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Nursing Management Diabetes Mellitus

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Title: Nursing Management Diabetes Mellitus


1
Nursing Management Diabetes Mellitus
  • Covenant School of Nursing
  • N201 Fall, 2009
  • Gloria Rodriguez, MSN.RN,CDE

2
Objectives
  • By the end of this lecture students should be
    able to
  • Differentiate between type 1 and type 2
  • diabetes mellitus
  • Identify the diagnostic and clinical
    significance of blood glucose test results
  • Describe the major complications of DM
  • Differentiate between DKA and HHNS

3
Diabetes Mellitus
  • A chronic multi-system disease related to
    abnormal insulin production or impaired insulin
    utilization.

4
Risk Factors
  • Family Hx. Of diabetes
  • Obesity esp. abdominal and viseral adiposity.
  • BMIgt 27
  • Race/Ethnicity
  • GDM or babies gt 9 lbs.
  • Mother is more at risk of developing DM if she
    has big babies
  • HTN gt 140/90 mm Hg
  • Triglycerides gt 200mg/dL
  • Prev. impaired glucose tolerance

5
Causes
  • Genetics
  • Autoimmune
  • Viral
  • Environmental

6
Metabolic Processes
  • Three Metabolic processes are important in
    ensuring a supply of glucose for body fuel.
  • 1) Glycolysis-the process through which glucose
    is broken down into water and carbon dioxide with
    the release of energy

7
Metabolic Processes
  • 2) Glycogenolysis- the breakdown of stored
    glycogen ( from the liver or skeletal muscles).
    This action is controlled by 2 hormones
  • epinephrine-breaks down glycogen in the muscle
  • glucagon-breaks down glycogen in the
    liver. Glucose from here can be directly released
    into the blood stream and used by the nervous
    system

8
Metabolic Processes
  • 3) Gluconeogenesis-building of glucose from new
    sources.
  • Hormones that stimulate gluconeogensis
  • Glucagon
  • Glucocorticoid hormones
  • Thyroid hormones
  • Process usually occurs in the liver

9
Normal Insulin Metabolism
  • Counterregulatory hormones. They work to oppose
    the effects of insulin. These hormones work to
    increase blood glucose levels by stimulating
    glucose production and output by the liver and
    decreasing the movt of glucose into the cells.
  • Glucagons
  • Epinephrine
  • Growth hormone
  • Cortisol

10
Hormonal Control of Metabolism
  • Insulin
  • A hormone secreted by the beta cells in the islet
    of Langerhans,
  • Normally released in small increments when food
    is ingested.
  • Controls blood glucose levels by regulating
    glucose production and storage
  • Insulin is regulated by serum glucose levels.
  • Consists of 2 polypeptide chains
  • The amt of insulin a person is secreting can be
    tested by checking the levels of C peptide
  • Rise in plasma insulin after a meal stimulates
    storage of glucose as glycogen in the liver and
    muscle. It also inhibits gluconeogenisis and
    enhances fat deposition (enhances fat to be
    placed/stored in the adipose tissue) in the
    adipose tissue and increase protein synthesis
  • The fall in insulin levels during the night when
    youre not eating facilitates the release of the
    stored glucose from the liver, protein from the
    muscles and fat, and thats how it kind of
    compensates for your hypoglycemia

11
Insulin
  • Insulin and glucagon
  • are hormones secreted
  • by islet cells within the
  • pancreas
  • Insulin is normally
  • secreted by the beta
  • cells (a type of islet cells)
  • of the pancreas
  • Stimulus for insulin is
  • high blood glucose levels

12
Hormonal Control of Metabolism
  • Amylin
  • 2nd beta cell hormone
  • Effects of Amylin
  • Amylin and insulin together suppress the
    secretion of glucagon by the liver
  • Amylin slows the transfer of nutrients to the
    intestine

13
Continued.
  • Glucagon
  • Produced in the alpha cells of the islets of
    Langerhans in the pancreas
  • Transported via the portal vein to the liver
  • Glucagon acts in opposition to insulin
  • Stimulates the break-down of glycogen and fats to
    glucose and promotes gluconeogensis from fats and
    proteins

14
Continued.
  • Catecholamines
  • Epinephrine and norepinephrine
  • Help maintain glucose levels during stressful
    situations by
  • 1. inhibiting insulin release and decreasing
    movement of glucose into cells
  • 2. promoting glycogenolysis by converting
    muscle and liver glycogen to glucose
  • 3 Increasing lipid activity, conserving energy.
    Causes mobilization of fatty acids and conserves
    glucose. The conservation of blood glucose
    mediated by these actions is important in the
    homostatic effect which occurs with hypoglycemia
    to increase the blood glucose levels

15
Continued.
  • Somatostatin
  • Produced in the pancreas by the delta cells in
    the islets of Langerhans
  • Somatostatin inhibits the secretion of insulin,
    glucagon and growth hormone.

