1. NURSING MANAGEMENT OF CLIENTS WITH DIABETES

2. Diabetes Mellitus  A chronic multisystem disease related to abnormal insulin production, impaired insulin utilization, or both  Affects 25.8 million people  Seventh leading cause of death  http://www.diabetes.org http://www.diabetes.org

3. Insult from Diabetes  Leading cause of  adult blindness  End-stage kidney disease  Non-traumatic lower limb amputation  Major contributing factor to  Heart disease  Stroke  Hypertension

4. Etiology and Pathophysiology  Combination of causative factors  Genetic  Autoimmune  Environmental  Absent/insufficient insulin and/or poor utilization of insulin

5. Etiology and Pathophysiology  Normal insulin metabolism  Produced by B-cells in islets of Langerhans  Released continuously into bloodstream in small increments with larger amounts released after food  Stabilizes glucose level in range of 70 to 120 mg/dL

7. Etiology and Pathophysiology  Insulin  Promotes glucose transport in skeletal muscle and adipose tissue  Storage of glucose as glycogen  Inhibits gluconeogenesis  Enhances fat deposition  Increases protein synthesis  Not necessary for glucose transport in brain, liver, blood cells

8. Etiology and Pathophysiology  Counter-regulatory hormones  Glucagon, epinephrine, growth hormone, cortisol  Oppose effects of insulin  Stimulate glucose production by liver  Decrease movement of glucose into cell  Help maintain normal blood glucose levels

9. Classes of Diabetes  Type I  Type 2  Gestational  Other specific types

10. Type 2 Diabetes  Metabolic syndrome increases risk for  Elevated glucose levels  Abdominal obesity  Elevated blood pressure  High levels of triglycerides  Decreased levels of HDLs  Gradual onset  Hyperglycemia may go on for many years  Many times discovered on routine lab testing

11. Type 1 Versus Type 2 Diabetes

12. Pre-diabetes  Individuals at risk for type 2 diabetes  Impaired glucose intolerance (IGT)  Two-hour oral glucose tolerance test (OGTT): 140 to 199 mg/dL  Impaired fasting glucose (IFG)  Fasting glucose level: 100 to 125 mg/dL  Asymptomatic but long-term damange already occurring  Patient teaching

13. Clinical Manifestations  Classic symptoms  Polyuria  Polydipsia  Polyphagia  Weight loss  Weakness  Fatigue  Nonspecific symptoms:  Classic symptoms of type 1 may manifest  Fatigue  Recurrent infection  Recurrent vaginal yeast  Prolonged wound healing  Visual changes Type 1Type 2

14. Diagnostics 1. Hemoglobin A1C level: 6.5% or higher 2. Fasting plasma glucose level: higher than 126 mg/dL 3. Two-hour plasma glucose level during OGTT: 200 mg/dL (with glucose load of 75 g) 4. Classic symptoms of hyperglycemia with random plasma glucose level of 200 mg/dL or higher 5. Fructosamine 6. Autoantibodies

15. Collaborative Care  Goals of diabetes management  Decrease symptoms  Promote well-being  Prevent acute complications  Delay onset and progression of long-term complications  Need to maintain blood glucose levels as near to normal as possible

16. Collaborative Care  Patient teaching  Nutritional therapy  Drug therapy  Exercise  Self-monitoring of blood glucose  Diet, exercise, and weight loss may be sufficient for patients with type 2 diabetes  All patients with type 1 require insulin

17. Insulin  Exogenous insulin  Insulin from an outside source  Required for type 1 diabetes  Prescribed for patients with type 2 diabetes who cannot control blood glucose by other means

18. Types of Insulin

19. Combination Insulin Therapy  Can mix short- or rapid-acting insulin with intermediate- acting insulin in same syringe  Provides mealtime and basal coverage in one injection  Commercially premixed or self-mix

20. Mixing, Storage, and Administration of Insulin

21. Mealtime Insulin  Insulin preparations  Rapid-acting (bolus) Lispro, aspart, glulisine Onset of action 15 minutes Injected within 15 minutes of mealtime  Short-acting (bolus) Regular with onset of action 30 to 60 minutes Injected 30 to 45 minutes before meal Onset of action 30 to 60 minutes

22. Insulin as a Pump  Insulin pump  Continuous subcutaneous infusion  Battery-operated device  Connected to a catheter inserted into subcutaneous tissue in abdominal wall  Program basal and bolus doses that can vary throughout the day  Potential for tight glucose control

23. Complications of Insulin Use  Problems with insulin therapy  Hypoglycemia  Allergic reaction  Lipodystrophy  Somogyi effect  Rebound effect in which an overdose of insulin causes hypoglycemia  Release of counterregulatory hormones causes rebound hyperglycemia  Dawn phenomenon  Morning hyperglycemia present on awakening  Due to release of counterregulatory hormones in predawn hours

24. Oral Agents  Work on three defects of type 2 diabetes  Insulin resistance  Decreased insulin production  Increased hepatic glucose production  Can be used in combination

25. Biguanides  Metformin (Glucophage)  Reduce glucose production by liver  Enhance insulin sensitivity  Improve glucose transport  May cause weight loss  Used in prevention of type 2 diabetes  Withhold if contrast medium is used  Withhold if patient is undergoing surgery or radiologic procedure with contrast medium  Day or two before and at least 48 hours after  Monitor serum creatinine  Contraindications  Renal, liver, cardiac disease  Excessive alcohol intake

26. Sulfonylureas  ↑ Insulin production from pancreas  Major side effect: hypoglycemia  Examples  Glipizide (Glucotrol)  Glyburide (Micronase, DiaBeta, Glynase)  Glimepiride (Amaryl)

27. Meglitinides  ↑ Insulin production from pancreas  Rapid onset: ↓ hypoglycemia  Taken 30 minutes to just before each meal  Should not be taken if meal skipped  Examples  Repaglinide (Prandin)  Nateglinide (Starlix)

28. a-Glucosidase Inhibitors  “ Starch blockers”  Slow down absorption of carbohydrate in small intestine  Take with first bite of each meal  Example  Acarbose (Precose)  Miglitol (Glyset)

29. Thiazolidinediones  Most effective in those with insulin resistance  Improve insulin sensitivity, transport, and utilization at target tissues  Examples  Pioglitazone (Actos)  Rosiglitazone (Avandia)  Rarely used because of adverse effects

30. Risk Factors for Diabetic Complications  Hypertension  Genetics  Smoking  Chronic hyperglycemia  Obesity  Poor diet (high fat, high carb)  Sedentary lifestyle

31. Complications of Diabetes

32. Chronicity and Diabetes  Damage to blood vessels  CAD, CVD, PVD  Retinopathy Blindness  Nephropathy Renal Failure  Dermopathy  Neuropathy  Infection

33. Gerontologic Considerations  Increased prevalence and mortality  Glycemic control challenging  Increased hypoglycemic unawareness  Functional limitations  Renal insufficiency  Diet and exercise: main treatment  Patient teaching must be adapted to needs

34. References  Ignatavicius, D. D. & Workman, M. L. (2010). Medical-surgical nursing: patient-centered collaborative care (6 th ed.). St. Louis, MO: Saunders Elsevier.  Lewis, S. L., Heitkemper, M. M., Dirksen, S. R., & Bucher, L. (2014). Medical-surgical nursing: Assessment & management of client problems (9 th ed.). St. Louis, MO: Mosby  Hogan, M., Dentlinger, N.C., & Ramdin, V. (2014). Medical-surgical: nursing pearson nursing reviews and rationales (3 rd ed.). Boston, MA: Pearson.