005 Mark Klimek

The information discusses diabetes, specifically diabetes mellitus and diabetes insipidus. Diabetes mellitus is an error in glucose metabolism, affecting the body's ability to use glucose as fuel, leading to cell damage. Diabetes insipidus, though similar in symptoms, is caused by low ADH levels leading to dehydration. The transcription also highlights differences in type 1 and type 2 diabetes, emphasizing treatment approaches such as diet, insulin, and exercise for type 1, and diet, oral medication, and activity for type 2. Understanding the importance of insulin in type 1 and diet in type 2 is crucial. Of all the diseases, you know, you should know, you should know diabetes. I'm not one to tell you to go learn all these laundry lists of diseases, but you do need to know your diabetes. So let's talk about it. Definition. Diabetes is an error of glucose metabolism. You don't metabolize your glucose well. That's what diabetes is. You cannot metabolize glucose for whatever reason. Sometimes it's a lack of insulin. Sometimes the cells become resisting to insulin. For whatever reason, you cannot metabolize glucose. So the problem with glucose is it's your primary fuel source. So diabetics get into trouble because they can't metabolize or use the primary fuel source. And without that, cells die. And that's why it's very bad. Now, don't confuse it with diabetes insipidus. Diabetes insipidus is a totally different disease. Diabetes insipidus is not a type of diabetes mellitus. It's a totally different disease. Diabetes, in the parenthesis, I want you to put diabetes insipidus is polyuria, polydipsia, leading to dehydration. Due to low ADH. Due to low ADH. So when you get a question about diabetes insipidus, and they want to know what you see, what do you see? Polyuria, polydipsia, and dehydration. Which looks a lot like diabetes mellitus, doesn't it? Because it has polyuria, polydipsia, and dehydration. So they look alike, even though they're not the same thing. That's why they share the same first name, diabetes. So if you're sitting there and you can't remember what diabetes insipidus is, what's the best way to remember? It's like diabetes mellitus, only just with the fluids. It's just the fluid part of diabetes mellitus. You don't get the glucose part, you just get the fluid part. And it's due to a low ADH. So what they'll ask you about diabetes insipidus is, a lot of times with diabetes insipidus, what they would ask you is, do you have a low urine output or a high urine output? And what you should say is, oh, okay, wait, diabetes insipidus. It's not diabetes, but it's like diabetes mellitus. And diabetes mellitus has a high urine output, so diabetes insipidus has a high urine output. You see how I want you to remember it? Now what is the opposite of diabetes insipidus? What's the opposite syndrome of diabetes insipidus called? S-I-A-D-H. So here's what I do. I don't ever remember, I don't memorize S-I-A-D-H, and I don't memorize diabetes insipidus. Why? Because I get the questions right. How can you get the questions right on S-I-A-D-H and diabetes insipidus and not memorize them? Everybody knows that diabetes mellitus has what? Polyuria and polydipsia, right? You should know that. So therefore, diabetes insipidus has what? Polyuria and polydipsia. So S-I-A-D-H is the opposite, so instead of polyuria, they have low urine output, oliguria, and they are not thirsty because they're retaining water. Do you see the thought? If they said to you, who gains weight? Diabetes insipidus, diabetes, who gains weight suddenly? Diabetes insipidus, diabetes mellitus, S-I-A-D-H. S-I-A-D-H. Why? Because diabetes insipidus and diabetes mellitus lose water, right? And when you lose water, you lose weight. S-I-A-D-H is the opposite. So who would have a urine output of 200 milliliters per hour for three hours straight and a normal blood glucose? Who would have diabetes insipidus? Who would have an output of 200 milliliters an hour for three hours in a row with a glucose of up to 280? Yeah, diabetes mellitus. Everybody says mellitus. I just am from the East Coast, so I say mellitus. Who has 10 cc's of urine out in three hours and a normal blood glucose? S-I-A-D-H. S-I-A-D-H. Do you see what I'm saying? I want you to memorize that because Boards does test DI and S-I-A-D-H regarding urine output. So the two diabetes look alike urine output-wise. The S-I-A-D-H looks opposite the two diabetes urine output-wise. What's the relationship between amount of urine and specific gravity of urine? What's the relationship? It's opposite. It's inverse or opposite, meaning the less the urine out, the higher the specific gravity. The more urine out, the... So what specific gravities would S-I-A-D-H have? S-I-A-D-H is opposite the diabetes. The diabetes, do they have more urine or less urine? Diabetes. They have more. S-I-A-D-H would have less. So if the urine volume is going down, the specific gravity goes up. So we have a high specific gravity. Whereas diabetes and syphilis, well that would have what kind of a urine output? High because the two diabetes have high urine output. So if the urine output is high, the specific gravity is low. So you see how you're going to do this? And if you know the specific gravity and the urine volume with the S-I-A-D-H and the D-I, you're ready to go with those two diseases. That's all they're going to test. So who would have the nursing diagnosis of S-I-A-D-H, D-I, and D-M? Which would have fluid volume deficit? Think it through. Fluid volume deficit would be what would you be doing with your output if you ended up with low fluid in your body, high output, and those would be what? D-M and D-I. Who would have fluid volume excess? S-I-A-D-H. You see how I want you to think it through? Okay. I always find if you link things with other things you know, it's a lot easier to remember them than just remember them separately. Okay, let's dive now into, let's quit talking about the pituitary. Let's talk about diabetes mellitus directly, the types. Type 1 versus type 2. You have to know these. They will expect you to know the differences between type 1 and type 2. Type 1 has three names. Insulin dependent, that's the I. Insulin dependent. J is juvenile onset. And K is ketosis