Diabetes

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Diabetes Insulin
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Diabetes Mellitus I

• Diabetes is a metabolic disorder that affects the
  way your body handles energy you get from the
  food you eat
• Normally, the food that you eat gets broken down
  into a smaller form of sugar (glucose) that is
  absorbed into the bloodstream. With the help of
  insulin, it enters your cells or opens the cells
  like a key, where the nutrients are used as
  energy

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• It is estimated that
• 18.2 million people in the U.S. have diabetes

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To produce or not to produce

• People with diabetes either do not produce
  insulin
• Or
• They do not use the insulin their body already has

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Types of diabetes

• Type I
• Type II
• Gestational Diabetes

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Type I Diabetes (IDDM)

• Usually diagnosed in children and young adults
• Type I occurs when the pancreas abruptly stops
  making insulin

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Type II (NIDDM)

• Occurs in people over the age of 40, but is
  occurring more frequently in children due to the
  rise of obesity
• About 90 of pts with diabetes, have Type II

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Type II

• One of two things can happen in Type II
• 1 some insulin is still produced but not
  enough to maintain normal glucose levels
• Or
• 2 the body just doesnt respond to the insulin
  being produced (resistant)

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Gestational Diabetes

• Occurs in pregnant women who previously didnt
  have diabetes
• In gestational diabetes, the body is unable to
  produce an adequate amount of insulin

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The Treatment of Diabetes

• Keeping control of blood glucose levels can
  reduce the risk of complications and can slow the
  progression of the disease
• Type I usually receives insulin injections
• Type II - usually can stay controlled with diet
  exercise, p.o. medications, or insulin if not
  controlled

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Insulin

• Produced in the Beta cells of the Islets of
  Langerhans in the pancreas

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Why do we need insulin?

• Insulin is needed to lower blood sugar in the
  blood, it does this because
• Insulin is the key and opens the cells of the
  body
• Once the cells are open, the nutrients and
  sugar go into the cell and dont stay in the
  blood

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Problem with inadequate or no insulin

• Inadequate secretion of insulin results in
  improper metabolism of carbs and fats and brings
  on diabetes characterized by hyperglycemia and
  glycosuria high sugar in blood and high sugar in
  urine
• The condition that results from the above
  information is called DIABETES

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2 types of diabetes

• Type I can start out in children or usually by
  the age of 30 y.o. This patient needs insulin to
  lower blood sugar
• Type II requires the use of pills to lower
  blood sugar. These are called Antidiabetics such
  as Actos and glucotrol/glipizide,
  Glucotrol/Metformin

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Causes of Diabetes Type I

• There is no cause or cure for diabetes
• Parents and patients will always ask if something
  they did, caused diabetesanswer is NO
• Type II can be cured today, with diet, exercise
  and carb control (usually)

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So what happens when you dont make insulin?
Its not a big deal

• Hyperglycemia
• Hypoglycemia
• See handout on this

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Hyperglycemia

• Person ends up with an excessive amount of sugar
  in the blood stream
• Pts with hyperglycemia can go into DKA will have
  fruity smelling breath along with Kussamaul
  respirations
• Do you remember ketones are being burned for
  energy? pink colored urine strip, wt loss,
  acidic blood

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Signs Symptoms of Ketoacidosis

• Extremely elevated blood sugars, have been known
  to be as high as 1200s
• Fruity smelling breath
• Tachycardic
• Hypotension d/t dehydration from 3Ps
• Coma-like statedrowsy
• Kussamauls respirations think of ketoacidosis

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Treatment for DKA?

• Hydration
• IV insulin what kind of insulin?
• Electrolyte replacement

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What kind of care does the nurse provide to a pt
with hyper or hypoglycemia?

• You MUST monitor the BG every 30 minutes,
  especially once treatment to fix the problem has
  taken place
• Never leave your pt alone for an extended period
  of time..stay on top of this type of problem
• Use this time as a time to teach the pt more
  about their diabetic condition

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INSULIN
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Sliding Scale

• Sliding scales are used to cut the blood sugar
  fairly quickly
• Sliding scales are written to be given in
  conjunction WITH normal daily insulin
• Sliding scale insulin is always fast acting,
  therefore, the only insulin you should see on a
  S.S. is REGULAR insulin or rapid acting log

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1 Example of a Sliding scale

• 130-150 2u Reg S.Q.
• 151-170 4u Reg S.Q.
• 171-190 6u Reg S.Q
• 191- 210 notify H.O.
• If pt usually gets 4u Reg with breakfast and his
  current accu-check is 174, how much insulin will
  you administer?

