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Diabetes Study Guide


1. What causes diabetes?
2. Signs and symptoms of hypoglycemia?
3. Signs and symptoms of hyperglycemia?
4. Risk factors for diabetes.
5. Functions of insulin.
6. What is gestational diabetes?
7. What is prediabetes?
8. What is type 1 diabetes? Risk factors? Signs and symptoms?
9. What is type 2 diabetes? Risk factors? Signs and symptoms?
10. What is metabolic syndrome? Signs and symptoms?
11. Normal blood glucose levels? What blood glucose level constitutes a diagnosis of diabetes?
12. What is a Glycated hemoglobin (Hgb A1C) test? What constitutes diabetes related to Hgb A1C?
13. Five components to manage diabetes?
14. Nutritional management of diabetes type 1 and type 2?
15. Review exercise for diabetes pg. 1206, chart 41-5.
16. Review insulin’s Rapid acting, short acting Intermediate acting, long acting and very long acting. Half life, peak times
of action, durations. Review pg 1209, chart 41.3.
17. Insulin’s: In the past, all insulin’s were obtained from beef (cow) and pork (pig) pancreases. Human insulin’s are now
widely available. They are produced by recombinant DNA technology and have largely replaced insulin from animal
sources: beef and pork insulin’s caused problems with allergy. That is very rarely a problem now. Insulin is
categorized by its pharmacokinetics.
Rapid acting Have an onset of action within 5-15 minutes, peak around 1 hour and last 2-4
Insulin lispro and as part hours. When you are giving this as a scheduled before-meal dose, in the hospital
(Humalog and Novolog doesn’t give it until the tray is in front of the patient. If the trays are delayed, the pt.
respectively) could have hypoglycemia.
Short acting Onset ½ - 1 hour, peak 2-3 hours, duration 4-6 hours.
This is good old regular
insulin
Intermediate – NPH and Onset 2-4 hours, peak 4-12 hours, duration 16-20 hours
lente. (Novolin N, Humalin
N, Novolin L)
Long acting – Ultralente Onset 6-8 hours, peak 12-16 hours, duration 20-30 hours.
Very long acting – glargine Onset within one hour, described as “peak-less” duration about 24 hours. May
(Lantus) or detemir not be mixed with any other insulin in the same syringe! These insulins were
(Levemir) designed to be constantly released and to be without a peak to mimic the body’s basal
insulin rate. However, they may have a small peak especially in some patients. For
glargine this may happen at around 5 hours after administration, for detemir (Levemir)
somewhere between 3-14 hours after administration.
Mixtures of insulin Are available to simplify administration for the patient. A mixture of regular and NPH
insulin is probably the most common

Complications – patients may become resistant to injected insulin. Of course, type 2 diabetes is defined by insulin
resistance. Another reason for resistance to injected insulin is the development of antibodies to the artificial insulin. This
is not nearly as common now that human insulin is used. This insulin resistance can sometimes be fairly severe. Insulin
is available in U500 concentrations for people who need very high insulin doses to overcome this.
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The goal of insulin therapy is to keep blood sugar as close to normal as possible all the time without serious
hypoglycemia. The body has a constant level of insulin – after all, the cells can’t use glucose without insulin. This is
very important to remember for the type 1 diabetic. They need some level of insulin at all times and their body
cannot supply it. Even if they don’t eat they need some insulin. If not, they quickly get into problems. Then, after a
meal, the pancreas releases more insulin in response to the elevated serum glucose. Insulin regimens try to mimic this.

Conventional: This is a simplified regimen. Intermediate, long, or very long acting insulin’s are used to provide the basal
rate and they are mixed with rapid or short acting insulin to provide the extra insulin for meals. This may be given in one
or two injections per day. With this regimen, the patient cannot vary the meal or exercise pattern, or hypo or
hyperglycemia will probably result.

Intensive: The patient adjusts insulin to blood glucose levels. This requires either an insulin pump or at least 3 injections
a day. The patient has a basal insulin – either a basal (constant) rate from the pump or an intermediate or longer acting
insulin, plus boluses based on the meal they consume and in response to hyperglycemia. This takes effort and intelligence
on the part of the patient, but permits the patient more flexibility in diet, exercise, and lifestyle.