16
Diabetes Classifications
  • Type 1
  • Type 2
  • Decreased sensitivity to insulin and impaired
    beta cell functioning which results in decreased
    insulin production
  • Gestational diabetes mellitus
  • Pre-diabetes
  • Secondary

17
Type 1 Diabetes Mellitus
  • Formerly Known as insulin-dependent
  • Destruction of their pancreatic cells, genetic,
    immunologic, and possibly environment
  • Persons do not inherit Type 1 itself but rather
    have a genetic predisposition

18
DCCT Study
  • Diabetes Control and Complications Trial (DCCT)
    conducted in 1993
  • Results showed that you can prevent the
    complications of diabetes.
  • Retinopathy
  • Nephropathy
  • Neuropathy
  • Maintaining blood glucose as close to normal as
    possible prevents or slows the progression of
    long-term diabetic complications

19
Type 2 Diabetes Mellitus
  • Most Prevalent
  • Two main problems
  • Insulin resistance
  • Impaired insulin secretion
  • Inappropriate glucose production by liver
  • Alteration in the production of hormones and
    cytokines by adipose tissue.

20
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21
Gestational Diabetes
  • Higher risk of C-section
  • Perinatal death
  • Neonatal complications
  • Risk of developing type 2 DM in 5 to 10 years is
    increased.

22
Gestational Diabetes
  • Any degree of glucose intolerance that causes
    during pregnancy.
  • Hyperglycemia develops during pregnancy-
    secretion of placental hormones (which causes
    insulin resistance)

23
Gestational Diabetes
  • High risk women should be screened at 24-28 weeks
    of gestation
  • Need oral glucose tolerance test or glucose
    challenge
  • A 2 hr. fasting level after 100ml glucose load of
    155 would indicate GDM

24
Secondary Diabetes
  • Causes
  • Damage/injury/interference or destruction of
    pancreas
  • Conditions
  • Cushing's
  • Hyperthyroidism
  • Recurrent pancreatitis
  • Use of parenteral nutrition

25
Secondary Diabetes
  • Medications
  • Corticosteroids
  • Thiazides
  • Dilantin
  • Atypical antipsychotics
  • Resolves when treatment of underlying condition
    is treated

26
Clinical Manifestations of Type 1 DM
  • Frequent urination
  • Increase in thirst
  • Weight loss
  • Increase hunger
  • Weakness

27
Clinical Manifestation of Type 2 Diabetes
  • Type 2 Non-specific Gradual Onset Include
    classic signs of Type 1
  • Most common signs of Type 2
  • Fatigue
  • Recurrent infections
  • Recurrent vaginal yeast infections
  • Prolonged wound healing
  • Visual changes- Blurred vision

28
Diagnostic Studies
  • Three Methods
  • Fasting plasma glucose level-gt
  • 126 mg-dl- no caloric intake for 8hr
  • Random or casual plasma glucose gt
  • 200mg/dl plus S/S
  • Two-hour OGTT level- gt 200mg/dl using a 75g
    glucose load

29
Assessment
  • History
  • Signs related to Dx. Of DM
  • hyperglycemia
  • hypoglycemia
  • Monitor frequency, timing, severity and
    resolution
  • BS monitoring
  • Status of symptoms
  • Adherence to Tx. Regimen
  • Lifestyle. culture, psychosocial and economic
    factors
  • Effects of complications

30
Assessment
  • Physical Exam
  • B/P sitting and lying-(orthostatic chg.)
  • BMI
  • Dilated eye exam
  • Foot exam
  • Skin exam
  • Neuro. exam
  • Oral exam

31
Continued
  • Labs
  • Hgb A1C
  • A long-term measure of glucose control that is a
    result of glucose attaching to hemoglobin for the
    life of the rbc (120 days).
  • Fasting lipid profile
  • Microalbuminuria
  • Serum Creatine
  • UA
  • EKG
  • Referrals-Opthal., Podiatry, Dietician

32
Goal
  • Be an active participant
  • To experience few or no episodes of acute
    hyper/hypoglycemia emergencies
  • Maintain BS levels as close to normal
  • Prevent, minimize or delay complications
  • Adjust lifestyle to decrease stress

33
Diabetes Prevention Program
  • Obesity 1 predictor of type 2 DM
  • DPP showed a modest wt. loss of 5-10 of body wt.
    with regular exercise-30 min 5X/wk
  • Dropped the risk of developing type 2 DM up to 58

34
Type 2 Diabetes Mellitus
  • Metabolic Syndrome is increased with Type 2 DM
  • Characterized by
  • Insulin resistance
  • Elevated insulin levels
  • High triglycerides
  • Decreased HDL levels
  • Increased LDL levels
  • HTN

