Mark Klimek NCLEX Review: Diabetes Mellitus, Diabetes Insipidus SIADH, Insulin, DKA, HHNK

Mark Klimek NCLEX Review: Diabetes Mellitus, Diabetes Insipidus SIADH, Insulin, DKA, HHNK

Diabetes Mellitus (DM), Diabetes Insipidus (DI), Insulin

 Diabetes mellitus = An error in glucose metabolism … Glucose is the body’s primary fuel source

- Can be a lack of insulin DM1

- Can be insulin resistance DM2

 

DIABETES INSIPIDUS = Not a type of DM! … It is insidious, diabetes w/out the glucose element

- It is Polyuria, Polydipsia leading to dehydration, due to low ADH.

- It is just the fluid part

 

So question is about low urine output or high urine output? …

Similar to DM, DI has a high urine output

 

What is the opposite of Diabetes Insipidus?

It is SIADH = Syndrome of inappropriate ADH (antidiuretic hormone)

 

So, DM has polyuria, polydipsia

Therefore, DI also has polyuria, polydipsia

However, SIADH is the opposite of the above 2 conditions …

- It presents w/ oliguria and no thirst

- Decrease urine output

- And then, decrease serum specific gravity (due to retention of water)

- Increase urine specific gravity (due to decrease urine volume)

 

Nursing Diagnosis?

- Lots of urine retained, specific gravity is low = SIADH

- Fluid Volume Deficit = DM, DI

- Fluid Volume Excess = SIADH

 

Diabetes

- Type I—Insulin dependent, Juvenile onset, Ketosis prone

- Type II—Non-insulin dependent, Adult onset, Non-ketosis prone

S/Sx of DM

   - Polyuria - pee a lot

   - Polydipsia - thirsty

   - Polyphagia - (eat/swallow a lot)

 

Treatment for DM Type I (if you don’t treat)

They will “DIE”

- Diet (calories from carbs, least important)

- Insulin (most important)

- Exercise

Treatment for Type II DM

They are “DOA”

- Diet (most important)

- Oral hypoglycemic

- Activity

 

Diet for DM2

- Primary treatment modality is Calorie restriction

- 1200 Cal, 1400 Cal, 1600 Cal

- These patients need to eat 6 small feeding per day—smaller more frequent meals—keeps blood sugar more stable

 

Question

What is the best dietary action a DM2 should take?

a. Restrict calories

b. Divide meal into 6 feedings a day

Answer: (a) because patient can eat 6 meals but does not limit the Cal with each meal Insulin acts to lower blood sugar

 

4 types of Insulin are covered here

 1. R-Regular insulin—clear solution, IV drip (HESI-intermediate, Rapid, Run IV)

- Onset: 1 hour

- Peak: 2 hours

- Duration: 4 hours … (Audio says 3 hours, but it is 4 hours)

- Pattern: 1-2-4 (Pay attention to peak)

 

2. N-NPH, Intermediate insulin—it is cloudy, N = Not So Clear, Fast (Cloudy = Suspension—it precipitates—can’t give IV drip), N = not so fast, not in the bag

- Onset: 6 hours

- Peak: 8 to 10 hours

- Duration: 12 hours

- Pattern: 6-8-10-12 (Hear the even #s and pay

attention to peak)

 

Clear = Solution

Cloudy = Suspension à Will precipitate (Not given over IV drip or put

in an IV bag)

 

Question

How would the board ask question about peak of insulin?

For instance, you give 30 units of insulin to a patient at 7 a.m. When do you check for hypoglycemia?

- Answer = Add the insulin peak time to the time of insulin administration

- For instance, if the patient was given NPH at 7 a.m., add 8 to 10 hours to the time

- Answer = Check for hypoglycemia between 3 and 5 p.m.

 

  

3. Lispro: (Humalog)

- Don’t give it AC (before meal) … Give it with the meal

- Onset: 15 min

- Peak: 30 min

- Duration: 3 hrs

- Pattern: 15-30-3

 

4. Glargine (Lantus)

- Long-acting insulin

- No Peak

- Duration 12 to 24 hrs

- Little to no risk for hypoglycemia (only one you can safely give at bedtime)

 

Note: Always check insulin expiration date

 

What action invalidates the manufacturers date?

