diabetes nur 105. diabetes mellitus statistics – approximately 21 million in the us= 7% of...

DiabetesNUR 105

DIABETES MELLITUS Statistics – approximately 21 million Statistics – approximately 21 million

in the US= 7% of population. in the US= 7% of population. Includes 6 million undiagnosed.Includes 6 million undiagnosed.

Definition – Diabetes mellitus is a Definition – Diabetes mellitus is a chronic disorder characterized by chronic disorder characterized by impaired metabolism and by impaired metabolism and by vascular and neurologic vascular and neurologic complications. A key feature of complications. A key feature of diabetes is elevated blood glucose diabetes is elevated blood glucose or hyperglycemia.or hyperglycemia.

DIABETES MELLITUS

PathophysiologyPathophysiology the blood glucose level is normally regulated by the blood glucose level is normally regulated by

insulin, a hormone produced by the beta cells in insulin, a hormone produced by the beta cells in the islets of Langerhans located in the pancreas.the islets of Langerhans located in the pancreas.

In health small amounts of insulin are secreted In health small amounts of insulin are secreted continuously into the bloodstream.continuously into the bloodstream.

The ingestion of carbohydrates triggers the The ingestion of carbohydrates triggers the secretion of a large volume of insulin. Insulin that secretion of a large volume of insulin. Insulin that is produced in one’s own body is called is produced in one’s own body is called endogenousendogenous, meaning it is internally produced. , meaning it is internally produced.

Insulin that is obtained from other sources and Insulin that is obtained from other sources and administered to a person is called administered to a person is called exogenousexogenous

DIABETES MELLITUS

PathophysiologyPathophysiology Glucagon (another hormone produced by Glucagon (another hormone produced by

the alpha cells of the pancreas) allows the alpha cells of the pancreas) allows the liver and muscles to release stored the liver and muscles to release stored glucose if the body is hypoglycemic (low glucose if the body is hypoglycemic (low blood glucose)blood glucose)

Insulin and glucagon work together to Insulin and glucagon work together to keep the blood glucose at a constant keep the blood glucose at a constant levellevel

The amount of glucose in the blood The amount of glucose in the blood regulates the rate of insulin secretedregulates the rate of insulin secreted

DIABETES MELLITUS

PathophysiologyPathophysiology Diabetes is caused by an inability of Diabetes is caused by an inability of

the pancreas to produce insulin, or the pancreas to produce insulin, or because the cells of the body cannot because the cells of the body cannot accept and use the insulin\accept and use the insulin\

Hyperglycemia (elevated blood Hyperglycemia (elevated blood glucose) is the result and cells do glucose) is the result and cells do not get the energy they neednot get the energy they need

DIABETES MELLITUS ClassificationsClassifications

Type I – Insulin Dependent Diabetes Mellitus Type I – Insulin Dependent Diabetes Mellitus (IDDM)(IDDM)

Previously called insulin-dependentPreviously called insulin-dependent Cause – the pancreas does not produce insulin at all or Cause – the pancreas does not produce insulin at all or

no endogenous insulin.no endogenous insulin. Triggered by an autoimmune destruction of cells in the Triggered by an autoimmune destruction of cells in the

pancreas – cause may be idiopathic (unknown) usually pancreas – cause may be idiopathic (unknown) usually occurs in children and young adultsoccurs in children and young adults

Onset – usually includes acute development of weight Onset – usually includes acute development of weight lossloss

Ketones may build up in the urine and blood (Ketosis)Ketones may build up in the urine and blood (Ketosis) Exogenous Insulin must be administered for the body to Exogenous Insulin must be administered for the body to

use for energyuse for energy

Insulin Increases the transport of glucose into the Increases the transport of glucose into the

resting muscle cell.resting muscle cell. Regulates the rate at which carbohydrates are Regulates the rate at which carbohydrates are

usedused Prevents the conversion of glycogen to glucosePrevents the conversion of glycogen to glucose Inhibits the conversion of glycogen to glucoseInhibits the conversion of glycogen to glucose Promotes fatty acid synthesisPromotes fatty acid synthesis Spares fatSpares fat Inhibits the conversion of fats to glucoseInhibits the conversion of fats to glucose Stimulates protein synthesis in the tissuesStimulates protein synthesis in the tissues Inhibits the conversion of protein into glucose.Inhibits the conversion of protein into glucose.

Lack of Insulin

Stimulates the conversion of Stimulates the conversion of glycogen to glucose= Higher blood glycogen to glucose= Higher blood glucoseglucose

Permits fat stores to break downPermits fat stores to break down Increases triglyceride storage in Increases triglyceride storage in

the e liverthe e liver Halts the storage of proteinsHalts the storage of proteins Causes protein to be dumped into Causes protein to be dumped into

the bloodstream.the bloodstream.

DIABETES MELLITUS ClassificationsClassifications

Type 2 – Non-Insulin Dependent Diabetes Mellitus Type 2 – Non-Insulin Dependent Diabetes Mellitus (NIDDM)(NIDDM)

AKA – Adult-onset Diabetes MellitusAKA – Adult-onset Diabetes Mellitus Inadequate endogenous insulin and the body's ability Inadequate endogenous insulin and the body's ability

to properly use insulin. Initially , beta cells respond to properly use insulin. Initially , beta cells respond inadequately to hyperglycemia, resulting in inadequately to hyperglycemia, resulting in chronically elevated blood glucose. The continuous chronically elevated blood glucose. The continuous high glucose level in the blood desensitizes the beta high glucose level in the blood desensitizes the beta cells so that they become less responsive to the cells so that they become less responsive to the elevated glucose. The specific resistor sites become elevated glucose. The specific resistor sites become insensitive to insulin.insensitive to insulin.

Usually gradual onset and with several risk factorsUsually gradual onset and with several risk factors Obese children now showing greater incidenceObese children now showing greater incidence Rarely have DKARarely have DKA

DIABETES MELLITUS

Other ClassificationsOther Classifications Gestational Diabetes Mellitus (GDM)Gestational Diabetes Mellitus (GDM)

Triggered by extra metabolic demands during Triggered by extra metabolic demands during pregnancypregnancy

May require insulin or may be diet controlledMay require insulin or may be diet controlled Usually resolved with birth of babyUsually resolved with birth of baby Predisposes mother to develop type-2 DM in the Predisposes mother to develop type-2 DM in the

futurefuture

Diabetes

Risk Factors for Type 1Risk Factors for Type 1 Other than genetic ones, none Other than genetic ones, none

known.known.