35
Type 2 Diabetes Mellitus
  • Metabolic Syndrome
  • Risk Factors
  • Central obesity
  • Sedentary lifestyle
  • Westernization
  • Certain ethnic groups

36
Five Components of Diabetes Management
  • Nutritional management
  • Exercise
  • Monitoring
  • Pharmacologic management
  • Education

37
Educators
  • Certified Diabetes Educators-CDE
  • Staff Nurses
  • RN or LVN

38
DRUG THERAPY
39
Types of Insulin
  • Only human insulin is used
  • Insulin's differ in onset, peak, and duration
  • Matched to clients activity

40
Rapid-Acting Insulin
  • Humalog or Novolog (LISPRO) (Aspart) (Glulisine)
  • Onset 10 30 min. Peak 1-2 hours. Effects last 2
    hrs 6 hrs
  • Used to
  • Rapidly reduce glucose level
  • Treat postprandial hyperglycemia
  • Prevent nocturnal hypoglycemia
  • Usually one shot a day before each meal for a
    total of 3 shots a day

41
Short-Acting Insulin
  • Humilin R, Novolin R, ReliOn R
  • Onset 30 min. 1 hr, Peak 2 4 hr
  • Effects last 4 6 hrs
  • Administer 20-30 mins. before eating
  • If mixing with NPH Regular is always drawn up
    first.

42
Intermediate Acting Insulin
  • NPH, Novolin N, Humulin N, ReliOn N
  • Cloudy
  • Onset 2 4 hrs, Peak 4 14 hrs
  • Effects last 16 24 hrs
  • 30 mins before meal

43
Long-Acting Insulin
  • Glargine (Lantus) clear
  • Onset 1-2 hours
  • Duration 12 - 24 hours
  • No peak
  • Cannot mix with other insulins
  • Cannot Prefill
  • Normally given once a day
  • Detemir (levemir) clear
  • (onset 3-4, peaks in 3-9, duration is 6-23
    hours)
  • Both are for basil gylcemic control, doesnt
    control post prandial levels (levels after you
    eat)

44
Storing Insulin
  • Insulin can be stored at room temp. for 30 days
  • In the refrigerator until expiration date
  • Pre-filled pens 30 days in refrigerator
  • Pre-filled pens with insulin mixture are usually
    good for 30 days

45
Dos and Donts of Insulin
  • Keep spare insulin
  • Inspect for flocculation (frosted whitish
    coating) before use
  • Avoid extreme temperatures , do not freeze
  • Keep out of direct sunlight or in a hot car

46
Selecting Sites
  • Recommendations
  • Do not use same site more than once in 2-3 weeks
  • Do not inject insulin to limb which will be used
    to exercise.
  • Use same anatomic area at the same time of day

47
Selecting Sites
  • Abdomen- more stable and radid absorption
  • Arms- posterior surface
  • Thighs anterior surface
  • Hips

48
Insulin Syringes
  • Syringes selected should match insulin
    concentration
  • 3 types of syringes available
  • 1 ml-holds 100 units
  • 0.5ml-holds 50u
  • 0.3 ml-holds 30u

49
Complications of insulin Therapy
  • Local allergic reaction( itching, erythema, and
    burning around inject. Site
  • Systemic allergic reactions (urticaria and
    antiphylactic shock)
  • Insulin lipodystrophy( atrophy of tissue)

50
Complications of Insulin Therapy
  • Dawn Phenomenon-hyperglycemia that is present
    when awakening from release of counterregulatory
    hormones in the predawn hours.
  • More severe when growth hormone is peaking
    (Adolescence and young adulthood)
  • Treatment- adjustment in timing of insulin or an
    increase in insulin

51
Complications of Insulin Therapy
  • Somogyi effect
  • Rebound effect overdose of insulin produces
    hypoglycemia
  • During the hours of sleep
  • Counterreglatory hormones released , stimulate
    lipolysis, gluocneogensis, and glycogenolysis and
    in turn produce rebound hyperglycemia and ketosis.

