1. Focus on Diabetes Mellitus NUR 171

2. How insulin works

3. Mixing Insulins Fig. 49-3. Commercially available insulin preparations showing onset, peak, and duration of action.

4. Diabetes Mellitus Collaborative Care Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Patient teaching  Self-monitoring of blood glucose  Nutritional therapy  Drug therapy  Exogenous Insulin  Oral Antidiabetic drugs  Exercise

5. Insulin  Regimen that closely mimics endogenous insulin production is basal-bolus.  Long-acting (basal)  Injected once a day at bedtime or in the morning  Released steadily and continuously  No peak action  Cannot be mixed with any other insulin or solution  Rapid/short-acting (bolus) before meals

6. Subcutaneous Injection Sites Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Fig. 49-5. Injection sites for insulin.

7. Insulin Pen Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Fig. 49-6. Parts of insulin pen.

8. Insulin Pump Fig. 49-7. A, OmniPod Insulin Management System. The Pod holds and delivers insulin. B, The Personal Diabetes Manager (PDM) wirelessly programs insulin delivery via the Pod. The PDM has a built-in glucose meter.

9. Patient Education  Insulin storage  Dose preparation  Syringes  Blood glucose monitoring  Infection control measures  Diet therapy

10. Dawn Phenomenon  Dawn phenomenon  The dawn phenomenon is a normal rise in blood sugar as a person's body prepares to wake up.  In the early morning hours, hormones (growth hormone, cortisol, and catecholamines) cause the liver to release large amounts of sugar into the bloodstream. For most people, the body produces insulin to control the rise in blood sugar.growth hormonecortisolcatecholaminesliverinsulin  If the body doesn't produce enough insulin, blood sugar levels can rise. This may cause high blood sugar in the morning (before eating).insulinblood sugar levels

11. Insulin Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Problems with insulin therapy  Somogyi effect  Dawn Phenomena

12. Oral Antidiabetic (OA)Agents Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Work on three defects of Type 2 Diabetes

13. Drug Therapy Oral Agents Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Sulfonylureas  Meglitinides  Biguanides  α -Glucosidase inhibitors  Thiazolidinediones

14. Biguanides Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Reduce glucose production by liver  Enhance insulin sensitivity at tissues  Improve glucose transport into cells  Do not promote weight gain  Onset < 1 hour, Peak 1-3 hours, Duration 24 hours  Example  Metformin (Glucophage)

15. Sulfonylureas Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  ↑ insulin release from pancreas  ↓ chance of prolonged hypoglycemia  It works best if given 30 minutes before meals, usually before breakfast.  Onset 1 hour, Peak 1-3 hours Duration 6-8 hours  Examples  Glipizide (Glucotrol)  Glimepiride (Amaryl)

16. Meglitinides Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Increase insulin secretion from pancreas  Taken 30 minutes before each meal up to time of meal  Short duration of action so take with meals  Onset 15-60 min, Peak 1 hour, Duration 4-6 hours  Should not be taken if meal skipped  Examples  Repaglinide (Prandin)  Nateglinide (Starlix)

17. α -glucosidase inhibitors Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  “Starch blockers”  Slow down absorption of carbohydrate in small intestine  They are to be taken with the first bite of each meal  Onset 1-1.5 hours, Peak 2 hours, Duration unknown  Example  Acarbose (Precose)

18. Thiazolidinediones (Glitazones)  decrease insulin resistance by enhancing the sensitivity of insulin receptors.  directly stimulate peripheral glucose uptake and storage  inhibit glucose and triglyceride production in the liver  Onset: Delayed, Peak 2 hour, Duration unknown  Example: Pioglitazone (Actos)

19. Which symptom requires immediate intervention during a hypoglycemic episode? A. Confusion B. Hunger C. Headache D. Tachycardia

20. When should a patient with type 1 diabetes avoid exercise? A. When serum glucose is less than 150 B. During colder months C. When ketones are present in the urine D. When emotional stressors are high for the patient

21. A 23-year-old patient with a history of type 1 diabetes is admitted to the ED with nausea and abdominal pain. His respiratory rate is 34/min with deep breaths and a fruity smell to his breath. He is responsive, but difficult to arouse. 1. What does the nurse suspect is happening with this patient? 2. What serum glucose level would the nurse expect to see with this patient?

22. The student nurse asks why the patient is breathing so rapidly and deeply. What is the nurse’s best response? A. “His serum pH is high and this is a compensatory mechanism.” B. “His serum pH is low and this is a compensatory mechanism.” C. “His serum potassium is high and this is a compensatory mechanism.” D. “His serum potassium is low and this is a compensatory mechanism.”

23. In the ED, the patient is diagnosed with diabetic ketoacidosis (DKA). What is the nurse’s first priority for managing this condition? A. Airway assessment B. Fluid and electrolyte correction C. Administration of insulin D. Administration of IV potassium

24. Case Study  B.G., age 58, was diagnosed with type 2 adult-onset diabetes mellitus 10 years ago. Although he has type 2 diabetes mellitus, he has needed to take insulin for the last 2 years. He has been recovering, without complications, from a laparoscopic cholecystectomy, but his blood glucose levels have shown some wide fluctuations over the past 24 hours. The physician has changed his insulin from regular to lispro (Humalog) to see if it will provide better control of his blood glucose levels.

25.  1.Before his surgery, B.G.'s hemoglobin A1C level was 9%. What does this value imply regarding his glycemic control?  2.While reviewing the instructions for the lispro insulin, B.G. states, “I took my regular insulin shots about 30 minutes before my meals. Hopefully I can keep that same routine.” How will the nurse respond to this statement?  3.After his discharge, B.G. wakes up one morning feeling nauseated. He gives himself the lispro insulin injection, but then after eating breakfast he vomits and cannot keep any food down. What must he do at this time?