DM Med/ Surg Practice Questions(Using notes and book)

1) On a cellular level, what is the difference found between Type 1

and Type 2 DM? Beta cell (insulin) destruction is seen in Type 1, whereas insulin resistance is seen in Type 2

2) Where is insulin produced? In the Beta cells of the Islets of Langerhans located in the pancreas.

3) What are the actions of insulin? Controls the level of glucose in the blood by regulating the production and storage of glucose. It is necessary for metabolism of carbs, proteins, and fats

4) Why are the terms “insulin-dependent diabetes” and “non-insulin dependant diabetes” no longer used? Because they focus on the basis of treatment of diabetes rather than the underlying cause

5) What percentage of Americans are DM pts? 20%6) What percentage of Americans is considered pre-diabetic? 40%7) What are some risk factors for developing diabetes? Family Hx.

Of diabetes, Obesity esp. abdominal and visceral adiposity, BMI> 27%, Race/Ethnicity, GDM or babies > 9 lbs., HTN > 140/90 mm Hg, Triglycerides > 200mg/dL, Prev. impaired glucose tolerance

8) There are 3 metabolic processes that are important in ensuring adequate glucose for body fuel. These 3 are glycolysis, glycogenolysis and gluconeogenesis. Give a description of each process Glycolysis: breakdown of glucose into water and carbon dioxide form. Glycogenolysis: breakdown of glycogen into glucose by the liver. Gluconeogenesis: building of glucose from new sources

9) What hormones stimulate gluconeogenesis? glucagon , glucocorticoid hormones, thyroid hormones

10) Another hormone is found in the Beta cells of the pancreas that works along with insulin to decrease glucose levels. What is this hormone? Amylin

11) So when blood sugar is too high, insulin is secreted. What is secreted when blood sugar is too low? Glucagon

12) Where is glucagon produced? The alpha cells of the pancreas13) Two catecholamines help maintain glucose levels during

stressful times. They inhibit insulin release, promote glycogenolysis and conserve energy. What are they? Epinephrine and norepinephrine

14) This hormone, made in the delta cells of the pancreas, inhibits insulin secretion. What is it called? Somatostatin

15) What are the 2 main problems with insulin seen in Type 2 DM? Impaired insulin secretion, and insulin resistance.

16) What lab tests are used to diagnose DM? FPG-Fasting Plasma Glucose- 8hrs after fasting; Casual (random) glucose- no regard to

food; OGTT- oral glucose tolerance test- 2 hours after glucose taken ; HgbA1C- glucose levels for past 120 days; **The fasting plasma glucose is the most popular

17) What levels diagnose DM in each of these tests?FPG- >equal to- 126mg/DlRandom - >/equal to 200mg/dlOGTT >/ equal to 200mg/dlHba1c> 7%

18) What does ‘post-prandial’ mean? Blood sugar level 2 hrs after eating

19) What occurs to cause gestational diabetes? Hormones needed for placental growth can also block insulin’s actions leading to high serum glucose levels. This is what cause glucose intolerance over time.

20) What are the goal blood sugars we should see in pregnant women 1hr before meals and 2 hrs post- prandially? 1hr before meals: 105mg/dl; 2hrs after meals: 130-140mg/dl

21) When should pregnant women be screened for gestational DM? During 24-28wks of pregnancy

22) So if the ideal post-prandial blood sugar for a pregnant women is 130-140mg/dl, what level would diagnose GDM? Level of 155 or greater.

23) What causes Secondary DM? Any type of damage/injury/ or interference to the pancreas

24) Secondary DM can be resolved when the underlying cause is treated. What disease processes could lead to Secondary DM? Renal failure, CAD, Cushing’s, hyperthyroidism, recurrent pancreatitis, use of parenteral nutrition

25) What medications could cause DM? Corticosteroids, thiazides, dilantin, anti psychotics

26) What are some s/s of Type 1 (acute onset) DM? 3 P’s Polydipsia, polyuria, polyphagia, weight loss, weakness

27) What are some s/s of Type 2 (gradual onset) DM? Fatigue, Recurrent yeast infections and poor wound healing (bacteria loves sugar) , visual changes

28) What would you expect to see in a physical assessment of a person with DM? Blood pressure (sitting and standing), BMI, foot –eye- neuro- oral exams29) What lab tests would you expect to perform for a diabetic? HbA1C, lipid levels, serum creatinine, UA, Ekg30) What is the #1 predictor of Type 2 DM? Obesity31) Some risk factors for Metabolic syndrome are: central obesity,

westernization, sedentary lifestyle, certain ethnic groups32) Why should we use U-100 syringes instead of Tuberculin syringes? Tuberculin syringes could increase risk for insulin med error

33) What are the 2 types of insulin? Natural (human), modified (synthetic)34) What are the 3 groups of insulin?1) Short acting (a) rapid (b) slower acting 2) Intermediate, 3) Long- acting

Ok just study these and know that you gotta make sure your pt has eaten 30min within giving insulin.