DIABETES MELLITUS Risk factors Type IIRisk factors Type II

Sedentary LifestyleSedentary Lifestyle Family HxFamily Hx Age 40 years or olderAge 40 years or older History of Gestational DMHistory of Gestational DM History of delivering infant weighing more than 10lbsHistory of delivering infant weighing more than 10lbs African American (33% higher risk for type 2 DM)African American (33% higher risk for type 2 DM) Latin American/Hispanic (greater than 300% higher Latin American/Hispanic (greater than 300% higher

risk for type 2 DM)risk for type 2 DM) ObesityObesity American Indians (33% to 50% higher risk for type 2 American Indians (33% to 50% higher risk for type 2

DM)DM)

DIABETES MELLITUS

S/SS/S Polydipsia (excessive thirst)Polydipsia (excessive thirst) Polyuria (excessive urinationPolyuria (excessive urination Polyphagia (excessive hunger)Polyphagia (excessive hunger) DehydrationDehydration FatigueFatigue Visual changes like blurred visionVisual changes like blurred vision Elevated blood glucoseElevated blood glucose

DIABETES MELLITUS

S/SS/S H/AH/A Poor wound healing and recurrent Poor wound healing and recurrent

infectionsinfections Confusion and changes in mentationConfusion and changes in mentation Occasional muscle crampsOccasional muscle cramps Weight loss in type 1 DM (glucose is Weight loss in type 1 DM (glucose is

not available to the cells, body not available to the cells, body breaks down fat and protein for breaks down fat and protein for energy, called ketosisenergy, called ketosis

Diagnosis of Diabetes

A patient who meets one or more of A patient who meets one or more of the following criteria on two separate the following criteria on two separate occasions is considered to have DM:occasions is considered to have DM: 1. Symptoms of polyuria, polydipsia, 1. Symptoms of polyuria, polydipsia,

polyphagia, unexplained weight loss plus polyphagia, unexplained weight loss plus random glucose level greater than random glucose level greater than 200mg/dl. A random reading is based on 200mg/dl. A random reading is based on a blood sample drawn any time of day a blood sample drawn any time of day without regard to mealtimes.without regard to mealtimes.

Diagnoses of Diabetes

2. Fasting serum glucose level 2. Fasting serum glucose level greater than 126mg/dl (after at greater than 126mg/dl (after at least an 8-hour fast)least an 8-hour fast)

3. Two-hour posprandial glucose 3. Two-hour posprandial glucose level above 200mg/dl during an oral level above 200mg/dl during an oral glucose tolerance test. The test glucose tolerance test. The test must use a glucose load of 75gm of must use a glucose load of 75gm of anhydrous glucose dissolved in anhydrous glucose dissolved in water. This test is often water. This test is often unnecessary.unnecessary.

Glucose Tolerance Test

Client consumes diet of 150-300gm of Client consumes diet of 150-300gm of carbohydrates for 3 days before the test.carbohydrates for 3 days before the test.

The patient is then given a Glucola drink with The patient is then given a Glucola drink with 75gm of carbs and instructed to remain quiet.75gm of carbs and instructed to remain quiet.

Glucose can be given IV if patient is unable to Glucose can be given IV if patient is unable to drink, (not as accurate as oral)drink, (not as accurate as oral)

Blood is drawn then at Blood is drawn then at 30 minutes30 minutes 1 hour1 hour Then hourly for 3 or 5 hours.Then hourly for 3 or 5 hours. Heparin Lock may be inserted into a vein so multiple Heparin Lock may be inserted into a vein so multiple

venipunctures are not needed.venipunctures are not needed.

DIABETES MELLITUS• Diagnostic TestDiagnostic Test

Glycosylated Hemoglobin Test (GHb) or (HbA1c) – Glycosylated Hemoglobin Test (GHb) or (HbA1c) – provides an accurate long term index of average provides an accurate long term index of average blood glucose and tells how effective Diabetes blood glucose and tells how effective Diabetes therapy has been during the preceding 8-12 weeks therapy has been during the preceding 8-12 weeks (normal value – 3.5-6.2%; good control - 7.5%; poor (normal value – 3.5-6.2%; good control - 7.5%; poor control >9.0%)control >9.0%)

Self Monitoring Blood Glucose or finger stick – most Self Monitoring Blood Glucose or finger stick – most common method, checked before meals and common method, checked before meals and bedtime; if BS > 240 mg/dl test for ketones in the bedtime; if BS > 240 mg/dl test for ketones in the urineurine

Clinitest and Testape – indicate glucose in urineClinitest and Testape – indicate glucose in urine

DIABETES MELLITUS

Diagnostic TestsDiagnostic Tests Acetest and Ketostix – indicate Acetest and Ketostix – indicate

presence of ketones in urinepresence of ketones in urine C-Peptide – indicates how much insulin C-Peptide – indicates how much insulin

body is making, may help determine body is making, may help determine Type-I or Type-2 DMType-I or Type-2 DM

Fasting insulin levelFasting insulin level Other test to be monitored because of Other test to be monitored because of

effects of DM:effects of DM: Lipid profile, Sr. Cr. And urine Lipid profile, Sr. Cr. And urine

microalbumin levels to monitor kidney microalbumin levels to monitor kidney function, urinalysis, and ECGfunction, urinalysis, and ECG

DIABETES MELLITUS TreatmentTreatment

The only cure is a pancreas transplant and The only cure is a pancreas transplant and pancreatic cell transplantpancreatic cell transplant

Every patient requires an individual treatment plan – Every patient requires an individual treatment plan – The goals for the patient with Diabetes The goals for the patient with Diabetes Mellitus include:Mellitus include:

Monitoring and control of blood glucoseMonitoring and control of blood glucose Prevention and early detection of complicationsPrevention and early detection of complications Lipid level monitoringLipid level monitoring Dietary and weight managementDietary and weight management Participating in an exercise planParticipating in an exercise plan Maintaining good health, annual physicals, attention to self Maintaining good health, annual physicals, attention to self

carecare Medications as neededMedications as needed

DIABETES MELLITUS Tx Medical Nutrition Therapy (MNT) GoalsMedical Nutrition Therapy (MNT) Goals

Attain and maintain optimal metabolic Attain and maintain optimal metabolic outcomes (glucose, lipids, blood pressure).outcomes (glucose, lipids, blood pressure).

Prevent and treat the chronic complications of Prevent and treat the chronic complications of diabetes (obesity, dyslipidemia, cardiovascular diabetes (obesity, dyslipidemia, cardiovascular disease, hypertension, nephropathy).disease, hypertension, nephropathy).

Improve health through healthy food choices Improve health through healthy food choices and physical activity.and physical activity.

Address individual nutritional needs while Address individual nutritional needs while considering lifestyle, personal, and cultural considering lifestyle, personal, and cultural preferences.preferences.

Recommended Calorie Distribution for Insulin Dependent Patients

Proteins=15% to 20% (as long as kidney Proteins=15% to 20% (as long as kidney functions are normal)functions are normal)

Carbohydrates and monosaturated Carbohydrates and monosaturated fats= 55% -60%fats= 55% -60%

Saturated Fats: Less than 10%Saturated Fats: Less than 10%

Sodium Intake should not exceed Sodium Intake should not exceed 2400mg/day2400mg/day

Weight Loss

Weight loss is seldom a goal for Weight loss is seldom a goal for the older type 2 diabetic unless the older type 2 diabetic unless weight is more than 11/2 times weight is more than 11/2 times the normal for height and frame.the normal for height and frame.

Carbohydrate Counting

Useful for people who use Useful for people who use intensive insulin therapy or intensive insulin therapy or pumps.pumps.

Insulin doses are based on total Insulin doses are based on total grams of Carbs to be ingested.grams of Carbs to be ingested.

