UPDATED DIABETES LECTURE 2012

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Focus on Diabetes Mellitus: 

Focus on Diabetes Mellitus ABSN N120 T. Valenta FNP, RN, MSN, PHN 7/21/2012 1

Definition of Diabetes : 

Definition of Diabetes A chronic multisystem disease related to Abnormal insulin production Impaired insulin utilization Or both A disorder of CHO, protein and fat metabolism resulting from an imbalance between insulin availability and insulin need. (Porth) 7/21/2012 2

Prevalence: 

Prevalence Total prevalence of diabetes Total: 25.8 million children and adults in the United States—8.3% of the population—have diabetes. Diagnosed: 18.8 million people Undiagnosed: 7.0 million people Prediabetes: 79 million people* New Cases: 1.9 million new cases of diabetes are diagnosed in people aged 20 years and older in 2010. 7/21/2012 4

Statistics : 

Statistics 7 th leading cause of death Leading cause of End-stage renal disease Adult blindness Non-traumatic lower limb amputations Major contributing factor Heart disease Stroke (Based on 2011 stats) 7/21/2012 5

Glucose: 

Glucose The liver stores and manufactures glucose During a meal, the liver will store glucose as glycogen When not eating, the liver supplies glucose in 2 ways glycogenolysis gluconeogenesis

Glucose Homeostasis: 

Glucose Homeostasis Glucose is main fuel for CNS: 2 sources Diet Liver (our glucose reservoir). Brain cannot make or store , needs continuous supply Need BG 68-105 mg/dL to support brain

Normal Insulin Metabolism: 

Normal Insulin Metabolism Produced by the  cells of the Islets of Langerhans of the pancreas. Insulin transports sugar into cells Stabilizes glucose range to 70 to 120 mg/dl 7/21/2012 8

Normal Insulin Secretion: 

Normal Insulin Secretion 7/21/2012 9 Fig. 49-1 Insulin is released continuously into bloodstream in small increments with larger amounts released after food intake

Counter Regulatory Hormones: 

Counter Regulatory Hormones Glucagon/ Epinephrine/ Norepinephrine/ Cortisol and Growth Hormone Oppose effects of insulin Increase blood glucose levels to prevent hypoglycemia Persistent elevation produces insulin sensitivity 7/21/2012 10

Hyperglycemia: 

Hyperglycemia Not enough insulin High blood glucose A major cause of complications

Hyperglycemia Manifestations: 

Hyperglycemia Manifestations Three P’s – polyuria polydypsia polyphagia Glycosuria Dehydration Hypotension Mental Changes Fever Hypokalemia Hyponatremia Seizure Kussmaul Respirations Coma Death

Hypoglycemia: 

Hypoglycemia Low blood glucose Blood glucose level less than 70 mg/dl 7/21/2012 13

Hypoglycemia: Manifestations: 

Hypoglycemia: Manifestations Confusion Irritability Diaphoresis Tremors Hunger Weakness Visual disturbances Can mimic alcohol intoxication Seizures, coma 7/21/2012 15

Metabolic Syndrome (Syndrome X: Insulin Resistance Syndrome): 

Metabolic Syndrome (Syndrome X: Insulin Resistance Syndrome) Individuals with metabolic syndrome at increased risk for type 2 diabetes, CAD and stroke 2 most important risk factors of Metabolic Syndrome are: Central obesity (apple-shape) Insulin Resistance 7/21/2012 17

Metabolic Syndrome: 

Metabolic Syndrome 3 of the following Excess abdominal fat Waist > 40 men , > 35 women Blood glucose > 110 mg/dl Triglycerides > 150 mg/dl HDL < 40 mg/dl (men) < 50 mg/dl (women) BP 130/85 or higher

Pre-diabetes= Impaired Fasting Glucose: 

Pre-diabetes= Impaired Fasting Glucose Not high enough for diabetes diagnosis ADA criteria: fasting plasma glucose level from 100- 125 mg/ dL Increase risk for developing type 2 diabetes Prevent by regular exercise and healthy weight 7/21/2012 19