- Opening the package

- Once the package is open, the new expiration date is 30 days after that

- Open package without an opening or expiration date should be thrown out

- Label the package either with

   - “OPEN” and date package is open

   or

   - “EXP” and expiration date

- Once the package is open, refrigeration is optional

   - However, unopened bottle must be kept refrigerated

   - Although it is good practice to teach patient to refrigerate insulin at home

 

Exercise potentiates insulin action

- Exercise is like another shot of insulin

- Therefore, if a student is schedule to play soccer (exercise) this afternoon … It is necessary to decrease the dosage of insulin

- In addition, the school nurse must give the student rapidly metabolized carbohydrates—snacks or juice

 

Sick Days … Patient has a fever or the flu, and so on

- Serum glucose levels go up

- Need their insulin even though patient is eating

- Take sips of water because they get dehydrated

- Any sick diabetic patient has 2 problems

   - Hyperglycemia and Dehydration

 

Acute complications of Diabetes

- Low blood glucose—a.k.a. Hypoglycemia or Hypoglycemic shock or Insulin shock/reaction

- Why are some of the causes

   - Not enough food

   - Too much insulin (#1 cause, can lead to permanent brain damage)

   - Too much exercise

 

What does hypoglycemia look like?

Think of a Drunk patient in Shock

- Drunk

   - Staggering gait

   - Slurred speech

   - Cerebral impairment (labile)

   - Slow reaction time

   - Decrease social inhibition

- Shock—Vasomotor collapse

   - Tachycardia, tachypnea, Low BP

   - Cold/clammy, mottled skin

 

Treatment

- Give patient sugars or rapidly metabolizable carbohydrate such as:

   - Juice (any), candy, regular soda, milk (lactose), honey, icing, jelly, jam

- Boards want sugar + starch or protein

   - For example, apple juice + turkey, Milk is sugar/protein—1/2 cup Skim milk

• Bad answer

   - Candy + Soda—1 sugar is good, 2 sugars are bad

   - 5 packs of sugar emptied into a glass of orange juice

- Unconscious patients - pay attention to location

- Glucagon IM if the mother is on the phone

- Dextrose IV (D10, D50) if in the ER

 

DKA—High Glucose in a Type I (keto is the clue!)

Causes

- Too much food

- Not enough insulin

- Not enough exercise

- #1 cause acute viral Upper Respiratory Infection within last 2 weeks

 

S/Sx of DKA is “DKA”

- Dehydration (dry, poor skin elasticity and turgor, warm) … Water is a coolant (you overheat)

- Ketones in serum, Kussmauls, High K+

- Acidosis, Acetone breath, Anorexia due to nausea

 

Note: Ketone in urine does not necessarily means DKA

 

Treatment

- Insulin IV (Regular!)

- IV fluid! 200 mL/hr (some of the fastest rate)

 

HHNK or HHS or HHNS

- High blood sugar in a Type 2

- These patients don’t burn ketones, no acid

- Whenever you see HHNK, think dehydration

- Severe Dehydration!

   - Skin is dry, flushed, decreased turgor, increased HR

   - #1 Nursing diagnosis: fluid volume deficit (same as dehydration)

   - #1 Nursing intervention: Rehydration!

   - Outcomes in successful treatment: Increase urine output, Moist mucous membrane, etc.

   - Long-term complications: Poor perfusion, Peripheral neuropathy

 

Between DKA and HHNK

Which one is more dependent on insulin?

- DKA patient is more dependent on insulin

- HHNK patient needs to be rehydrated

Which one has a higher mortality rate?

- More patients die HHNK

Which is a higher priority?

- DKA is a more acute condition and responds very quickly to insulin

- HHN patients show up late in the emergency room and do not readily respond to treatment

 

Long-term complication of diabetes

Related to

- Poor tissue perfusion

or

- Peripheral neuropathy

Examples of long-term complications: Renal failure, Gangrene, Heart failure, Urinary incontinence, Pt can’t feel a burn on the foot

For instance:

- Renal failure is a cause of poor perfusion

- Urinary incontinence is a cause of peripheral neuropathy

 

Which lab test is the best indicator of long-term blood glucose level?

- Hb A1C, a.k.a. glycosated Hb or glycosylated Hb.

Average blood sugar over last 90 days

- (Hb = Hemoglobin)

- Hb < 6 is normal

- Hb > 8 is out of control

- Hb 7 Borderline—have patient come in for evaluation