Well balanced diet within the Well balanced diet within the prescribed distribution of proteins, prescribed distribution of proteins, fats, and carbsfats, and carbs

DIABETES MELLITUS Treatment (Basic Guidelines)Treatment (Basic Guidelines)The ADA advocates a variety of meal plans based The ADA advocates a variety of meal plans based

on the patient’s abilities and commitmentson the patient’s abilities and commitments ADA Exchange Diet – six exchange lists, ADA Exchange Diet – six exchange lists,

prescribed as total calories and number of prescribed as total calories and number of exchanges from each group (NOT AS POPULAR exchanges from each group (NOT AS POPULAR NOW)NOW)

CHO Counting – a tool to maintain blood CHO Counting – a tool to maintain blood glucose and lipid levels. Count grams of carbs, glucose and lipid levels. Count grams of carbs, and measure servings. Offers more flexible and measure servings. Offers more flexible food choices and may achieve better controlfood choices and may achieve better control

DIABETES MELLITUS

Treatment (Basic Guidelines)Treatment (Basic Guidelines)ADA advocatesADA advocates Glycemic Index – describes how much Glycemic Index – describes how much

blood glucose level rises with a specific blood glucose level rises with a specific food compared to an equivalent amount food compared to an equivalent amount of glucose. Rarely used in clinical of glucose. Rarely used in clinical practice except with highly motivated , practice except with highly motivated , educated patientseducated patients

Month-O-Meals – booklets with complete Month-O-Meals – booklets with complete and interchangeable menus, excellent and interchangeable menus, excellent for patients “who want to be told what for patients “who want to be told what and when to eat.”and when to eat.”

DIABETES MELLITUS Treatment (Exercise)Treatment (Exercise)

Regularity and amount of exercise is Regularity and amount of exercise is importantimportant

Muscles use glucose and lower circulating Muscles use glucose and lower circulating blood glucoseblood glucose

Promotes utilization of CHO, improves Promotes utilization of CHO, improves circulation, lipid levels, cardiovascular circulation, lipid levels, cardiovascular status, weight loss and decreases stressstatus, weight loss and decreases stress

Should be individualizedShould be individualized Medic Alert BraceletMedic Alert Bracelet

Exercise and Diabetes Have a complete medical examination before starting a Have a complete medical examination before starting a

program.program. Because circulating insulin may be inadequate to Because circulating insulin may be inadequate to

ensure glucose uptake, avoid exercise when your ensure glucose uptake, avoid exercise when your serum glucose is greater than 250mg/dl and ketosis is serum glucose is greater than 250mg/dl and ketosis is present.present.

Exercise with caution if your serum glucose is greater Exercise with caution if your serum glucose is greater than 300mg/dl and no ketosis is present.than 300mg/dl and no ketosis is present.

5G of simple carb should be consumed at the end of 30 5G of simple carb should be consumed at the end of 30 minutes and at 30 minute intervalsminutes and at 30 minute intervals

Wear comfortable shoes.Wear comfortable shoes.

Exercise Diabetes Warm up with 5-10 minutes of aerobicWarm up with 5-10 minutes of aerobic Discuss with physician whether to alter food or insulin Discuss with physician whether to alter food or insulin

intake before exercise.intake before exercise. Avoid exercise during the peak action of insulin and Avoid exercise during the peak action of insulin and

oral hypoglycemic agents when hypoglycemia is more oral hypoglycemic agents when hypoglycemia is more likely to occur.likely to occur.

Carbohydrates snacking may be necessary with Carbohydrates snacking may be necessary with prolonged or intense exercise.prolonged or intense exercise.

If you take insulin, inject it in the abdomen rather than If you take insulin, inject it in the abdomen rather than an extremity before a workout because the drug is an extremity before a workout because the drug is absorbed much more quickly from the abdomen.absorbed much more quickly from the abdomen.

Some people experience hypoglycemia several hours Some people experience hypoglycemia several hours after exercise, have food available for these situations.after exercise, have food available for these situations.

Wear medic alert bracelet.Wear medic alert bracelet.

DIABETES MELLITUS

Pharmacologic ManagementPharmacologic Management Insulin – key regulator for passage Insulin – key regulator for passage

of glucose into the cells for energyof glucose into the cells for energy Produced by beta cells of pancreasProduced by beta cells of pancreas Plays a significant role in protein and Plays a significant role in protein and

lipid metabolismlipid metabolism Pancreas secretes insulin at a steady Pancreas secretes insulin at a steady

rate of 0.5-1 unit per hourrate of 0.5-1 unit per hour

DIABETES MELLITUS Pharmacological ManagementPharmacological Management InsulinInsulin

Hyperglycemia is caused by three abnormalitiesHyperglycemia is caused by three abnormalities Liver produces excess glucoseLiver produces excess glucose Absent or impaired insulin production and secretion by the Absent or impaired insulin production and secretion by the

pancreaspancreas Insulin resistance peripherallyInsulin resistance peripherally

Historically insulin obtained from beef or pork Historically insulin obtained from beef or pork pancreaspancreas

Today biosynthetic human insulin is used almost Today biosynthetic human insulin is used almost exclusivelyexclusively

Human insulin is purerHuman insulin is purer More effectMore effect Lower incidence of causing allergies/resistanceLower incidence of causing allergies/resistance

DIABETES MELLITUS Pharmacological ManagementPharmacological Management InsulinInsulinThe nurse must be aware of the onset, peak, and The nurse must be aware of the onset, peak, and

duration of insulin, so that decisions can be duration of insulin, so that decisions can be made, as to when to give the insulin and when made, as to when to give the insulin and when to be alert for symptoms of low blood glucose – to be alert for symptoms of low blood glucose – as when patients go for test and proceduresas when patients go for test and procedures Onset – time required for medication to have an Onset – time required for medication to have an

initial effect or actioninitial effect or action Peak – when the agent will have the maximum effectPeak – when the agent will have the maximum effect Duration – length of time that the agent remains Duration – length of time that the agent remains

active in the bodyactive in the body

Rapid Acting Insulin

Insulin lispro (Humalog)Insulin lispro (Humalog) ClearClear Onset 15 minutesOnset 15 minutes Peak 0.5-1 hourPeak 0.5-1 hour Duration 3-4 hoursDuration 3-4 hours Administer 15 minutes before eating.Administer 15 minutes before eating.

Rapid Acting Insulin

Insulin aspart (Novolog)Insulin aspart (Novolog) Clear Clear Onset: 15 minutesOnset: 15 minutes Peak: 1-3 hoursPeak: 1-3 hours Duration: 3-5 hoursDuration: 3-5 hours

Short Acting Insulin

Regular Insulin (Humulin R, Regular Insulin (Humulin R, Novolon R)Novolon R)

Color –ClearColor –Clear Onset- 30 minutes to 1 hourOnset- 30 minutes to 1 hour Peak- 2-5 hoursPeak- 2-5 hours Duration- 6-8 hoursDuration- 6-8 hours ONLY INSULIN GIVEN IV Humlin RONLY INSULIN GIVEN IV Humlin R

Intermediate Acting

NPH insulinNPH insulin CloudyCloudy Onset- 1.5 hoursOnset- 1.5 hours Peak- 4-12 hoursPeak- 4-12 hours Duration- 10-24 hoursDuration- 10-24 hours

Long-Acting

Insulin Glargine (Lantus)Insulin Glargine (Lantus) Onset- 1-2 hoursOnset- 1-2 hours DOES NOT PEAKDOES NOT PEAK Duration- 20-24 hoursDuration- 20-24 hours CANNOT MIX WITH OTHER CANNOT MIX WITH OTHER

INSULINSINSULINS

Inhaled Rapid-Acting , Short Acting

Insulin human rDNA orgin Insulin human rDNA orgin (Exubera)(Exubera)

Powder in blister packsPowder in blister packs Onset- 9-18 minutesOnset- 9-18 minutes Peak- 27 minutesPeak- 27 minutes