Types of Diabetes Mellitus: 

Types of Diabetes Mellitus Two most common types Type 1 Type 2 ( 90% of all cases ) 7/21/2012 20

Pre-diabetes: 

Pre-diabetes

Type 1 Diabetes Mellitus: 

Type 1 Diabetes Mellitus Rapid onset Little or no insulin Insulin dependent 20-30% heredity Ketosis prone Severe Complication: DKA

Clinical Manifestations Type 1 Diabetes Mellitus: 

Clinical Manifestations Type 1 Diabetes Mellitus Classic symptoms Polyuria (frequent urination) Polydipsia (excessive thirst) Polyphagia (excessive hunger) Weight loss Weakness Fatigue 7/21/2012 23

Type 2 Diabetes Mellitus: 

Type 2 Diabetes Mellitus Gradual Onset Some insulin produced Changes in lifestyle may be sufficient 90% hereditary Prevalence increases with age Most common type Severe Complication: HHS 7/21/2012 24

Clinical Manifestations Type 2 Diabetes Mellitus: 

Clinical Manifestations Type 2 Diabetes Mellitus Nonspecific symptoms May have classic symptoms of type 1 Fatigue Recurrent infections Recurrent vaginal yeast or monilial infections Prolonged wound healing Visual changes (blurred vision) 7/21/2012 25

Diagnostic Studies: 

Diagnostic Studies Three methods of diagnosis Fasting plasma glucose level >126 mg/dl Random or casual plasma glucose ≥ 200 mg/dl plus symptoms Two-hour OGTT (Oral Glucose Tolerance Test)level ≥ 200 mg/dl using a glucose load of 75 g (norm: > 140 and <200) 7/21/2012 26

FPG: 

FPG Fasting Normal FPG is below 100 mg/dl. A person with prediabetes has a fasting blood glucose level between 100 and 125 mg/dl. If the blood glucose level rises to 126 mg/dl or above, a person has diabetes.

OGTT: 

OGTT The person's blood glucose is checked after fasting and again 2 hours after drinking a glucose-rich drink. Normal blood glucose is below 140 mg/dl 2 hours after the drink. In prediabetes, the 2-hour blood glucose is 140 to 199 mg/dl. If the 2-hour blood glucose rises to 200 mg/dl or above, a person has diabetes.

Hemoglobin A1C test: 

Hemoglobin A1C test Not diagnostic but monitors success of treatment Shows the amount of glucose attached to hemoglobin molecules over RBC life span (90 to 120 days) A1C 5.6% or below is normal A1C 6.5% or above is diabetes 7/21/2012 29

Diabetes Mellitus Monitoring Blood Glucose: 

Diabetes Mellitus Monitoring Blood Glucose Self-monitoring of blood glucose ( SMBG ) Enables patient to make self-management decisions regarding diet, exercise, and medication Important for detecting episodic hyperglycemia and hypoglycemia Patient training is crucial 7/21/2012 30

Diabetes Mellitus Maintenance: 

Diabetes Mellitus Maintenance Normal blood glucose levels: Fasting: 70–130 mg/dL (3.9-7.2 mmol/L) Ater meals less than 180 mg/dL (10 mmol/L). Many experts advise patients to check their urine for ketones when blood glucose is more than 240 mg/dl

Goals of diabetes management: 

Goals of diabetes management Decrease symptoms Promote well-being Prevent acute complications Delay onset and progression of long-term T he most important patient outcome is the reduction of glucose to near-normal levels . (A1C < 7) 7/21/2012 32

Diabetes Mellitus Collaborative Care: 

Diabetes Mellitus Collaborative Care Patient teaching Self-monitoring of blood glucose Nutritional therapy Drug therapy Exercise 7/21/2012 33

Drug Therapy Insulin: 

Drug Therapy Insulin Regimen that closely mimics endogenous insulin production is basal-bolus Long-acting (basal) once a day Rapid/short-acting (bolus) before meals 7/21/2012 34

