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1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 46 Diabetes Mellitus and Hypoglycemia.

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Presentation on theme: "1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 46 Diabetes Mellitus and Hypoglycemia."— Presentation transcript:

1 1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 46 Diabetes Mellitus and Hypoglycemia

2 2Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Learning Objectives Describe the role of insulin in the body. Explain the pathophysiology of diabetes mellitus and hypoglycemia. Describe the signs and symptoms of diabetes mellitus and hypoglycemia. Explain tests and procedures used to diagnose diabetes mellitus and hypoglycemia. Discuss treatment of diabetes mellitus and hypoglycemia. Explain the difference between type 1 and type 2 diabetes mellitus.

3 3Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Learning Objectives Differentiate between acute hypoglycemia and diabetic ketoacidosis. Describe the treatment of a patient experiencing acute hypoglycemia or diabetic ketoacidosis. Describe the complications of diabetes mellitus. Identify nursing interventions for a patient diagnosed with diabetes mellitus or hypoglycemia. Identify nursing interventions for a patient diagnosed with ketoacidosis.

4 4Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Diabetes Mellitus

5 5Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pathophysiology Chronic disorder of impaired metabolism with vascular and neurologic complications Key feature is elevated blood glucose, called hyperglycemia Blood glucose level normally regulated by insulin, a hormone produced by beta cells in the islets of Langerhans located in the pancreas

6 6Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Type 1 Absence of endogenous insulin Formerly called juvenile-onset diabetes because it most commonly occurs in juveniles and young adults An autoimmune process, possibly triggered by a viral infection, destroys beta cells, the development of insulin antibodies, and the production of islet cell antibodies (ICAs) Affected people require exogenous insulin for the rest of their lives

7 7Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Type 2 Inadequate endogenous insulin and bodys inability to properly use insulin Beta cells respond inadequately to hyperglycemia; results in chronically elevated blood glucose Continuous high glucose level in the blood desensitizes the beta cells; they become less responsive to the elevated glucose More common in adults; increasing in children Controlled by diet and exercise; may require oral hypoglycemic agents or exogenous insulin

8 8Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Role of Insulin Glucose Insulin stimulates active transport of glucose into cells If insulin absent, glucose remains in the bloodstream Blood becomes thick, which increases its osmolality Increased osmolality stimulates the thirst center Increased fluid does not pass into body tissues; high serum osmolality retains fluid in the bloodstream As blood passes through the kidneys, some glucose eliminated Osmotic force created by glucose draws extra fluid and electrolytes with it, causing abnormally increased urine volume

9 9Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Role of Insulin Fatty acids Promotes fatty acid synthesis and conversion of fatty acids into fat, which is stored as adipose tissue Also spares fat by inhibiting breakdown of adipose tissue and mobilization of fat and by inhibiting the conversion of fats to glucose Without adequate insulin, fat stores break down and increased triglycerides are stored in the liver Increased fatty acids in the liver can triple the production of lipoproteins; promotes atherosclerosis

10 10Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Role of Insulin Protein Enhances protein synthesis in tissues and inhibits the conversion of protein into glucose Amino acids are admitted into cells; enhances rate of protein formation while preventing protein degradation Without adequate insulin, protein storage halts; large amounts of amino acids dumped into the bloodstream High levels of plasma amino acids place people with diabetes at risk for development of gout Changes in protein metabolism lead to extreme weakness and poor organ functioning

11 11Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Etiology An autoimmune malfunction may cause complete destruction of the islets of Langerhans in the pancreas, creating type 1 diabetes Islet cell antibodies are identified in more than 80% of all people with type 1 diabetes at the time of diagnosis

12 12Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 46-1

13 13Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Risk Factors Obesity Sedentary lifestyle Family history of diabetes Age 40 years and older History of gestational DM History of delivering infant weighing more than 10 lb African American (33% higher risk for type 2 DM) Latin American/Hispanic (>300% higher risk for type 2 DM) American Indians (33%-50% higher risk for type 2 DM)

14 14Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Risk Factors Metabolic syndrome Thought to be a precursor to diabetes Impaired glucose tolerance, high serum insulin, hypertension, elevated triglycerides, low HDL cholesterol, altered size and density of LDL cholesterol Believed that metabolic syndrome is a chronic low-grade inflammatory process affecting endothelial tissue Long-term effects: atherosclerosis, ischemic heart disease, left ventricular hypertrophy, type 2 DM Research directed at learning how to detect this syndrome early and what interventions might slow or arrest the progress

15 15Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Long-Term Complications

16 16Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Microvascular Complications Retinopathy Pathological changes in the retina that are associated with DM Nephropathy Kidney damage

