Pediatrics > Diabetes > Flashcards

Diabetes Flashcards

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1
Q

DM

A

Chronic dx of metabolism char by partial or complete deficiency of insulin
- most common metabolic disease in kids
- 1/3 people get DM type 2 before they die

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2
Q

Normal carb metabolism

A

Insulin lets sugar go from blood to cells to fuel
- good insulin=good blood sugar
- never going to be high

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3
Q

Carb metabolism for people with type 1

A

Insulin is absent or low so sugar can’t get into the cell so the cells starve and tell the brain they are hungry and we need to eat. Then sugar accumulates in the blood and the body pulls fluid from the cells into the blood and the excess fluid passes thru the kidney—dehydration and thirst. Liver breaks down protein and fat to make sugar and ketone bodies form as a byproduct of this.

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4
Q

Why are ketones bad?

A

They alter the F & E balance and cause acidosis when they gather in the blood—acidic blood

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5
Q

Diagnostic criteria for diabetes

A
  • fasting plasma glucose over 126
  • plasma glucose over 200 2hr post CHO load in an oral glucose tolerance test (OGTT)
  • random finger stick (casual blood glucose) over 200 with symptoms—3 Ps (polydipsia, polyuria, polyphagia)
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6
Q

Pre-diabetes diagnostics

A
  • impaired fasting glucose (100-125)
  • impaired glucose tolerance (BG 140-199 2hr post CHO load)
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7
Q

Type 1 diabetes in kids

A
  • diagnosed in kids and young adults
  • insulin-dependent kids
  • body doesn’t make insulin; autoimmune destruction of pancreatic beta cells
  • 5% of all diabetes
  • rarely overweight
  • rarely fam hx
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8
Q

Type 2 diabetes in kids

A
  • childhood diagnosis rates rising
  • 45% new DM cases in kids
  • usually non-insulin dependent
  • body fails to make or use insulin well
  • often overweight
  • often fam tendency
  • tx is wt maintenance/loss, exercise, insulin, oral agents like metformin
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9
Q

CM of Type 1

A

3 Ps—polydipsia, polyphagia, polyuria, enuresis (bed wetting after they were trained not to do that), irritable, unusual fatigue, ab pain, weight loss

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10
Q

Type 2 CM

A
  • overweight
  • fatigue
  • frequent infections (monilial)
  • acanthosis nigrocans (darker patches in skin folds)
  • commonly thrush
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11
Q

Diabetes management education

A
  • medical nutrition therapy
  • med admin (oral and insulin)
  • urine monitoring
  • dev issues
  • glucose monitoring
  • hypo/hyper management
  • sick day management
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12
Q

Medical nutrition therapy (MNT)—conventional

A

Consistent CHO intake where number of carbs are limited
- need specific amt of carbs per meal
- fat can increase blood sugar later
- based on a child eating a certain amount of carbs at a certain time of day (uncertain)
- BID or TID dosing

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13
Q

MNT—intensive (modern)

A

Kids eat whatever they want and you give insulin based on their finger stick and how many carbs they ate
- basal/bolus insulin dosing

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14
Q

Objective of nut management

A
  • appropriate meal and snack planning
  • balance carb, fat, protein
  • extra food during inc exercise
  • consistent meal times
  • avoid high sugar (cake and candy) unless special event—may need extra dose but don’t want to leave them out
  • develop appropriate insulin regimen and exercise program (inc insulin with extra food and dec insulin need with strenuous exercise)
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15
Q

Carb sources

A
  • Bread, cereal, grains, pastries, rice, pasta
  • milk and dairy
  • fruit
  • veg
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16
Q

Carb-free foods

A
  • meat
  • cheese
  • sugar-free jello
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17
Q

Metformin

A

Biguanides class
- dec hepatic glucose output and has a minor effect in inc insulin sensitivity
- oral agents rare for kids

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18
Q

Insulin therapy

A
  • mimic pancreas action in people w/o diabetes
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19
Q