Drug Therapy Insulin: 

Drug Therapy Insulin Rapid-acting (bolus) Lispro (Humalog), Aspart (Novolog) Injected 0 to 15 minutes before meal Onset of action 15 minutes Short-acting (bolus) Regular (Humulin, Novolin, Velosulin) Injected 30 to 45 minutes before meal Onset of action 30 to 60 minutes 7/21/2012 35

Drug Therapy Insulin: 

Drug Therapy Insulin Long-acting (basal) Lantus (glargine) Injected daily at bedtime or in am Released steadily and continuously Onset 1-1 ½ hours No peak action Duration 20-24 hours Cannot be mixed with any other insulin or solution 7/21/2012 36

Drug Therapy: 

Drug Therapy Storage of insulin Do not heat/freeze In-use vials may be left at room temperature up to 4 weeks Lantus only for 28 days Extra insulin should be refrigerated Avoid exposure to direct sunlight 7/21/2012 37

Drug Therapy Insulin: 

Drug Therapy Insulin Available as U100 1 ml contains 100 units of insulin No alcohol swab on site needed before injection (at home; hospitals still use alcohol swabs) 7/21/2012 38

Subcutaneous Injection Sites: 

Subcutaneous Injection Sites 7/21/2012 39

Insulin: 

Insulin Administration of insulin (cont’d) Hand washing with soap adequate Do not recap needle 45- to 90-degree angle depending on fat thickness of patient Insulin pens preloaded with insulin now available 7/21/2012 40

Insulin: 

Insulin Problems with insulin therapy Hypoglycemia Allergic reactions Lipodystrophy Somogyi effect Dawn phenomenon 7/21/2012 41

Hypoglycemia: symptoms: 

Hypoglycemia: symptoms Confusion Irritability Diaphoresis Pallor Tremors Hunger Weakness Visual disturbances Can mimic alcohol intoxication Untreated can progress to loss of consciousness, seizures, coma, and death 7/21/2012 42

Hypoglycemia: 

Hypoglycemia At the first sign Check blood glucose If <60-70 mg/dl, begin treatment If >60-70 mg/dl, investigate further for cause of signs/symptoms If monitoring equipment not available, treatment should be initiated 7/21/2012 43

Hypoglycemia Treatment: 

Hypoglycemia Treatment If alert enough to swallow “Rule of 15” (choose 1) 3-4 glucose tabs 4 to 6 oz fruit juice Regular soft drink 1 c skim milk Avoid foods with fat ( Decrease absorption of sugar) 7/21/2012 44

Problems with Insulin Therapy: 

Problems with Insulin Therapy Somogyi effect Rebound effect in which too much insulin causes hypoglycemia Usually during hours of sleep (2-3 am) Counter-regulatory hormones released causing rebound hyperglycemia and ketosis Prevent by giving a protein and carb stack at bedtime. 7/21/2012 46

Problems with Insulin Therapy: 

Problems with Insulin Therapy Dawn phenomenon Characterized by hyperglycemia present on awakening in the morning Due to release of counter-regulatory hormones in predawn hours (5-9 am) 7/21/2012 47

Client Education : 

Client Education Storage and dose preparation Syringes Blood glucose monitoring Interpretation of results Frequency of testing Blood glucose therapy goals

Method of Administration: 

Method of Administration Continuous subcutaneous infusion of insulin Implanted insulin pumps Injection devices New technology includes: Inhaled insulin Transdermal patch (being tested)

Insulin Pen: 

Insulin Pen 7/21/2012 50

Insulin Pump: 

Insulin Pump Continuous sub-Q infusion Battery operated device Connected via plastic tubing to a catheter inserted into sub-Q tissue in abdominal wall 7/21/2012 51

Oral Agents: 

Oral Agents Work on three defects of type 2 diabetes Insulin resistance Decreased insulin production Increased hepatic glucose production 7/21/2012 52