prone. K-E-T-O-S-I-S-P-R-O-N-E. Ketosis prone. Now, one of those three will not be used after April 1. Which name will not be used after April 1? Juvenile onset. Okay, type 2, the names are not all of those. Instead of insulin dependent, it is non-insulin dependent. Instead of ketosis prone, it is non-ketosis prone. And instead of juvenile, it is adult. Which of those three will not be used after April 1? Adult onset. So you'll actually have to memorize less after April 1. C, the signs and symptoms. You must know the three P's. Polyuria. Polydipsia. And polyphagia. Poly-P-H-A-G-I-A. P-H-A-G-I-A. Polyphagia. What does polyphagia mean? What's it mean? I can't hear. Thirsty is polydipsia. What's polyphagia? Increased appetite. Technically, no. Polyphagia does not mean increased appetite, although we use it to mean that. What does polyphagia actually mean? Increased swallowing. Now, if you eat a lot, what are you doing? Increasing your swallowing. But I want you to understand that that's not... When they say polyphagia, they are not always talking about eating a lot. For example, would polyphagia be a sign of increased bleeding after a tonsillectomy? Yes. And they're not talking about eating a lot, they're talking about swallowing a lot. See, so don't... You understand, polyphagia technically means what? Swallowing a lot. In the context of diabetes, it's talking about eating a lot. Polyphagia only means eating a lot in this single context. Everywhere else, polyphagia means frequent swallowing. Okay? Treatment. If you don't treat type 1s, they can die. D-I-E. D for diet, I for insulin, and E for exercise. You treat diabetic type 1s with diet, insulin, and exercise. Of the three, which one is the most important treatment modality? Insulin. Insulin. By far and away, insulin is the most important. Which one is the least important of the three? Diet. Nope. Diet. We do not mess around with type 1 diets anymore. We pretty much let them eat generally what they want. They count their carbs, they do their AccuCheck, and they give themselves the insulin accordingly. We don't restrict their diets like we used to. Now, we do tell them to lay off a bunch of refined carbohydrates, like pure sugars, but they can even eat those nowadays, as long as they count their carbs and give themselves injections of insulin, according to their AccuCheck. However, the type 2s are different. Type 2s, if you don't treat them, they end up DOA. That doesn't mean dead on arrival. What that means is D for diet, O for oral hypoglycemic, which is the pill, and A stands for activity. Okay, of those three, which one for a type 2 is the most important treatment modality? Diet. So what is the least important for a type 1 is the most important for a type 2. It's a huge difference. In fact, most physicians would like type 2 diabetes to be controlled with diet alone. They would really, really like that. I don't know if anybody watches Biggest Loser ever, and they'll say, I had diabetes and I don't have diabetes anymore. No, you still have diabetes. You're just controlling it because you're losing weight. Is anybody watching the current season? I'm not really watching. I just watch it every so often. There's a girl there, and she's wearing an insulin pump. You see it's like taped here. They don't show it off, but she's wearing an insulin pump, and she's still over 200 and something pounds. It's interesting when she gets down, do we not see that anymore? Because probably we won't. We probably won't see that pump there anymore. But she is a type 1, so it may not work. But it'll be interesting. A lot of people, diabetes can be controlled with just diet alone, particularly type 2s. Okay, turn the page, and let's talk about diet, insulin, and exercise more in depth. When we talk about diet, who are we talking about primarily? Which type? Type 2s. We're talking about type 2s. Letter A, it is a calorie restriction. The primary dietary modification we make with type 2s in their diet is to restrict their calories. That's the primary thing we do. Hence, you get things like the 1,200-calorie ADA diet, the 1,800-calorie, the 1,600-calorie. It tells you that calories are important because that's how it's named. Calorie restriction is the most important part of a diabetic diet. Letter B, they need six small feedings a day. If they have 1,800 calories, how do you split that 1,800 calories into six separate feeds? What does that do? It keeps it level, so you don't get these big peaks. If you chop that all in three meals, you're going to have these three big peaks. If you do it in six, it's going to be more level. Therefore, the blood glucose is going to stay more normal glycemic. Which one would be best? Let's look at a question like this. You have a type 2 diabetic. What is the best dietary action to take? A, restrict their calories to an appropriate level. B, divide their food into six feedings a day. Now, don't jump to conclusions because you have to understand this is a best question. In a best question, how many do you get to do? If you say you're going to do one, you're not going to do the other. In fact, you're going to do the opposite of the other. If you pick A, they're going to follow their calorie restriction, and it's 1,600 calories. If you say I am going to give them 1,600 calories a day, what does that mean you're not going to do? They're going to get it in three meals a day. They're going to get 16 of their calories in three meals because we're not going to split it in six. That's what you're saying if you pick calorie restriction as your best answer. Let's see what you're saying if you split it into six meals, six feedings. If you pick that, you're saying what? I'm going to split it into six feedings, but what? But they can eat as many calories as they want. So what would be better for a diabetic? To get six feedings a day eating as many calories as they want or to eat three meals a day following their calorie restriction. What would be better? So what is the best answer? Calorie restriction. Do you see what I'm saying? Because usually when you shout out an answer or you jump to an answer, without the thinking you tend to go to the wrong one. So think it through. Are you understanding this process that I'm teaching you about how to deal with best questions? How