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Medical surgical nursing, Lecture notes of Medicine

Academy College Medicine

Prof. Malcolm Man

Nursing chapter 53 diabetes. chapter notes

Typology: Lecture notes

2025/2026

Uploaded on 01/30/2026

arrrrrri 🇺🇸

3 documents

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DIABETES — DETAILED NURSING STUDY GUIDE (Expanded)

1) PATHOPHYSIOLOGY — quick recap (important for applying care)

Insulin: secreted by pancreaticβ-cells; promotes glucose uptake in muscle/adipose and suppresses

hepatic glucose production.

Hyperglycemiaresults from: ↓ insulin secretion, ↑ insulin resistance, or both → osmotic diuresis,

dehydration, electrolyte shifts, and cellular energy failure.

Ketogenesisoccurs when insulin is very low and counterregulatory hormones drive lipolysis → free

fatty acids → ketones (DKA).

Nursing focus:Know why dehydration, potassium shifts, and altered mental status happen so you can

anticipate monitoring and interventions.

2) CLINICAL PRESENTATIONS (what to assess)

Polyuria, polydipsia, polyphagia, weight loss(T1 more abrupt).

Type 2may present with fatigue, recurrent infections, poor wound healing, visual changes.

DKA: Kussmaul respirations, fruity breath, dehydration, abdominal pain, K+ shifts.

HHS: profound hyperglycemia, severe dehydration, neuro deficits (confused → coma), minimal

ketones.

Nursing focus:Targeted assessment: vitals, mental status, skin turgor, mucous membranes, capillary

refill, urine output, lung sounds (fluid overload risk), foot/skin inspection.

3) DIAGNOSTIC & MONITORING TARGETS (memorize these)

A1Cdiagnostic cut point:≥ 6.5%.

Fasting plasma glucose (FPG): ≥ 126 mg/dL.

2-hr OGTT: ≥ 200 mg/dL(75 g glucose load).

Random glucose ≥ 200 mg/dL + symptoms.

Glycemic targets (typical):

oA1C goal:<7%(individualize: older/fragile pts may have higher target).

oPreprandial glucose:80–130 mg/dL.

oPeak postprandial (1–2 h):<180 mg/dL.

Nursing focus:Know testing frequency:A1C q3 months until controlled, then q6 months; SMBG

frequency individualized; urine microalbumin annually; serum creatinine and eGFR annually; fasting lipid

panel yearly; dilated eye exam annually.

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**DIABETES — DETAILED NURSING STUDY GUIDE (Expanded)

PATHOPHYSIOLOGY — quick recap (important for applying care)**  Insulin : secreted by pancreatic β-cells ; promotes glucose uptake in muscle/adipose and suppresses hepatic glucose production.  Hyperglycemia results from: ↓ insulin secretion, ↑ insulin resistance, or both → osmotic diuresis, dehydration, electrolyte shifts, and cellular energy failure.  Ketogenesis occurs when insulin is very low and counterregulatory hormones drive lipolysis → free fatty acids → ketones (DKA). Nursing focus: Know why dehydration, potassium shifts, and altered mental status happen so you can anticipate monitoring and interventions. 2) CLINICAL PRESENTATIONS (what to assess)  Polyuria, polydipsia, polyphagia, weight loss (T1 more abrupt).  Type 2 may present with fatigue, recurrent infections, poor wound healing, visual changes.  DKA : Kussmaul respirations, fruity breath, dehydration, abdominal pain, K+ shifts.  HHS : profound hyperglycemia, severe dehydration, neuro deficits (confused → coma), minimal ketones. Nursing focus: Targeted assessment: vitals, mental status, skin turgor, mucous membranes, capillary refill, urine output, lung sounds (fluid overload risk), foot/skin inspection. 3) DIAGNOSTIC & MONITORING TARGETS (memorize these)  A1C diagnostic cut point: ≥ 6.5%.  Fasting plasma glucose (FPG): ≥ 126 mg/dL.  2-hr OGTT: ≥ 200 mg/dL (75 g glucose load).  Random glucose ≥ 200 mg/dL + symptoms.  Glycemic targets (typical): o A1C goal : <7% (individualize: older/fragile pts may have higher target). o Preprandial glucose : 80–130 mg/dL. o Peak postprandial (1–2 h) : <180 mg/dL. Nursing focus: Know testing frequency: A1C q3 months until controlled, then q6 months ; SMBG frequency individualized; urine microalbumin annually; serum creatinine and eGFR annually; fasting lipid panel yearly; dilated eye exam annually.

4) INSULIN — types, timing & nursing points (memorize onset/peak/duration)  Rapid-acting (lispro, aspart, glulisine)

o Onset: ~10–15 min; Peak: ~1–2 hr; Duration: ~3–5 hr.

o Administer at/just before meals (or within 15 min).  Short-acting (regular)

o Onset: ~30–60 min; Peak: ~2–4 hr; Duration: ~5–8 hr.

o Give 30–45 min before meals if using.  Intermediate (NPH)

o Onset: ~2–4 hr; Peak: ~4–12 hr; Duration: ~12–18 hr.