Rapid acting insulin

A

Aspart (Novolog)/Lispro (humalog)
Onset: 15m
Peak: 1h
Duration: 3-4h

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20
Q

Short acting insulin

A

Human regular
Onset: 30 min
Peak: 3h
Duration: 6-8h

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21
Q

Intermediate acting insulin

A

NPH/Lente
Onset: 1-2h
Peak: 6-8h
Duration: 12-18h

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22
Q

Long-acting

A

Glargine (Lantus)
- Mimicks steady release of insulin throughout the day that is normal in people without DM
Onset: 4-6h
Peak: 8-20h
Duration: 24h

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23
Q

Management tools for intensive insulin therapy

A
  • insulin pens
  • blood glucose meters—attach on upper arm
  • SQ ports—changes q7-10 days
  • insulin pumps—only gives short acting; deliver steady boluses
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24
Q

Insulin pump NC

A

Give short acting insulin in steady boluses
- $$$
- can stop working—need backup or batteries with you
- kids can get frequent infections
- good if kids can’t manage sticks

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25
Blood glucose monitoring (timing)
BG monitored at least 4x/day (before meals and bed) - also checked if kid feels hypoglycemia or has sx - check before recess or exercise
26
Urine ketone monitoring (timing)
- any time BG levels over 240 on 2 separate occasions - during illness - pump therapy—BG levels over 240 on any occasion
27
Management tools for intensive insulin therapy
- rapid acting insulin - basal rate - bolus—match insulin dose to actual carb intake; insulin to carb ratio - correction factor—correct for BG above desired level (insulin correction factor) - pump emergency kit—batteries, syringes, needles
28
Insulin dosing calculations
- Insulin to CHO ratio 1:18 - Correction factor 1 unit:50 BG>150mg/dl - BC: 227 - CHO: 48 227-150=77 77/50=1.54 48/18=2.66 Calculated dose: 1.54+2.66=4.2—round at the end of
29
Dev issues with diabetes and toddlers
- parents must learn misbehavior vs hypoG - encourage kids to report “funny” feelings - expect food jags - give choices regarding SBGM, injection site and food choices
30
Dev issues with diabetes; preschool
- pressure kids this isn’t punishment - encourage kids to help with wipe finger, remove cap on pincer - teach kids to report lows to adult and what to eat when they feel low
31
Dev issues with diabetes: school age
- edu school personnel about it - encourage independence with supervision - encourage extracurriculars and eating a little more - 11-12 can give own injections
32
Dev issues with diabetes; adolescents
- can care for self - more willing to take multiple injections - risk takers tho - sleep late, may skip breakfast - don’t think things will happen to them - need continual parental involvement and support - may try alc—need to know it will lower BG bc inhibits glycogen release from sugar; need to snack while you do that - can have periods of hyperglycemia with menstruation and ED
33
Sick day management
- give insulin as scheduled - check BG more frequently - monitor urine for ketones
34
Normal fasting BG levels
80-120
35
Hypoglycemia
- treated when under 60 - dev bc body lacks glucose to turn into energy - causes: too little food, too much insulin, vom, exercise, change in schedule - s/s: low BG, hunger, headache, confusion, shaky, dizzy, sweaty, cold and clammy
36
Hypoglycemia tx
Treat under 60-65 - treat with 15g of fast acting CHO every 15 minutes until back up (1/2 cup juice or soft drink, 1 c WHITE milk (no choc bc takes longer to bring it up), glucose tabs, cake icing gel) - Rule of 15–15g of CHO and recheck blood sugar Q15 minutes until normal - follow with meal or snack - if feel yourself getting low and have diabetes, can eat/drink carbs w/o checking
37
Glucagon NC
- Glucagon emergency kit (dose is 1 mg) - injection into SQ or IM—turn pt onto side immediately bc may puke (prevent asp) - feed after awake - glucagon expires
38
Hyperglycemia
- excess glucose in blood - glucose over 180 by definition - Causes: excess carbs, too little activity, too little insulin, illness/infx - s/s: high BG, high glucose in urine, freq urine, inc thirst
39
Hyperglycemia tx