do you deal with a best question? Narrow it down to how many? Two. If you can narrow it down to one, what should you do? Pick it. Okay. But everybody tells me they can only narrow it down to two, and then they don't know what to do. Well, if you narrow it down to two, then what do you say? I will do this one but not do that one. And then flip it around. I'll do that one without doing this one. Pick one of those you'll like better. So pick the answer that you're going to do in the one you like better. Question? Would that still be the same if you're talking to a patient who is like four pounds or used to, like let's say the baseline is four pounds of calories a day. Okay. But they have been real good at letting those up to six in the fifth year. Okay. Would that still be accurate to say they can still slash those like instantly into 1800 calories? Okay. Write the question. Are you talking about a question or are you talking about what do you do in real life? I'm saying, yeah, so like a board question. Okay. Write the question, and then I'll give you the answer. But I need to know how you're going to phrase the question here. Would it be more preferable for a 400-pound patient who's baseline is 4,000 calories a day to help control their type 2 diabetes? Okay. What is the best answer? Okay, what's the best answer? Now, if the answers are reduce them to 1,200 calories versus teach them to separate the calories into six meals, and they're talking about starting, I might seriously question the 1,200 calorie because it's such a big, huge drop initially. But the best would be to drop to 1,200 calories. The best answer still is 1,200 calories. I probably wouldn't do it first. Remember yesterday I said there's a big difference between a first and a best. So if they said to me, what would you do first? I'm not dropping him to 1,200 calories first. I'm going to teach him how to separate it, then I'm going to start whittling down each time to get him there. Does that make sense? Yes. I think in your case, the six meals would be the first thing you might do in that scenario. But see, the only time that works is when you wrote that scenario specifically that way. Which board doesn't get that picky? They go more general because they want to know if you miss it, did you not know what to do generally? Then they can say you shouldn't pass. You see what I'm saying? Because if you didn't know what to do in some specific unusual occurrence, if you miss it, they can't really fault you because nobody else knew it. Does that make sense? The problem is in school you guys are given all these bizarre questions that are tricky and they add this in and they go, oh, but you forgot about that. So you miss it. And you get socialized into thinking that's the way. But on boards they don't do that. But you have to trust that boards is there. And it really is. They are well-tested questions. Okay, does that answer the question? Yes. Let's see. Insulin. Insulin acts to do what to the blood glucose? What does insulin do to the glucose? Lower. It lowers the blood. That's good to hear. I went to a school one time and I asked that question and everybody said, Ray. I said, oh, boy, how did my work cut out for me here? So insulin acts to lower your blood glucose. Now, there are four types of insulin you need to know. Now, there are many, many types of insulin, but there are four that you really need to know for boards. You don't need to know exubera, bieta, epidura. You do need to know R and Lispro, Humalog, and Lantus, Galargine. So let's talk about these four. Regular insulin, the ones with the big, bold R on the bottom. It has actually lots of different names. It could be Humulin R, Ilatin R, Novolin R. The name is irrelevant. What is important is that big, bold letter R. That means it is regular. Its onset is in one hour. Its peak is in two hours. Its duration is three hours. It is clear. It's clear. In the bottle, it's clear. So it's a solution. So it can be IV drip. This is the insulin you use when you use IV drip insulin. Now, HESI will call this an intermediate-acting insulin. The product insert that comes with the bottle from the manufacturer that the FDA approved says it is a rapid, short-acting insulin. So I don't know why HESI insists on changing the FDA's classification. But if you learned this was intermediate, it is still considered by the FDA as a product insert, as a short, rapid-acting insulin. Why do you think a lot of people are starting to talk about regular not as a short, rapid, but as an intermediate? Exactly. Because five years ago, ten years ago, we didn't have Lispra. And the fastest one was regular. Now we have Lispra that works in one-fourth the time that regular does. And it's kind of silly to talk about Lispra as being the same time phase as R, isn't it? But I really believe that if boards ask you, is R short, rapid, or intermediate, you should go with what the FDA and the product insert says, not what HESI says. Do you see what I'm saying? If HESI books anything from Elsevier, we'll say it's intermediate. MPH insulin, M, is truly an intermediate-acting insulin. It's a true intermediate-acting insulin. Its onset is in six hours. Its peak is eight to ten hours. And its duration is 12 hours. It is cloudy. It is a suspension, as all cloudy things are. They are not solutions. Cloudy things are suspensions. Clear are solutions. Cloudy are suspensions. And the bad thing about a suspension is a suspension precipitates, meaning the particles fall to the bottom over time. So you cannot give this drug IV drip, or you will overdose them and their brain will die. But there's a general rule. Never put anything cloudy in an IV bag, right? When I have students clinically, I'll teach them something that can help them a little bit. When they pull out an R, a bottle of R from the shelf or the refrigerator, I'll say, what does that R mean? And they will say, regular. And I will tell them, no, it doesn't. Whereupon they start to panic. And I say, wait a minute, I'm just trying to teach you something here, so don't panic. Yes, it does mean regular, but I'm trying to tell you that R really means two other things. That R stands for rapid and run. Rapid meaning it's what? Fast acting. And run means? Run it IV. They will