retinopathy

23.4. Nephropathy

23.5. Neuropathy

23.6. Infections

23.7. Hypertension

23.8. Poorly Controlled Diabetes

23.8.1. Diabetic Ketoacidosis (Type 1)

23.8.2. Fluid and Electrolyte Imbalance

23.9. Nail care

23.10. Chronic Foot Complications

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

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

23.10.3. Teach frequent assessment of feet

23.10.4. Proper footwear

23.10.5. Diligent wound care for foot ulcers

23.10.6. Neuropathic arthropod (Charcot's foot) Ankle and foot changes that lead to joint dysfunction and footdrop Increases chance of foot ulcer

23.11. Chronic Skin Problems

23.11.1. Diabetic dermopathy Most common Red-brown, round or oval patches

23.11.2. Acanthosis nigricans Manifestation of insulin resistance Brown-black skin seen on flexures, axillae, and neck

23.11.3. Defect in mobilization of inflammatory cells and impaired phagocytosis

23.11.4. Necrobiosis lipoidica diabeticorum Red-yellow lesions

23.12. Infection

23.12.1. Recurring/persistent infections

23.12.2. Treat promptly and vigorously

23.12.3. Hand hygiene and flu/PNU vaccine

24. Diagnostic Studies

24.1. Hemoglobin A1C

24.1.1. Does not require fasting

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

24.1.3. Normal A1C: 4.5%-6.5%

24.2. Fructosamine

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

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

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

24.3. Autoantibodies

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

24.4. Urine Studies

24.4.1. Urine testing for glucose

24.4.2. Urine testing for ketone bodies

24.4.3. Tests for renal function Presence of protein such as albumin to detect early onset of nephropathy 24-hour urine test for creatinine clearance to evaluate renal function if albumin is present

25. Criteria for Diabetes

25.1. A1C > 6.5%

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

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

25.4. 2 hour plasma glucose > 200 mg/dl during an OGTT

25.5. Pre-Diabetes

25.5.1. A1C of 5.7%-6.4%

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

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

26. Glucose Lowering Agents

26.1. Insulin

26.1.1. Categorized according to onset, peak action, and duration. Rapid-Acting The -logs: lispro (Humalog), aspart (NovoLog), glulisine (Apidra) Onset: 10-30 mins. Peak: 30 mins - 3 hours Duration: 3-5 hours Short-Acting Regular (Humulin R, Novolin R) Onset: 30 mins - 1 hour Peak: 2-5 hours Intermediate-Acting NPH (Humulin N, Novolin N) Onset: 1.5-4 hours Peak: 4-12 hours Duration: 12-18 hours Long-Acting glargine (Lantus), detemir (Levemir), degludec (Tresiba) Onset: 0.8-4 hours Peak: Less defined, or no pronounced peak Duration: 16-24 hours

26.1.2. Basal-Bolus Regimen Most closely mimics endogenous insulin production Rapid or short acting (bolus) insulin before meals Rapid Acting Insulin (Bolus) Short Acting Insulin (Bolus) Intermediate or long acting (basal) background insulin once or twice daily Intermediate Acting Insulin (Basal) No prolonged exposure to sunlight Long Acting Insulin (Basal) Combination Insulin (premixed) Provides both mealtime and basal coverage but not as effective as basal-bolus regimen Decreases the number of injections NPH/regular 70/30 Good for patients unable to draw up two types of insulin

26.1.3. Administration Subcutaneous injection Allow no air bubble in the syringe Don't mix insulin of different manufactures Abdomen is the fastest absorption area IV: Regular only Never oral Storage Unopened: refrigerator Opened: room-temperature Pre-filled syringes: store upright for 1 week if mixed, 30 days if not Open vials and pens can be stored at room-temp for 4 weeks Insulin Pump Continuous subcutaneous infusion Program basal and bolus douses that can vary throughout the day Keep glucose levels in a tighter range Inhaled Insulin Afrezza Rapid-acting inhaled insulin Administered at beginning of each meal or within 20 mins of starting Not a substitute for long-acting insulin