- check urine ketones - moderate to large ketones, call HCP ASAP - inc caffeine-free fluids - don’t inc activity bc can worsen ketone state
40
Ketosis
Body begins to burn fat for energy which makes ketones, which are acidic substance that are made when the body breaks down fat for energy. - ketone concentration btwn 0.3-7
41
Ketoacidosis
- ketones build up in blood and make more acidic - severe form of ketosis - reflects levels of 7.0 mmol/L or higher - lowers the pH to 7.3 or lower - s/s—deep rapid breathing, confusion, lethargy, and pain
42
Acidosis diagnosis
- ABG - electrolytes: Na, K, Cl, HCO3 - anion gap: (Na+K)-(Cl+HCO3); high gap means metabolic acidosis; happen in diabetes bc bicarb is low
43
DKA
- complex state of hyperglycemia, ketosis, acidosis - HyperG over 300 - evidence of significant ketosis - acidosis (pH<7.3 or HCO3<15) - emergency
44
DKA sx
Deep, rapid breathing, FRUITY breath odor, very dry mouth, N/V, lethargy and drowsy - dehydration sx w/o excessive UOP - vom w/o diarrhea - resp distress w/o lung pathology - Kussmaul breathing
45
Causes of mortality from DKA
Not too deadly - failure to diagnose - cerebral edema - hypo/hyperkalemia - hypoglycemia - hypovolemia
46
DKA pathology
Absolute or relative insulin deficiency that is accompanied by an inc in counter-reg hormones (glucagon, cortisol, GH, epi) which enhances gluconeogenesis, glyconeolysis, and lipolysis - K exchanges with H+ ions so K shifts EC and H+ shifts IC - shifted EC K is peed out thru osmotic diuresis - High serum osmolarity drives water from IC to EC, causing dilutional hyponatremia and sodium is lot in osmotic diuresis
47
Effects of DKA
Inc ketogenesis, dec alkali reserve, ketoacidosis, lactic acidosis, hyperglycemia, glucosuria, loss of water and electrolytes, dehydration, impaired renal function
48
Patho of DKA dehydration
- Hyperglycemia—glycosuria—osmotic diuresis—dehydration - Excess counter-regulatory hormones—ketogenesis—acidosis
49
Therapy for DKA
- fluid replacement FIRST—NS for first hour - insulin and electrolyte therapy SECOND - careful monitoring
50
How to give insulin for DKA
- prime tubing with insulin and give starting at 0.1 unit/kg/hr - assess VS, BG, neuro status before giving - stop insulin pump before beginning - 2 nurse check—HIGH ALERT - NEVER give as bolus - turns off production of ketones and dec BG - check glucose hourly - don’t drop it faster than 50-100/hour - low-dose insulin dec risk of hypoG or hypoK - when BG reaches 250-300, maintain insulin and begin dextrose infusion
51
Why not give insulin in first hour?
Inc risk of cerebral edema
52
When to stop giving insulin infusion for DKA?
When pH is over 7.3 and/or HCO3 is over 15 and serum ketones have cleared—means the acidosis has resolved - anion gap under 12 usually - pt able to eat
53
Potassium admin guidelines
- consult with pharmacy before admin - start replacing K after initial fluid resuscitation and at same time as starting insulin therapy - CLOSELY MONITOR - pt with DKA usually have large K deficit - K replacement should continue thru IVF therapy - max rate of IV K is institution specific
54
Dextrose admin
- Give when glucose reaches 250-300 to prevent hypoG - check glucose hourly until stable - check electrolytes every 2-4h until stable
55
Bicarbonate therapy
- usually contraindicated in peds bc risk of cerebral edema
56
Hourly monitoring for DKA
Hourly assess—VS, neuro, I/O, BG, K level *immediately note chx in neuro status
57
Q2 hour monitoring for DKA
- urine ketones - serum beta-OH—ketones in blood - labs (at least q2)—serum glucose, electrolytes, BUN, calcium, Mg, Phosphorus, hematocrit, blood gases - continuous cardiac monitoring
58
Additional measures for DKA
- may need O2 or suction - may need catheter or bladder watch
59
When do DKA kids get sent to ICU?
- Severe DKA (pH under 7.1-7.2 in young kid) - altered LOC - under age 5 - inc risk for cerebral edema (younger) *PREP for intubation *caution with meds that may alter mental status
60
What is the usual rate of fluids given for DKA?
10 mL/kg/hr or maybe 20 mL/kg/hr
61
NC when insulin is turned off
- Rapid acting, SQ insulin given - feed child - give known diabetics their previous dosing but may need additional rapid acting insulin - new pts get 0.7-1 units/kg/day
Pediatrics
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