Diabetes NUR 105.

Diabetes NUR 105

DIABETES MELLITUS Statistics – approximately 21 million in the US= 7% of population. Includes 6 million undiagnosed. Definition – Diabetes mellitus is a chronic disorder characterized by impaired metabolism and by vascular and neurologic complications. A key feature of diabetes is elevated blood glucose or hyperglycemia.

DIABETES MELLITUS Pathophysiology
the blood glucose level is normally regulated by insulin, a hormone produced by the beta cells in the islets of Langerhans located in the pancreas. In health small amounts of insulin are secreted continuously into the bloodstream. The ingestion of carbohydrates triggers the secretion of a large volume of insulin. Insulin that is produced in one’s own body is called endogenous, meaning it is internally produced. Insulin that is obtained from other sources and administered to a person is called exogenous

Glucagon (another hormone produced by the alpha cells of the pancreas) allows the liver and muscles to release stored glucose if the body is hypoglycemic (low blood glucose) Insulin and glucagon work together to keep the blood glucose at a constant level The amount of glucose in the blood regulates the rate of insulin secreted

Diabetes is caused by an inability of the pancreas to produce insulin, or because the cells of the body cannot accept and use the insulin\ Hyperglycemia (elevated blood glucose) is the result and cells do not get the energy they need

DIABETES MELLITUS Classifications
Type I – Insulin Dependent Diabetes Mellitus (IDDM) Previously called insulin-dependent Cause – the pancreas does not produce insulin at all or no endogenous insulin. Triggered by an autoimmune destruction of cells in the pancreas – cause may be idiopathic (unknown) usually occurs in children and young adults Onset – usually includes acute development of weight loss Ketones may build up in the urine and blood (Ketosis) Exogenous Insulin must be administered for the body to use for energy

Insulin Increases the transport of glucose into the resting muscle cell. Regulates the rate at which carbohydrates are used Prevents the conversion of glycogen to glucose Inhibits the conversion of glycogen to glucose Promotes fatty acid synthesis Spares fat Inhibits the conversion of fats to glucose Stimulates protein synthesis in the tissues Inhibits the conversion of protein into glucose.

Lack of Insulin Stimulates the conversion of glycogen to glucose= Higher blood glucose Permits fat stores to break down Increases triglyceride storage in the e liver Halts the storage of proteins Causes protein to be dumped into the bloodstream.

DIABETES MELLITUS Classifications
Type 2 – Non-Insulin Dependent Diabetes Mellitus (NIDDM) AKA – Adult-onset Diabetes Mellitus Inadequate endogenous insulin and the body's ability to properly use insulin. Initially , beta cells respond inadequately to hyperglycemia, resulting in chronically elevated blood glucose. The continuous high glucose level in the blood desensitizes the beta cells so that they become less responsive to the elevated glucose. The specific resistor sites become insensitive to insulin. Usually gradual onset and with several risk factors Obese children now showing greater incidence Rarely have DKA

DIABETES MELLITUS Other Classifications
Gestational Diabetes Mellitus (GDM) Triggered by extra metabolic demands during pregnancy May require insulin or may be diet controlled Usually resolved with birth of baby Predisposes mother to develop type-2 DM in the future

Diabetes Risk Factors for Type 1 Other than genetic ones, none known.

DIABETES MELLITUS Risk factors Type II Sedentary Lifestyle Family Hx
Age 40 years or older History of Gestational DM History of delivering infant weighing more than 10lbs African American (33% higher risk for type 2 DM) Latin American/Hispanic (greater than 300% higher risk for type 2 DM) Obesity American Indians (33% to 50% higher risk for type 2 DM)

DIABETES MELLITUS S/S Polydipsia (excessive thirst)
Polyuria (excessive urination Polyphagia (excessive hunger) Dehydration Fatigue Visual changes like blurred vision Elevated blood glucose

DIABETES MELLITUS S/S H/A Poor wound healing and recurrent infections
Confusion and changes in mentation Occasional muscle cramps Weight loss in type 1 DM (glucose is not available to the cells, body breaks down fat and protein for energy, called ketosis

Diagnosis of Diabetes A patient who meets one or more of the following criteria on two separate occasions is considered to have DM: 1. Symptoms of polyuria, polydipsia, polyphagia, unexplained weight loss plus random glucose level greater than 200mg/dl. A random reading is based on a blood sample drawn any time of day without regard to mealtimes.