Insulin Pump Pharmacological ManagementPharmacological Management Insulin PumpInsulin Pump Battery operated device, worn on a belt with a needle Battery operated device, worn on a belt with a needle

inserted in SC tissueinserted in SC tissue Provides a continuous low-dose insulin infusionProvides a continuous low-dose insulin infusion Patient can add a bolus prior to meals and snacks Patient can add a bolus prior to meals and snacks

based on blood sugarbased on blood sugar Allows for tighter control of blood glucose and more Allows for tighter control of blood glucose and more

flexible lifestyle; patient needs to be conscientious, flexible lifestyle; patient needs to be conscientious, intensive – self-monitoring of blood glucose is essentialintensive – self-monitoring of blood glucose is essential

Site is changed every 24-48 hoursSite is changed every 24-48 hours Used with all types of insulinUsed with all types of insulin

DIABETES MELLITUS Pharmacological ManagementPharmacological Management Insulin PensInsulin Pens Pre-filled insulin cartridge loaded into a pen-like holderPre-filled insulin cartridge loaded into a pen-like holder Two typesTwo types

Disposable – pre-filled with set amounts of insulin, once used, it Disposable – pre-filled with set amounts of insulin, once used, it is thrown awayis thrown away

Non-disposable – insulin cartridge is replaced when emptyNon-disposable – insulin cartridge is replaced when empty Both require a pen needle, which is screwed onto the Both require a pen needle, which is screwed onto the

tip of the pentip of the pen Easy to use, no need to draw up insulin from a vialEasy to use, no need to draw up insulin from a vial Dose can be set for patients with visual and dexterity Dose can be set for patients with visual and dexterity

issuesissues More expensive that vials, not all types insulin available More expensive that vials, not all types insulin available

for use in pensfor use in pens Cannot mix insulin so two injections requiredCannot mix insulin so two injections required

DIABETES MELLITUS SLIDING SCALE

Glucose Results

< 70 mg/dl

70-150 mg/dl

<0.8 u/kg <1.2 u/kg <1.5 u/kg <2 u/kg Other151-200 mg/dl 1 2 3 4201-250 mg/dl 2 4 6 8251-300 mg/dl 3 6 9 12301-350 mg/dl 4 8 12 16351-400 mg/dl 5 10 15 20>400 mg/dl 10 16 20 25

Coverage

No coverage. Treat low glucose per protocol. Call MD.No CoverageCross Through Columns Not Used

Insulin Storage of InsulinStorage of Insulin

Store insulin in a cool place, refrigeration Store insulin in a cool place, refrigeration preferred, away from direct sunlightpreferred, away from direct sunlight

Unopened shelf life – 1 yearUnopened shelf life – 1 year Once opened, shelf life – 30 days; must be Once opened, shelf life – 30 days; must be

dated and initialed when openeddated and initialed when opened Do not freeze; pre-filled syringes should Do not freeze; pre-filled syringes should

be kept in a vertical position with needles be kept in a vertical position with needles up; roll syringe to remix solution before up; roll syringe to remix solution before givinggiving

DIABETES MELLITUS Pharmacological ManagementPharmacological Management Administration of InsulinAdministration of Insulin

Administered subcutaneously (Regular insulin is the Administered subcutaneously (Regular insulin is the only insulin given only insulin given IM or IVIM or IV))

Roll the vial of cloudy insulin, do not shake, to avoid Roll the vial of cloudy insulin, do not shake, to avoid bubbles, causing an inaccurate dose to be drawnbubbles, causing an inaccurate dose to be drawn

When mixing insulin, inject an amount of air equal to When mixing insulin, inject an amount of air equal to the insulin dose into the cloudy vial first, remove the insulin dose into the cloudy vial first, remove syringe, draw up air equal to dose of clear, then syringe, draw up air equal to dose of clear, then draw up clear insulin, remove syringe, now draw up draw up clear insulin, remove syringe, now draw up cloudycloudy

Be careful not to inject any cloudy insulin into the Be careful not to inject any cloudy insulin into the clear bottle. Regular insulin is always drawn up firstclear bottle. Regular insulin is always drawn up first

DIABETES MELLITUS

Pharmacological ManagementPharmacological Management Administration of InsulinAdministration of Insulin

Before giving the insulin dose, Must Before giving the insulin dose, Must Always Be Checked by Another NurseAlways Be Checked by Another Nurse

Administer 30 minutes before mealsAdminister 30 minutes before meals Inject a mixed dose of insulin within 5 Inject a mixed dose of insulin within 5

minutes of preparation, because after this minutes of preparation, because after this time the regular insulin binds to the NPH time the regular insulin binds to the NPH insulin and its action is reducedinsulin and its action is reduced

During stress, illness, or surgery, the patient During stress, illness, or surgery, the patient maybe managed with sliding scale insulin maybe managed with sliding scale insulin (Regular only) where the dose is dependent (Regular only) where the dose is dependent on the finger-stick blood glucose levelon the finger-stick blood glucose level

DIABETES MELLITUS

Pharmacological ManagementPharmacological Management Administration sitesAdministration sites

Rotation of sites is essential to prevent Rotation of sites is essential to prevent lipodystrophy, a spongy swelling at or lipodystrophy, a spongy swelling at or around site which can interfere with around site which can interfere with absorptionabsorption

Careful records must be maintainedCareful records must be maintained Aspiration before and massaging after Aspiration before and massaging after

injection on longer recommendedinjection on longer recommended Abdominal injection sites preferred for Abdominal injection sites preferred for

rapid, consistent absorptionrapid, consistent absorption Injection site should be 1 inch from previous Injection site should be 1 inch from previous

sitesite

Complications of Insulin Therapy

Complications of Insulin TherapyComplications of Insulin Therapy Hypoglycemia – blood glucose drops below Hypoglycemia – blood glucose drops below

50 and most often occurs before meals or 50 and most often occurs before meals or when insulin action is peakingwhen insulin action is peaking

Somogyi Phenomenon – Patient’s blood Somogyi Phenomenon – Patient’s blood glucose rises in spite of increasing insulin glucose rises in spite of increasing insulin dosedose Insulin causes hypoglycemia at night, generating a Insulin causes hypoglycemia at night, generating a

release of glucose-elevating hormones release of glucose-elevating hormones (epinephrine, cortisol, and glucagon) which then (epinephrine, cortisol, and glucagon) which then REBOUNDS to manifest as hyperglycemia in early REBOUNDS to manifest as hyperglycemia in early morningmorning

Somogyi Phenomenon

Diagnoses- Measure blood glucose Diagnoses- Measure blood glucose between 2 and 4 am and again at between 2 and 4 am and again at 7am.7am.

The 2 and 4 am levels below The 2 and 4 am levels below 60mg/dl and a 7am level above 60mg/dl and a 7am level above 180mg/dl support the diagnosis.180mg/dl support the diagnosis.