pull out the N bottle. And what's the first question I ask them? What does the N stand for? And they'll say NPH. And I'll say, no. And they'll start to panic. And I'll say, wait a minute, I'm just trying to teach you something here. That N actually stands for two other things. Do you know what that N stands for? Not so fast. Not so fast, which means it's what? Intermediate and not in the bag. Which means you never put it where? IV. Because I want my students, the minute they pull that N off the shelf, what do they say? It says a big N on it. And they say what? Not so fast and not in the bag. So they will never what? Draw it up and stick it in an IV bag because they know N is not in the bag insulin. Actually, my students will forget that it's NPH. They'll call it not in the bag and not so fast insulin. And R, they'll call it rapid and run insulin. And I think that's kind of functional. It kind of works. All right. Now, let's talk about the onsets, the peaks, and durations of these famous insulins. Look at the pattern. What do you see as you read across the page? 1, 2, 4, 6, 8, 10, 12. 1, 2, 4, 6, 8, 10, 12. What are you counting on? 3, 2, 3, 4. Did I mess up something? What did I say? Okay. The regular onset is, I'm sorry, 1. Peak is 2. Duration is 4. I'm sorry. Did I say 3? I was thinking Lispro. I'm sorry. So, it's 1, 2, 4, 6, 8, 10, 12. Do you hear the even numbers? So, what's 1, 2, 4? Regular. What's 6, 8, 10, 12? N. So, just remember 1, 2, 4, 6, 8, 10, 12. 1, 2, 4, 6, 8, 10, 12. Which of those will they test the most commonly? Of those... No, they test N and regular equally. The peaks. They test the peaks. So, what do you really have to remember? 2 and 8 and 10. The way they'll test it... In fact, how do they test it? You tell me how they test it. What does the question read like? If you're high, blood sugar and... They gave you... You gave 30 units of N at 7 in the morning. Then what do they ask? When would you check for hypoglycemia? Which means low sugar. Well, the low sugar is going to be when the meds at its peak. So, that's the way they ask for the peak without ever asking about the peak. They ask about hypoglycemia, which is the peak. So, if you gave N at 7, when would you check for hypoglycemia, which is the peak? N. N. You gave N at 3 p.m. to 5 p.m. Somewhere between 3 and 5 p.m. Or late afternoon, they would say. See how that works? Take the peak, add it to the time they gave it. That's when you check for the hypoglycemia or the peak. Humulon. Lispro. The world's fastest acting insulin. Its onset is in 15 minutes. It peaks in 30 minutes, and its duration is 3 hours. 1533. 1533. So, when do you give this insulin? As they begin to eat. So, you give it with meals, not AC. What does AC mean? PC means after meals, post PC. A means ante, or before. So, AC means before the meal. Do you give Lispro AC before the meal? No. You give it with the meal. So, be real careful with your words there. The word before is wrong. The word with is correct. I tell my students, if you're not interrupting their meal to give them their Lispro, you're doing it wrong. You don't give it when the trays arrive on the unit, because it may take another 15 minutes until they get past. By then, the Lispro is already working. And then you can't arouse them to eat, because it's peaking. Alright. Lantus. Lantus is a long-acting insulin. It is called Glargine. G-L-A-R-G-I-N-E. And nowadays, they're most likely to call it Glargine rather than Lantus. Glargine. It's a long-acting insulin. It is so slowly absorbed, it has no essential peak. It is so slowly absorbed, it has no essential peak. What that means is, this one has low risk for hypoglycemia. Little to no risk of hypoglycemia. So, this drug is the only insulin you can safely give at bedtime. Because they will not go hypoglycemic during the night with this one. The others, you cannot give at bedtime. The only time you can give the others at bedtime, well, you never give N at bedtime. But the only time you can give R or Lispro at bedtime is if what? Your AccuCheck said they were sky high, then you can give it. But you wouldn't routinely give Lispro or regular at bedtime. You can give Glargine routinely at bedtime, regardless of the glucose. Duration is 12 to 24 hours. So, those are the main insulins and what they're going to say. Letter B, check the expiration dates on your insulin. Please, that's important. What action by the nurse invalidates the manufacturer's expiration date? What action by the nurse invalidates the manufacturer's expiration date on the bottle? What's that? Opening it. Opening it up. The minute you open a vial of insulin, what is now no longer valid? So, the manufacturer's expiration date is only good as long as it's still closed and sealed and unopened. Once you open it, now the manufacturer's date is irrelevant. What becomes the new expiration date is 30 days after that. And make sure you write on the bottle that date and make sure you write EXP or opened. Why do you need to write opened and then the date or EXP and then the date? Why can you not just write the date on it? Well, if I come along and I see a date, I don't know if that's when you open it and I don't know if that's when it expires. If I'm in doubt, I will throw it out and I'll throw that insulin away. So, you put EXP and a date or opened and a date, okay? Make sure you're clear. Refrigeration is optional, meaning you don't have to refrigerate insulin in the institution. But you do have to teach patients to refrigerate their insulin at home. Now, in the hospital, the insulin that probably should be refrigerated are the unopened vials. However, once a nurse opens a vial, two things happen. Number one, the manufacturer's expiration date is no good anymore. You've got to write a new expiration date on it. And number two, it now does not have to be refrigerated in the hospital. So, as they said to you, what's the most important thing, the best thing to do when you are dealing with insulin in the hospital? In your between, check the expiration date before you give it and refrigerate it when not using it. What's the best answer? Well, you'd have to figure that out. If you pick check the expiration date before you give it, you're not going to do the other one, which was what? So, you're