Diagnoses of Diabetes 2. Fasting serum glucose level greater than 126mg/dl (after at least an 8-hour fast) 3. Two-hour posprandial glucose level above 200mg/dl during an oral glucose tolerance test. The test must use a glucose load of 75gm of anhydrous glucose dissolved in water. This test is often unnecessary.

Glucose Tolerance Test
Client consumes diet of gm of carbohydrates for 3 days before the test. The patient is then given a Glucola drink with 75gm of carbs and instructed to remain quiet. Glucose can be given IV if patient is unable to drink, (not as accurate as oral) Blood is drawn then at 30 minutes 1 hour Then hourly for 3 or 5 hours. Heparin Lock may be inserted into a vein so multiple venipunctures are not needed.

DIABETES MELLITUS Diagnostic Test
Glycosylated Hemoglobin Test (GHb) or (HbA1c) – provides an accurate long term index of average blood glucose and tells how effective Diabetes therapy has been during the preceding 8-12 weeks (normal value – %; good control - 7.5%; poor control >9.0%) Self Monitoring Blood Glucose or finger stick – most common method, checked before meals and bedtime; if BS > 240 mg/dl test for ketones in the urine Clinitest and Testape – indicate glucose in urine

DIABETES MELLITUS Diagnostic Tests
Acetest and Ketostix – indicate presence of ketones in urine C-Peptide – indicates how much insulin body is making, may help determine Type-I or Type-2 DM Fasting insulin level Other test to be monitored because of effects of DM: Lipid profile, Sr. Cr. And urine microalbumin levels to monitor kidney function, urinalysis, and ECG

DIABETES MELLITUS Treatment
The only cure is a pancreas transplant and pancreatic cell transplant Every patient requires an individual treatment plan – The goals for the patient with Diabetes Mellitus include: Monitoring and control of blood glucose Prevention and early detection of complications Lipid level monitoring Dietary and weight management Participating in an exercise plan Maintaining good health, annual physicals, attention to self care Medications as needed

DIABETES MELLITUS Tx Medical Nutrition Therapy (MNT) Goals
Attain and maintain optimal metabolic outcomes (glucose, lipids, blood pressure). Prevent and treat the chronic complications of diabetes (obesity, dyslipidemia, cardiovascular disease, hypertension, nephropathy). Improve health through healthy food choices and physical activity. Address individual nutritional needs while considering lifestyle, personal, and cultural preferences.

Recommended Calorie Distribution for Insulin Dependent Patients
Proteins=15% to 20% (as long as kidney functions are normal) Carbohydrates and monosaturated fats= 55% -60% Saturated Fats: Less than 10% Sodium Intake should not exceed 2400mg/day

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

Carbohydrate Counting
Useful for people who use intensive insulin therapy or pumps. Insulin doses are based on total grams of Carbs to be ingested. Well balanced diet within the prescribed distribution of proteins, fats, and carbs

DIABETES MELLITUS Treatment (Basic Guidelines)
The ADA advocates a variety of meal plans based on the patient’s abilities and commitments ADA Exchange Diet – six exchange lists, prescribed as total calories and number of exchanges from each group (NOT AS POPULAR NOW) CHO Counting – a tool to maintain blood glucose and lipid levels. Count grams of carbs, and measure servings. Offers more flexible food choices and may achieve better control

DIABETES MELLITUS Treatment (Basic Guidelines) ADA advocates
Glycemic Index – describes how much blood glucose level rises with a specific food compared to an equivalent amount of glucose. Rarely used in clinical practice except with highly motivated , educated patients Month-O-Meals – booklets with complete and interchangeable menus, excellent for patients “who want to be told what and when to eat.”

DIABETES MELLITUS Treatment (Exercise)
Regularity and amount of exercise is important Muscles use glucose and lower circulating blood glucose Promotes utilization of CHO, improves circulation, lipid levels, cardiovascular status, weight loss and decreases stress Should be individualized Medic Alert Bracelet

Exercise and Diabetes Have a complete medical examination before starting a program. Because circulating insulin may be inadequate to ensure glucose uptake, avoid exercise when your serum glucose is greater than 250mg/dl and ketosis is present. Exercise with caution if your serum glucose is greater than 300mg/dl and no ketosis is present. 5G of simple carb should be consumed at the end of 30 minutes and at 30 minute intervals Wear comfortable shoes.