For example, the patient may take a fixed dose of insulin glargine (Lantus) at bedtime, check blood sugar before
breakfast. Based on the blood sugar level, and the number of servings of carbohydrates the patient is going to eat for
breakfast, the patient calculates and insulin dose based on a plan that is individualized for that patient.

Or, a patient will wear an insulin pump. Insulin pumps are made by several manufacturers and this is one example. The
purpose of an insulin pump is to provide constant insulin and be able to respond to changes in blood sugar, like the
pancreas. Rapid-acting insulin’s are used in the pump, so that adjustments will take effect rapidly. The pump is fitted
with a small syringe containing the insulin (around 1.5 - 3mL) which connects to tubing and canula that is inserted into
the subq tissue. Sites are changed every 3 days and sites rotated. The pump is programmed with a basal (constant) rate
perhaps 0.5-2 units of insulin per hour. Then, at meal time, a bolus dose is programmed into the pump based on the
number of grams of carbohydrates consumed at the meal.

The newest coolest addition is addition of a continuous blood glucose monitor that will transmit information to an insulin
pump. The glucose monitor is worn in a similar manner to the pump and will continuously monitor and display glucose
and will set off alarms (set by the user) for low and high blood sugar. However, it is not quite yet an “artificial pancreas”.
In fact, the manufacturer suggests that pt’s not treat themselves based on the reading from the continuous monitor, but
rather use a conventional meter to check their blood sugar. The continuous monitor is calibrated to finger sticks 2-4 times
per day in addition. However, we are getting closer.

Oral Antidiabetic Agents: Used for patients with type 2 diabetes who cannot be treated with diet and exercise. A
combination of oral drugs may be used.

Major side effect: hypoglycemia. Nursing interventions: monitor blood glucose, and for hypoglycemia and other
potential side effects.

Patient teaching
We’ll talk about oral anti-diabetics. If diet and weight loss do not control type2 diabetes, these agents are tried.
However, about 50% of diabetics who start on these will eventually need insulin. One note – for gestational diabetics,
these are not used. Insulin is used to control blood sugar if diet is not adequate. There are 3 main divisions of oral
anti-diabetic agents.

Secretagogues – these are meds that stimulate the pancreas to increase insulin secretion. Obviously, they can only be
used for type 2 diabetics. If there are no beta cells, all the stimulation in the world will not help. A risk of Secretagogues
is hypoglycemia. These bypass the normal pancreatic “shut off” mechanism and force the pancreas to secrete insulin no
matter what.

Sulfonlyureas – these have been around a long time. The meds listed here are 2nd generation – the first generation
sulfonurea are not often used anymore. Sulfonurea may have cross-allergy with other sulfa drugs. These may cause
photosensitivity and GI problems; Glipizide (Glucotrol) Give 30 minutes ac Gyburide Available in 2 forms –
nonmicronised (Micronase, Diabeta) and micronised (Glynase)
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The 2 forms are NOT interchangeable! The absorption, and therefore the dose differs. Glimepiride (Amaryl), Give
Gyburide and Glimepiride with meals

Meglitinides these also are Secretagogues, but they are non sulfa drugs. They have a similar onset of action to the
sulfonurea (~1hr), but a shorter duration of action, so the pancreas can get back to normal between meals. Therefore these
have a lower risk of hypoglycemia than sulfonurea. A dose is taken before each meal. If a meal is skipped, skip the dose.
If a meal is added, the patient is usually instructed to add a dose (order needed in the hospital). More closely mimics
normal pancreatic function than sulfonurea. Give 30 minutes before meals.

Nateglinide (Starlix) & Repagliinide (Prandin); Insulin sensitizing agents – these do NOT increase secretion of insulin.
These make the cells more able to respond to the insulin. These agents used alone do NOT cause hypoglycemia. They
are often combined with Secretagogues to improve control. In fact, metformin is marketed in combination pills with
sulfonurea.

Biguanide Metformin (Glucophage) is probably the first line oral antidiabetic. It does work to counter the
pathophysiology of DM type 2 and we have a lot of experience with it. Give with meals, usually twice a day, or the
extended release form may be used once a day – it is recommended to be given with the evening meal (remember, unless
combined with a Secretagogues, this will not cause hypoglycemia).
Lactic acidosis is a rare, but potentially fatal adverse effect. To avoid – D/C or use caution in pt’s undergoing surgery or
who are dehydrated. Do not use in renal impairment. Smelter, et al is wrong. Hold metformin for 24- 48 hours before
or AFTER IV contrast agent or until creatinine in normal after IV contrast.