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Another Example of a Sliding Scale

• 125 145 2u
• 146 160 4u
• 161 180 6u
• 181 200 Call H.O
• AM insulin order 4u Humulog QD
• Pts accu-check in a.m. is 171, how much insulin
  will you give?

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Dr. will decide on a sliding scale or not

• NOT ALL PTS HAVE SLIDING SCALES
• Check Dr.s order to see if there is a sliding
  scale along with ordered insulin dose

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What actually is a bottle of insulin

• Insulin from a vial is a protein, obtained from
  that pancreas of a bovine (pertains to cattle)
  and porcine (pertains to pig) that affects
  metabolism of glucose
• When prepared medically, insulin is prepared from
  pork of beef

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What Happens When We Eat?

• We eat, swallow, and the food gets churned and
  broken down in the stomach.
• It passes through the sm. intestine where more
  breaking down occurs.
• This triggers the pancreas to send out insulin to
  the blood.
• Upon the nutrients getting ready to be sent to
  the bloodstream and then into cells, insulin
  comes along and opens all of the cells.
• The nutrients enter the blood and then the cells
  and then we are happy! ?

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How does insulin work you ask?

• When injected into a person with Diabetes, it
  produces the following effects
• Normal storage of glycogen in the liver and
  muscle tissue
• Causes a reduction in blood sugar level by
  facilitating the metabolism of glucose
• Causes a disappearance of Ketones

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Insulin

• Is ALWAYS expressed in units NOT mls

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How can insulin be administered, via what route?

• REGULAR insulin is the only insulin that can be
  given SQ or IV drip

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Insulin comes in various types according to how
fast it works

• 1. Rapid
• 2. Short acting
• 3. Intermediate
• 4. Long acting

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We will discuss the following

• Rapid acting Novolog and Humalog
• Short acting Regular
• Intermediate - NPH
• Long acting known as Lantus
• There are many other insulins to know but not for
  this class, youll get more in next semester.
  See full chart in hand-out

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Obtaining a blood glucose reading

• You can do this with the use of a blood
  glucometer
• Or in obtaining a venipuncture

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Where to poke the finger?

• NEVER POKE DIRECTLY IN THE MIDDLE OF THE PAD,
  this hurts and bleeds too much
• Use a place along side the nail bed region, in
  the upper most portion of the finger

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Route of insulin?

• All must be given Subcutanously
• Only one can be given IV _____________
• NEVER GIVE INSULIN IMtakes too long to act

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Preparing insulin

• Roll the vials of all insulin except NPH
• NPH may be gently shaken
• In the hospital, use alcohol and let it dry
• Inject SQ at a 45 degree angle
• No aspiration needed
• May keep vial unrefrigerated
• Must mark date, time, initials on newly opened
  insulin

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Insulin Syringe insulin syringes have orange caps
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Drawing up insulin

• Always requires 2 nurses to check the dosage
• Checking the insulin dosage with another nurse
  will help protect against overdose, adverse
  reactions and error from occurring

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Acceptable site to administer insulin into
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How to administer insulin?

• ALWAYS SQ
• This is given at a 45 degree angle
• No rubbing of the injection site
• NO aspiration of insulin upon administration
• Absorption occurs most quickly in the ABDOMEN
  followed by the arms, thigh, hips

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Choosing which site to inject

• SITE ROTATION is a MUST
• If you continue to inject into the same site,
  lipodystrophy will occur.
• Lipodystrophy is the build up of fat or scarring
  in the SQ tissue. Insulin injected here will not
  absorb correctly uncontrolled, erratic blood
  glucose readings

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Injecting insulin into exercised limbs

• If a pt is planning to exercise, do not inject
  into areas of the body that will be moving. This
  will cause an increase in the absorption of that
  insulin too quickly

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Using new syringes vs. used ones?