Exercise Diabetes Warm up with 5-10 minutes of aerobic
Discuss with physician whether to alter food or insulin intake before exercise. Avoid exercise during the peak action of insulin and oral hypoglycemic agents when hypoglycemia is more likely to occur. Carbohydrates snacking may be necessary with prolonged or intense exercise. If you take insulin, inject it in the abdomen rather than an extremity before a workout because the drug is absorbed much more quickly from the abdomen. Some people experience hypoglycemia several hours after exercise, have food available for these situations. Wear medic alert bracelet.

DIABETES MELLITUS Pharmacologic Management
Insulin – key regulator for passage of glucose into the cells for energy Produced by beta cells of pancreas Plays a significant role in protein and lipid metabolism Pancreas secretes insulin at a steady rate of unit per hour

DIABETES MELLITUS Pharmacological Management Insulin
Hyperglycemia is caused by three abnormalities Liver produces excess glucose Absent or impaired insulin production and secretion by the pancreas Insulin resistance peripherally Historically insulin obtained from beef or pork pancreas Today biosynthetic human insulin is used almost exclusively Human insulin is purer More effect Lower incidence of causing allergies/resistance

DIABETES MELLITUS Pharmacological Management Insulin
The nurse must be aware of the onset, peak, and duration of insulin, so that decisions can be made, as to when to give the insulin and when to be alert for symptoms of low blood glucose – as when patients go for test and procedures Onset – time required for medication to have an initial effect or action Peak – when the agent will have the maximum effect Duration – length of time that the agent remains active in the body

Rapid Acting Insulin Insulin lispro (Humalog) Clear Onset 15 minutes
Peak hour Duration 3-4 hours Administer 15 minutes before eating.

Rapid Acting Insulin Insulin aspart (Novolog) Clear Onset: 15 minutes
Peak: 1-3 hours Duration: 3-5 hours

Short Acting Insulin Regular Insulin (Humulin R, Novolon R)
Color –Clear Onset- 30 minutes to 1 hour Peak- 2-5 hours Duration- 6-8 hours ONLY INSULIN GIVEN IV Humlin R

Intermediate Acting NPH insulin Cloudy Onset- 1.5 hours
Peak hours Duration hours

Long-Acting Insulin Glargine (Lantus) Onset- 1-2 hours DOES NOT PEAK
Duration hours CANNOT MIX WITH OTHER INSULINS

Inhaled Rapid-Acting , Short Acting
Insulin human rDNA orgin (Exubera) Powder in blister packs Onset minutes Peak- 27 minutes

Insulin Pump Pharmacological Management Insulin Pump
Battery operated device, worn on a belt with a needle inserted in SC tissue Provides a continuous low-dose insulin infusion Patient can add a bolus prior to meals and snacks based on blood sugar Allows for tighter control of blood glucose and more flexible lifestyle; patient needs to be conscientious, intensive – self-monitoring of blood glucose is essential Site is changed every hours Used with all types of insulin

DIABETES MELLITUS Pharmacological Management Insulin Pens
Pre-filled insulin cartridge loaded into a pen-like holder Two types Disposable – pre-filled with set amounts of insulin, once used, it is thrown away Non-disposable – insulin cartridge is replaced when empty Both require a pen needle, which is screwed onto the tip of the pen Easy to use, no need to draw up insulin from a vial Dose can be set for patients with visual and dexterity issues More expensive that vials, not all types insulin available for use in pens Cannot mix insulin so two injections required

DIABETES MELLITUS SLIDING SCALE

Insulin Storage of Insulin
Store insulin in a cool place, refrigeration preferred, away from direct sunlight Unopened shelf life – 1 year Once opened, shelf life – 30 days; must be dated and initialed when opened Do not freeze; pre-filled syringes should be kept in a vertical position with needles up; roll syringe to remix solution before giving

DIABETES MELLITUS Pharmacological Management Administration of Insulin
Administered subcutaneously (Regular insulin is the only insulin given IM or IV) Roll the vial of cloudy insulin, do not shake, to avoid bubbles, causing an inaccurate dose to be drawn When mixing insulin, inject an amount of air equal to the insulin dose into the cloudy vial first, remove syringe, draw up air equal to dose of clear, then draw up clear insulin, remove syringe, now draw up cloudy Be careful not to inject any cloudy insulin into the clear bottle. Regular insulin is always drawn up first