17 17Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Macrovascular Complications Accelerated atherosclerotic changes in the person with diabetes Associated with coronary artery disease (CAD), cerebral vascular accidents (CVA or stroke), and peripheral vascular disease (PVD)

18 18Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Long-Term Complications

19 19Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Neuropathic Complications Neuropathy: pathologic changes in nerve tissue Mononeuropathy affects a single nerve or group of nerves Polyneuropathy involves both sensory and autonomic nerves Autonomic neuropathy affects the sympathetic and parasympathetic nervous systems

20 20Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Hypoglycemic Unawareness The usual symptoms of tachycardia, palpitations, tremor, sweating, and nervousness may be absent Patient may suddenly have changes in mental status as the first sign of hypoglycemia

21 21Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Long-Term Complications Foot complications of diabetes May have foot problems associated with neuropathy, inadequate blood supply, or a combination Mechanical irritation Thermal injury Chemical irritation

22 22Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Long-Term Complications: Prevention Diabetes Control and Complications Trial (DCCT): intensive treatment of type 1 DM delayed the onset or slowed the progress of diabetic retinopathy, nephropathy, and neuropathy Outcome of United Kingdom Prospective Diabetes Study (UKPDS): similar benefits of tight control with type 2 DM

23 23Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Long-Term Complications: Prevention ADA recommends Blood pressure: <130 systolic, <80 diastolic Total cholesterol: <200 mg/dL LDL: <100 mg/dL HDL: >45 mg/dL for men (>55 mg/dL for women) Triglyceride: <150 mg/dL

24 24Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Acute Emergency Complications

25 25Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Acute Hypoglycemia Dangerous drop in blood glucose Causes Taking too much insulin, not eating enough food or not eating at the right time, an inconsistent pattern of exercise Gastroparesis, renal insufficiency, and certain drugs including aspirin and beta-adrenergic blockers

26 26Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Acute Hypoglycemia Signs and symptoms Adrenergic: shakiness, nervousness, irritability, tachycardia, anxiety, lightheadedness, hunger, tingling or numbness of the lips or tongue, and diaphoresis Neuroglucopenia: drowsiness, irritability, impaired judgment, blurred vision, slurred speech, headaches, and mood swings progressing to disorientation, seizures, and unconsciousness

27 27Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Acute Hypoglycemia Treatment Give patient 10 to 15 g of quick-acting carbohydrates Repeat every 15-30 minutes until blood glucose is >70 mg/dL for adults, 80 to 100 mg/dL for older adults and children If patient is unable to swallow, an IM or subcutaneous injection of 1 mg of glucagon or an IV dose of 50 mL of 50% dextrose should be given as ordered or per protocol

28 28Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Diabetic Ketoacidosis (DKA) Life-threatening emergency caused by a relative or absolute deficiency of insulin Early signs and symptoms Anorexia, headache, and fatigue As condition progresses, classic symptoms of polydipsia, polyuria, and polyphagia develop If untreated, patient becomes dehydrated, weak, and lethargic with abdominal pain, nausea, vomiting, fruity breath, increased respiratory rate, tachycardia, blurred vision, and hypothermia

29 29Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Diabetic Ketoacidosis (DKA) Late signs Air hunger (Kussmauls respirations), coma, and shock Death can result without prompt medical care

30 30Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Diabetic Ketoacidosis (DKA) Treatment aimed at correction of three main problems Dehydration Electrolyte imbalance Acidosis

31 31Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Hyperglycemic Hyperosmolar Nonketotic Syndrome Patient goes into a coma from extremely high glucose levels (>600 mg/dL) There is no evidence of elevated ketones Pancreas produces enough insulin to prevent breakdown of fatty acids and formation of ketones, but not enough to prevent hyperglycemia Persistent hyperglycemia causes osmotic diuresis, resulting in loss of fluid and electrolytes Dehydration and hypernatremia develop May be caused by the same factors that trigger ketoacidosis

32 32Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Diagnosis One or more of the following criteria on two separate occasions is considered DM Polyuria, polydipsia, polyphagia, unexplained weight loss plus random glucose level >200 mg/dL Fasting serum glucose level >126 mg/dL (after at least an 8- hour fast) Two-hour postprandial glucose level >200 mg/dL during oral glucose tolerance test (OGTT) under specific guidelines. Test must use a glucose load of 75 g of anhydrous glucose dissolved in water

33 33Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Diagnosis Prediabetes Individuals with impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT) Individuals should receive education on weight reduction and increasing physical activity

34 34Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Diagnosis Oral glucose tolerance test Diet of 150 to 300 g carbohydrate for 3 days before test Night before test, patient fasts after midnight Morning of test, blood drawn for fasting serum glucose Patient then given a drink (Glucola) containing 75 g of carbohydrates and instructed to remain quiet Blood drawn at 30 minutes and 1 hour after the ingestion of glucose. After these two samples, blood is drawn at hourly intervals until the test is completed

