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10.

Healthy diabetic eating includes Limiting foods that are high in sugar Eating smaller portions, spread out over the day Being careful about when and how many carbohydrates you eat Eating a variety of whole grain foods, fruits and vegetables every day Eating less fat Limiting your use of alcohol !sing less salt "he patient should e#ercise $" LE$%" &0 min'& #(s wee) to burn e#tra calories and insulin to prevent it from being stored and possibly lose enough weight and lose the s's# of diabetes mellitus. "he patient should maintain an ade*uate amount of rest around + hours of sleep a night to help maintain or lose weight and develop a normal insulin routine. ,eeping the blood sugar level in chec) is crucial for diabetics to prevent damage to their body that will *uic)ly cause problems and interfere with their lifestyle. 11. $ction -nsulin is used to let the glucose from the food we eat get into the tissues and be metaboli.ed to fuel our bodies. /omplications Lower blood sugar. -nsulin will lower blood sugar, but beyond a certain point, very *uic)ly, it is going to start to store. "he patient needs to ma)e sure they are e#ercising, eating the right foods, and eating in moderation. -nsulin resistance occurs when insulin cannot get through the tissues to put the glucose into it, this is one of the causes of type 0 diabetes.

1apid $cting Humalog and 2ovalog are very rapid acting 3nset4 10 15 min. 6ea)4 1 hour 7uration4 0 8 hours %hort $cting 1egular 9Humalog 1, 2ovolin 1: ;;;;32L< insulin used in -=s;;;; 3nset4 &0 min 1 hour 6ea)4 0 & hours 7uration4 8 10 hours -ntermediate $cting 26H 9Humuin 2: 3nset4 0 8 hours 6ea)4 8 10 hours 7uration41> 00 hours Long $cting !ltralente 3nset4 > + hours 6ea)4 10 1> hours 7uration4 00 &0 hours =ery Long $cting Lantus 3nset4 ?ithin 1 hour 6ea)4 2o pea), continuous 7uration400 &0 hours ;;;;;$lways read the label carefully to ma)e sure you have the correct type of insulin. -nsulin is one of the drugs that @!%" H$=E "?3 6E36LE(% $6613=$L before being given. $lways use an insulin syringe. $lways remove /LE$1 to /L3!7< in the syringe. 1otate inAection sites 10. Diabetic ketoacidosis (DKA) (NOT ENOUGH INSULIN!) -<ou will start getting severe deh dratio!. ?ith 7,$, you will start off being

hyperglycemia 9$ lot of sugar in the blood:. <ouBve got big molecules of sugar in the blood thin) of these as a magnet, and they pull water into the blood and the body says we have too much water in the blood, so the body starts to send it out by causing you to urinate in large amounts because of this you are going to become dehydrated. $lso, as you begin to lose water, you are going to start losing electrolytes. $s you begin to try to burn off all this e#tra glucose 9sugar:, you become acidotic from the e#cess )etones. Keto!es co"e #ro" b$r!i!% #at a!d the are "ost& associated 'ith T (e I Diabetes) <ouBve got all these )etones floating around which are not good for your body. This is 'here the !a"e diabetic ketoacidosis co"es #ro") -*ost co""o! res(irator (atter!+ ,usmahl 1espiration 9very deep, very fast rate: the reason for this breathing is because you are trying to blow off the e#cess /30 which is a way to get rid of the acid because of the acidosis. -f the person has a normal response, then they will now become al)alotic, if not then they will still lower their acidotic state. -"he patient(s breath will smell fruity most li)ely. "he fruitiness comes from the )etones. H (er%& ce"ic h (eros"o&ar !o!ketotic s !dro"e (HHNS or HHNK) (A &ot o# &ar%e "o&ec$&es o# s$%ar i! the b&ood ', !o keto!es) "ype -- diabetics rarely ma)e very many )etones because they can still ma)e insulin. "hey can still end up dehydrated Aust li)e with 7,$, but youBre not going to be loo)ing for the )etones as much. "his syndrome will still lead to diuresis. ------*ai! s "(to" 'ith DKA a!d HHNS+ DEH.D/ATION -0ith DKA1 o$ are %oi!% to have to dea& 'ith the (otassi$" "ost& 1 'atchi!% #or the h (er the! h (o) -0ith HHNS1 'e are "ore co!cer!ed 'ith the h (er rather tha! h (o%& ce"ia) 1&. 7,$ N$rsi!% *a!a%e"e!t+ /orrect the fluid and electrolyte imbalance so first of all we are going to monitor our blood glucose for the ne#t 1 0 hours, and we will probably give a low dose of -= insulin according to orders. <ou donBt give a subcutaneous insulin to someone with diabetic )etoacidosis because the subcutaneous tissue is dehydrated and poorly infused, so what happens is if you correct the dehydration and you have given them subC insulin, all the sudden they get this massive amount because itBs Aust been siting in there doing nothing. This is 'h 'e %ive I2 i!s$&i! o!& here) ?e monitor the hemodynamic readings 9=%, blood pressure, consciouness:. Di!a&& 'e are %oi!% to "o!itor #or si%!s o# h (erka&e"ia beca$se that is $s$a&& (rese!t i! the #irst 3 ho$rs o# i!terve!tio!) A#ter the #irst 3 ho$rs1 'e are %oi!% to "o!itor #or h (oka&e"ia) -4asica&& 'he! o$ %ive i!s$&i!1 it5s %oi!% to drive the (otassi$" #ro" the e6trace&&$&ar #&$id back i!to the ce&&1 'hich co$&d ca$se a dro( i! (otassi$") As reh dratio! occ$rs1 (otassi$" 'i&& dro() Later1 as the &eve&s ret$r! to !or"a&1 'e 'i&& (robab& have to be%i! %ivi!% (otassi$" s$((&e"e!ts1 'hich is 'h o$ 'atch #or h (erka&e"ia as the (atie!t