Somogyi PhenomenonSomogyi Phenomenon• May be inadvertently treated with an May be inadvertently treated with an

increase insulin dosage – making increase insulin dosage – making problems worseproblems worse

• Symptoms – night sweats, restlessness, Symptoms – night sweats, restlessness, early morning nausea, H/A and confusionearly morning nausea, H/A and confusion

• Treatment – Decreasing evening dose of Treatment – Decreasing evening dose of exogenous insulin by 2-3 units every 3 or exogenous insulin by 2-3 units every 3 or 4 days until the rebound hyperglycemia is 4 days until the rebound hyperglycemia is brought under control. Bedtime snack brought under control. Bedtime snack may also be helpfulmay also be helpful


Dawn PhenomenonDawn Phenomenon Caused by natural release of growth Caused by natural release of growth

hormone and cortisol during the early hormone and cortisol during the early morning hours causing morning hours causing hyperglycemiahyperglycemia

Treatment – adjust evening insulin Treatment – adjust evening insulin dose by 1 or 2 units and give at a dose by 1 or 2 units and give at a later timelater time

DIABETES MELLITUS

Pharmacological ManagementPharmacological Management Oral Hypoglycemic MedicationsOral Hypoglycemic Medications

Usually given to DM Type-2 patients who Usually given to DM Type-2 patients who are not controlled with exercise and diet are not controlled with exercise and diet alonealone

Remember they are not “insulin pills” Remember they are not “insulin pills” because insulin is a protein and would be because insulin is a protein and would be digested. These drugs improve the digested. These drugs improve the body’s sensitivity to insulin body’s sensitivity to insulin

The pancreas must be partially The pancreas must be partially functioningfunctioning

DIABETES MELLITUSPharmacological ManagementPharmacological Management Classifications – Insulin StimulatorsClassifications – Insulin Stimulators

Stimulates beta cells to increase insulin secretion and Stimulates beta cells to increase insulin secretion and increases insulin receptor sensitivityincreases insulin receptor sensitivity

May be given with other classes of oral agentsMay be given with other classes of oral agents Should be administered 15-30 minutes before meals, Should be administered 15-30 minutes before meals,

except for Diabinese which is given with breakfastexcept for Diabinese which is given with breakfast Avoid alcoholic beverages – may cause Antabuse-lke Avoid alcoholic beverages – may cause Antabuse-lke

reactions (facial flushing, pounding H/A, breathlessness, reactions (facial flushing, pounding H/A, breathlessness, and nauseaand nausea

Alcohol can potentiate the hypoglycemic effects, so if Alcohol can potentiate the hypoglycemic effects, so if taken, should be taken with mealstaken, should be taken with meals

Drugs come from same family as sulfonamide antibiotics, Drugs come from same family as sulfonamide antibiotics, must watch for allergies to sulfa drugsmust watch for allergies to sulfa drugs

Side effects – weight gain, skin rash, GI upset, hemolytic Side effects – weight gain, skin rash, GI upset, hemolytic anemia, cholestasis , sulfa allergies.anemia, cholestasis , sulfa allergies.

PRAMLINTIDE (Symlin)

The medication pramlintide (Symlin) The medication pramlintide (Symlin) carries with it an FDA BLACK BOX carries with it an FDA BLACK BOX WARNING!!!WARNING!!!

This medication has the potential to This medication has the potential to cause severe hypoglycemia within 3 cause severe hypoglycemia within 3 hours of administration. It is critically hours of administration. It is critically important that the nurse observe the important that the nurse observe the patient closely for any signs or patient closely for any signs or symptoms of hypoglycemia.symptoms of hypoglycemia.

Sulfonylureas (Stimulator)

Lowers blood sugar by stimulating Lowers blood sugar by stimulating the beta cells of the pancreas to the beta cells of the pancreas to secrete more insulin and secrete more insulin and increasing the sensitivity of increasing the sensitivity of insulin receptors.insulin receptors.

A significant adverse effect of the A significant adverse effect of the sulfonyureas is the risk of sulfonyureas is the risk of hypoglycemia.hypoglycemia.

Biguanides

Metaformin (Glucophage, Fortamet)Metaformin (Glucophage, Fortamet) Action- Inhibits hepatic glucose Action- Inhibits hepatic glucose

production, increases insulin production, increases insulin sensitivity.sensitivity.

Side Effects- Lactic Acidosis, Side Effects- Lactic Acidosis, hypoglycemia when used with hypoglycemia when used with sulfonylurea or meglitnide.sulfonylurea or meglitnide.

Advantage: Does not cause insulin Advantage: Does not cause insulin releaserelease

Meglitinides

PrandinPrandin StarlixStarlix Secrete pancreatic secretion of Secrete pancreatic secretion of

insulininsulin Side Effects- Hypoglycemia, Side Effects- Hypoglycemia,

weight gain.weight gain. Stimulate Pancreas for Insulin Stimulate Pancreas for Insulin

secretion but shorter acting than secretion but shorter acting than sulfonylureasulfonylurea

Thizolidnediones

Actos (Pioglitzaone) GIVE WITH MEALSActos (Pioglitzaone) GIVE WITH MEALS Avandia (Rosiglitzaone)Avandia (Rosiglitzaone) Increases insulin sensitivity in the Increases insulin sensitivity in the

tissuestissues Side Effects- Hypoglycemia when Side Effects- Hypoglycemia when

used with sulfonylurea or meglitinide, used with sulfonylurea or meglitinide, weight gain, decreased effectiveness weight gain, decreased effectiveness of oral contraceptives, possible liver of oral contraceptives, possible liver dysfunction.dysfunction.

Notify doctor of weight gain an Notify doctor of weight gain an edema.edema.

Alpha –Glucosidase Inhibitors

Absorption Delayers – inhibit enzymes in the Absorption Delayers – inhibit enzymes in the small intestine and pancreas small intestine and pancreas Reduces rate of CHO digestion and absorptionReduces rate of CHO digestion and absorption Results in a reduced glucose absorptionResults in a reduced glucose absorption May be given with other oral agentsMay be given with other oral agents Give at start of mealsGive at start of meals Side effects – diarrhea, flatulence, abdominal Side effects – diarrhea, flatulence, abdominal

painpain Acarbose (Precose)Acarbose (Precose) Miglitol (Glyset)Miglitol (Glyset)

Complications of Diabetes Mellitus

Hyperglycemia – occurs when patient is unable Hyperglycemia – occurs when patient is unable to compensate for the increased blood glucoseto compensate for the increased blood glucose

Caused by over eating, stress, not enough Caused by over eating, stress, not enough insulin, or other medications, and/or illnessinsulin, or other medications, and/or illness

S/S – similar to when 1S/S – similar to when 1stst diagnosed – polyuria, diagnosed – polyuria, lethargy, polydipsia, H/A, polyphagia, blurred lethargy, polydipsia, H/A, polyphagia, blurred vision, coma, BG > 300 mg/dl, n/vvision, coma, BG > 300 mg/dl, n/v

Treatment – assess cause, notify MD if Treatment – assess cause, notify MD if vomiting, and monitor blood glucose closely vomiting, and monitor blood glucose closely

Call MD if BG > 200 mg/dl for changes in Call MD if BG > 200 mg/dl for changes in medicationmedication

If BG > 300 mg/dl, call MD, check urine for If BG > 300 mg/dl, call MD, check urine for ketones and increase fluid intakeketones and increase fluid intake

Hypoglycemia Causes:Exogenous

CausesCauses Predisposing Predisposing FactorsFactors

OccurrenceOccurrence

InsulinInsulin Intentional or Intentional or accident ODaccident OD

Inadequate food Inadequate food intakeintake

Increased exerciseIncreased exercise

Decrease insulin Decrease insulin requirementrequirement

Other medicationsOther medications

MOST MOST FREQUENT FREQUENT CAUSE OF CAUSE OF HYPOGLYCEMIAHYPOGLYCEMIA




Oral Oral hypoglycemic hypoglycemic agentsagents

Intentional or Intentional or accident ODaccident OD

Inadequate food Inadequate food intakeintake

Other medicationsOther medications

Frequent cause Frequent cause of of hypoglycemia hypoglycemia with with sulfonylurea's sulfonylurea's and and meglitinides.meglitinides.