DIABETES MELLITUS Pharmacological Management Administration of Insulin
Before giving the insulin dose, Must Always Be Checked by Another Nurse Administer 30 minutes before meals Inject a mixed dose of insulin within 5 minutes of preparation, because after this time the regular insulin binds to the NPH insulin and its action is reduced During stress, illness, or surgery, the patient maybe managed with sliding scale insulin (Regular only) where the dose is dependent on the finger-stick blood glucose level

DIABETES MELLITUS Pharmacological Management Administration sites
Rotation of sites is essential to prevent lipodystrophy, a spongy swelling at or around site which can interfere with absorption Careful records must be maintained Aspiration before and massaging after injection on longer recommended Abdominal injection sites preferred for rapid, consistent absorption Injection site should be 1 inch from previous site

Complications of Insulin Therapy
Hypoglycemia – blood glucose drops below 50 and most often occurs before meals or when insulin action is peaking Somogyi Phenomenon – Patient’s blood glucose rises in spite of increasing insulin dose Insulin causes hypoglycemia at night, generating a release of glucose-elevating hormones (epinephrine, cortisol, and glucagon) which then REBOUNDS to manifest as hyperglycemia in early morning

Somogyi Phenomenon Diagnoses- Measure blood glucose between 2 and 4 am and again at 7am. The 2 and 4 am levels below 60mg/dl and a 7am level above 180mg/dl support the diagnosis.

Somogyi Phenomenon May be inadvertently treated with an increase insulin dosage – making problems worse Symptoms – night sweats, restlessness, early morning nausea, H/A and confusion Treatment – Decreasing evening dose of exogenous insulin by 2-3 units every 3 or 4 days until the rebound hyperglycemia is brought under control. Bedtime snack may also be helpful

Dawn Phenomenon Caused by natural release of growth hormone and cortisol during the early morning hours causing hyperglycemia Treatment – adjust evening insulin dose by 1 or 2 units and give at a later time

DIABETES MELLITUS Pharmacological Management
Oral Hypoglycemic Medications Usually given to DM Type-2 patients who are not controlled with exercise and diet alone Remember they are not “insulin pills” because insulin is a protein and would be digested. These drugs improve the body’s sensitivity to insulin The pancreas must be partially functioning

DIABETES MELLITUS Pharmacological Management
Classifications – Insulin Stimulators Stimulates beta cells to increase insulin secretion and increases insulin receptor sensitivity May be given with other classes of oral agents Should be administered minutes before meals, except for Diabinese which is given with breakfast Avoid alcoholic beverages – may cause Antabuse-lke reactions (facial flushing, pounding H/A, breathlessness, and nausea Alcohol can potentiate the hypoglycemic effects, so if taken, should be taken with meals Drugs come from same family as sulfonamide antibiotics, must watch for allergies to sulfa drugs Side effects – weight gain, skin rash, GI upset, hemolytic anemia, cholestasis , sulfa allergies.

PRAMLINTIDE (Symlin) The medication pramlintide (Symlin) carries with it an FDA BLACK BOX WARNING!!! This medication has the potential to cause severe hypoglycemia within 3 hours of administration. It is critically important that the nurse observe the patient closely for any signs or symptoms of hypoglycemia.

Sulfonylureas (Stimulator)
Lowers blood sugar by stimulating the beta cells of the pancreas to secrete more insulin and increasing the sensitivity of insulin receptors. A significant adverse effect of the sulfonyureas is the risk of hypoglycemia.

Biguanides Metaformin (Glucophage, Fortamet)
Action- Inhibits hepatic glucose production, increases insulin sensitivity. Side Effects- Lactic Acidosis, hypoglycemia when used with sulfonylurea or meglitnide. Advantage: Does not cause insulin release

Meglitinides Prandin Starlix Secrete pancreatic secretion of insulin
Side Effects- Hypoglycemia, weight gain. Stimulate Pancreas for Insulin secretion but shorter acting than sulfonylurea

Thizolidnediones Actos (Pioglitzaone) GIVE WITH MEALS
Avandia (Rosiglitzaone) Increases insulin sensitivity in the tissues Side Effects- Hypoglycemia when used with sulfonylurea or meglitinide, weight gain, decreased effectiveness of oral contraceptives, possible liver dysfunction. Notify doctor of weight gain an edema.