52
Major Classes of Medications
  • Thiazolidnedones Biguanides Drugs that
    sensitize the body to insulin and/or hepatic
    glucose
  • production
  • Sulfonylures Meglitnides
  • Drugs that stimulate the pancreas to make more
    insulin

53
Major Classes of Medications
  • Alpha-glucosidase Inhibitors
  • Drugs that slow the absorption of starches
  • Incretin Mimetic
  • Stimulate release of insulin, decrease
    glucagon secretion, increase satiey and decrease
    gastric emptying
  • Amylin Analog
  • Decrease gastric emptying , decrease
    glucagon secretion, decrease endogenous glucose
    output from liver, increase satiey

54
Incretin Mimetic
  • Byetta Exenatide
  • Synthetic peptide stimulates release of insulin
    from pancreatic B cells.
  • Suppression of glucagon, decrease glucose from
    liver
  • Slowing of gastric emptying
  • Not indicated with insulin use
  • Administer SubQ

55
Nutritional Therapy
56
Nutrition
  • Nutrition meal planning and weight control are
    the foundation of diabetes self-management
  • Need to control total caloric intake to attain or
    maintain a reasonable body weight and have good
    glycemic control

57
Nutrition Management Goals
  • Near normal blood glucose
  • Meet energy needs
  • Achieve lipid profile and B/P levels to reduce
    cardiovascular risks
  • Improve health thru healthily food choices and
    exercise
  • Cultural preferences of each individual

58
Nutrition Management
  • Weight loss is the key to treatment
  • BMI of 25 29 is considered overweight
  • BMI 30 is considered obese
  • Obesity is associated with increased resistance
    to insulin
  • http//www.nhlbi.nih.gov/guidelines/
  • obesity/bmi_tbl.htm for a BMI table

59
Meal Planning
  • Meal plans needs to be adjusted to patients
    ethnic background and culture.
  • If patient is on insulin, timing and meal content
    can be adjusted if a person is exercising.
  • Advances of insulin allows for more flexibility.

60
Meal Planning
  • Review patients diet history.
  • Identify patients eating habits and lifestyle.
  • Assess need for weight loss, weight gain, or
    weight maintenance.

61
Dietary Needs
  • For most diabetics a healthy diet consists of
  • 50 to 60 of calories from carbohydrates
  • 10-20 of calories from protein
  • 20-30 or less of calories from fat

62
Carbohydrates
  • Recommended 50 to 60 of calories from
    carbohydrates
  • Carbohydrates consist of sugars and starches
  • Carb. counting is a useful tool for blood glucose
    management
  • Low Carb. Diets are not recommended for persons
    with DM

63
Fats
  • Recommended fat content lt20-30 of total calories
  • Saturated fats limited to 10 total calories
  • Limit total dietary cholesterol to lt300mg per day
  • May help reduce cholesterol levels

64
Proteins
  • Less than 10 of total energy consumed.
  • Moderate to high protein not recommended- Too
    much saturated fat and unnecessary stress on
    kidney to excrete excess nitrogen

65
Fiber
  • Helps lower total cholesterol and low-density
    lipoprotein cholesterol in the blood
  • Soluble and Insoluble
  • Addition/increase of fiber in the meal plan
    should be gradual

66
Alcohol
  • High in calories
  • No nutritive value
  • Promotes triglycerdemia
  • Promotes hypoglycemia
  • Weight gain

67
Considerations
  • Decrease caloric intake by 500-1000 calories if
    client needs to lose 1-2 per week.
  • Self-prescribed diets not good due to hormonal
    changes that can occur from fasting. Include
    increased synthesis and release of glucagons and
    stimulate liver glucogenalysis and could increase
    BS

68
Different Meal Plans
  • Carbohydrate Counting
  • Exchange List
  • Food Pyramid Guide
  • Glycemic Index
  • Portion Control
  • Plate Method

69
Sweeteners
  • Nutritive
  • Contain calories
  • Fructose (fruit sugar)
  • Sorbitol and Xylitol
  • Non-nutritive
  • Few or no calories
  • NutraSweet (aspartame)-4 cal. Per packet
  • Splenda (sucralose)

70
EXERCISE
71
Benefits of Exercise
  • Lowers blood glucose
  • Decrease Cardiovascular risk factors.
  • Psychological well being.
  • Improvement in insulin secretions.

72
Exercise
  • Lowers blood glucose
  • Increases uptake of glucose by body muscles
  • Improving insulin usage
  • Improves circulation and muscle tone

73
Benefits of Exercise
  • Lowers blood glucose
  • Decreases cardiovascular risk factors
  • Improved functioning of the cardiovascular
    system.
  • Improved strength and physical activity capacity
  • Reduced risk factors of coronary artery disease

74
Exercise
  • Resistance strength training increases lean
    muscle mass thereby increasing resting metabolic
    rate.
  • Also helps to decrease weight, decrease stress,
    and maintains well being.

75
Exercise and Cardiovascular Diseases
  • Alters blood lipid levels
  • Increases levels of high density lipo-protein
    (HDL)
  • Decreases total cholesterol and triglyceride
    levels
  • Important to patients with diabetes with an
    increase risk of cardiovascular disease.

76
Precautions with Exercise
  • Blood glucose levels gt 250 mg/dl and ketones
    urine should not exercise until urine test
    negative for ketones and blood glucose levels are
    near to normal ( ADA, 2004).