%ets &ess deh drated)

HH2%'HH2,- -N$rsi!% *a!a%e"e!t+ /eh dratio! ('hich is the "ai! thi!% that 'e are doi!% #or both DKA a!d HHNS) 'ith I2s1 'e are %oi!% to re(&ace the #&$id as ordered7 !or"a&& 'e start 'ith !or"a& sa&i!e or 8 !or"a& sa&i!e to re(&ace it) 0e ad"i!ister the I25s thro$%h a! i!#$sio! ($"( i! this case) Add a &itt&e de6trose to o$r I2 'ith o$r i!s$&i! a!d #&$id beca$se as the b&ood s$%ars be%i! to dro(1 o$ have to 'atch #or h (o%& ce"ia) So at so"e (oi!t1 'e are %oi!% to add a &itt&e de6trose) -I! short ter"s1 'h a!d 'he! 'e $se de6trose+ 0hi&e o$r (atie!t is %etti!% #&$ids a!d i!s$&i!1 at so"e (oi!t the doctor 'i&& co"e i! check the b&ood s$%ar a!d decide that (atie!t see"s to be reh drated1 so &et5s add a &itt&e de6trose (or %&$cose) to this "i6t$re) This is 'h he is doi!% it+ As 'e are reh drati!% that h (er%& ce"ia ca! beco"e h (o%& ce"ia1 'e "a or "a !ot $se so"e i!s$&i! there beca$se as a t (e II 'ith HHNS1 o$ are sti&& "aki!% so"e i!s$&i!)

15. Lo!% ter" co"(&icatio!s o# diabetes /auses damage in the large' small vessels. 9Dundus of eye, )idney, brain: ;-f you )eep the $1/ in the normal limits, then you wonBt have a lot of complications. !nli)e with a hemorrhagic stro)e or a thrombotic stro)e, in a stro)e with a diabetic person, you have all these little damaged vessels in their and they can brea) at anytime or any place. <ou tend to have a lot of small stro)es all in your brain. "end to have a lot more coronary artery disease ;?ill definitely have a lot of diabetic patients on a cardiac unit. Atherosc&erosis+ Hardening of the arteries H (er&i(ide"ia (A &ot o# #at i! the b&oodstrea")+ Dat builds up which causes the artherosclerosis

Ne(hro(ath + 7amage to or disease of the )idney I# o$ have so"eo!e 'ho be%i!s to s(i&& (rotei!s i! their $ri!e #ro" diabetes1 $s$a&& 'ithi! 9 ears o$ 'i&& be%i! to see re!a& #ai&$re #ro" this (!e(hro(ath )) ?hen you see protein in the urine, itBs because glomerulus has been damaged and you can slow it down but once damage is done, itBs done. Ne$ro(hathies+ 2erves become damaged to the point that you start losing the ability to feel. Because of this lac) of feeling, they will start having blisters and holes in their feet, hips, butt, bac), shoulders. 2europathy can cause numbness, tingling, and pain. -This is 'h it is a "$st to &ook at diabetics #eet a!d ski!) Ne$ro%e!ic b&adder+ <ou can pee on yourself because your bladder has

a spasm and you have neuropathy to go with it and the pt. wonBt reali.e. :eri(hera& vasc$&ar atherosc&erosis+ %ame thing happens centrally that happens peripherally, you will start losing blood supply in parts of your body and it begins to necrose. !sually starts in distal parts 9li)e the foot: of the body and wor)s its way bac) to the center of the body.

1>. "each the patient about what they don(t already )now about diabetes. @a)e them aware of what may happen and let them be in charge of their goals. /hec) the patient(s s)in often and chec) for signs of decubitus on the patient. /hec) their bony prominences and loo) for redness and scabs. Encourage the patient to stop smo)ing, drin)ing and to start e#ercising to prevent long term complications. ?hen in the hospital, get the patient up and moving, if able, and encourage them to ma)e the right choices after leaving.

1E. "he patient(s blood sugar should be chec)ed regularly and especially right before they go in for surgery. -f they(re going later in the day, the physician should be called and consulted with about their blood sugar level and whether their insulin should be held that day to prevent a crash in the 31. "he patient( s surgery wounds should be closely monitored since a long term effect of diabetes is prolonged healing time and they are very susceptible to infection. "he patient should have proper nutrition after surgery to help their wounds heal and )eep their blood sugar within a normal range.

