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