77
Precautions
  • Exercising increases blood glucose
  • Exercising increases the secretion of glucagon,
    growth hormone and catecholamines
  • Liver releases more glucose resulting in an
    increase in blood glucose level.

78
Type 1 and Exercise
  • Do not have same effect as Type 2
  • Hypoglycemia can occur many hours after exercise.
    (Up to 48 hours) due to depletion of glycogen
    stores is a contributing factor of hypoglycemia
  • Food amount required varies from person to person.

79
Exercise and Insulin
  • The physiologic decrease in circulating insulin
    that normally occurs cannot occur in persons
    being treated with insulin.
  • Need to monitor BS before, during and after
    exercise to determine alterations in food or
    insulin
  • Food amount varies from person to person.

80
Carbohydrate Replacement During Exercise
81
Type 1 and Exercise
  • If you are participating in long periods of
    exercise
  • Check blood sugar before, during and after
    exercise period and snack on carbohydrate snacks
    as needed to maintain blood glucose level.

82
Type 2 and Exercise
  • Obese people with Type 2
  • Exercise and dietary management improves glucose
    metabolism and enhances loss of body fat
  • Improves insulin sensitivity and may decrease the
    need for insulin or oral agents.

83
Recommendations
  • Exercise at the same time each day.
  • Exercise the same amount of time each day.
  • If patient has diabetic complications, alter the
    exercise type and amount as necessary. Increased
    B/P assoc. with exercise may aggravate diabetic
    retinopathy

84
Recommendations
  • Start slow and gradually increase exercise
  • Always discuss with physician before starting any
    exercise program for a medical evaluation with
    appropriate diagnostic studies before beginning.

85
Precautions with Exercise
  • Blood glucose levels gt 250 mg/dl and ketones
    urine should not exercise until urine test
    negative for ketones and blood glucose levels are
    near to normal ( ADA, 2004).

86
Precautions
  • Exercising increases blood glucose
  • Exercising increases the secretion of glucagon,
    growth hormone and catecholamines
  • Liver releases more glucose resulting in an
    increase in blood glucose level.

87
Monitoring
88
Monitoring
  • Blood glucose monitoring is a cornerstone in
    diabetes management.
  • Self-monitoring of blood glucose (SMBG) is
    recommended by the ADA.
  • Many types of glucometers-Pick the one that best
    suits the patient. Consider ease of use, skill
    level,cost of strips, visual numbers etc.

89
Monitoring
  • Potential hazards of SMBG- patients may report
    erroneous blood glucose values as a result of
    using incorrect technique.
  • Improper application of blood
  • Improper meter cleaning
  • Damage to reagent strips
  • Coding of meter

90
Candidates for SMBG
  • Uncontrolled diabetes
  • A tendency for hypoglycemia
  • Hypoglycemia unawareness
  • Patients on insulin
  • During illness

91
Monitoring
  • According to the ADA patients on insulin should
    test at least four times a day, usually before
    meals and at bedtime.
  • Persons not receiving insulin and on orals should
    test two-three times a day, including a 2hpp
  • Important to keep a logbook and take to all
    doctors appointments.
  • Persons will tend not to monitor if not taught
    how to use results.

92
Continuous Glucose Monitoring
  • Available
  • Senor attached to an infusion set inserted
    subcutaneously in the abdomen and connected to a
    device worn on a belt.
  • Worn for 72 hours and downloaded for review.
  • Glucowatch- worn on wrist

93
Glycated Hemoglobin
  • Referred to as HgbA1c or A1C
  • Reflects average blood glucose levels over a
    period of approximately 2 to 3 months, (ADA, 2004)

94
Acute Complications
95
Acute Complications
  • Hypoglycemia-Abnormally low blood glucose level
    (lt70mg/dL)
  • Causes
  • Too much insulin or oral hypoglycemic agents
  • Too little food or excessive exercise
  • Delayed or skipped meals

96
Hypoglycemia
  • Two categories
  • Adrenergic
  • Mild hypoglycemia- sympathetic nervous system is
    stimulated- surge of epinephrine and
    norepinephrine
  • S/S- sweating, tremor, tachycardia, palpitations,
    nervousness, and hunger.

97
Hypoglycemia
  • Central nervous symptoms
  • Moderate hypoglycemia- deprives the brain cells
    of needed fuel for functioning
  • S/S- inability to concentrate, headache,
    lightheadness, confusion, memory lapse, numbness
    of the lips and tongue, slurred speech, impaired
    coordination, emotional changes, irrational or
    combative behavior, double vision and drowsiness

98
Management/Teaching
  • Treat hypoglycemia using Rule of 15
  • Teaching Component
  • Teach patients to carry some form of simple sugar
    with them at all times.
  • Avoid over treating hypoglycemia
  • Consistent pattern of eating and administering of
    insulin.