Oral Agents: Biguanides: 

Oral Agents: Biguanides First line of treatment for DM Type 2 Metformin plus lifestyle changes to decrease weight and increase activity Biguanides Reduce glucose production by liver Enhance insulin sensitivity at tissues Improve glucose transport into cells Does not promote weight gain 7/21/2012 53

Drug Therapy Oral Agents: Sulfonylureas: 

Drug Therapy Oral Agents: Sulfonylureas Glucotrol (Glipizide); Amaryl (Glimepiride) Sulfonylureas ↑ Insulin production from pancreas ↓ Chance of prolonged hypoglycemia 7/21/2012 54

Drug Therapy Oral Agents Thiazolidinediones: 

Drug Therapy Oral Agents Thiazolidinediones Avandia (rosiglitazone). Actos (pioglitazone) Thiazolidinediones Improves insulin sensitivity Most effective in those with insulin resistance 7/21/2012 55

Drug Therapy Other Agents: 

Drug Therapy Other Agents Byetta (exenatide); Victoza (liraglutide) Increases insulin secretion Decreases glucagon secretion (decreases BG) Incretin mimetic: Reduces food intake Slows gastric emptying Not to be used with insulin 7/21/2012 56

Oral Hypoglcemics Key Points: 

Oral Hypoglcemics Key Points Monitor serum glucose levels Teach patient signs and symptoms of hyper/hypoglycemia Altered liver, renal function will affect medication action Avoid OTC meds without MD approval Assess for GI distress and sensitivity Know appropriate time to administer med

Documentation: 

Documentation Document the administration of glucose tablets, juice, Glucagon, and D50 in the Medication Record. Record in the nursing notes the signs and symptoms displayed, treatment administered, initial and subsequent glucose reading and notifications to the attending physician.

Nutritional Therapy: 

Nutritional Therapy Cornerstone of care for person with diabetes Most challenging for many people Overall Goal: Assist people in making changes in nutrition and exercise 7/21/2012 59

Diet: 

Diet American Diabetic Association Food groups/ exchanges CHOs – 45-65% Fats – 25-30% Protein - <10%

Diet: 

Diet Type 2 diabetes mellitus Emphasis based on achieving glucose, lipid, and blood pressure goals Calorie reduction 7/21/2012 61

ETOH: 

ETOH Alcohol High in calories/No nutritive value Promotes hypertriglyceridemia Detrimental effects on liver Moderate use can cause severe hyperglycemia whereas severe alcohol use can lead to hypoglycemia 7/21/2012 62

Exercise : 

Exercise Purpose - reduce the amount of insulin needed Should be individualized After medical clearance Slowly- gradual progression Monitor blood glucose levels before, during, and after exercise If BG >250 caution zone (check urine for ketones) 7/21/2012 63

Nursing Diagnoses: 

Nursing Diagnoses Ineffective therapeutic regimen management Risk for injury Risk for infection Powerlessness Imbalanced nutrition: More than body requirements 7/21/2012 64

Planning: 

Planning Overall goals Prevent or delay chronic complications Lifestyle adjustments with minimal stress 7/21/2012 65

Nursing Implementation: 

Nursing Implementation Health promotion Identify those at risk Routine screening for overweight adults over age 45 FPG (Fasting plasma glucose) is preferred method in clinical settings 7/21/2012 66

Nursing Implementation: 

Nursing Implementation Stress of illness and surgery ↑ Blood glucose level Continue regular meal plan ↑ Intake of non-caloric fluids Continue taking oral agents and insulin Frequent glucose monitoring Ketone testing if glucose > 240 mg/dl 7/21/2012 67

Nursing Management: 

Nursing Management Patients undergoing surgery or radiologic procedures requiring contrast medium should hold their metformin the day of surgery and 48 hours Begun after serum creatinine has been checked and is normal 7/21/2012 68

Nursing Implementation: 

Nursing Implementation Ambulatory and home care Overall goal is to enable patient or caregiver to reach an optimal level of independence Insulin therapy and oral agents Personal hygiene 7/21/2012 69