Thiazolidinedione – also insulin sensitizers like metformin. May be used alone or in combination with insulin or a
Secretagogues (Contraindicated in liver disease). Recent black-box warning for avandia. These may increase the
risk of developing heart failure. They increase plasma volume. Also decreases the effectiveness of oral contraceptives.
Give without regard to meals. Pioglitazone (pi-o-glit-a-zone) (Actos) – once a day; Rosiglitazone (roe-zi-glit-a-zone)
(Avandia) – once or twice a day

Alpha-Glucosidase Inhibitors; Acarbose (Precose); This drug works very differently than the others. It works in the GI
tract to inhibit enzymes that break down complex sugars and starches into glucose. So, If it is in the gut as the same time
as carbohydrates, glucose absorption is slowed and the blood sugar rises more slowly after a meal and the pancreas is
better able to keep up. Not for type 1 diabetes or gestational diabetes (none of the oral meds are). 2 big nursing
interventions. Precose must be given with the first bite of food with each meal. Hypoglycemia is not a problem in
monotherapy, but if the pt is on Acarbose and insulin or Secretagogues and does become hypoglycemic, the pt
MUST be treated with glucose – sucrose (table sugar) will have a very delayed absorption.
Acarbose causes a lot of GI symptoms – flatulence, diarrhea, abd pain.

Incretin analogs. Incretin are hormones secreted by the gut in response to food intake. Incretin stimulates the pancreas
to increase insulin production, decrease glucagon production, and decrease intestinal motility. These are approved for
type 2 diabetes only

Actions: Stimulate insulin release, Turn off glucagon release – glucagon is released from alpha cells in the
pancreas and causes the liver to release glucose, Produce feeling of satiety, and Slow gastric emptying (actually
increased in most people with diabetes)

Exenatide (Byetta) – exenatide mimics human Incretin. It is now approved as an adjunct therapy in patients with
diabetes already on diet, exercise, or oral agent therapy.. People are losing on average about 8 to 12 pounds
without even trying. Exenatide is given by injection (it comes in a pen) twice a day one hour before meals. Mild GI
symptoms occurred. For type 2 diabetes only

Sitaliptin (Januvia) is given po. Januvia is for type 2 diabetes. The recommended regimen of Sitaliptin for all
approved indications is 100 mg once daily with or without food. The most commonly observed adverse events that
occurred more often in the Sitaliptin group vs placebo (incidence, > 5%) included stuffy or runny nose and sore throat,
upper respiratory tract infection, and headache. Gastrointestinal effects were also noted, including abdominal pain
(Sitaliptin, 2.3% vs placebo, 2.1%), nausea (1.4% vs. 0.6%), and diarrhea (3.0% vs 2.3%). Treatment was not linked to
weight gain or loss from baseline, and the incidence of hypoglycemia was similar to that of placebo (1.2% vs. 0.9%).
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Amylin analog – pramlintide (Symlin). Amylin is produced by the beta cells of the pancreas and is nearly absent in
type 1 diabetes, and is not released normally in type 2 diabetes. Amylin has similar effects to Incretin – slows gastric
emptying, signals fullness, and turns off glucagon (which causes a rise in blood sugar). Risk for significant hypoglycemia
– not used if patients are unaware of hypoglycemia or not compliant. Not used with very poor control (Hgb A1c of 9 or
more). Injected before each major meal (30 gm carb or more) – cannot be mixed with insulin, must be at least 2 in away.
Only in abd or thigh (not arm). Check blood sugar 1-2 hrs after. Used for type 1 or 2 Side effects – hypoglycemia,
nausea (the nausea gets better).

The insulin pump, The MiniMed Paradigm 522 and 722 Insulin Pumps have a list price of $6,195.* An optional starter kit
for the continuous glucose monitoring components has a list price of $999. Insurance covers the pump usually, but not
any continuous blood glucose monitoring just yet.

18. Sick day rules?


19. DKA signs and symptoms, nursing actions?
20. HHNS signs and symptoms, nursing actions?
21. Long-term complications of diabetes?
22. Geriatric changes with diabetes?
23. Surgery and diabetes?
24. Nursing process and diabetes?

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