going to check the expiration date but leave it out of the refrigerator. Or you will what? Refrigerate it and not check any expiration dates and maybe give expired insulin. So, would it be better to give cold expired insulin or warm, non-expired insulin? Warm, non-expired. Warm, non-expired. You see what I'm saying? So, the best answer is expiration date. Okay, exercise potentiates insulin, which means does the same thing as. Potentiates means does the same thing as. I want you guys to think of insulin. I'm sorry. I want you to think of exercise as another shot of insulin. Whenever the question says, Andy exercised, what do I want you to replace those words with? Andy got another shot of insulin. She's going to play soccer this afternoon. Replace that with what? And she's going to get another shot of insulin this afternoon. He has gym class this morning. He's going to get an extra shot of insulin this morning. You see what I'm saying? So, if that's the case, if you have more exercise, what's that mean? More shots of insulin, you actually need less insulin. But if you have less exercise, you need more insulin because exercise is like an extra shot of insulin. So, if a diabetic is going to play soccer in the afternoon, what should the school nurse do? He's going to get an extra shot of insulin, so he better what? What should he take to the game? Rapidly metabolizable carbohydrates, right? As a snack before the game and during the game. Diabetics get sick for other reasons besides their diabetes, like they get the flu, they get diarrhea, they get otitis media. What do they do when they're sick? Well, when the diabetic is sick, their glucose is going to go up. It will never go down. It always goes up. So, they have to take their insulin, even though they're not eating. To the diabetic, let's say a diabetic gets the GI flu and he is nauseated and he's throwing up and he's not eating. What's he going to say? Well, I'm not eating, so I shouldn't take my... That's wrong. Your glucose is going to go up even if you're empty out when you're under the stress of illness. So, they take their insulin, even though they're not eating. Number two, take sips of water because they're going to get dehydrated. Diabetics get dehydrated. It probably would be worth your while to remember that a sick diabetic has two problems, hyperglycemia and dehydration. Any sick diabetic is going to have those two problems, so just count on it. Hyperglycemia and dehydration, always. Every sick diabetic will have those problems. And then stay as active as possible. Why? It helps lower the glucose. And a sick diabetic, even if they're not eating, their sugar is going to go which direction? Up. All right. Now, before lunch... We're going to go to lunch at noon. Before lunch, I want to cover the complications of diabetes and we'll see where we're at after that. There are three acute complications of diabetes and a boatload of products. Let's talk about the acute complications first. You should never go to boards not knowing this. They test this all the time. You have to know your signs and symptoms and treatment of the three acute complications of diabetes. The first one is low blood glucose in a type 1 or a type 2. It's called insulin shock, insulin reaction, or hypoglycemia. It has a bunch of names. It means their sugar is low, their glucose is low. Now, what in the world would ever cause a diabetic's glucose to go low? That's a good question. Because when a diabetic isn't sick but has diabetes, what does their sugar run? High or low? High. And when they get sick, it runs even higher. So, if you're well, it's high, and if you're sick, it's even higher. So, how in the world could it ever go low? Great question. Well, here are the causes. Not enough food. Too much insulin or medication. And too much exercise. Wouldn't those all make the sugar go down? However, one of them is the primary cause. Which one is the primary cause? Too much medication. In fact, I would say that it is impossible, impossible, for a diabetic to have a low glucose without being over-medicated. So, over-medication is the number one, almost sole cause of hypoglycemia in diabetics. The danger here is brain damage. And the bad thing about brain damage is permanent. So, this is no small thing. You can destroy people's lives as a nurse by over-medicating them with insulin. You can take an alert-oriented person like me and cause me to be in a persistent, vegetative state in a nursing home for the rest of my life because you made one mistake with insulin. What were the signs and symptoms? The signs and symptoms you must know because boards will want to see if you can pick up hypoglycemia just by looking at the patient. Now, the easiest way I know to memorize the signs and symptoms of hypoglycemia are drunk, in shock. Drunk, in shock. Now, what am I talking about on this one? Here's what I'm saying. Most of you guys in here know what drunk people look like. Okay? So, what does a drunk person look like? Describe it for me. Baggering. Baggering game. Blurred speech. Judgment. Poor judgment. Impaired judgment. Reaction time. Delay. Emotions. Drunk person's emotions. Talk to me. Okay, but they won't say all over the place. They'll use a fancy word called labile. L-A-B-I-L-E, which means all over the place. Laugh, cry, laugh, cry. Could they be a little obnoxious and belligerent? A little bit loud? Decreased social inhibition? Those are all signs of hypoglycemia. So, anything that would characterize a drunk person will also characterize a hypoglycemic person because both people are having cerebral cortical compromise. Now, the other part of the picture is shock. They also look like they are in shock, which is the basomotor part of the syndrome. So, what does a person in shock look like? Low blood pressure. Tachycardia. Tachypnea. What else? Skin. Cold. Pale. Clammy. Could it be muscle in the extremities? Patchy. Yeah? So, what I want you to do is I'm assuming that everybody in here knows what drunk people look like. And I'm assuming you know what shock looks like. So, I'm saying to get hypoglycemia, all you do is add those two. Drunk plus shock. So, I don't want you to memorize any new list. Just derive the new one from two old ones you already knew. So, drunk is drunk, shock