Acute Complications: 

Acute Complications Diabetic ketoacidosis (DKA) Hyperosmolar hyperglycemic syndrome (HHS) Hypoglycemia 7/21/2012 70

Diabetic ketoacidosis (DKA): 

Diabetic ketoacidosis (DKA ) Caused by profound deficiency of insulin Characterized by Hyperglycemia > 300 mg/dl Ketosis (blood & urine) Acidosis Dehydration Most likely occurs in type 1 7/21/2012 71

Acute Complications of DKA: 

Acute Complications of DKA Too rapid a drop in glucose may cause hypoglycemia Cerebral edema Sudden change in osmolarity of ECF : water shifts to bodies cells (brain) Potassium loss As acidosis is corrected, K+ moves from extracelluar to intracellular compartment (hypokalemia) 7/21/2012 72

Hyperosmolar hyperglycemic syndrome (HHS): 

Hyperosmolar hyperglycemic syndrome (HHS) Life-threatening syndrome Less common than DKA Most frequently seen in patients over 60 years with DM type 2 Two factors that precipitate hyperglycemia leading to HHS ↑ CHO intake ↑ insulin resistance 7/21/2012 73

HHS: 

HHS Signs and Symptoms Blood glucose > 600 mg/dl Hypotension Mental changes Dehydration Hypokalemia Hyponatremia 7/21/2012 74

Nursing management DKA/HHS: 

Nursing management DKA/HHS Patient closely monitored Administration IV fluids Insulin therapy Electrolytes Assessment Renal status Cardiopulmonary status Level of consciousness 7/21/2012 75

Chronic Complications of DM: 

Chronic Complications of DM 7/21/2012 76

Chronic Complications: 

Chronic Complications Angiopathy Macrovascular Diseases of large and medium-sized blood vessels Occur with greater frequency and with an earlier onset in diabetics Development promoted by altered lipid metabolism common to diabetes 7/21/2012 77

Chronic Complications: 

Chronic Complications Macrovascular Tight glucose control may delay atherosclerotic process Risk factors Obesity Smoking Hypertension High-fat intake Sedentary lifestyle 7/21/2012 78

Diabetes Chronic Complications: 

Diabetes Chronic Complications Microvascular In response to chronic hyperglycemia Is specific to diabetes unlike macrovascular Eyes (retinopathy) Kidneys (nephropathy) Skin (dermopathy) 7/21/2012 79

Diabetes Chronic Complications: 

Diabetes Chronic Complications Diabetic retinopathy Microvascular damage to retina Most common cause of new cases of blindness in people 20 to 74 years 7/21/2012 80

Diabetes Chronic Complications: 

Diabetes Chronic Complications Diabetic nephropathy Random urine test Urine should not contain protein. + protein indicates renal problem Leading cause of end-stage renal disease 7/21/2012 81

Diabetes Chronic Complications: 

Diabetes Chronic Complications Diabetic neuropathy 60% to 70% of patients with diabetes have some degree of neuropathy 2 types: sensory (most common and autonomic) 7/21/2012 82

Diabetes Chronic Complications: 

Diabetes Chronic Complications Diabetic neuropathy : Sensory most common form Affects hands and/or feet bilaterally (stocking, glove pattern) Manifestations: Loss of sensation, abnormal sensations, pain, and paresthesias 7/21/2012 83

Diabetes Chronic Complications: 

Diabetes Chronic Complications Diabetic neuropathy (cont’d) Sensory Usually worse at night Foot injury and ulcerations can occur without the patient having pain 7/21/2012 84

Neuropathy: Neurotrophic Ulceration: 

Neuropathy: Neurotrophic Ulceration 7/21/2012 85 Distal symmetric neuropathy is #1 risk for foot ulcers

Diabetes Chronic Complications: 

Diabetes Chronic Complications Neuropathy: Autonomic Can affect nearly all body systems Complications Gastroparesis Cardiovascular abnormalities Sexual function Neurogenic bladder 7/21/2012 86