PRAMLINITIDE!PRAMLINITIDE!




AlcoholAlcohol Particularly likely Particularly likely in chronically in chronically malnourished or malnourished or acutely food-acutely food-deprived clientsdeprived clients

Occurs in 6-36 Occurs in 6-36 hr of ingesting hr of ingesting moderate to moderate to large amounts large amounts of alcoholof alcohol




ExerciseExercise Increased Increased duration and duration and intensity of intensity of exercise increases exercise increases glucose uptake glucose uptake and normally and normally decreases insulin decreases insulin secretionsecretion

Occurs with Occurs with both insulin both insulin sulfonylurea sulfonylurea administration administration and intense and intense exercise, but exercise, but may be may be unpredictable unpredictable in onset.in onset.

Hypoglycemia Causes:Endogenous



Organic Organic hypoglycemiahypoglycemia

Insulinoma (tumor Insulinoma (tumor of beta cells of the of beta cells of the pancreatic islets pancreatic islets of Langerhansof Langerhans

Uncommon Uncommon neoplasm of neoplasm of beta cells beta cells

Hypoglycemia Causes:Endogenous



Extrapancreatic Extrapancreatic neoplasm'sneoplasm's

May be May be mesenchymal mesenchymal tumors, tumors, hepatomas, hepatomas, adrenocortical adrenocortical carcinomas, carcinomas, gastronintestinal gastronintestinal tumors, tumors, lymphomas, or lymphomas, or leukemiasleukemias

Rare; most Rare; most common in common in adults 40-70 adults 40-70 yrs of age.yrs of age.

Hypoglycemia Causes:Functional



Alimentary Alimentary hypoglycemiahypoglycemia

(Dumping (Dumping Syndrome)Syndrome)

Rapid dumping of Rapid dumping of carbohydrates carbohydrates into upper small into upper small intestineintestine

PostgastrectomPostgastrectomyy




Drug Related Drug Related (ethanol, (ethanol, haloperidol, haloperidol, pentamdine, pentamdine, salicylates) salicylates) reactive reactive hypoglycemiahypoglycemia

Syndrome with Syndrome with symptoms such as symptoms such as diaphoresis, diaphoresis, tachycardia, tachycardia, tremulousness, tremulousness, headache, fatigue, headache, fatigue, drowsiness, and drowsiness, and irritabilityirritability

Rarely Rarely diagnosed diagnosed throughout the throughout the world, May be world, May be overdiagnosed overdiagnosed in the United in the United States States according to according to statement by statement by ADAADA




Rapid Rapid discontinuation discontinuation of TPNof TPN

Endocrine Endocrine deficiency states deficiency states (cortisol, growth (cortisol, growth hormone, hormone, glucagons, glucagons, epinephrine)epinephrine)

Easily Easily PreventedPrevented




Glucocorticoid Glucocorticoid deficiencydeficiency

Critical illness Critical illness (cardiac, hepatic, (cardiac, hepatic, and renal disease)and renal disease)

A danger for A danger for any person with any person with adrenal adrenal insufficiency.insufficiency.




Severe Liver Severe Liver DeficiencyDeficiency

Insufficient Insufficient glucose ouput by glucose ouput by liverliver

Fasting Fasting hypoglycemiahypoglycemia




Lack of body Lack of body stores for stores for protein, fat and protein, fat and carbohydratescarbohydrates

Profound Profound MalnutritionMalnutrition

Common, also Common, also found with found with relative relative frequency in frequency in kwashiorkorkwashiorkor




Prolonged Prolonged Muscular Muscular exerciseexercise

Metabolism of Metabolism of energy-producing energy-producing substancessubstances

Occurs if Occurs if exercise is too exercise is too prolonged or prolonged or severe or if severe or if nutritional nutritional intake and intake and carbohydrate carbohydrate stores are stores are insufficient.insufficient.

Hypoglycemia

Hypoglycemia – result of excess secretion of insulin, Hypoglycemia – result of excess secretion of insulin, leading to blood glucose below 50 mg/dlleading to blood glucose below 50 mg/dl Cause – skipping meals, exercise, or medicated with too much Cause – skipping meals, exercise, or medicated with too much

insulininsulin Most often occurs before meals and when insulin is peakingMost often occurs before meals and when insulin is peaking Repeated or extremely low BG levels may cause neurologic Repeated or extremely low BG levels may cause neurologic

damagedamage S/S – hunger, H/A, diaphoresis, blurred vision, S/S – hunger, H/A, diaphoresis, blurred vision,

irritability, confusion, pallor, tremors, seizures, comairritability, confusion, pallor, tremors, seizures, coma Treatment – assess possible causes, get finger-stick BGTreatment – assess possible causes, get finger-stick BG Administer “fast sugar” immediately if patient is alert Administer “fast sugar” immediately if patient is alert

(15 grams of CHO – 4-6 oz. orange juice)(15 grams of CHO – 4-6 oz. orange juice) If unconscious and no IV access,1 mg glucagon (SC) or If unconscious and no IV access,1 mg glucagon (SC) or

IM per hospital protocolIM per hospital protocol IV 50ml of 50% Dextrose. IV 50ml of 50% Dextrose.

Hypoglycemia Recheck glucose in 15 minutes and repeat Recheck glucose in 15 minutes and repeat

procedure until improvement notedprocedure until improvement noted Call MD if no improvementCall MD if no improvement Educate patient to recognize and prevent Educate patient to recognize and prevent

low blood glucose symptomslow blood glucose symptoms Self Monitoring of Blood Glucose LevelsSelf Monitoring of Blood Glucose Levels

Test blood glucose levels two to four times a day, ac and Test blood glucose levels two to four times a day, ac and hshs

Teach how to use lancets or lasers to obtain blood Teach how to use lancets or lasers to obtain blood samplesample

Teach to use a log or diary to record glucose levelsTeach to use a log or diary to record glucose levels

Diabetic Keto Acidosis (DKA)

1.1. Tissues cannot utilize glucose without Tissues cannot utilize glucose without insulin, resulting in an increase in insulin, resulting in an increase in serum glucose levels.serum glucose levels.

2.2. The high osmotic pressure created by The high osmotic pressure created by excess glucose leads to osmotic excess glucose leads to osmotic diuresis (polyuria). As glucose is diuresis (polyuria). As glucose is eliminated in the kidneys, so are eliminated in the kidneys, so are large amounts of water and large amounts of water and electrolytes (electrolyte imbalance)electrolytes (electrolyte imbalance)

DKA 3. The patient voids large amounts of 3. The patient voids large amounts of

dilute urine (polyuria)dilute urine (polyuria) 4. To make matters worse, the 4. To make matters worse, the

sympathetic nervous system responds sympathetic nervous system responds to the cellular need for fuel by to the cellular need for fuel by converting glycogen to glucose and converting glycogen to glucose and manufacturing additional glucose.manufacturing additional glucose.

5. As glycogen stores are depleted, 5. As glycogen stores are depleted, the body begins to burn fat and the body begins to burn fat and protein for energy.protein for energy.