is shock. Add them together, you get hypoglycemia. So, when you get to select all that apply for hypoglycemia, what do you do? Go through and select everything that applies to whom. A drunk and then select everything that applies to a person in shock. And I'm not talking about anaphylactic or neurogenic or septic shock. I'm talking about shock shock. Generic, basic, oh my goodness I'm bleeding to death shock. Well, what do you do for it? Number one, administer rapidly metabolizable carbohydrate, i.e. sugars. If you're looking for the word sugar and it's not there, they probably are saying rapidly metabolizable carbohydrate because that is synonymous with the word sugar. Now, what would be some examples of a rapidly metabolizable carbohydrate that you could give in a hypoglycemic situation? Any juice. There's nothing magical about orange. It could be apple, grape, pineapple, guava, pomegranate, grape. What else besides fruit juices? Now, what, low calorie sugar free pop? No, regular pop. Which a lot of people think, oh wow, cool, I need to have pop. What else? Chewed up candy, let them chew it up. What else? What? Well, crackers don't have enough sugar. Milk is great because it has lactose. It's got the sugar. Honey, icing, jam, jelly. Those are great rapidly metabolizable carbohydrates. Okay, however, boards really want you not to give just a sugar. They want you to give an ideal combination of foods, which is the next point. What is the ideal combination of foods? You want a sugar plus a starch or protein. That's where the crackers come from. The crackers are the starch. The orange juice is the sugar. Orange juice and crackers, good job because you got the sugar and you got the starch. Or you could say apple juice and a slice of turkey. Because what would that be? Sugar plus protein, which is why the milk is so fantastic because when you drink milk, what are you getting? Sugar and protein, which is perfect. But you use low, you use skim milk because you don't want them to burn fat for the ketones, right? So it's one half cup skim milk. Fantastic answer for hypoglycemia. One half cup skim milk. What's a bad answer? What's a bad combination of foods to give them? What would be a bad combination of foods to give them? Such as? No, no, not carbs. Carbs are too broad. Yes. Yes. Giving them a bottle of pop and a bunch of candy to chew on. You know, one sugar is good, two sugars are bad. So give them one sugar and one starch, one sugar and one protein. So what do you think about five packs of sugar emptied into a glass of orange juice? Not the way to go. Not the way to go. What if they're unconscious, what do you give them? Glycogen. Glycogen. Or glucagon, actually. Glucagon. Which gives you this. Immobilizes the glycogen. Glucagon IM. A shot, an intramuscular injection of glucagon. What else can you give them? Buy another route. Dextrose per IV. Dextrose per IV. D5 is not going to do it. It's going to be D10, D50. D5, a whole liter of D5 only gives you 300 calories. Yeah, you need some D10, D50. You need some real powerful dextrose. Not just D5 will do it. So, what will determine which one you give? D50 IV or the glucagon IM? Because they're both appropriate. So, what will determine that? The setting. The setting though. If you are talking to the mom and dad over the phone, and they're asking what they do with their unconscious, hypoglycemic, diabetic kid, what do you tell them to give? The IM glucagon that they should have in the refrigerator. They should all have one in there. What do you not tell them to do? Start an IV of D50. However, if they tell you it's in the emergency department, and you've got a severely unconscious hypoglycemic line with a glucose of 7, what do you give them? IV of dextrose. Well, good luck starting the IV. Because they look like a what? Drunk in shock. And what happens to peripheral vessels in shock? Shook. So, good luck. That's why I love saline locks and heparin locks, intermittent venous access devices. Because if I need a lifeline in an emergency, they're just going to be there. Because the hardest time to start an IV, a lifeline, is in an emergency because they clamp down peripherally, and you can't get a vessel. You can't get a cannulation because it's vasoconstricted. That's one where you just aim for where the veins are supposed to be. You know, because you can't see anything. All right. Number two. High blood glucose in a type 1. It's called DKA. Diabetic Ketoacidosis or Diabetic Coma. Have you heard of DKA? I hope you have. Who gets it? Only type 1. What should have told you it was only type 1? How should you have known it was only a type 1? That only type 1 gets diabetic ketoacidosis. Because another name for type 1 is what? Ketosis prone. And type 2 is non-ketotic. So how can a non-ketotic have diabetic ketoacidosis? They can't. Only a ketosis prone type 1 can have DKA. Well, what would cause their glucose to go high? Well, too much food, not enough medication, not enough exercise will make the glucose go way high. However, none of those are the number one cause of DKA. The number one cause of DKA is below. The number one cause of DKA is acute viral upper respiratory infections within the last two weeks. So what causes DKA? Number one cause of DKA. A type 1 gets what? The virus of the month club at school. Right? And they get the upper respiratory viral pharyngitis that every kid in school has. Right? And they recover from that within three to five days like everybody is. But after they recover initially, what starts happening? They start going downhill and getting more and more lethargic because this is called diabetic ketoacidotic coma, DKA. So they start going downhill. So that when they come in the ER and you check their blood glucose and it's 850 and they have the signs of DKA, what do you ask mom and dad? Not when the last time they ate. Have they had a viral infection the last two weeks? If they had a viral infection, upper respiratory, in the last two weeks, what will they almost always say? Yes. And what caused the glucose to go high was the stress of that illness that was not shut off. And they started to burn fats for fuel and they got into a negative situation. Well, what are the signs and symptoms of DKA? Turn the page. What are the signs