99
Hypoglycemia
  • Emergency Measures
  • For patients who are unconscious or cannot
    swallow.
  • Glucagon 1mg injection can be given SubQ

100
Hypoglycemia Unawareness
  • No warning signs and symptoms of hypoglycemia
  • Increase risk of dangerously low BS
  • Related to autonomic neuropathy

101
Diabetic Ketoacidosis (DKA)
  • DKA caused by an absence or markedly inadequate
    amounts of insulin.
  • Caused by disorders in the metabolism of fats,
    CHO, and proteins.

102
Ketoacidosis
  • Signs and Symptoms
  • Nausea and vomiting
  • Rapid breathing
  • Extreme tiredness and drowsiness
  • Weakness

103
DKA
  • Three main clinical features
  • Hyperglycemia
  • Dehydration and electrolyte loss
  • Acidosis, Brunner Suddath.
  • Insulin defeiency leads to breakdown of fat (
    lipolysis) into free fatty acids and glycerol.
  • Free fatty acids are converted into ketone bodies
    by the liver.

104
DKA
  • Three main causes of DKA
  • Decreased or missed dose of insulin
  • Illness or infection
  • Undiagnosed or untreated diabetes
  • Treatment
  • IV fluid and electrolyte replacement

105
DKA Treatment
  • Correct fluid and electrolytes
  • Correct acidosis
  • Provide adequate insulin
  • Establish cause of DKA
  • Can be mild to severe

106
DKA
  • Signs and Symptoms
  • Due to Na and K loss in urine clients experience
  • Muscle weakness
  • Extreme fatigue
  • Malaise
  • Cardiac arrhythmias can lead to cardiac arrest
  • Acidosis-fruity breath, tachycardia and
    hypotension

107
Monitoring and Managing Potential Complications
  • Fluid Overload- Administering fluids rapidly to
    treat DKA or HHNS
  • Hypokalemia-due to treatment of DKA-loss of
    potassium
  • Cerebral Edema-cause unknown, may be by rapid
    correction of hyperglycemia- resulting in fluid
    shift

108
Hyperglycemia Hyperosmolar Nonketotic Syndrome
(HHNS)
  • Serious condition Blood glucose 800-1000 mg/dl
  • Ketosis usually minimal or absent
  • Defect is usually lack of effective insulin
    (insulin resistance)
  • Presistent hyperglycemia causes osmotic diuresis
    which results in losses of water and
    electrolytes. To maintain osmotic equilibrium,
    water shifts from the intracellular fluid space
    to the extracellular fluid space. With glycosurea
    and dehydration, hypernatremia and increased
    osmolarity occurs.
  • Usually occurs in older adults

109
Causes of HHNS
  • Acute illness
  • Medications that exacerbate hyperglycemia
  • Dialysis treatment

110
HHNS
  • Hypotension
  • Profound dehydration
  • Tachycardia
  • Variable neurological signs
  • Morality rate- 10 to 40
  • Treatment-fluid replacement and correct
    electrolytes

111
Comparison of DKA and HHNS
  • DKA
  • HHNS
  • While can occur in both, usually occurs in Type 1
  • Precipitated by
  • omission of insulin, physiologic stress
    (infection, surgery, etc.)
  • Onset
  • Rapid (lt24 hours)
  • Blood Glucose Levels
  • Usually gt250
  • Arterial pH levels
  • lt 7.3
  • Serum and urine ketones
  • Present
  • Serum Osmolality
  • 300-350
  • BUN and Creatinine levels
  • Elevated
  • Mortality Rate
  • lt 5
  • While can occur in both, usually occurs in Type 2
    (esp. elderly)
  • Precipitated by
  • Physiologic stress (infection, surgery, etc.)
  • Onset
  • Slower (over several days)
  • Blood Glucose Levels
  • Usually gt 600
  • Arterial pH levels
  • Normal
  • Serum and urine ketones
  • Absent
  • Serum Osmolality
  • gt350
  • BUN and Creatinine levels
  • Elevated
  • Mortality Rate
  • 10-40

112
Long-term complications
113
Macrovascular Complications
  • Diseases of large and medium-size vessels
  • Atherosclerosis- From altered lipid metabolism
  • Cerebral Vascular
  • Peripheral Vascular Disease
  • Adults with DM 2-4 times increased risk of hear
    and cerebral vascular

114
Microvascular Diseases
  • Microvascular diseases are unique to diabetes
  • Capillary basement membrane thickening
  • The basement membrane surrounds the endothelial
    cells of the capillary. Researchers believe that
    increased blood glucose levels react thru a
    series of biochemical responses to thicken the
    basement membrane to several times its normal
    thickness
  • 2 areas affected
  • Retina
  • kidneys

115
Diabetic Retinopathy
  • Results from chronic hyperglycemia
  • Most common cause of new cases of blindness in
    persons ages 20-74
  • Non-proliferative-most common form
  • Proliferative- most severe form

116
Retinopathy
  • Non-Proliferative- Partial occlusion of small
    blood vessels in the retina-develop
    microanueryms. Vision can be affected if Macula
    is involved.
  • Proliferative-Retinal capillaries become
    occluded, hemorrhage. If blood vessels pull
    retina can cause a tear or partial or complete
    detachment of retina.