We will never use NPH in an IV during surgery, we will use regular Consult with physician before giving sliding scale

D$"(i!% s !dro"e+ Because of the high sugar content, you literally Fdump itG and everything flushes out because of the sugar. <ou can literally crash out because of this syndrome. -t is the osmotic diuresis again.

1+. Ora& A!tidiabetic A%e!ts (/e#erri!% to t (e II diabetes a&so re#erred to !o!i!s$&i! de(e!de!t "e&&it$s) "ype -- is not really non insulin dependent because

sometimes they have to be on insulin. "ype - is technically considered insulin dependent. S$&#o! &$reas (;st Ge!eratio! dr$%s)+ E6+ To&i!ase1 Ori!ase1 Diabi!ese< %timulate the pancreatic beta cells to ma)e more insulin, they also improve the binding between insulin and itBs receptor sites. "hese drugs ma)e your pancreas wor) harder. $s you get older, your beta cells canBt do it anymore. 3ver time, the sulfonylureas ma)e not wor) as well. Side e##ects i!c&$de+ Blood sugar can drop 9hypoglycemia:, weight gain because you are ma)ing more insulin so you are storing more and more, there is a reaction with the drugs 2%$-7% 9aspirin, ibuprofen:, ?arfarin 9for blood clots:, and sulfonamides. -f the pt. is on something that could cause a drug reaction, you need to loo) at their chart and loo) at their allergiesH have they had a reaction of these drugs with their sulfonylureas. $lways as) the patient if they have had these drugs together in the past and were there any problems. -f they say yes, then you need to call the doctor and let him )now how long they have been on the drugs in order to get his approval before giving it. $void alcohol because they are at high ris) for hypoglycemia. =!d Ge!eratio! S$&#o! &$reas+ E6+ G& b$ride1 G&i(i>ide1 G&ic&a>ide< 7o the same as first generation with effect and side effects. "he difference is that it doesnBt cause *uite as many side effects as first generation, so )eep this in mind. 4i%$a!ides+ E6+ *et#or"i! a!d G&$cova!ce<7ecrease insulin resistance and it does this at the peripheral sites. -t cannot be used with type - patients because they donBt have any insulin. -t also decreases the liverBs production of glucose which is another way of lowering glucose. 9"eacher seems to be referring more to @etformin: Side e##ects i!c&$de+ -ncrease in lactic acid, can also cause renal impairment 9need to especially watch liver function studies:, donBt give to patients with a serum creatinine greater than 1.8. ;Iood drug but you need to especially worry about the patients renal function. Thia>o&idi!edio!es+ E6+ Ava!dia a!d Actos<Dor patients who have "ype -who also ta)e insulin. -t enhances the action on insulin at the receptor site without increasing insulinBs secretion from the beta cells. -n other words, it ma)es the insulin that you do have at the receptor site more effective.

Side e##ects+ "he bad thing is that $vandia specific, there is a huge increase ris) of heart attac). "his drug is banned from Europe and we only have &000 patients on it in the !% today. Blac) bo# warnings and we use avandia very sparingly. $ctos has been lin)ed to increased bladder cancer, there is a 80J increased chance if you have been on the drug for more than 1 year. Both of these drugs can inAure the liver so you must do liver function tests monthly for the first 10 months. $lso, for both of these drugs it can increase womenBs ovulation during menopause, so you can become pregnant even when you thin) itBs least possible. A&(ha %&$cosidase i!hibitors+ E6+ Arcabose :recose<?or)s with type -patients and wor)s by delaying absorption in the gut with patients meals. ?e are preventing the absorption of the glucose in the first place after they eat. <our postprandial 9after you eat: your blood sugar drops. -t does not increase insulin secretion or wor) with insulin at all. ?e can add this drug to any of the other

insulinBs as an adAunct or use it alone. "he advantage is that it is not systemically absorbed, so it is safer. -t is only wor)ing in the gut. "he disadvantage is diarrhea and flatulence. "his drug must be ta)en -@@E7-$"EL< 61-31 to the meal or it will not wor). /e>i&i!e+ 9Kust briefly wanted to tal) about this: "his is not in a group because it is gone, and it is now ta)en completely off the mar)et because when patients started ta)ing it, they started dying of liver failure.

*e%&iti!ides+ E6+ :ra!di!<stimulates an increase in the insulin from the beta cells in the pancreas. ?e donBt use it with type - patients because they do not produce any insulin. -t has a very fast action and a short duration. Because of the short duration and fast action, we have much less side effects. 00. Hemoglobin $1c is used to determine the patient(s Hgb levels for the previous > months. -t is a very good way to tell if the patient has good control over their diabetes or if they need more wor). 01. Sick da ? r$&es+ Even when the patient is sic), you still need to ta)e your insulin as prescribed, eat the same foods, but increase your fluidsL "his will prevent dehydration. /hec) glucose every 8 hours, and if they have a B% greater than 080mg then they need to also chec) for )etones about every & 8 hours. -f they are positive for )etones, they need to call the doctor and possibly come in.