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Nursing Field Notes / Endocrine Β· Diabetes Management Β· Med-Surg
🍬 DIABETES SET NG-290 Diabetes β€” the disease NG-292 Diabetes II β€” management NG-291 DKA vs HHS NG-288 Steroids

Diabetes II πŸ’‰

Part 2 of 2 β€” insulin, oral agents, sick days, hypoglycemia, feet and self-monitoring

NG-292 ENDOCRINE Β· MANAGEMENT PAGE ADHD-friendly visual edition

This page = the treatment. Which insulin, when it peaks, which pill does what, what to do on a sick day, how to rescue a low, and the foot-care teaching that prevents amputations. The sister page NG-290 β€” Diabetes = the disease: patho, type 1 vs type 2, the 3 P's, diagnostic numbers and long-term complications. Read that one first if the "why" isn't solid yet.

⏱️ Peaks + PlatesFood must be there when the insulin peaks β€” that is when hypoglycemia happens.
πŸ’‰ Only REGULAR goes IV"Regular goes right into the vein." Everything else is subcutaneous.
🚨 Rule of 1515 g fast carb β†’ wait 15 min β†’ recheck β†’ repeat if still ≀70.
🩺 Sick day = STILL take insulinIllness raises sugar. Never omit basal insulin because the patient isn't eating.
πŸ’‰

INSULIN

STEP 1 Β· TIMING IS EVERYTHING

Every insulin does the same job. The whole exam is when it starts, when it peaks, and how long it lasts β€” because the peak is when your patient gets into trouble.

πŸ“ˆ Onset Β· peak Β· duration β€” the action curves

INSULIN ACTION CURVES Β· hours after a subcutaneous dose Rounded standard teaching ranges β€” exact figures vary by product and source. Verify against your current drug reference and facility policy. 0246 8101214 16182022 24 HOURS INSULIN EFFECT PEAK PEAK BROAD PEAK NO pronounced peak β€” flat basal RAPID β€” lispro Β· aspart Β· glulisine onset β‰ˆ15 min Β· peak β‰ˆ1–2 h Β· duration β‰ˆ3–5 h SHORT β€” REGULAR (the only IV insulin) onset β‰ˆ30 min Β· peak β‰ˆ2–4 h Β· duration β‰ˆ6–10 h INTERMEDIATE β€” NPH (cloudy) onset β‰ˆ1–2 h Β· peak β‰ˆ4–12 h Β· duration β‰ˆ18–24 h LONG β€” glargine Β· detemir (clear, peakless) no marked peak Β· roughly 24 h basal coverage
🚨 NCLEX trap: never give a rapid-acting insulin and then let the meal be delayed. See the tray before you inject.
DEEPER DIVE The full pharmacology page for insulins is NG-224 β€” NCLEX Drugs 8 Β· Insulins in the Pharmacology set (open NG-224). This page assumes those timing bands rather than re-deriving them.
🧠 Rapid = Right now. Regular = Right into the vein. NPH = Not fast, Peaks in the afternoon. Glargine = Gone flat, Give once.

⚑ RAPID acting β€” lispro, aspart, glulisine

Give it with the food in front of you. Onset β‰ˆ15 min.

  • Clear. Given SQ (also used in insulin pumps).
  • Best choice for correcting a high sugar before a meal.
  • Highest short-term hypoglycemia risk if the meal doesn't arrive.
🧠 Tray at the bedside, then the needle.

πŸ’Š SHORT acting β€” REGULAR insulin

The only insulin that can go in a vein. Clear.

  • IV push or IV infusion (drip) β€” used in DKA/HHS and hyperkalemia.
  • SQ dosing usually ~30 min before a meal.
  • It is the insulin you draw up first when mixing with NPH.
🧠 "Regular goes Right into the vein." If a question puts any other insulin in an IV bag, that answer is wrong.

🌫️ INTERMEDIATE β€” NPH (the cloudy one)

  • Cloudy β€” the only routinely cloudy insulin. Gently roll between the palms to resuspend; never shake.
  • SQ only. Never IV, never in a drip.
  • Usually given twice a day; the broad afternoon peak means the patient needs food when it peaks.
🧠 Cloudy = Can't go in a vein.