117
Legal Blindness
  • A visual acuity that is lt20/200 in the better eye
    with corrective lenses and or a visual acuity
    field of lt 20 degrees.

118
Nursing Management
  • Prevention is key
  • If vision loss occurs, nursing education must
    address the patients adjustment to vision
    impairment

119
Medical Management
  • Control of blood glucose
  • Tight control of blood glucose reduced risk of
    developing retinopathy by 76 compared to that of
    conventional therapy
  • Control of hypertension
  • Cessation of smoking

120
Nephropathy
  • Microvascular complication
  • Damage to small blood vessels that supply
    glomeruli of the kidney
  • Leading cause of end-stage renal disease
  • About 50 of all new ESRD cases a year are
    diabetics

121
Risk factors
  • HTN
  • Genetic predisposition
  • Native Americans, Hispanics, and African
    Americans with Type 2 DM are at greater risk of
    developing ESRD than Whites
  • Smoking
  • Chronic hyperglycemia
  • Studies DCCT and UKPDS showed significant
    reduction when near-normal blood glucose control
    was achieved and maintained

122
Treatment
  • Aggressive B/P management with Ace inhibitor
  • Yearly screening for microalbuminuria in the urine

123
Treatment of Diabetic Nephropathy
  • Hypertension Control - Goal lower blood pressure
    to lt120/80 mmHg
  • Antihypertensive agents
  • Angiotensin-converting enzyme (ACE) inhibitors
  • captopril, enalapril, lisinopril, benazepril,
    fosinopril, ramipril, quinapril, perindopril,
    trandolapril, moexipril
  • Angiotensin receptor blocker (ARB) therapy
  • candesartan cilexetil, irbesartan, losartan
    potassium, telmisartan, valsartan, esprosartan
  • Beta-blockers

124
Treatment of Diabetic Nephropathy (cont.)
  • Glycemic Control
  • Pre-prandial plasma glucose 90-130 mg/dl
  • A1C lt7.0
  • Peak postprandial plasma glucose lt180 mg/dl
  • Self-monitoring of blood glucose (SMBG)
  • Medical Nutrition Therapy
  • Restrict dietary protein to RDA of 0.8 g/kg body
    weight per day

125
Treatment of End-Stage Renal Disease (ESRD)
  • There are three primary treatment options for
    individuals who experience ESRD
  • 1. Hemodialysis
  • 2. Peritoneal Dialysis
  • 3. Kidney Transplantation

126
Diabetic Neuropathy
  • About 60-70 of people with diabetes have mild to
    severe forms of nervous system damage, including
  • Impaired sensation or pain in the feet or hands
  • Slowed digestion of food in the stomach
  • Carpal tunnel syndrome
  • Other nerve problems
  • More than 60 of nontraumatic lower-limb
    amputations in the United States occur among
    people with diabetes.

127
Risk Factors
  • Glucose control
  • Duration of diabetes
  • Damage to blood vessels
  • Mechanical injury to nerves
  • Autoimmune factors
  • Genetic susceptibility
  • Lifestyle factors
  • Smoking
  • Diet

128
Pathogenesis of Diabetic Neuropathy
  • Metabolic factors
  • High blood glucose
  • Advanced glycation end products
  • Abnormal blood fat levels
  • Ischemia
  • Nerve fiber repair mechanisms

129
Autonomic neuropathy
  • Affects the autonomic nerves controlling internal
    organs
  • Peripheral
  • Genitourinary
  • Gastrointestinal
  • Cardiovascular
  • Is classified as clinical or sub-clinical based
    on the presence or absence of symptoms

130
Continued.
  • Hypoglycemic unawareness
  • Sudomotor neuropathy- absence of sweating of the
    extremities with a compensatory increase in upper
    body sweating.
  • Sexual Dysfunction

131
Essentials of Foot Care
  • Examination
  • Annually for all patients
  • Patients with neuropathy - visual inspection of
    feet at every visit with a health care
    professional
  • Advise patients to
  • Use lotion to prevent dryness and cracking
  • File calluses with a pumice stone
  • Cut toenails weekly or as needed
  • Always wear socks and well-fitting shoes
  • Notify their health care provider immediately if
    any foot problems occur