and symptoms of DKA? I like it because they are DKA. You can get the signs and symptoms from the initials of the disease. So D stands for dehydration. They look dehydrated. You should have known that because what did I tell you? Sick diabetics always get and a high sugar. And these people have a high sugar and they are dehydrated. The K stands for three things that start with the letter K. They have ketones. Now, just for fun, DKA. Tell me if this is a true statement. DKA, they will have ketones in their blood. They will have ketones in their blood. True. K. DKA. Everybody with ketones in their urine has DKA. No. So you can have ketones in your urine and not have DKA. But if you have ketones in your blood, you have DKA. So it's the ketones in the blood that confirms the diagnosis. The ketones in the urine, that doesn't typically mean that you have DKA. K, the second K is Kuzmo. They Kuzmo. What's that mean? Deep and rapid. They hyperventilate. Deep and rapid Kuzmo. And the third K is K. They have a high K. Which means what? Potassium. Potassium. The A stands for three things that start with an A. They are acidotic. What kind of acid does this? Metabolic. And that fits with Matt Kuzmo, doesn't it? A, they have acetone breath. Acetone breath, which means they have a fruit odor to the breath. And it's not always a nice mango essence. Either. It can be a rather funky fruity smell. And A, they have anorexia due to nausea. Anorexia. What's that mean? They don't want to eat. They don't want to eat. Why? Because they're nauseated. So, if you said to me, Mark, what are the signs and symptoms of DKA? I'd say, well, let me think here now. D, dehydration. So, they're what? Dry. Leakage membrane. Weeks ready. Pulse dry. Skin poor. Elasticity. Headache. What would the skin be if you're dehydrated? Poor elasticity. What else? Dry. What temperature? No. Water in your body performs the same function as water in your car. If you dehydrate your car, meaning spring a leak in your radiator, and you leak water out of your car, and you dehydrate your car, what will happen to your engine? In low overheat. So, water is a coolant. So, if you dehydrate, you overheat. Your skin will be what? Hot and flushed. Hot, flushed, dry. That's dehydration. See, I'm assuming you knew the dehydration signs. Maybe that was an assumption I shouldn't make. So, DKA, first you check off all the dehydration signs, right? Then what do you check off? Ketones, Ku-Smol, and K. Then you check off acidosis, acetone breath, and anorexia due to nausea. DKA. 1D, 3K, 3A. And those are the signs and symptoms of DKA. Well, what do you do for it? Well, they're dehydrated and their sugar's high. So, what do you do for the dehydration? IV fluids. Low or fast rate? Fast rate. This one would be around 200 an hour. Some of the fastest rates you'll use are these ones. Burn is, of course, the fastest rate that you run in the first phase. But these ones are pretty high. And what do you put in the bag? The IV bag. To lower the sugar. Regular insulin. You can run that. So, you're going to get an IV with regular insulin run at about 200 an hour. That's pretty standard. And the main solution doesn't matter. It doesn't matter whether it's normal saline, 0.45 D5, 0.45 D5W. You're going, but their sugar's high, why are they getting D5? What did I say about D5? 300 calories. So, even if you're running at 200 an hour, they're only getting 60 calories an hour. That's nothing. You see what I'm saying? And anyhow, the D5 molecule is small, so it just goes right out. As soon as it gets in your bloodstream, it goes into the tissue. It doesn't even stay in your bloodstream to contribute to your glucose. If you guys have ever been taught to worry about the dextrose in the IV bag because of a diabetic, that's poor teaching because that doesn't even stay in the veins. It goes into the tissue. The dextrose in the bag, if it's D5, will not create a hyperglycemia situation. Now, D10 will, D50 will, but D5 will not. So, don't worry about the dextrose in the bag. It's no big deal. We used to be all over that when I was in school. Oh, here's our buddy. Get the D5 out of there. Not real good practice anymore. Okay, number three, low blood glucose. I told you the type 1 is the same as type 2. Number four, high blood glucose in the type 2 is called HHNK, HHNC, and some places call it HHS or HHNS. Which one do you guys use? HHNK? Anybody use HHS? HHNS? HHNC? It's all the same thing. Who gets this? Which type? Why should you have known that a type 2 gets this? What in the name tells you it's a type 2? Non-ketotic. And whenever you see the prefix non, you know it's a type 2. Type 2s are the ones that have the non. Type 1 never has anything that has non in it. Now, how many of you in here, if you got a bunch of questions on HHNK, hyperosmolar, hypothalamic, non-ketotic coma, on your test, would kind of get a little nervous? Simply because of the length of the name. Well, this is actually one of the easiest questions you can get because it is very simple to understand. Letter B, this is dehydration. That's all it is. Here's my point. How many of you in here, if I told you, you have a choice of taking two tests? One test is 20 questions over the causes, signs and symptoms, and treatment of HHNK. And the other test is over the causes, signs and symptoms, and treatment of dehydration. Would you have a preference? Which one would you rather take? No, but before I said anything, half an hour ago, what would you have chosen? Dehydration, not HHNK. But what's the reality? It's the exact same test. So, here's my point. Wherever you see the phrase hyperosmolar, hyperglycemic, non-ketotic coma, you can pull that out and plug in what word? Dehydration. Answer that question, you will get it right 100% of the time. So, what would the skin look like in HHNK? Don't answer that. What would the skin look like in dehydration? Low water. Hot, flushed, dry. What would be the number one nursing diagnosis that you would see with HHNK? We'll refuse to answer that. What would be the number one nursing diagnosis you would see with dehydration? Fluid, volume, deficit would be your number one nursing diagnosis. What would be your number one nursing intervention or medical intervention for a client with HHNK? Well, I