Care of Patients with Diabetes Mellitus Chapter 67 Care of Patients with Diabetes Mellitus Glucometer for measuring serum glucose levels.

Insulin Physiology Proinsulin, secreted by and stored in the beta cells of the islets of Langerhans in the pancreas, is transformed by the liver into active insulin. Insulin attaches to receptors on target cells, where it promotes glucose transport into the cells through the cell membranes.

Types of Diabetes Type 1 Type 2 Gestational (GDM) Other specific conditions resulting in hyperglycemia

Absence of Insulin Hyperglycemia Polyuria Polydipsia Polyphagia Ketone bodies Hemoconcentration, hypovolemia, hyperviscosity, hypoperfusion, and hypoxia Acidosis, Kussmaul respiration Hypokalemia, hyperkalemia, or normal serum potassium levels

Acute Complications of Diabetes Diabetic ketoacidosis Hyperglycemic-hyperosmolar state (HHS) Hypoglycemia from too much insulin or too little glucose

Chronic Complications of Diabetes Macrovascular/microvascular disease Retinopathy (vision problems) Nephropathy (kidney dysfunction) Neuropathy (nerve dysfunction)

Macrovascular Complications Cardiovascular disease Cerebrovascular disease

Microvascular Complications Eye and vision complications Diabetic neuropathy Diabetic nephropathy Male erectile dysfunction

Metabolic Syndrome Also called syndrome X Classified as simultaneous presence of metabolic factors known to increase risk for developing type 2 diabetes and cardiovascular disease

Health Promotion and Maintenance Control of diabetes and its complications is major focus for health promotion activities

Assessment History Blood tests Fasting plasma glucose (FPG) Oral glucose tolerance test (OGTT) Other blood tests Screening Ongoing assessment—glycosylated hemoglobin assays, glycosylated serum proteins and albumin, urine tests, tests for kidney function

Testing Sensation Placement sites of monofilaments for testing of protective sensation.

Treatment Options Oral therapies Insulin therapies Nutritional considerations Exercise Surgical intervention Foot care Wound care

Patient Education Insulin storage Dose preparation Syringes Blood glucose monitoring Infection control measures Diet therapy

Activity: Patient with a Diabetic Condition Etiologies, risk factors, comorbidities Assessment findings Diagnostic tests Nurse’s role Interdisciplinary team’s role Treatment/intervention priorities Teaching/health promotion information Community resources

What does the nurse suspect is happening with this patient? A 23-year-old patient with a history of type 1 diabetes is admitted to the ED with nausea and abdominal pain. His respiratory rate is 34/min with deep breaths and a fruity smell to his breath. He is responsive, but difficult to arouse. What does the nurse suspect is happening with this patient? What serum glucose level would the nurse expect to see with this patient? The manifestations point to diabetic ketoacidosis. The patient’s glucose level is most likely >300 mg/dL.

(cont’d) The student nurse asks why the patient is breathing so rapidly and deeply. What is the nurse’s best response? “His serum pH is high and this is a compensatory mechanism.” “His serum pH is low and this is a compensatory mechanism.” “His serum potassium is high and this is a compensatory mechanism.” “His serum potassium is low and this is a compensatory mechanism.” ANS: B As ketone levels rise, the buffering capacity of the body is exceeded and the pH of the body decreases, leading to metabolic acidosis. Kussmaul respirations (very deep and rapid) cause respiratory alkalosis in an attempt to correct the acidosis by exhaling carbon dioxide.

(cont’d) In the ED, the patient is diagnosed with diabetic ketoacidosis (DKA). What is the nurse’s first priority for managing this condition? Airway assessment Fluid and electrolyte correction Administration of insulin Administration of IV potassium ANS: A The first priority is airway management, rapidly followed by the administration of insulin, fluids, and correction of any electrolyte imbalances.

(cont’d) Twenty minutes later, the patient is admitted to the ICU for DKA management. The patient is receiving IV regular insulin with frequent finger sticks to check his glucose level. His potassium level is 2.5 and IV potassium supplements have been ordered. What assessment must be made before giving the IV potassium? Production of at least 30 mL/hr of urine Level of consciousness and orientation Finger stick glucose of less than 200 mg/dL Respiratory rate of less than 24/min ANS: A Hypokalemia is a common cause of death in the treatment of DKA. Before giving IV potassium, make sure the patient produces at least 30 mL/hr of urine.

(cont’d) Two days later the patient is recovered and is preparing for discharge. His wife asks about what they can do to prevent this from happening again. What should the nurse teach the patient and his wife? (Select all that apply.) Check blood glucose levels every 4 to 6 hours if anorexia, nausea, or vomiting is experienced. Check urine ketones when blood glucose is greater than 300 mg/dL. Decrease fluid intake when nausea and vomiting occur. Watch for and report any illness lasting more than 1 to 2 days. Monitor glucose whenever the patient is ill. ANS: A, B, D, E It is important to teach the patient to reduce the risk of dehydration by maintaining fluid and food intake. Small amounts of fluid may be tolerated even when vomiting is present. The patient should drink at least 3 L of fluid daily and increase this amount when infection is present.

Audience Response System Questions Chapter 67 Audience Response System Questions 21

Question 1 What percent of the United States population has diabetes? 3.2% 5.6% 8.3% 10.1% Answer: C Rationale: An estimated 25.8 million children and adults in the United States—8.3% of the population—have diabetes; 18.8 million people are diagnosed, 7.0 million are undiagnosed, 79 million have pre-diabetes, and 1.9 million new cases were diagnosed in people aged 20 and older in 2010. (Source: Accessed August 15, 2011, from http://www.diabetes.org/diabetes-basics/diabetes-statistics/?utm_source=WWW&utm_medium=DropDownDB&utm_content=Statistics&utm_campaign=CON)

Question 2 Which symptom requires immediate intervention during a hypoglycemic episode? Confusion Hunger Headache Tachycardia Answer: A Rationale: Glucose is necessary for brain function. Confusion is a marker of severe hypoglycemia requiring immediate intervention. Irritability/anxiety, hunger, tachycardia, headache, sweating, and seizures are additional signs of hypoglycemia.

Question 3 When should a patient with type 1 diabetes avoid exercise? When serum glucose is less than 150 During colder months When ketones are present in the urine When emotional stressors are high for the patient Answer: C Rationale: Exercise should be avoided if ketones are present in the urine. Ketones indicate that current insulin levels are not adequate and that exercise would elevate blood glucose levels. (Source: Accessed August 15, 2011, from http://diabetes.niddk.nih.gov/dm/pubs/physical_ez/index.aspx)