πŸ›οΈ LONG acting β€” glargine, detemir

  • No peak, no mix. Clear, but never mixed in a syringe with another insulin.
  • Glargine typically once daily at the same time each day; detemir may be once or twice daily.
  • Provides the flat basal layer; meal coverage comes from a separate rapid/short insulin.
🧠 "No Peak, No Mix." Long-acting insulin is the mattress; rapid insulin is the pillow you add on top.

πŸ”¬ Where it goes in β€” sites, angle and the tissue underneath

SUBCUTANEOUS INJECTION Β· site + depth stay ~2 in (5 cm) from the umbilicus β‘  ABDOMEN β€” fastest, most predictable β‘‘ UPPER OUTER ARM β‘’ FRONT/OUTER THIGH β‘£ UPPER OUTER BUTTOCK β€” slowest Rotate within one region rather than hopping between regions β€” absorption differs by site. Do NOT inject a limb about to be exercised β€” the faster blood flow speeds absorption. Do not massage the site afterwards. AIR 90Β° 45Β° TARGET: subcutaneous FAT too deep = MUSCLE = absorbs too fast lipohypertrophy (same spot every day) epidermis dermis muscle 90Β° for most adults with a short pen needle; 45Β° if very thin or using a longer needle. STORAGE Unopened vials/pens: refrigerate. In-use: room temp, discard by the product's labeled in-use limit. Never freeze. Discard if clumped, frosted or discolored.
🧠 Abdomen is the freeway, buttock is the country road. Same insulin, different speed limit β€” so keep one patient in one neighborhood.

πŸ₯› Mixing NPH + Regular β€” clear before cloudy

MIXING Β· air into cloudy, air into clear, draw CLEAR then CLOUDY 1 Β· AIR into CLOUDY needle stays ABOVE the liquid 2 Β· AIR into CLEAR Regular insulin = clear 3 Β· DRAW the CLEAR Regular FIRST β€” always 4 Β· DRAW the CLOUDY NPH second β€” one syringe, both doses
🚨 Why clear first? If cloudy NPH gets into the Regular vial it contaminates the entire supply and changes its action. Contamination in the other direction is far less consequential.
🧠 "You want CLEAR days before CLOUDY ones." RN = Regular before NPH. Both mnemonics, same order.

⭐ 7 insulin rules that get tested

  • Peaks + Plates β€” food must be present at the peak.
  • No Peak, No Mix β€” glargine and detemir go alone in the syringe.
  • IV = Regular only β€” push or infusion.
  • Clear β†’ Cloudy when drawing up a mix.
  • Rotate sites; abdomen absorbs most predictably; stay ~2 in from the umbilicus.
  • Sick days = still take insulin, even if not eating (see below).
  • Hypoglycemia ≀70: awake β†’ feed them; not awake β†’ IV dextrose (or glucagon if no IV).
🧠 Say the list as a rhythm: Peaks · Mix · IV · Clear · Rotate · Sick · Low.
πŸ’Š

ORAL & NON-INSULIN AGENTS

STEP 2 Β· TYPE 2 ONLY

Diet and exercise come BEFORE any pill. Then metformin is usually the first-line drug. Learn each class by which organ it argues with.

πŸ—ΊοΈ Which organ does each class talk to?

FIVE ORGANS, FIVE MECHANISMS LIVER BIGUANIDE Β· metformin ↓ liver glucose output Β· ↑ insulin sensitivity Minimal hypoglycemia alone Β· usually FIRST-line ⚠ lactic acidosis Β· renal caution Β· IV contrast PANCREAS (beta cells) SULFONYLUREAS Β· glipizide Β· glyburide Β· glimepiride Squeeze the beta cell β†’ more insulin released ⚠ HYPOGLYCEMIA is the headline risk Β· weight gain avoid alcohol Β· sun protection Β· caution in elderly MEGLITINIDES (repaglinide) = fast & short β€” no meal, no dose MUSCLE & FAT TZD Β· pioglitazone ↑ sensitivity at muscle/fat ⚠ FLUID RETENTION avoid in heart failure monitor liver Β· weight gain SMALL INTESTINE Ξ±-GLUCOSIDASE Β· acarbose Slows carb breakdown in the gut ⚠ treat lows with pure GLUCOSE INCRETIN drugs GLP-1 "-tide" (injected, NOT insulin) β€” slows gastric emptying Β· weight loss DPP-4 "-gliptin" = oral, gentler KIDNEY SGLT2 INHIBITORS Β· "-flozin" canagliflozin Β· dapagliflozin Β· empagliflozin Block glucose reabsorption β†’ glucose is peed OUT ⚠ dehydration Β· genital yeast & UTI Β· euglycemic DKA
🧠 Liver · Pancreas · Muscle · Gut · Kidney. Five doors into the same problem. Name the organ and the side effects fall out of it.