• Each time a pt uses an insulin syringe for their
  dose of insulin, the syringe should be discarded
  into the proper waste container
• Coffee can or approved needle box should be used
  to avoid needle sticks to others
• Pts will frequently cleanse the end of a used
  insulin syringe only to reuse it to save .
  Cellulitis or other contaminants may cause
  problems for the pt. Always encourage to use of
  a new syringe with each injection/dose

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Pre-filled insulin syringe

• These are prepared by drug companies and look
  similar to a chunky ink pen. Pt dials up the
  amount of insulin needed and that amount is
  delivered. This alleviates the need to measure
  the amount using ones own vision
• Kids can use this pen

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Oral hypoglycemics

• Are not oral insulin (FYI did you know that if
  you attempted to take SQ insulin by mouth your
  stomach acid and enzymes would dismantle insulin?
  Insulin can ONLY be taken SQ)
• You must make some insulin to get these pills
• Therefore.
• Only Type II can take these

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Oral hypoglycemics or anti-diabetic pills

• Glucatrol (glipizide)
• Diabeta, Micronase (glyburide)
• Metformin (glucophage)
• Precose (acrabose)
• Avandia (rosiglitazone)

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Oral hypoglycemics work in 1 of 3 ways

• 1.) Increase the amt of insulin the beta cells
  make by stimulating the beta cells to release
  more insulin
• 2.) Improves insulin sensitivity by making the
  receptor cells more receptive
• 3.) Stops the liver from making glucose
• All of these will change the amt of glucose left
  in the blood
• KNOW THIS FOR 2ND SEMESTER CLINICALS FOR STOCKWELL

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Problems with high blood sugar

• Remember this is called hyperglycemia
• Over time, high blood sugars damage organs such
  as eyes, blood vessels, skin, glomerulus

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Normal Blood glucose levels

• 70-110mg/dl

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Lab tests

• Hemoglobin A1c is ordered to detect ones blood
  glucose levels over a 3month period
• Pts get caught cheating with this test
• Normal level today should be 6 or less
• If you are over 7, Dr. scolds you

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Other serious problems that occur with high blood
sugars

• Stroke
• M.I.
• Renal failure
• blindness

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Diet

• Pts are now taught to control blood glucose
  levels by controlling the intake of carbohydrates
• Carbohydrates break down into a smaller form of
  glucose that fits through the digestive track and
  out into the blood
• Pts are now counting carbohydrate servings. 1
  serving of carb 15 grams of carbohydrates
• Pts are then told to eat 3-5 servings /meal
  depending on your age, size and gender

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Diet for the diabetic client

• Diet must be tailored to meet the pts needs
• Not all pts eat the same things
• Not all pts have the same schedule
• If a Dietician isnt consulted, chances are that
  the pt will not be compliant

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The Diabetic Diet is Aimed at 5 Criteria That
Should Be Followed

• 1) Maintain as near normal blood glucose levels
  as possible
• 2) Achieve optimal serum lipid levels
• 3) Provide adequate calories to maintain a
  reasonable weight
• 4) Prevent complications of diabetes
• 5) Improve overall health

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American Diabetic Association (ADA)

• Recommends eating from the My Food Pyramid
• Eating less saturated fats and cholesterol
• Eating less sodium
• Individuals taking insulin or oral hypoglycemics
  should eat at consistent times synchronized with
  the actions of the medications used
• Distribute calories eaten over 24 hours with
  eating regular meals and snacks. This will
  prevent extreme highs or lows in blood glucose
  readings

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Once the diagnosis is made

• MUCH teaching needs to be done
• This teaching needs to be done by YOU

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Education

• Lots of education is needed with diabetes
• Nurses play a huge role in educating

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TEST

• Where do we poke the finger when obtaining BG
  readings?
• A. pad
• B. side near nail
• C. palm
• D. near the palm

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Can a diabetic client eat whatever he wants?

• A. Yes
• B. No

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A BG reading of 89 is?

• A. low
• B. high
• C. normal

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A BG reading of 210 is?

• A. low
• B. high
• C. Normal

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What color is NPH insulin?

• A. clear
• B. cloudy

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Which type of insulin can only be given IV

• A. regular
• B. NPH
• C. Lantus
• D. 70/30

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What type of insulin can only be used in a
sliding scale?

• A. NPH
• B. Lantus
• C. Regular/Humalog
• D. no insulin can be used in a sliding scale

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Can you use a TB syringe to administer insulin?

• A. Yes
• B. No

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What kind of unique breath will we see in the pt
with DKA?

• A. Foul
• B. alcohol-like
• C. Fruity
• D. sulfer-like

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The End