26.1.4. Hyperglycemia in the morning

26.1.5. Adverse Effects Hypoglycemia Somogyi Effect High evening dose of insulin causes low glucose in the night, body reacts causing hyperglycemia Treatment: less insulin in the evening Carry rapidly absorbed carbs with you! Decreased insulin production Dawn Phenomenon Hyperglycemia on awakening Growth hormones and cortisol are secreted by the body during the early morning, causing an increase in blood sugar More common in children Treatment: increase insulin or adjust insulin administration time Allergic Reaction Systemic Response Lipodystrophy

26.2. Oral Agents

26.2.1. Work on three defects of Type 2 diabetes Insulin resistance Increased hepatic glucose production

26.3. Connected to a catheter inserted into abdominal tissue

26.4. Non-insulin Drug Therapy

26.4.1. Biguanides metformin (Glucophage) Reduces glucose production by liver Withhold if patient is undergoing surgery or radiologic procedure with contrast medium (dyes) Increase insulin production from pancreas Does not increase insulin production Does not cause hypoglycemia Used in prevention of Type 2 diabetes BIGuanides = BIGgest oral antidiabetic Monitor serum creatinine SE: diarrhea, flatuelence

26.4.2. Sulfonylureas Increases insulin production from pancreas Major SE: hypoglycemia, weight gain Contraindications: renal, liver, or cardiac disease Not for patients with sulfa allergy

26.4.3. Increases insulin, lowers glucagon

26.4.4. Meglitinides

26.4.5. Alpha-glucosidase inhibitors "Starch blockers" SE: gas, abdominal pain, diarrhea

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

26.4.7. Thiazolidinediones Rarely used because of adverse effects Discontinued Doubled risk of bone fractures in women with DM Type 2

26.4.8. Depeptidyl Peptidase-4 (DDP-4) Inhibitor SE: pancreatitis, lowered potential for hypoglycemia

26.4.9. Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors Increases glucose excretion SE: increased genital tract infections and UTI's, hypoglycemia

26.4.10. Dopamine Receptor Agonist Increases dopamine receptor activity SE: orthostatic hypotension

26.4.11. Glucagonlike Peptide-1 Receptor Agonists non-insulin injection Not usually used for Type 1 DM SE: N/V, hypoglycemia, diarrhea, headache, acute pancreatitis, and kidney problems

26.4.12. Amylin Analog Injection used in addition to mealtime insulin Type 1 or 2 DM Not a replacement for insulin Combination Therapy Blend two different drug classes together Less pills for a patient to take Patient and HCP must be aware of drug interactions that could cause hypo/hyperglycemia SE: hypoglycemia

26.5. SE: hypoglycemia, weight gain

27. Self-Monitoring of Blood Glucose (SMBG)

27.1. Enables decisions regarding diet, exercise, and medication

27.2. Helps identify hypo/hyperglycemia

27.3. A must for insulin users

27.4. Never share meters!

27.5. Inaccurate BG Readings

27.5.1. Expired test strips

27.5.2. Squeezing the finger

27.5.3. Unclean hands with food/sugar

27.5.4. Not checking control solution regularly

27.5.5. Obtaining sample from alternate sites

27.5.6. Dehydration, elevated hematocrit

27.5.7. Always recheck!

28. Hypoglycemia

28.1. Rapid onset of symptoms

28.1.1. Confusion

28.1.2. Irritability

28.1.3. Diaphoresis - cold and clammy!

28.1.4. Tremors

28.1.5. Hunger

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

28.3. Quickly reversible

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

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

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

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

28.6. Treatment

28.6.1. Rule of 15 Consume 15g os simple carbs Recheck BG in 15 mins Repeat if BG remains <70

28.6.2. Actue Care Setting 50% dextrose, 20-50mL IVP

29. Sick Day Care

29.1. Take meds as prescribed

29.1.1. Get annual flu shot!

29.2. Test BG q. 4 hours

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

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

29.5. Report moderate ketones to HCP

30. Intraoperative Management

30.1. Observe clients for S/S of hypoglycemia

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