Alpha –Glucosidase Inhibitors
Absorption Delayers – inhibit enzymes in the small intestine and pancreas Reduces rate of CHO digestion and absorption Results in a reduced glucose absorption May be given with other oral agents Give at start of meals Side effects – diarrhea, flatulence, abdominal pain Acarbose (Precose) Miglitol (Glyset)

Complications of Diabetes Mellitus
Hyperglycemia – occurs when patient is unable to compensate for the increased blood glucose Caused by over eating, stress, not enough insulin, or other medications, and/or illness S/S – similar to when 1st diagnosed – polyuria, lethargy, polydipsia, H/A, polyphagia, blurred vision, coma, BG > 300 mg/dl, n/v Treatment – assess cause, notify MD if vomiting, and monitor blood glucose closely Call MD if BG > 200 mg/dl for changes in medication If BG > 300 mg/dl, call MD, check urine for ketones and increase fluid intake

Hypoglycemia Causes:Exogenous
Predisposing Factors Occurrence Insulin Intentional or accident OD Inadequate food intake Increased exercise Decrease insulin requirement Other medications MOST FREQUENT CAUSE OF HYPOGLYCEMIA

Predisposing Factors Occurrence Oral hypoglycemic agents Intentional or accident OD Inadequate food intake Other medications Frequent cause of hypoglycemia with sulfonylurea's and meglitinides. PRAMLINITIDE!

Predisposing Factors Occurrence Alcohol Particularly likely in chronically malnourished or acutely food-deprived clients Occurs in 6-36 hr of ingesting moderate to large amounts of alcohol

Predisposing Factors Occurrence Exercise Increased duration and intensity of exercise increases glucose uptake and normally decreases insulin secretion Occurs with both insulin sulfonylurea administration and intense exercise, but may be unpredictable in onset.

Hypoglycemia Causes:Endogenous
Predisposing Factors Occurrence Organic hypoglycemia Insulinoma (tumor of beta cells of the pancreatic islets of Langerhans Uncommon neoplasm of beta cells

Hypoglycemia Causes:Endogenous
Predisposing Factors Occurrence Extrapancreatic neoplasm's May be mesenchymal tumors, hepatomas, adrenocortical carcinomas, gastronintestinal tumors, lymphomas, or leukemias Rare; most common in adults yrs of age.

Hypoglycemia Causes:Functional
Predisposing Factors Occurrence Alimentary hypoglycemia (Dumping Syndrome) Rapid dumping of carbohydrates into upper small intestine Postgastrectomy

Predisposing Factors Occurrence Drug Related (ethanol, haloperidol, pentamdine, salicylates) reactive hypoglycemia Syndrome with symptoms such as diaphoresis, tachycardia, tremulousness, headache, fatigue, drowsiness, and irritability Rarely diagnosed throughout the world, May be overdiagnosed in the United States according to statement by ADA

Predisposing Factors Occurrence Rapid discontinuation of TPN Endocrine deficiency states (cortisol, growth hormone, glucagons, epinephrine) Easily Prevented

Predisposing Factors Occurrence Glucocorticoid deficiency Critical illness (cardiac, hepatic, and renal disease) A danger for any person with adrenal insufficiency.

Predisposing Factors Occurrence Severe Liver Deficiency Insufficient glucose ouput by liver Fasting hypoglycemia

Predisposing Factors Occurrence Lack of body stores for protein, fat and carbohydrates Profound Malnutrition Common, also found with relative frequency in kwashiorkor

Predisposing Factors Occurrence Prolonged Muscular exercise Metabolism of energy-producing substances Occurs if exercise is too prolonged or severe or if nutritional intake and carbohydrate stores are insufficient.

Hypoglycemia Hypoglycemia – result of excess secretion of insulin, leading to blood glucose below 50 mg/dl Cause – skipping meals, exercise, or medicated with too much insulin Most often occurs before meals and when insulin is peaking Repeated or extremely low BG levels may cause neurologic damage S/S – hunger, H/A, diaphoresis, blurred vision, irritability, confusion, pallor, tremors, seizures, coma Treatment – assess possible causes, get finger-stick BG Administer “fast sugar” immediately if patient is alert (15 grams of CHO – 4-6 oz. orange juice) If unconscious and no IV access,1 mg glucagon (SC) or IM per hospital protocol IV 50ml of 50% Dextrose.

