Diabetes NUR 171 Adapted by Crystal Perez, MSN, RN. Created by. D. Losicki, MSN, RN

Altered Mechanisms in Type 1 and Type 2 Diabetes

Normal Insulin function

Comparison of DM1 and DM2 DM1 Acute S/S onset 3 P’s polydypsia, polyuria, polyphagia Weight loss Weakness Fatigue DKA DM2 S/S non specific Fatigue Recurrent infections Prolonged wound healing Visual changes

Collaborative Assessment Glycosylated Hemoglobin (Hgb A1C) Fasting Plasma Glucose (FPG) Oral Glucose Tolerance Test (OGTT) Random Blood Glucose (RBG)

Collaborative Assessment Blood Studies Glycosylated hemoglobin (A1c test) Normal:4-6% Glucose tolerance test ( 2-hr post load result Normal: <140 Fasting blood glucose test: Normal: <100 Chart 67-1

Priority Problems: Potential for injury related to hyperglycemia Potential for impaired wound healing related to endocrine and vascular effects of diabetes Potential for injury related to diabetic neuropathy Pain related to diabetic neuropathy Potential or injury related to diabetic retinopathy induced vision Potential for kidney disease related to impaired renal circulation Potential for hypoglycemia Potential for DKA Potential for hyperglycemia-hyperosmolar state and coma

Collaborative Care Patient and caregiver teaching and follow-up programs Nutritional therapy Exercise therapy Self-monitoring of blood glucose (SMBG) Oral and other agents Enteric-coated aspirin Angiotensin-converting enzyme (ACE) inhibitors Antihyperlipidemic drugs

Insulin Short-Acting: Regular insulin or humalin R Rapid-acting synthetic insulin analogs, which include lispro (Humalog), aspart (NovoLog), and glulisine (Apidra Long Acting : Insulin glargine (Lantus) and detemir (Levemir) Once daily: steady and continuous insulin release, Do not have a peak of action (Detemir can be given twice daily.). Glargine and detemir must not be diluted or mixed with any other insulin or solution. accuracy before use. Intermediate: NPH basal insulin that has a duration of 10 to 16 hours.

Onset, Peak and Duration of Insulins

Mixing Insulins Table No other drug maybe mixed Insulin glargine should not be mixed with anything else. NPH and short-acting insulin formulations when mixed may be used immediately or stored for future use. Rapid-acting insulin can be mixed with NPH When a rapid acting insulin is mixed with either an intermediate acting or long-acting insulin must be injected within 15 mins before a meal Do not mix any other insulin type with insulin glargine, insulin detemir, or with any of the premixed insulin formulations, such as Humalog mix 75/25.

Insulin Devices

Oral Antidiabetics (OA) Sulfonylurea: Increase insulin production Meglitinides: rapid/short-lived insulin Biguanide: (Insulin sensitizers) ↓ Rate of hepatic glucose production; augments glucose uptake by tissues, especially muscles α-Glucosidase Inhibitors: Delay absorption of glucose from GI tract Thiazolidinediones: ↑ Glucose uptake in muscle; ↓ endogenous glucose production Dipeptidyl Peptidase-4 (DPP-4) Inhibitors : Enhances the incretin system, stimulates release of insulin from pancreatic β cells, and ↓ hepatic glucose production

OA Con’t Combination agents: combine 2 meds with different mechanisms of action. Ie Glucovance ( Glyburide with metformin). Insulin therapy

Newer Antidiabetic Agents Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Incretin Mimetics: Amylin Analog

Dawn Phenomenon Results from a nighttime release of growth hormone that causes blood glucose elevations at about 5-6am It is managed by providing more insulin for the overnight period.

Somogyi phenomenon Morning hyperglycermia from the counterregulatory response to night time hypoglycermia. It is managed by ensuring adequate dietary intake at bedtime and evaluating the insulin dose and exercise programs to prevent conditions that lead to hypoglycemia.

Hyperglycemia Somogyi Low BS during sleep Counter regulatory effect causes high BS on awakening Check BS Decrease morning insulin dose Insulin dose decrease Dawn Phenomena High BS on awakening Counter regulatory release in pre dawn hours More severe when growth hormone is at its peak during adolescence and young adulthood. Morning insulin increased

Agents that potentiate hyper and hypoglycemia HYPERglycemic potentiators 1.Glucocorticoids 2.Estrogens 3.Diuretics 4.Dilantin 5.B blockers HYPOglycemic potentiators 1.ETOH 2.Salicylates 3. MAO inhibitors Mask s/s of hypoglycemia 1.B blockers

Pancreas Transplantation Can be used as a treatment option for patients with type 1 diabetes mellitus. Can improve the quality of life by eliminating the need for exogenous insulin, f frequent blood glucose measurements, and many of the dietary restrictions imposed by the disorder.

Nutritional Therapy Greatest impact when provided at the onset of the diagnosis of the disease Eat a varied diet according to the current Food Pyramid Maintain exercise habits that will lead to improved metabolic control Carbs: 130g/day Protein: 15-20% total calories Fat: <7% total calories Cholesterol <200mg/day Alcohol: < 1/day women, < 2/day men Cholesterol less than 200 mg/day High fiber foods

Plate Method Vs. Food Pyramid

Exercise

NANDA’S Diabetes Mellitus Ineffective self-health management Imbalanced nutrition: more than body requirements Risk for injury Risk for peripheral neurovascular dysfunction Interventions/Meds/Complications

Complications Hyperglycemia DKA Hypoglycemia Macrovascular CAD CVA PVD Microvascular Nephropathy Neuropathy Retinopathy

Complications Patients with DM have up to a 25% lifetime risk for developing a foot ulcer. Increased risk for amputation The 5-year mortaility rate after leg or foot amputation ranges from 39%-67% Table 67-7 goes over the management of Peripheral neuropathy.

Diabetic Nephropathy Microvascular complication Leading cause of end-stage renal disease (ESRD) in the United States Risk of nephropathy is about the same in patients with either type 1 or type 2 diabetes Annual Screening albumin-to-creatinine ratio in a random spot urine collection for albumin Serum creatinine Treatment: ACE or ARB

Diabetic Neuropathy Sensory Neuropathy Most common Affects hands and feet bilaterally “Stocking/glove” neuropathy Key: Control glucose RX: TCA [amitriptyline],SSRI [duloxetine], antisezure [gabapentin ] Autonomic Neuropathy Affects all body systems Delayed gastric emptying (gastroparesis) Hypoglycemia d/t delayed gastric emptying ED Neurogenic bladder

Diabetic Retinopathy Non proliferative Most common Partial occlusion small BV of retina causing capillary microaneurysms Proliferative Most severe Affects retina and vitreous Collaborative Care Annual dilated eye exams DM 1 within 5 years of diagnosis

Hypoglycemia Glucose level below 70mg/dL Sx: Sweating, hungar, irritability, anxiety,tachycardia, are early warning signs Table ½ cup of fruit juice 4 tablesppons of suhar 1 tablespoon of honey or syrup Retest glucose in 15 mins, repeat treatment if sx do not resolve Follow with carb and protien.