35 35Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Treatment Nutritional management Medical nutrition therapy (MNT) is an important part of diabetes management; should be included in diabetes self-management education Because of complexity of nutritional management, a registered dietitian should be part of the diabetes management team, and the individual with diabetes should be included in decision making

36 36Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Treatment Exercise Effective adjunct for people with diabetes Aids in weight loss, improves cardiovascular conditioning, improves insulin sensitivity, and promotes a sense of well-being Exercising muscle uses glucose at 20 times the rate of a muscle at rest and does not require insulin

37 37Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Insulin Therapy All patients with type 1 disease need insulin injections; some patients with type 2 disease may eventually need insulin Insulins classified by source and course of action Source: human, pork, or beef (beef is being phased out) Course of action: rapid acting, short acting, intermediate acting, and long acting All rapid-acting and short-acting insulins are clear The other insulins are cloudy

38 38Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 46-2

39 39Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Insulin Therapy Route Oral: insulin cannot be given orally because it is rendered useless in the gastrointestinal tract Subcutaneously: all insulins can be given subcutaneously Intravenously: ONLY regular insulin can be given intravenously Inhalation: a form of insulin that can be taken by inhalation has recently been approved, but it is not yet widely used

40 40Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Insulin Therapy Concentrations U-100 insulin has 100 units/mL Most commonly used U-500 insulin has 500 units/mL Used only in emergencies and for patients who are extremely insulin resistant U-40 insulin has 40 units/mL Not available in the United States

41 41Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Insulin Therapy Premixed insulin products Contain both Regular and NPH insulin 70% NPH and 30% Regular insulin 50% NPH and 50% Regular insulin 75% NPH and 25% Lispro

42 42Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Insulin Therapy Dosing schedules Conventional therapy Typically uses a combination of a short-acting and an intermediate- or long-acting insulin Intensive therapy To achieve tight control; may require 3 or 4 injections daily Continuous subcutaneous insulin infusion Patient has indwelling subcutaneous catheter connected to an external portable infusion pump; pump delivers Regular insulin continuously

43 43Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Insulin Therapy Insulin mixing Two types can be mixed in one syringe to avoid two injections Insulin injection Site rotation helps prevent lipohypertrophy or lipoatrophy Absorption rate varies with different body sites American Diabetes Association recommends rotating sites within one anatomic area rather than moving among all areas See Figure 46-3

44 44Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 46-3

45 45Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Insulin Therapy Insulin pump Needle is inserted subcutaneously in an appropriate part of the anatomy Pump is programmed to deliver a steady trickle of insulin throughout the day and can provide a bolus of insulin at mealtimes

46 46Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 46-4

47 47Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Insulin Therapy Intranasal route Only 10% of the drug is absorbed through the nasal mucosa, making it relatively expensive to use Nasal irritation is a frequent side effect Only Regular insulin is given intranasally Insulin catheter Indwelling subcutaneous catheters may be placed in the abdomen to permit repeated insulin injections without repeated needlesticks

48 48Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Oral Hypoglycemic Agents If patients with type 2 DM unable to control blood glucose with nutrition and exercise, physician may prescribe oral hypoglycemics Sulfonylureas (three generations), alpha-glucosidase inhibitors, biguanides, thiazolidinediones, D- phenylalanines, meglitinides Combination oral medications ACTOplus met (pioglitazone and metformin), Avandamet (rosiglitazone and metformin), Avandaryl (rosiglitazone and glimepiride), Glucovance (glyburide and metformin), Metaglip (glipizide and metformin)

49 49Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Self-Monitoring of Blood Glucose Allows patients to monitor blood glucose levels to regulate their diet, exercise, and medication regimens to remain euglycemic Portable electronic glucose meters have largely replaced other methods of self- monitoring

50 50Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Glycosylated Glucose Levels Glycosylated hemoglobin (HbA 1c ) reflects glucose levels over the past few months Fructosamine levels reflect those over several weeks

51 51Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Complications of Therapy Hypoglycemia A person injects too much insulin, does not eat enough, eats at the wrong time, or exercises inconsistently: glucose levels may suddenly drop Somogyi phenomenon Rebound hyperglycemia in response to hypoglycemia Dawn phenomenon An increase in fasting blood glucose levels between 5 and 9 AM that is not related to hypoglycemia

52 52Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Assessment Ketoacidosis: ketonuria, Kussmauls respirations, orthostatic hypotension, hypertension, nausea, vomiting, lethargy, or change in level of consciousness Hypoglycemic patient: expect to find tachycardia, anxiety, trembling, and decreasing level of consciousness Be alert for indications of hyperosmolar nonketotic coma