πŸ’Š METFORMIN β€” the first-line one

Answer first: metformin rarely causes hypoglycemia on its own, because it doesn't force insulin out of the pancreas β€” it tells the liver to stop dumping glucose.

  • Often supports modest weight loss; take with food to blunt GI upset (nausea, diarrhea, metallic taste).
  • Lactic acidosis is the rare, serious risk β€” much more likely with renal impairment, hypoxia, sepsis or heavy alcohol use.
  • Teach: avoid excessive alcohol. Report muscle aches, unusual fatigue, trouble breathing, feeling very cold.
  • Usually held around iodinated IV contrast studies β€” follow your facility protocol for when to stop and when to restart after renal function is rechecked.
  • Long-term use can lower vitamin B12.
🧠 Metformin argues with the LIVER, not the pancreas. That single fact explains "no hypoglycemia" and "no weight gain".

🚨 SULFONYLUREAS β€” the hypoglycemia class

Glipizide, glyburide, glimepiride β€” they make the beta cell release insulin whether or not the patient ate.

  • Hypoglycemia is the #1 adverse effect β€” skipped meals are dangerous.
  • Weight gain is expected.
  • Alcohol β€” can trigger both hypoglycemia and a flushing/disulfiram-like reaction with some agents.
  • Photosensitivity β€” sunscreen and protective clothing.
  • Use cautiously in older adults and in renal or hepatic impairment (drug accumulates β†’ prolonged lows).
🧠 "-ide" squeezes the pancreas β†’ the sugar can slIDE too low.

⚠️ TZD β€” pioglitazone Β· the "ONE heart" drug

  • Improves insulin sensitivity in muscle and fat.
  • Fluid retention β†’ avoid in heart failure. New pitting edema, sudden weight gain, crackles or dyspnea = stop and report.
  • Monitor liver function; avoid in active liver disease.
  • Weight gain and increased fracture risk with long-term use.
🧠 Pioglitaz-ONE β€” ONE heart, don't drown it.

πŸ’§ SGLT2 inhibitors β€” "-flozin"

Canagliflozin, dapagliflozin, empagliflozin. They block glucose reabsorption in the kidney so glucose is peed out.

  • Expect more urination β†’ dehydration, orthostatic hypotension, dizziness.
  • Genital yeast infections and UTIs β€” sugary urine feeds organisms. Teach perineal hygiene and to report burning/itching.
  • Can cause ketoacidosis with only mildly elevated glucose ("euglycemic DKA") β€” take symptoms seriously even when the meter looks fine.
🧠 "-flozin makes you flow-zin." More urine, more thrush, more falls in an older adult.