35) What should you remember when storing insulin? It can be stored for 30 days @ room temp, may be refrigerated until exp. Date, pre-filled pens can be @ room temp or refrigerated for 30 days.36) What are the ‘do’s and don’ts’ storing of insulin Avoid temperature extremes (don’t freeze or heat), inspect for flocculation (frosted whitish coating), always keep a spare insulin37) When selecting insulin injection sites what are some things to take into consideration? Always rotate sites to prevent lipodystrophy, don’t use the same site more than once in 2-3 weeks, always space injections at least 1 inch apart, don’t inject a limb that you are about to exercise38) Insulin should always be given with an insulin or U-100 syringe rather than a Tuberculin syringe to help prevent insulin med errors. It also should always be given @ a 45 degree angle. What sites are appropriate to give SQ insulin injections? Arms (posterior), thighs (anterior), abdomen, hips39) What are some complications of insulin therapy? lipodystrophy (atrophy of tissue), local rxn (itching, burning around injection site), systemic rxn (anaphylactic shock, urticaria or hives)40) What is the dawn phenomenon The dawn phenomenon is hyperglycemia upon awakening. This occurs with the release of counterregulatory hormones that rise in pre-dawn hours. 41) How can we treat it? By adjusting the time insulin is taken @ night or increasing the dose42) What is the Somogyi effect? rebound elevation of glucose brought on by hypoglycemia. This may lead to ketosis or coma43) Thiazolidnedones (Avandia) and Biguanides (Metformin) help to decrease overall glucose production and decrease insulin resistance. What is the main action of Sulfonylurias (Glipizide) and Meglitinides (Prandin)? They stimulate the pancreas to make insulin44) What are the actions of alpha glucosidase inhibitors (Precose)? They slow the absorption of starches

Types of Insulin (Intermediate)

12-246-81-2Levemir

intermediate/long acting

10-204-81-2Novolin N

10-204-81-2Humulin N

10-204-81-2NPH

DurationPeakOnsetInsulin(intermediate)

Types of Insulin (long-acting)

Duration

16-20

PeakNot

Predictable

Onset

2-4Ultralente

Duration

24

Peak

Flat

Onset

1-2

Glargine

(Lantus)

45) Byetta and Symalin SQ injections that delay gastric emptying, increase satiety, and decrease glucagon secretion. What is the main action that differs them? Byetta stimulates insulin release and Symalin decrease glucose output by liver46) What is the key to nutritional treatment for Type 2 DM weight loss47) What BMI is considered overweight? Obese? Overweight= 24-29; Obese >3048) When meal planning for a diabetic, ethnic backgrounds, insulin timing, diet history, lifestyle and eating habits, and weight changes and maintenance are all factors. In dealing with caloric intake, what % of calories should come from carbs, proteins, and fats? 50-60% from carbs, 10-20%from proteins and 20-30% from fats.49) What is the recommended daily cholesterol for a DM pt? <300mg50) Why are sat. fats and moderate to high amounts of protein not recommended for the DM pt? It causes unnecessary stress on kidneys to excrete excess nitrogen51) What are the benefits of exercise for DM pt? Lowers blood glucose and decreases risk for CVD. It increases HDLs and decreases triglyceride and cholesterol levels52) What type of exercise increases lean muscle mass and metabolism and decreases weight and stress? Resistance strength training53) Exercise will also raise blood glucose levels. Should a person continue to exercise with a blood glucose >250 and ketones in their urine? No. They shouldn’t exercise until levels are acceptable (80-120mg/dl) and urine is free of ketones54) Exercise has different effects on each 2 types of diabetics. In Type 2 it is encouraged to help lose weight and decrease insulin resistance. On the other hand, in Type 1 hypoglycemia can be more severe and occur up to 48 hrs after exercise due to loss of glycogen. What can we teach our Type 1 patients? Monitor blood sugar before, during, and after exercise and keep carb snacks available.55) What can we recommend to the DM pt on exercise? Exercise @ the same time of the day for the same amount of time, may need stress test if pt has cardiac dysrythm., high BP may aggravate retinopathy, start slow and gradually increase.56) What is the cornerstone in DM mgmt? Blood glucose monitoring

When self- monitoring glucose at home these are the levels you would want to have 1 hr before eating, 2hrs after eating, and before bedtime

1hr before eating: 30-90mg/dl- before2 hours after eating: 100-140mg/dl after Bedtime: 140- 180mg/dl @HS