132
Foot Care
  • Complications of DM contribute to an increased
    risk of foot infections.
  • A foot infection is a preventable infection.
  • Foot care measures should be practiced on a daily
    basis.
  • Foot care tips-chart pg. 1287

133
Complications
  • Diabetic foot ulcers
  • Begins with soft tissue injury of foot.
  • Formation of fissure between toes or in area of
    dry skin.
  • Formation of callus.
  • Ingrown toenails
  • Cracks in skin
  • Venous insufficiency is a contributing cause of
    foot ulcers

134
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135
Type of Injuries
  • Chemical
  • Traumatic
  • Thermal

136
Foot Infections
  • Signs and Symptoms
  • Drainage
  • Swelling
  • Redness (cellulites of leg)
  • Gangrene
  • Usually first signs of foot problem

137
Treatment of Foot Ulcers
  • Bed rest
  • Antibiotics
  • Debridement
  • Good control of blood glucose (usually increases
    with infection).

138
Treatment of Foot Ulcers
  • If patient has PVD, ulcers may not heal due to
    the decreased ability of oxygen, nutrients, and
    antibiotics to reach the injured tissue.
  • Amputation may be necessary to prevent spread of
    infection

139
Other Complications
  • Skin- Acanthosis nigricans- dark , coarse,
    thicken skin on the neck.
  • Diabetic dermatopathy-red-brown flat-topped
    papules
  • Granuloma annulare- type 1- autoimmune- partial
    rings of papules, often in dorsal surface of
    hands and feet

140
Infections
  • More susceptible to infections
  • Defect in the mobilization of inflammatory cells
    and an impairment of phagocytosis.
  • Recurrent yeast infections
  • Treatment must be prompt and aggressive.

141
Special Issues
  • Patient undergoing surgery
  • During stress such as surgery, blood glucose
    levels rise as a result of an increase level of
    stress hormones.
  • If hyperglycemia is not controlled- osmotic
    diuresis may lead to excessive loss of fluids and
    electrolytes.
  • Hypoglycemia- withhold SQ insulin morning of
    surgery

142
Hospitalization
  • Factors affecting hyperglycemia
  • Changes in treatment regimen
  • Medications (eg. Glucocorticoids
  • IV Dextrose
  • Overly vigorous treatment of hypoglycemia.

143
Special Issues
  • Patient undergoing surgery
  • During stress such as surgery, blood glucose
    levels rise as a result of an increase level of
    stress hormones.
  • If hyperglycemia is not controlled- osmotic
    diuresis may lead to excessive loss of fluids and
    electrolytes.
  • Hypoglycemia- withhold SQ insulin morning of
    surgery

144
Hospitalization
  • Factors affecting hyperglycemia
  • Changes in treatment regimen
  • Medications (eg. Glucocorticoids
  • IV Dextrose
  • Overly vigorous treatment of hypoglycemia.

145
Continued
  • Factors affecting hypoglycemia
  • Overuse of sliding scale
  • Lack of dosage changes when dietary intake is
    changed.
  • Overly vigorous treatment of hyperglycemia
  • Delayed meal after lispro or aspart insulin
  • The chart she wants us to look at shows a stick
    with a wire on the end of it (a mono-filiament)
    being poked at 5 pressure points on the bottom of
    the foot (big toe, 4th toe, and 3 spots along the
    ball of the foot). You poke them to see if they
    can feel it. This is what you do when assessing
    the sensory threshold in pts with DM. They can
    also do it themselves

146
Alterations in Meal Plan
  • If client is NPO- insulin dose may need to be
    changed for type 2
  • Type 1 may need to administer insulin
  • Frequent blood glucose monitoring.
  • Clear liquids need to be caloric
  • Tube feeding-important to administer insulin at
    regular intervals.

147
Promoting Self-Care
  • Address any underlying factors affecting diabetes
    control.
  • Simplify the treatment regimen
  • Adjust regimen to meet patients request.
  • Provide positive reinforcement and encouragement.

148
Education
  • Flexibility is important.
  • Teach what client wants to learn not what you
    think they need to learn!!
  • The major goal of education is an educated
    client.
  • Do not try to teach everything in one session.

149
Nursing Diagnoses
  • Deficient knowledge r/t diabetes self care
    skills/information.
  • Potential self care deficit r/t physical
    impairments or social factors.
  • Anxiety r/t loss of control, fear of inability to
    manage diabetes, misinformation r/t diabetes,
    fear of diabetes complications.
  • Risk for infection r/t potential sensory loss in
    feet.

150
Nursing Diagnoses
  • Imbalanced Nutrition Related to increase in
    stress hormones
  • Risk for impaired skin integrity related to
    immobility and lack of sensation.

151
Goals
  • Improved nutritional status
  • Maintenance of skin integrity
  • Ability to perform basic diabetes
    self-management.
  • Prevent short and long term diabetes
    complications
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