refuse to answer that. What would be the number one nursing or medical intervention in a patient who is dehydrated? Giving fluid. You see? What would be some outcomes you would want to see in a client with HHNK? Increased output. Coming what direction? Up. What's that? Moist mucous membranes. All the things that you would like to see if somebody were dehydrated. What would the outcomes of your treatment want to be? So I guess what I'm saying is don't make HHNK hard. Make it easy. It's nothing more than dehydration. It's actually DKA without the K or the A. Because if you take DKA and you take the K out and the A out, what do you have left? Dehydration. That's HHNK. Why do HHNKers not get the Ks and the As and only the Ds? Because they don't burn fat. They don't make ketones. If you don't make ketones, you don't get ketones. If you don't get ketones, you don't get acid. If you don't get acid, you don't Kusmol. If you don't Kusmol... I mean, if you don't get acid, you don't have the K shift that raises it. If you don't have the ketones, you don't have the acetone breath. And if you don't have that, your lining of your gut doesn't swell and make you nauseous. So what did I just rule off the DKA list? All of the what? Ks and all of the As and the only thing I had left was the D. That's why HHNK is just the D. Whereas DKA is the D, the K, the A. Does that make sense? I want you to look at this. Okay. Therefore, which one is the use of insulin most essential in treating? HHNK or DKA? Which one is insulin the most essential in treating? Well, if I said HHNK and DKA, you would immediately change HHNK to what? Dehydration. And if I said, in what situation do you need to use insulin? DKA or dehydration? What would you say? DKA. So the answer is DKA. You don't have to use insulin with HHNK. All you have to do is rehydrate them because they are dehydrated. By the way, which one is more life-threatening? Which one has a higher mortality rate, more people die of? HHNK or DKA? DKA. No, actually more die from HHNK. Which one, if a DKA-er comes into the ER and an HHNK comes into the ER, who is higher priority? The DKA-er. The DKA-er. Which doesn't seem to make any sense. Because I just said, who has a higher mortality rate? HHNK. HHNK. But who is a higher priority? DKA. DKA. Well, can someone explain that to me? They come in a lot later because they don't have the acidosis, the ketosis that makes people see symptoms. And so they get worse and worse and worse. So by the time they come, they're already bad. But a DKA-er is acutely ill with all these symptoms that we can quickly treat with a simple rehydration with insulin. You see? Whereas the HHNK-er will probably be treated with IVs but probably in such a bad state they're probably not going to make it anyhow. Is that what I'm saying? Now, who would die first if we didn't treat them? HHNK or DKA? DKA. But we treat them so they actually have a lower mortality rate even though it's more life-threatening. Did everybody get that? Okay. Long-term complications of diabetes are related to two problems. Oh, by the way, B said this is dehydration. C says the signs and symptoms are like signs and symptoms of dehydration and the treatment is rehydration. Did you get those blanks filled in? Good. Number five. The long-term complications of diabetes are related to letter A, poor tissue perfusion and B, peripheral neuropathy. Poor tissue perfusion and peripheral neuropathy. Now, what are some long-term complications? They are not DKA, HHNK, and hypoglycemia. Those are acute complications. I'm talking about renal failure, gangrene, stasis ulcers, blindness, impotence, heart disease, brain disease. So, if they ask you, diabetics have renal failure. What would this be due to? Well, it's one of two. Which two is it up? It's one of the two. Either what? Poor tissue perfusion or peripheral neuropathy. If it's renal failure, which one do you think it is? Poor tissue perfusion. If it's that they lost control of their bladder and they are now incontinent, what is that? Peripheral neuropathy. They can't feel it when they injure themselves. Peripheral neuropathy. They don't feel well once they injure themselves. Poor tissue perfusion. See, you're going to always blame it on either poor tissue perfusion or peripheral neuropathy, whichever one makes the most sense. It'll be pretty logical for you. Number six. Which lab test is the best indicator of long-term blood glucose control? The hemoglobin A1C. The HA1C. HA1C. The hemoglobin A1C. It's also called the glycosated hemoglobin. The glycosated hemoglobin. I've also heard it called the glycosylated hemoglobin. It's the same thing. Glycosylated hemoglobin, glycosated hemoglobin, hemoglobin A1C are all the same test. Now, what numbers do you want to see with the HA1C? You want it to be six and low. Six and low. Six and low. Just six. Now, on boards, they never test units. All you need to know is numbers, which is great. What hemoglobin A1C means you're out of control? Eight and above is out of control. So in the sixes and lower means in control. Eight and higher means out of control. So where's the problem? With a seven. So the question is, when they come in with a hemoglobin A1C of seven, what's the conclusion? Yeah. They're on the board. So what do they need? Some workup. They need some evaluation. They need to be brought in the hospital checking out what's going on. They might have some infection somewhere. So a hemoglobin A1C of seven means we need to check on you. Six means you're good to go. Eight means you're out of control. Seven means maybe. So just so you understand what the implications of those numbers. You'll see on TV that I just saw it advertised the other day. It said that a certain thing lowers the A1C .9, which actually is really almost the whole point, which could take you from out of control almost to control. So it doesn't sound like much of a change, but for an A1C, a .9 change is huge. All right. Let's get our... Is it stuck here? Here. Okay. Let's get our blood sugars up. I feel bad because we're going to end up doing dumping syndrome right after lunch. That's not good. That's kind of what happens. When we did that one day, we brought in our meal that day, and we were doing... We were supposed to do an anorexia.