DKA

6. Fat metabolism produces acidic 6. Fat metabolism produces acidic substances called ketone bodies that substances called ketone bodies that accumulate and lead to metabolic accumulate and lead to metabolic acidosis.acidosis.

7. Protein metabolism results in the 7. Protein metabolism results in the loss of lean muscle mass and a loss of lean muscle mass and a negative nitrogen balance.negative nitrogen balance.

DKA Signs and Symptoms

Early- Anorexia, headache, and fatigue.Early- Anorexia, headache, and fatigue. Progresses to-Polydipsia, Polyuria, Progresses to-Polydipsia, Polyuria,

Polyphagia. Polyphagia.

Dehydration, Weakness, Lethargy, Dehydration, Weakness, Lethargy, Abdominal Pain, Nausea, Emesis, Fruity Abdominal Pain, Nausea, Emesis, Fruity Breath, Increased Respiratory Rate, Breath, Increased Respiratory Rate, Tachycardia, blurred Vision, Tachycardia, blurred Vision, Hypothermia.Hypothermia.

Late: Air Hunger (due to acidosis) Late: Air Hunger (due to acidosis) Kussmauls Respirations, Coma, Shock Kussmauls Respirations, Coma, Shock and Deathand Death

DKA Treatment

Diabetic KetoacidosisDiabetic Ketoacidosis TreatmentTreatment

Maintain patent airwayMaintain patent airway IV fluids to maintain fluid and electrolyte IV fluids to maintain fluid and electrolyte

balancebalance Insulin managementInsulin management Monitor renal function, especially K+ levels Monitor renal function, especially K+ levels

and add IV potassium per ordersand add IV potassium per orders Monitor BG q 1-2 hoursMonitor BG q 1-2 hours VS q1-2 hours ABGs q 1hourVS q1-2 hours ABGs q 1hour Keep patient warmKeep patient warm


Hyperglycemia Hyperosmolar Nonketotic Hyperglycemia Hyperosmolar Nonketotic Syndrome (HHNKS)Syndrome (HHNKS) Extreme hyperglycemia without acidosis, Extreme hyperglycemia without acidosis,

because some insulin is being produced, cells are because some insulin is being produced, cells are not starved; therefore, ketones are not seen in not starved; therefore, ketones are not seen in the blood or urinethe blood or urine

Patient may not feel physically ill because there Patient may not feel physically ill because there is no ketoacidosisis no ketoacidosis

Usually occurs in NIDDM when diabetes is Usually occurs in NIDDM when diabetes is uncontrolled or during stress or infectionuncontrolled or during stress or infection

S/S – extreme thirst, severe dehydration, S/S – extreme thirst, severe dehydration, alterations in LOC – confused, shock, coma. alterations in LOC – confused, shock, coma. Blood glucose very high, from 800-2400 Blood glucose very high, from 800-2400 mg/dl, blood osmolarity (concentration) very mg/dl, blood osmolarity (concentration) very high > 320 mOsm/kghigh > 320 mOsm/kg


HHNKSHHNKS TreatmentTreatment

IV fluid replacementIV fluid replacement IV insulinIV insulin Monitor electrolytesMonitor electrolytes Monitor BGMonitor BG

Long-term Complications of Diabetes Mellitus

Seen in Type I and Type II Seen in Type I and Type II diabeticsdiabetics

Complications r/t the effects of Complications r/t the effects of chronic hyperglycemiachronic hyperglycemia

Macrovascular complications – Macrovascular complications – involving large blood vessels and involving large blood vessels and microvascular involving the tiny microvascular involving the tiny blood vesselsblood vessels


Macrovascular – Circulatory SystemMacrovascular – Circulatory System AtherosclerosisAtherosclerosis HypertensionHypertension Elevated LDL, cholesterol and triglyceride levelsElevated LDL, cholesterol and triglyceride levels Increased platelet clottingIncreased platelet clotting These factors increase the incidence of heart These factors increase the incidence of heart

attack, stroke, and poor circulation of the feet attack, stroke, and poor circulation of the feet and legsand legs

MicrovascularMicrovascularEyes – Retinopathy (damage to the tiny retinal Eyes – Retinopathy (damage to the tiny retinal

blood vessels) leading to blindnessblood vessels) leading to blindnessHigh incidence of cataracts at an earlier ageHigh incidence of cataracts at an earlier age


Diabetic ulcer and gangreneDiabetic ulcer and gangrene


GangreneGangrene

Foot Care

Inspect DailyInspect Daily Wash in warm not hot waterWash in warm not hot water Dry feet watch between toesDry feet watch between toes Cut the nails straight across unless doctors order Cut the nails straight across unless doctors order

requires podiatristrequires podiatrist Clean Cotton socks DailyClean Cotton socks Daily Proper Fitting shoesProper Fitting shoes Never wear open sandalsNever wear open sandals Use socks and blankets to warm feetUse socks and blankets to warm feet Test H20 temp before stepping into bath or showerTest H20 temp before stepping into bath or shower Elevate Feet whenever possibleElevate Feet whenever possible


Diabetic RetinopathyDiabetic Retinopathy


AtherosclerosisAtherosclerosis


HemodialysisHemodialysis


MicrovascularMicrovascular Kidneys – Nephropathy (damage to the Kidneys – Nephropathy (damage to the

vessels within the kidneys) vessels within the kidneys) DM is the leading cause of end-stage renal DM is the leading cause of end-stage renal

disease (ESRD), leading to kidney failuredisease (ESRD), leading to kidney failure Native Americans, Hispanics, and African-Native Americans, Hispanics, and African-

Americans at highest riskAmericans at highest risk Hemodialysis or peritoneal dialysis is needed Hemodialysis or peritoneal dialysis is needed

when kidneys have lost most of their functionwhen kidneys have lost most of their function Keep accurate I/O if orderedKeep accurate I/O if ordered Urine TestingUrine Testing

Tests for glucose and ketonesTests for glucose and ketones Urine tested for ketones during illness, stress, and Urine tested for ketones during illness, stress, and

pregnancypregnancy Presence of ketones indicates glucose level > 300 and Presence of ketones indicates glucose level > 300 and

should be reported to MD immediatelyshould be reported to MD immediately


MicrovascularMicrovascularNerves – Neuropathy (nerve damage) is the Nerves – Neuropathy (nerve damage) is the

most common chronic complicationmost common chronic complication Sensorimotor polyneuropathy – aka peripheral Sensorimotor polyneuropathy – aka peripheral

neuropathy – causes numbness (paresthesias) neuropathy – causes numbness (paresthesias) and pain or burning sensation in lower and pain or burning sensation in lower extremetiesextremeties

Patient at risk for foot injuriesPatient at risk for foot injuries Avoid tight fitting garments and shoesAvoid tight fitting garments and shoes Autonomic neuropathies affect:Autonomic neuropathies affect:

GI – gastroparesis (delayed gastric emptying), GI – gastroparesis (delayed gastric emptying), constipation, diarrheaconstipation, diarrhea

GU – retention, neurogenic bladderGU – retention, neurogenic bladder Reproductive – male impotenceReproductive – male impotence


Other ComplicationsOther Complications InfectionsInfections

Patients with diabetes more prone to infections Patients with diabetes more prone to infections d/t delayed healing from impaired circulationd/t delayed healing from impaired circulation

Insulin requirements may need to be increased Insulin requirements may need to be increased if infection presentif infection present

WBCs become sluggish and ineffectiveWBCs become sluggish and ineffective Periodontal disease increased d/t bacteria and Periodontal disease increased d/t bacteria and

plaqueplaque Foot complications with DM leading cause of Foot complications with DM leading cause of

amputationamputation Observe for signs of infection, injury or stress Observe for signs of infection, injury or stress

and teach patient to do the sameand teach patient to do the same

Sick Day CareTreatment/Nursing ManagementTreatment/Nursing Management MedicationMedication

Take insulin as prescribed. Take insulin as prescribed. Adjust dose as directed depending on Glucose readingsAdjust dose as directed depending on Glucose readings It oral hypoglycemia, take your usual dose. Do not increase It oral hypoglycemia, take your usual dose. Do not increase

unless doctors order. If your have emesis the doctor may order unless doctors order. If your have emesis the doctor may order sub q insulin.sub q insulin.