 Long-acting (glargine, detemir, degludec)

o Onset: ~1–2 hr; no pronounced peak ; Duration: ~24+ hr (degludec longer).

Basal-bolus regimen : long-acting basal once daily + rapid/short bolus at meals. Combination : premixed insulins for simpler regimens. Nursing focus:  Rotate injection sites (prevent lipodystrophy).  Use exact dosing and syringe/pen instructions; double-check high doses.  Watch for hypoglycemia at peak times.  Store insulin per manufacturer instructions. 5) INSULIN THERAPY — important safety & complication management  Hypoglycemia : recognize T I R E D mnemonic; treat using Rule of 15 (15 g simple carb → recheck 15 min). If unconscious: IV D50 or IM glucagon 1 mg.  Somogyi effect : nocturnal hypoglycemia → rebound hyperglycemia; consider bedtime snack or ↓ night insulin dose.  Dawn phenomenon : early morning hyperglycemia due to nocturnal GH/cortisol surge; may need ↑ basal insulin or change timing.  Lipodystrophy : avoid reusing same site. Nursing focus: Monitor glucose trends, educate patient on peak times, and teach hypoglycemia prevention and treatment. 6) ORAL & NON-INSULIN AGENTS — mechanisms & nursing notes

8) EXERCISE — monitoring & safety  150 min/week moderate aerobic + resistance 3×/week.  Before exercise, check glucose ; if <100 mg/dL, consume carbohydrate first; if >250 and ketones present, do not exercise.  After prolonged exercise, hypoglycemia can occur hours later — advise snack or reduce insulin. Nursing focus: Provide individualized plan; document education and follow-up. 9) SELF-MONITORING OF BLOOD GLUCOSE (SMBG) & CGM  SMBG : frequency varies — insulin users often test before meals and bedtime; during illness q4h; before/after exercise.  CGM : useful for insulin users and those with hypoglycemia unawareness.  Teach: correct technique, site rotation, calibration if required, log keeping, and actions for out-of- range values. Nursing focus: Demonstrate device, check competency, and arrange supplies. 10) ACUTE COMPLICATION MANAGEMENT — nursing priorities DKA (typical steps)

Airway, breathing, circulation.
IV access & fluid resuscitation (0.9% NaCl initially; change to 0.45% as appropriate; add dextrose once glucose ~250 mg/dL).
IV regular insulin drip (e.g., 0.1 U/kg/hr ).
Replace potassium BEFORE insulin if K+ low (<3.3 mEq/L) — hold insulin & replace K+ until K≥3.3.
Monitor glucose hourly, electrolytes (esp. K+), ABG, urine output, mental status. Nursing focus: Hourly glucose checks, strict I&O, cardiac monitoring (K+ shifts), neuro checks to watch for cerebral edema (esp. children; watch for sudden decline or headache). HHS  Aggressive fluid replacement and insulin titration; monitor neuro status and electrolytes.  Expect very high glucose (>600 mg/dL) and greater osmolarity issues. Nursing focus: Prevent rapid osmolar shifts; frequent neuro and cardiovascular monitoring. 11) HYPOGLYCEMIA — recognition & stepwise treatment

 If alert & able to swallow : Rule of 15 (15 g simple carb → recheck 15 min → repeat as needed). o Examples: 4 oz juice, 4 oz regular soda, 3–4 glucose tablets.  If not alert : IV D50 (20–50 mL of 50% dextrose) or IM glucagon 1 mg.  After recovery, give a snack with protein/complex carb to prevent recurrence. Nursing focus: Document event, identify cause (missed meal, insulin error), revise plan, and teach prevention. 12) CHRONIC COMPLICATIONS — prevention & nursing actions Retinopathy  Annual dilated eye exam; control A1C and BP. Refer for laser or anti-VEGF as indicated. Nephropathy  Annual urine albumin-to-creatinine ratio (microalbumin).  Manage BP (<130/80 individualized) and use ACE inhibitors/ARBs if albuminuria. Neuropathy & Foot Care  Daily foot inspection : look for cuts, blisters, redness.  Wash feet daily, dry between toes, moisturizer (not between toes), trim nails straight.  Avoid walking barefoot; choose properly fitting shoes.  Refer to podiatry for calluses, thick nails, deformities.  Educate on early reporting of foot ulcers. Nursing focus: Perform comprehensive foot exam at every visit for high-risk patients and document findings. 13) INFECTION & VACCINES  Increased infection risk — teach prompt reporting and treatment.  Recommend influenza and pneumococcal vaccines per guidelines. Nursing focus: Reinforce hygiene, early treatment, and vaccination status checks. 14) SICK-DAY RULES (practical patient teaching)  Continue insulin/oral agents unless HCP advises otherwise.  Check glucose every 3–4 hours ; check ketones if BG > 250 mg/dL.  Hydrate with sugar-free fluids if possible; if unable to eat, substitute with clear liquids with carbs.  Seek medical care if persistent vomiting, BG > 300 mg/dL with ketones, or signs of dehydration. Nursing focus: Provide written sick-day plan and hotline number; document patient understanding.