Diabetes Chronic Complications: 

Diabetes Chronic Complications Foot complications Most common cause of hospitalization in diabetes Result from combination of microvascular and macrovascular diseases 7/21/2012 87

Diabetes Chronic Complications: 

Diabetes Chronic Complications Foot Complications Risk factors Sensory neuropathy Peripheral arterial disease Other contributors Smoking Clotting abnormalities Impaired immune function Autonomic neuropathy 7/21/2012 88

Diabetes Chronic Complications: 

Diabetes Chronic Complications Infection Diabetics more susceptible to infections Loss of sensation may delay detection Treatment must be prompt and vigorous 7/21/2012 91

Diabetes Chronic Complications: 

Diabetes Chronic Complications Integumentary complications Acanthosis nigricans Dark, coarse, thickened skin 7/21/2012 92

Diabetes Chronic Complications: 

Diabetes Chronic Complications Necrobiosis lipoidica diabeticorum Associated with DM type 1 Red-yellow lesions Skin becomes shiny, revealing tiny blood vessels 7/21/2012 93

Diabetes Gerontologic Considerations: 

Diabetes Gerontologic Considerations Prevalence increases with age Hypoglycemia unawareness is more common Presence of delayed psychomotor function could interfere with treating hypoglycemia 7/21/2012 94

The End: 

The End

Which nutritional group should the nurse teach the diabetic client with normal renal function to rigidly control to reduce the complications of diabetes? : 

7/21/2012 96 Fats Fiber Proteins Carbohydrates Which nutritional group should the nurse teach the diabetic client with normal renal function to rigidly control to reduce the complications of diabetes?

Answer A: 

Answer A Diabetes causes abnormalities in fat metabolism that lead to hyperlipidemia. The high lipid levels promote atherosclerosis and many pathologic consequences of vascular insufficiency. Although fats are essential and the diet of a person with diabetes needs to contain some fat, total fats should be limited to 15% to 20% of the total daily caloric intake. 7/21/2012 97

??: 

?? The earliest sign of nephropathy is ____________________. 7/21/2012 98

microalbuminuria: 

microalbuminuria Rationale: Chronic high blood glucose causes hypertension in the kidney blood vessels and excess kidney perfusion. The blood vessels become leaky, especially in the glomerulus which allows filtration of larger particles (including albumin) which form deposits in the kidney tissue and blood vessels. The vessels narrow, decreasing kidney oxygenation and leading to kidney hypoxia and cell death. 7/21/2012 99

The 45-year-old diabetic client has proliferative retinopathy, nephropathy, and peripheral neuropathy. What should the nurse teach this client about exercise?: 

The 45-year-old diabetic client has proliferative retinopathy, nephropathy, and peripheral neuropathy. What should the nurse teach this client about exercise? 7/21/2012 100 “The type of exercise that would most efficiently help you to lose weight, decrease insulin requirements, and maintain cardiovascular health would be jogging for 20 minutes 4 to 7 days each week.” “Considering the complications you already have, vigorous exercise for an hour each day is needed to prevent progression of disease.” “Considering the complications you already have, you should avoid engaging in any form of exercise.” “Swimming or water aerobics 30 minutes each day would be the safest exercise routine for you.”

Answer D: 

Answer D Exercise is not contraindicated for this client, although modifications are necessary based on existing pathology to prevent further injury. A person with nephropathy and peripheral neuropathy should avoid jogging or any activity that increases blood pressure or jars kidneys and joints. Swimming, or, if the client does not know how to swim, dancing or doing exercises in water, provides support for joints and muscles, greatly reducing the risk for injury while increasing the uptake of glucose and promoting cardiovascular health. 7/21/2012 101

Which nutritional problem should the nurse be more alert for in older adult clients with diabetes mellitus? : 

Which nutritional problem should the nurse be more alert for in older adult clients with diabetes mellitus? 7/21/2012 102 Obesity Malnutrition Alcoholism Hyperglycemia