Hypoglycemia Recheck glucose in 15 minutes and repeat procedure until improvement noted Call MD if no improvement Educate patient to recognize and prevent low blood glucose symptoms Self Monitoring of Blood Glucose Levels Test blood glucose levels two to four times a day, ac and hs Teach how to use lancets or lasers to obtain blood sample Teach to use a log or diary to record glucose levels

Diabetic Keto Acidosis (DKA)
Tissues cannot utilize glucose without insulin, resulting in an increase in serum glucose levels. The high osmotic pressure created by excess glucose leads to osmotic diuresis (polyuria). As glucose is eliminated in the kidneys, so are large amounts of water and electrolytes (electrolyte imbalance)

DKA 3. The patient voids large amounts of dilute urine (polyuria)
4. To make matters worse, the sympathetic nervous system responds to the cellular need for fuel by converting glycogen to glucose and manufacturing additional glucose. 5. As glycogen stores are depleted, the body begins to burn fat and protein for energy.

DKA 6. Fat metabolism produces acidic substances called ketone bodies that accumulate and lead to metabolic acidosis. 7. Protein metabolism results in the loss of lean muscle mass and a negative nitrogen balance.

DKA Signs and Symptoms Early- Anorexia, headache, and fatigue.
Progresses to-Polydipsia, Polyuria, Polyphagia. Dehydration, Weakness, Lethargy, Abdominal Pain, Nausea, Emesis, Fruity Breath, Increased Respiratory Rate, Tachycardia, blurred Vision, Hypothermia. Late: Air Hunger (due to acidosis) Kussmauls Respirations, Coma, Shock and Death

DKA Treatment Diabetic Ketoacidosis Treatment Maintain patent airway
IV fluids to maintain fluid and electrolyte balance Insulin management Monitor renal function, especially K+ levels and add IV potassium per orders Monitor BG q 1-2 hours VS q1-2 hours ABGs q 1hour Keep patient warm

Hyperglycemia Hyperosmolar Nonketotic Syndrome (HHNKS) Extreme hyperglycemia without acidosis, because some insulin is being produced, cells are not starved; therefore, ketones are not seen in the blood or urine Patient may not feel physically ill because there is no ketoacidosis Usually occurs in NIDDM when diabetes is uncontrolled or during stress or infection S/S – extreme thirst, severe dehydration, alterations in LOC – confused, shock, coma. Blood glucose very high, from mg/dl, blood osmolarity (concentration) very high > 320 mOsm/kg

HHNKS Treatment IV fluid replacement IV insulin Monitor electrolytes Monitor BG

Long-term Complications of Diabetes Mellitus
Seen in Type I and Type II diabetics Complications r/t the effects of chronic hyperglycemia Macrovascular complications – involving large blood vessels and microvascular involving the tiny blood vessels

Macrovascular – Circulatory System Atherosclerosis Hypertension Elevated LDL, cholesterol and triglyceride levels Increased platelet clotting These factors increase the incidence of heart attack, stroke, and poor circulation of the feet and legs Microvascular Eyes – Retinopathy (damage to the tiny retinal blood vessels) leading to blindness High incidence of cataracts at an earlier age

Diabetic ulcer and gangrene

Gangrene

Foot Care Inspect Daily Wash in warm not hot water
Dry feet watch between toes Cut the nails straight across unless doctors order requires podiatrist Clean Cotton socks Daily Proper Fitting shoes Never wear open sandals Use socks and blankets to warm feet Test H20 temp before stepping into bath or shower Elevate Feet whenever possible

Diabetic Retinopathy

Atherosclerosis

Hemodialysis

Microvascular Kidneys – Nephropathy (damage to the vessels within the kidneys) DM is the leading cause of end-stage renal disease (ESRD), leading to kidney failure Native Americans, Hispanics, and African-Americans at highest risk Hemodialysis or peritoneal dialysis is needed when kidneys have lost most of their function Keep accurate I/O if ordered Urine Testing Tests for glucose and ketones Urine tested for ketones during illness, stress, and pregnancy Presence of ketones indicates glucose level > 300 and should be reported to MD immediately