⭐ Which drug does which thing β€” quick table

Class Β· exampleMechanismThe thing you must teach or watch
Biguanide Β· metformin↓ hepatic glucose output, ↑ sensitivityLactic acidosis risk; hold around IV contrast per policy; GI upset; ↓ B12
Sulfonylurea Β· glipizide, glyburideStimulates insulin releaseHypoglycemia, weight gain, alcohol, sun sensitivity
Meglitinide Β· repaglinideFast, short insulin release with mealsNo meal β†’ no dose
TZD Β· pioglitazone↑ insulin sensitivityFluid retention β†’ avoid in heart failure; liver monitoring
Ξ±-glucosidase inhibitor Β· acarboseSlows carbohydrate absorptionFlatulence/bloating; treat lows with pure glucose only
DPP-4 Β· sitagliptin ("-gliptin")Prolongs incretin hormonesLow hypoglycemia risk; report severe abdominal pain (pancreatitis)
GLP-1 agonist Β· liraglutide ("-tide")Incretin mimic; slows gastric emptyingInjected but NOT insulin; nausea, weight loss; report severe abdominal pain
SGLT2 Β· empagliflozin ("-flozin")Dumps glucose into the urineDehydration, UTIs/yeast, euglycemic DKA
🚨 Oral agents are for type 2. A person with type 1 makes no insulin β€” pills that squeeze a dead pancreas cannot work. Type 1 always needs insulin.
🧠 Only the secretagogues (sulfonylureas, meglitinides) and insulin routinely cause hypoglycemia. That is the single most useful sorting rule in the whole section.
🍽️

DIET & SICK DAYS

STEP 3 Β· TEACH

Diet and exercise come before every pill and every injection β€” and illness is the day the plan usually falls apart.

πŸ₯— DIET β€” brown beats white

Answer first: consistent carbohydrate, high fiber, spread across the day.

  • Choose BROWN / whole: beans, brown rice, whole-grain bread, oats, vegetables, nuts β€” high fiber = slower glucose rise.
  • Limit WHITE / refined: white bread, white rice, potatoes and fries, sugary cereal.
  • Avoid concentrated simple sugars β€” regular soda, candy, fruit juice, sweet tea β€” except when treating a low.
  • Do not skip meals, especially on a secretagogue or insulin. Consistency matters more than perfection.
  • Alcohol: with food only, and it can cause delayed hypoglycemia hours later.
SAME CARBS, TWO CURVES baseline WHITE Β· refined BROWN Β· high fiber spike… …then crash slow, low, steady time after the meal β†’
🧠 If it's white and fluffy, the sugar spikes. If it's brown and chewy, it drips in slowly.

πŸƒ EXERCISE β€” the free insulin

  • Activity lowers glucose and improves receptor sensitivity for hours afterwards.
  • Check glucose before exercising; carry a fast carbohydrate.
  • Don't inject into a limb you're about to work hard β€” faster absorption, faster low.
  • Wear proper footwear and inspect feet afterwards.
  • If glucose is very high with ketones present, don't exercise β€” it can push the sugar higher.
🧠 Exercise is a dose of insulin you didn't have to inject β€” so count it like one.

πŸ€’ SICK DAY RULES β€” the most-missed teaching point

Illness RAISES blood sugar. Stress hormones push glucose up even when the patient can't eat. Never omit basal insulin just because the patient isn't eating.

1
Keep taking insulin. Doses may need adjusting β€” they do not get skipped. Type 1 patients who stop insulin on a sick day go into DKA.
2
Check glucose more often β€” commonly every 3–4 hours, per the patient's plan.
3
Check ketones (urine or blood) when sick, or when glucose stays high β€” especially in type 1.
4
Keep drinking. Sugar-free fluids if glucose is high; carbohydrate-containing fluids (broth, gelatin, regular soda, juice) if they cannot eat solids and sugar is falling.
5
Call the provider for: vomiting/diarrhea that won't stop, inability to keep fluids down, moderate-to-large ketones, persistently high glucose despite correction, fever, confusion or rapid breathing.
🚨 Classic question: "A child with type 1 is nauseated and not eating β€” do we still give insulin?" YES. Adjust and monitor, but the insulin does not stop.
🧠 Sick days SICK: Still take insulin · Increase monitoring · Check ketones · Keep fluids going.

🧾 Everyday self-care teaching

  • Carry fast sugar at all times β€” glucose tabs in the bag, the car and the desk.
  • Medical alert identification β€” bracelet or card.
  • Never share a pen, needle or lancet, even with a new needle.
  • Dispose of sharps in a rigid, puncture-proof container.
  • Dental care β€” gum disease worsens control, and control worsens gum disease.
  • Vaccinations β€” influenza and pneumococcal are routinely recommended; infection is the #1 trigger of a crisis.
🧠 Sugar in the pocket, ID on the wrist. Two habits that end most emergencies before they start.
🚨

HYPOGLYCEMIA

STEP 4 Β· THE EMERGENCY

Low sugar kills faster than high sugar. The brain has no glucose reserve.