Answer B: 

Answer B Older adults are more at risk for developing malnutrition as a result of multiple factors. Inadequate income, poor dentition, decreased cognition, decreased motor ability, depression, and lack of understanding about what foods constitute an adequate diet all contribute to an increased risk for malnutrition among all older adult clients, including those with diabetes mellitus. 7/21/2012 103

The client getting ready to engage in a 30-minute, moderate-intensity exercise program performs a self-assessment. Which data indicate that exercise should be avoided at this time? : 

The client getting ready to engage in a 30-minute, moderate-intensity exercise program performs a self-assessment. Which data indicate that exercise should be avoided at this time? 7/21/2012 104 Ketone bodies in the urine Blood sugar level of 155 mg/dL Pulse rate of 66 beats/min Weight 1 pound higher than the week before

ANSWER A: 

ANSWER A The presence of ketone bodies in the urine is a contraindication to exercise because it indicates that the amount of insulin available is inadequate to promote intracellular glucose transport and utilization. Exercise would lead to further elevations in blood glucose levels. 7/21/2012 105

Which change in clinical manifestations in a client with long-standing diabetes mellitus alerts the nurse to the possibility of renal dysfunction?: 

Which change in clinical manifestations in a client with long-standing diabetes mellitus alerts the nurse to the possibility of renal dysfunction? 7/21/2012 106 Loss of tactile perception The presence of glucose in the urine The presence of ketone bodies in the urine A sustained increase in blood pressure from 130/84 to 150/100

Answer D: 

Answer D Hypertension is both a cause of renal dysfunction and a result of renal dysfunction. 7/21/2012 107

What instruction should the nurse emphasize when teaching the diabetic client about how to alter diabetes management during a period of illness that includes nausea and vomiting. : 

What instruction should the nurse emphasize when teaching the diabetic client about how to alter diabetes management during a period of illness that includes nausea and vomiting. 7/21/2012 108 “Continue your prescribed exercise regimen.” “Avoid eating or drinking to reduce vomiting.” “Do not use insulin or take your oral antidiabetic agent.” “Monitor your blood glucose levels at least every 4 hours.”

Answer D: 

Answer D Treatment decisions and alterations will be made on the basis of blood glucose levels and the presence of ketone bodies in the urine. 7/21/2012 109

The client on an intensified insulin regimen consistently has a fasting blood glucose between 70 and 80 mg/dL, a postprandial blood glucose level below 200 mg/dL, and a hemoglobin A1c level of 5.5%. What is the nurse’s interpretation of these findings?: 

The client on an intensified insulin regimen consistently has a fasting blood glucose between 70 and 80 mg/ dL , a postprandial blood glucose level below 200 mg/ dL , and a hemoglobin A1c level of 5.5%. What is the nurse’s interpretation of these findings? 7/21/2012 110 The client is at increased risk for developing hypoglycemia. The client is at increased risk for developing hyperglycemia. The client is demonstrating signs of insulin resistance. The client is demonstrating good control of blood glucose.

Answer D: 

Answer D The client is maintaining blood glucose levels within the defined ranges for goals in an intensified regimen (fasting blood glucose 60 to 120 mg/dL; postprandial blood glucose less than 200 mg/dL; hemoglobin A1c 4% to 6%). 7/21/2012 111

Which of the following does not affect the process of self-monitoring of blood glucose (SMBG)? (Select all that apply.): 

Which of the following does not affect the process of self-monitoring of blood glucose (SMBG)? (Select all that apply.) A. Hypotension B. Quantity of blood C. Peripheral neuropathy D. Altitude and temperature E. Anemia F. Triglyceride level G. Accuracy of BGM monitor H. Storage of test strips 7/21/2012 112

ANSWER C: 

ANSWER C Rationale: The presence of peripheral neuropathy affects sensation; it does not affect the ability of the operator to obtain a sufficient drop of blood for testing. 7/21/2012 113