DietDiet Eat normal diet on scheduleEat normal diet on schedule If N & V, replace carbohydrate solid foods with fruit juice, If N & V, replace carbohydrate solid foods with fruit juice,

regular soft drinks, or Jell-Oregular soft drinks, or Jell-O Monitoring Blood Sugar and KetonesMonitoring Blood Sugar and Ketones

Monitor Q4 and recordMonitor Q4 and record If severely ill Q2 hoursIf severely ill Q2 hours Dip urine for Ketones if BG over 240mg/dlDip urine for Ketones if BG over 240mg/dl

When to Call Physician

If emesis, abdominal pain or temp If emesis, abdominal pain or temp above 100.2 Fabove 100.2 F

If blood glucose is above 200mg/dlIf blood glucose is above 200mg/dl If Ketones are in urineIf Ketones are in urine If you cannot reach physician GO TO If you cannot reach physician GO TO

ERER


Treatment/Nursing ManagementTreatment/Nursing Management Priorities in hospitalPriorities in hospital

A nursing care plan should be A nursing care plan should be formulated with complete formulated with complete understanding of cause of admissionunderstanding of cause of admission

A thorough and ongoing assessmentA thorough and ongoing assessment Knowledge of the current symptoms, Knowledge of the current symptoms,

potential complications, lab values, potential complications, lab values, and medicationsand medications

Discharge planning should be Discharge planning should be initiated as soon as possibleinitiated as soon as possible

Diabetes Mellitus

Treatment/Nursing ManagementTreatment/Nursing Management Patient EducationPatient Education

Is the key to effective self managementIs the key to effective self management Consider knowledge base, ability to learn, Consider knowledge base, ability to learn,

emotional and physical health, family influence, emotional and physical health, family influence, socio-economic status, cultural influences and socio-economic status, cultural influences and current lifestyle patternscurrent lifestyle patterns

Topics to teachTopics to teach Glucose monitoringGlucose monitoring - S/S of - S/S of

complicationscomplications Urine testingUrine testing - Lifestyle - Lifestyle

changeschanges Medication administrationMedication administration - Foot care- Foot care Dietary managementDietary management - Sick-day - Sick-day

managementmanagement


Treatment/Nursing ManagementTreatment/Nursing Management Foot CareFoot Care

Never use sharp ;objects to poke or dig under the toenail Never use sharp ;objects to poke or dig under the toenail or around the cuticleor around the cuticle

Ingrown toenails or nails that are thick should be cared Ingrown toenails or nails that are thick should be cared for by a podiatristfor by a podiatrist

After washing feet, gently rub any corns and callused After washing feet, gently rub any corns and callused areas with a pumice stone to control buildupareas with a pumice stone to control buildup

Use pads on corns to reduce pressureUse pads on corns to reduce pressure Sick-DaySick-Day

Teach to continue to take insulin or oral hypoglycemic Teach to continue to take insulin or oral hypoglycemic medicationsmedications

Monitor BG 4-6 times a day while sickMonitor BG 4-6 times a day while sick Check urine for ketonesCheck urine for ketones If BG >300 or presence of ketones, report to MDIf BG >300 or presence of ketones, report to MD Extreme n/v or diarrhea – report to MD – risk of extreme Extreme n/v or diarrhea – report to MD – risk of extreme

fluid loss is dangerousfluid loss is dangerous

Diabetes Mellitus

Treatment/Nursing ManagementTreatment/Nursing Management Emotional SupportEmotional Support

Encourage family involvementEncourage family involvement Encourage verbalization of feels/fearsEncourage verbalization of feels/fears Answer questionsAnswer questions Assist and follow up with consults as Assist and follow up with consults as

dietary, etc.dietary, etc. Stress importance of frequent Stress importance of frequent

primary care provider visitsprimary care provider visits

Deficient Knowledge

R/T- Lack of Knowledge of R/T- Lack of Knowledge of Diabetes ManagementDiabetes Management

Goals- Patient will correctly Goals- Patient will correctly describe type 1 diabetes and describe type 1 diabetes and treatment. Patient will treatment. Patient will demonstrate self medication, meal demonstrate self medication, meal planning, and understanding of planning, and understanding of management of exercise and drug management of exercise and drug effects.effects.

Ineffective Therapeutic Regimen Management

R/T- Financial, personal, or family R/T- Financial, personal, or family pattern disruptionpattern disruption

Goal- Client will express intent to Goal- Client will express intent to adhere to prescribed regimen of adhere to prescribed regimen of care.care.

Deficient Fluid Volume

R/T-Altered Urinary OutputR/T-Altered Urinary Output Goals-Client will maintain normal Goals-Client will maintain normal

blood volume, as evidence by blood volume, as evidence by normal tissue turgor, pulse, and normal tissue turgor, pulse, and blood pressure.blood pressure.

Imbalanced Nutrition:

Less or moreLess or more R/T:Alterations in insulin R/T:Alterations in insulin

availability or utilization.availability or utilization.

Risk for Injury

R/T- Adverse effects of drugs, R/T- Adverse effects of drugs, increased susceptibility to infectionincreased susceptibility to infection

R/T- Severe decrease in tissue R/T- Severe decrease in tissue perfusion in feet.perfusion in feet.

GoalsGoals Clients blood glucose will remain within Clients blood glucose will remain within

goal range established by physiciangoal range established by physician Patient will state measures to reduce risk Patient will state measures to reduce risk

of infections and will identify symptoms of infections and will identify symptoms that should be reported.that should be reported.

Ineffective Health Maintenance

R/T- Lack of knowledge of dietary R/T- Lack of knowledge of dietary management of DM, drug therapy, management of DM, drug therapy, and self-monitoringand self-monitoring

Goal- Client will demonstrate the Goal- Client will demonstrate the ability to adhere to prescribed diet ability to adhere to prescribed diet and drug therapy and to monitor and drug therapy and to monitor blood glucoseblood glucose

Ineffective Therapeutic Regimen Management

R/T- financial limitations and R/T- financial limitations and difficulties with transportation for difficulties with transportation for food, drugs, and medical carefood, drugs, and medical care

Goals-Client will manage her Goals-Client will manage her prescribed diet and drug therapy.prescribed diet and drug therapy.

Risk for Infection

R/T- Elevated blood Glucose LevelR/T- Elevated blood Glucose Level Goals:Goals: Interventions:Interventions:

diabetes nur 105. diabetes mellitus statistics – approximately 21 million in the us= 7% of...

Documents

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constant level insulin

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diabetes mellitus statistics

rate of insulin secreted