⏱️ THE RULE OF 15 β€” drawn

62 mg/dL GLUCOSE ≀ 70 + symptoms? Treat now. AWAKE & able to swallow? YES GIVE 15 g of FAST carbohydrate 4 oz juice or regular soda 3–4 glucose tablets 1 tbsp honey or sugar 8 oz low-fat milk ❌ NOT chocolate, peanut butter, ice cream or whole milk β€” FAT SLOWS ABSORPTION when you need speed. WAIT 15 MINUTES Β· RECHECK Still ≀ 70? Repeat the 15 g. Above 70? Give a snack with protein + complex carbohydrate if the next meal is more than an hour away. NO NOTHING BY MOUTH IV DEXTROSE 50% per order β€” fastest route if there is IV access NO IV? β†’ GLUCAGON IM / SQ / intranasal per order. Turn the patient on their SIDE β€” glucagon often causes vomiting. Then recheck glucose, and give carbohydrate by mouth as soon as it is safe to swallow.
🧠 Awake = Ask them to eat. Asleep = give the sugar in a vein. Never put food or fluid in the mouth of someone who cannot protect their airway.

🚨 Recognize it before the meter does

HIWASH β€” Headache Β· Irritable Β· Weakness Β· Anxious Β· Sweaty/Shaky Β· Hungry. Plus pallor, cool clammy skin, tachycardia, blurred vision, confusion, slurred speech.

Hypoglycemia unawareness β€” after many lows, or with beta blockers or autonomic neuropathy, the warning symptoms disappear. Beta blockers can mask the tremor and tachycardia, but sweating usually persists.

🚨 New confusion, odd behavior or a "drunk-looking" patient with diabetes = check a glucose before anything else.
🧠 Any change in behavior is a blood sugar until proven otherwise.

βœ… After the rescue β€” close the loop

  • Recheck glucose; document the episode, the treatment and the response.
  • Ask why: missed meal? extra activity? dose error? new drug? alcohol? illness?
  • Notify the provider for recurrent or severe lows β€” the regimen probably needs changing.
  • Re-teach the patient and family, and check that a glucagon kit is available and in date if they are on insulin.
🧠 Treat the low, then hunt the cause. A low that isn't explained will happen again tonight.
🦢

FEET & SELF-MONITORING

STEP 5 Β· PREVENT THE AMPUTATION

Neuropathy removes the pain warning, poor circulation removes the healing. A diabetic foot is a delicious feast for bacteria.

πŸ”¬ Foot care, drawn β€” and how to cut the nails

THE DIABETIC FOOT Β· where it breaks and why β‘  great toe β‘‘ metatarsal heads (the ball) β‘’ heel HIGH-PRESSURE ULCER SITES CROSS-SECTION Β· under the ball METATARSAL BONE . callus β†’ pressure β†’ painless ulcer β†’ bone If it reaches bone: osteomyelitis β†’ amputation risk TRIM NAILS STRAIGHT ACROSS . AVOID β€” "F.O.O.T." F β€” Flip-flops, sandals, heels, barefoot O β€” OTC corn & callus removers O β€” Overly HOT baths, pads, bottles T β€” Toe injuries; never cut nails curved Also avoid: nylon socks Β· vigorous rubbing Β· heavy powder between toes Β· self-cut calluses Test bath water with a THERMOMETER β€” numb feet cannot judge temperature.
🧠 Delicious Feast for bacteria. Goal in four words: clean · dry · injury-free · inspected daily.

βœ… Daily foot routine β€” the exam answers

  • Inspect DAILY, not weekly β€” use a mirror or ask a family member for the soles.
  • Wash with warm (not hot) water and mild soap; pat dry, especially between the toes.
  • Lotion on the top and bottom, never between the toes β€” moisture there breeds fungus.
  • Soft cotton or moisture-wicking socks, changed daily. Not nylon, no tight elastic bands.
  • Well-fitting closed shoes, broken in gradually; shake them out before putting them on.
  • Never go barefoot, indoors or out.
  • Trim nails straight across; a podiatrist manages thick nails, corns and calluses.
  • Report any non-healing sore, color change, or new numbness to the provider.
🧠 Look at the feet at every single visit. Shoes and socks off β€” this is the assessment students forget.