53 53Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Assessment Attempt to determine the following Type of diabetes Hypoglycemic agents: name, dosage, when last dose was taken Food and fluid intake for the past 3 days Relevant laboratory values: blood glucose, blood pH, bicarbonate levels, electrolytes, and osmolality and urine osmolality

54 54Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Health History Chief complaint and history of present illness Signs/symptoms that prompted patient to seek medical care Past medical history Type and duration of DM Name and dosage of prescribed medications and when they were last taken If patient monitors blood glucose, record type of equipment used, testing schedule, recent test results Family history Diabetes, heart disease, stroke, hypertension, hyperlipidemia

55 55Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Health History Review of systems Description of the patients general health Changes in skin moisture or turgor Inquire whether the patient has had floaters, diplopia (double vision), or blurred vision, or has seen white halos around objects Abdominal symptoms: diarrhea, abdominal bloating, and gas Problems passing or holding urine If any pain in the legs, note when it occurs Numbness, tingling, or burning in the extremities Changes in mental alertness or seizures

56 56Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Health History Functional assessment Explore factors that can affect patients ability to perform self-care, including literacy, financial resources such as health insurance, and family support

57 57Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Health History Physical examination Level of consciousness, posture and gait, and apparent well- being Vital signs, height, and weight Skin color, warmth, turgor, and lesions noted Inspect eye grounds for evidence of diabetic retinopathy or cataracts Be alert for a sweet, fruity odor to the patients breath that is common with ketoacidosis Carefully assess the feet Test gait, balance, and motor coordination

58 58Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Interventions Ineffective Health Maintenance Ineffective Therapeutic Regimen Management Risk for Deficient Fluid Volume Risk for Injury Activity Intolerance Chronic Pain Disturbed Sensory Perception or Impaired Skin Integrity Disturbed Thought Processes Ineffective Coping

59 59Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Hypoglycemia

60 60Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pathophysiology Develops when the blood glucose level falls to less than 45 to 50 mg/dL Symptoms occur at different blood levels according to individual tolerances and how rapidly the level falls

61 61Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Causes Exogenous hypoglycemia Results from outside factors acting on the body to produce a low blood glucose Include insulin, oral hypoglycemic agents, alcohol, or exercise

62 62Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Causes Endogenous hypoglycemia Occurs when internal factors cause an excessive secretion of insulin or an increase in glucose metabolism These conditions may be related to tumors or genetics

63 63Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Causes Functional hypoglycemia From a variety of causes, including gastric surgery, fasting, or malnutrition

64 64Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Signs and Symptoms Glucose level falls rapidly, causes epinephrine, cortisol, glucagon, and growth hormone to be secreted in an attempt to increase glucose levels Symptoms: weakness, hunger, diaphoresis, tremors, anxiety, irritability, headache, pallor, and tachycardia A blood glucose level that falls over several hours: symptoms attributed to lack of essential glucose to brain tissue Symptoms: confusion, weakness, dizziness, blurred or double vision, seizure, and in severe cases, coma

65 65Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Diagnosis The diagnosis of hypoglycemia not associated with diabetes can be based on fasting blood glucose, OGTT, intravenous glucose tolerance test, and 72-hour inpatient fasting Whipples triad The presence of symptoms Documentation of low blood glucose when symptoms occur Improvement of symptoms when blood glucose rises

66 66Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Treatment In an unconscious patient who has diabetes, hypoglycemia should be suspected until it is ruled out 50 mL of 50% glucose solution should be administered immediately The patient with a milder form of hypoglycemia Treated with 15 g carbohydrate If the patients condition does not improve, another 15 g of carbohydrate should be given after 10 minutes

67 67Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Treatment Prevention of hypoglycemia by proper food intake The diet is directed by the underlying cause If overproduction of insulin after carbohydrate ingestion, a low- carbohydrate, high-protein diet Restriction of carbohydrates to no more than 100 g/day is recommended Simple sugars avoided; complex carbohydrates encouraged Patients may tolerate smaller, more frequent meals. Alcohol should be avoided

68 68Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Assessment Present illness: shakiness, nervousness, irritability, tachycardia, anxiety, lightheadedness, hunger, tingling or numbness of the lips or tongue, nightmares, and crying out during sleep Note when episodes occur in relation to meals and particular food intake The past medical history documents diabetes, previous gastric surgery, abdominal cancer, or adrenal insufficiency Medications, paying particular attention to hypoglycemic agents

69 69Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Assessment Note hypoglycemic agents, prescribed dose, and the time last dose taken Functional assessment: information about current diet, exercise, alcohol intake, and the effects of symptoms on daily activities Important aspects of the physical examination include general behavior, appearance, pulse, and blood pressure

70 70Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Interventions Deficient Knowledge Risk for Injury Impaired Adjustment


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