Microvascular Nerves – Neuropathy (nerve damage) is the most common chronic complication Sensorimotor polyneuropathy – aka peripheral neuropathy – causes numbness (paresthesias) and pain or burning sensation in lower extremeties Patient at risk for foot injuries Avoid tight fitting garments and shoes Autonomic neuropathies affect: GI – gastroparesis (delayed gastric emptying), constipation, diarrhea GU – retention, neurogenic bladder Reproductive – male impotence

Other Complications Infections Patients with diabetes more prone to infections d/t delayed healing from impaired circulation Insulin requirements may need to be increased if infection present WBCs become sluggish and ineffective Periodontal disease increased d/t bacteria and plaque Foot complications with DM leading cause of amputation Observe for signs of infection, injury or stress and teach patient to do the same

Sick Day Care Treatment/Nursing Management Medication Diet
Take insulin as prescribed. Adjust dose as directed depending on Glucose readings It oral hypoglycemia, take your usual dose. Do not increase unless doctors order. If your have emesis the doctor may order sub q insulin. Diet Eat normal diet on schedule If N & V, replace carbohydrate solid foods with fruit juice, regular soft drinks, or Jell-O Monitoring Blood Sugar and Ketones Monitor Q4 and record If severely ill Q2 hours Dip urine for Ketones if BG over 240mg/dl

When to Call Physician If emesis, abdominal pain or temp above 100.2 F
If blood glucose is above 200mg/dl If Ketones are in urine If you cannot reach physician GO TO ER

Treatment/Nursing Management Priorities in hospital A nursing care plan should be formulated with complete understanding of cause of admission A thorough and ongoing assessment Knowledge of the current symptoms, potential complications, lab values, and medications Discharge planning should be initiated as soon as possible

Diabetes Mellitus Treatment/Nursing Management Patient Education
Is the key to effective self management Consider knowledge base, ability to learn, emotional and physical health, family influence, socio-economic status, cultural influences and current lifestyle patterns Topics to teach Glucose monitoring - S/S of complications Urine testing - Lifestyle changes Medication administration - Foot care Dietary management - Sick-day management

Treatment/Nursing Management Foot Care Never use sharp ;objects to poke or dig under the toenail or around the cuticle Ingrown toenails or nails that are thick should be cared for by a podiatrist After washing feet, gently rub any corns and callused areas with a pumice stone to control buildup Use pads on corns to reduce pressure Sick-Day Teach to continue to take insulin or oral hypoglycemic medications Monitor BG 4-6 times a day while sick Check urine for ketones If BG >300 or presence of ketones, report to MD Extreme n/v or diarrhea – report to MD – risk of extreme fluid loss is dangerous

Diabetes Mellitus Treatment/Nursing Management Emotional Support
Encourage family involvement Encourage verbalization of feels/fears Answer questions Assist and follow up with consults as dietary, etc. Stress importance of frequent primary care provider visits

Deficient Knowledge R/T- Lack of Knowledge of Diabetes Management
Goals- Patient will correctly describe type 1 diabetes and treatment. Patient will demonstrate self medication, meal planning, and understanding of management of exercise and drug effects.

Ineffective Therapeutic Regimen Management
R/T- Financial, personal, or family pattern disruption Goal- Client will express intent to adhere to prescribed regimen of care.

Deficient Fluid Volume
R/T-Altered Urinary Output Goals-Client will maintain normal blood volume, as evidence by normal tissue turgor, pulse, and blood pressure.

Imbalanced Nutrition:
Less or more R/T:Alterations in insulin availability or utilization.

Risk for Injury R/T- Adverse effects of drugs, increased susceptibility to infection R/T- Severe decrease in tissue perfusion in feet. Goals Clients blood glucose will remain within goal range established by physician Patient will state measures to reduce risk of infections and will identify symptoms that should be reported.

Ineffective Health Maintenance
R/T- Lack of knowledge of dietary management of DM, drug therapy, and self-monitoring Goal- Client will demonstrate the ability to adhere to prescribed diet and drug therapy and to monitor blood glucose

Ineffective Therapeutic Regimen Management
R/T- financial limitations and difficulties with transportation for food, drugs, and medical care Goals-Client will manage her prescribed diet and drug therapy.

Risk for Infection R/T- Elevated blood Glucose Level Goals:
Interventions:

Diabetes NUR 105.

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Diabetes NUR 105.

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