🩸 Self-monitoring of blood glucose

  • Wash hands with soap and warm water and dry β€” food residue on a finger gives a falsely high reading.
  • Use the side of the fingertip, not the center pad β€” fewer nerve endings, less pain.
  • Rotate fingers; let the arm hang or warm the hand if the drop won't form. Don't squeeze hard.
  • Check strip expiry and coding, and store strips in their sealed container.
  • Bring the meter and the log to appointments; continuous glucose monitors still need confirmation fingersticks in some situations.
🚨 Meter readings and lab values can differ. If the reading does not match the patient in front of you, recheck and consider a lab draw.
🧠 Dirty finger = fake high = wrong insulin dose. Wash first, every time.
⚑

QUICK RECALL

SAY IT OUT LOUD
⏱️ Peaks + PlatesFood at the peak, or the sugar bottoms out.
πŸ’‰ Clear β†’ Cloudy Β· Regular β†’ NPHAnd long-acting: No Peak, No Mix.
🚨 15 Β· 15 Β· repeatAwake β†’ feed. Not awake β†’ IV D50 (or glucagon, side-lying).
🦢 Daily · not weeklyInspect feet every day · straight-across nails · never barefoot.

➑️ Where to go next

Disease side: NG-290 β€” Diabetes (patho, type 1 vs 2, 3 P's, diagnostic numbers, complications). Emergencies: NG-291 β€” DKA vs HHS. Drug page: NG-224 β€” NCLEX Drugs 8 Β· Insulins (open). Steroids raise glucose in everyone: NG-288.

🎯 Cover & check β€” 10 rapid-fire questions
Q1: Which insulin can be given IV?
Regular insulin only β€” IV push or IV infusion. "Regular goes right into the vein." Everything else is subcutaneous.
Q2: You are mixing NPH and Regular. What order, and why?
Air into the cloudy NPH vial, air into the clear Regular vial, then draw Regular (clear) first and NPH (cloudy) second β€” so cloudy NPH never contaminates the Regular vial.
Q3: Which insulins must never be mixed with anything?
The long-acting basal insulins β€” glargine and detemir. "No peak, no mix."
Q4: A patient with type 1 has the flu, is vomiting and eating nothing. Do they take their insulin?
Yes. Illness raises blood glucose. Basal insulin continues, glucose is checked every 3–4 hours, ketones are checked, and fluids are pushed. Stopping insulin is how patients arrive in DKA.
Q5: List four things that count as 15 g of fast carbohydrate.
About 4 oz (Β½ cup) of fruit juice or regular soda, 3–4 glucose tablets, 1 tablespoon of honey/sugar, or 8 oz of low-fat milk. Avoid fatty foods β€” fat delays absorption.
Q6: Why is metformin usually held around IV contrast?
Contrast can impair renal function, and metformin plus renal impairment increases the risk of lactic acidosis. Follow facility policy for when to stop and when to restart after renal function is rechecked.
Q7: A patient on pioglitazone reports new ankle swelling and shortness of breath. What do you suspect?
Fluid retention worsening or unmasking heart failure. Hold and report β€” TZDs are avoided in heart failure. Assess weight, edema, lung sounds and dyspnea.
Q8: Which oral class demands that a low be treated with pure glucose rather than table sugar?
Alpha-glucosidase inhibitors (acarbose, miglitol). They block the enzyme that splits sucrose, so table sugar won't be absorbed fast enough β€” give glucose tablets or gel.
Q9: Where is the best site for insulin absorption, and what is the landmark rule?
The abdomen β€” fastest and most predictable. Stay about 2 inches (5 cm) away from the umbilicus, and rotate within the region rather than jumping between body areas.
Q10: Give four foot-care teaching points that show up as correct answers.
Inspect feet daily; wash in warm (not hot) water and dry carefully between the toes; wear well-fitting closed shoes and soft cotton socks, never barefoot; cut nails straight across and report any non-healing sore.