57) What can we teach our patients to avoid false blood sugar readings? Teach to get enough blood on the strip. Old meters need to be cleaned manually. Make sure reagent strips are not out of date, teach to program strip control # to glucose monitor if needed. If on insulin pt should test 4x a day, if on oral hypoglycemic 2-3x a day. Keep and take a logbook to all Dr. appts.58) There are 2 types of hypoglycemic states, mild and moderate. What happens in the body during each state? Mild- SNS is stimulated and catecholamines are released. Moderate- brain cells are deprived of glucose.59) What are the s/s of each? Mild- sweating, tremor, tachycardia,

palpitations, nervousness, and hunger. Moderate- inability to concentrate, headache, lightheadness, confusion, memory lapse, numbness of the lips and tongue, slurred speech, impaired coordination, emotional changes, irrational or combative behavior, double vision and drowsiness

60) What is the Rule of 15 that we can teach our patients to prevent hypoglycemia? For every 30min of exercise done eat 15gm of carbs

61) What is autonomic neuropathy? neuropathy that occurs in the nerves controlling certain organs that function involuntarily. –(MedicineNet.com) Gastrophoresis (when the stomach doesn’t empty all the way) is one symptom of this type of DM.

62) Hyperglycemia, dehydration, electrolyte loss, illness, infection, missed insulin, and undiagnosed or untreated DM can cause DKA to occur. On a cellular level what causes DKA? extremely low to no insulin production. Seen usually in Type 1

63) S/S of DKA re due to Na and K+ loss. What are the s/s of DKA? Kussmaul respirations (deep and rapid), sweet fruity breath, extreme drowsiness, weakness, n/v (from lactic acid build up), cardiac arrhythmias, tachycardia, and hypotension

64) What is the first line of treatment for DKA pts? Replace fluid loss with IVF, then begin insulin drip

65) What could occur if fluids are replaced too fast in DKA? fluid overloead, cerebral edema, hypokalemia

66) What does HHNS stand for Hyperglycemic hyperosmolar nonketontic syndrome. This is also a medical emergency.

67) What would the blood sugar of a pt. With HHNS look like? 800-1000mg/dl

68) What is the main difference between HHNS and DKA? Ketosis is minimal or absent

69) Persistant hyperglycemia will lead to osmotic diuresis. What will this result in? Loss of water and electrolytes.

70) What are the s/s of HHNS? Hypotension, Profound dehydration, Tachycardia, Variable neurological signs ; Morality rate- 10% to 40%

71) What is the treatment fro HHNS? fluid replacement and correct electrolytes

72) What is an example of macrovascular (medium to large vessel) damage in DM? CVD

73) What are examples of microvascular (capillary bed thickening) damage in DM? neuropathy, nephropathy, retinopathy, amputation situations, erectile dysfunction

74) What is the leading cause of death in DM pts? #1- CVD, high risk for HTN, CVA, MI also.

**Prevention is Key for long term complications of DM! Control blood sugar, BP, stop smoking.75) What is the #1 cause of renal failure for DM pts? Nephropathy76) There are 2 types of diabetic retinopathy, non-proliferate and

proliferate. What is occuring in each type? Non- proliferate- partial occlusive of blood vessels in eye; Proliferate- full occlusion of vessels in eye or hemorrhages seen

77) What BP meds are very ‘kidney protectant’ and used in decreasing risk for nephropathy?Ace inhibitors!.. but ARBS and Beta blockers can also be used

78) What are 3 options for the pt in ESRD? Hemodialysis, Peritoneal dialysis and Kidney transplant

What can we teach to our pt with DM neuropathy regarding foot care? Teach to perform monofilament test on foot. If pt can feel the monofilament ‘poke’ then they still have sensation to this area, if not, these areas are problem areas that have increase risk for breakdown. Diabetics CANNOT go barefoot and teach to check foot meticulously, wear thick white socks, teach patient to look at feet with a mirror, daily self foot exams for pt, don’t put lotion in between toes or cut toenail too short--> these could cause infectionBlisters may cause sores overnight!

Essentials of Foot Care• Examination

– Annually for all patients

– Patients with neuropathy - visual inspection of feet atevery visit with a health care professional

• Advise patients to:– Use lotion to prevent dryness and cracking

– File calluses with a pumice stone

– Cut toenails weekly or as needed

– Always wear socks and well-fitting shoes

– Notify their health care provider immediately if anyfoot problems occur

What are the treatments for foot ulcers? - Abx, bed rest, debridement, blood sugar control79) What is Sudomotor neuropathy? absence of sweating of the

extremities with a compensatory increase in upper body sweating80) Remember that bacteria love sugar. Increased and prolonged

blood sugar increases risk for infections. Stress also increases BG levels

81) What is seen in the DM pt with acanthosis nigricans? Dark, coarse, thickened skin on the neck.

82) Should insulin be given the morning of surgery? usually not to prevent hypoglycemia from occurring

**If client is NPO- insulin dose may need to be changed for type 2Type 1 may need to administer insulinFrequent blood glucose monitoring.Clear liquids need to be caloricTube feeding-important to administer insulin at regular intervals.