1. AH 1108
Diabetes

2. Adult Health1108 Unit Outcomes
1. Provide holistic, safe, evidence-based, age appropriate, culturally competent, and patient-centered care.
2. Apply ethical and legal principles.
3. Identify safety needs.
4. Utilize the nursing process to make care decisions.
5. Utilize sound nursing judgment to prioritize, delegate, and improve care.
6. Apply teamwork and collaboration.
7. Use available informatics to provide and document care.

3. Professional Identity
Nursing Concepts
Human Flourishing
Nursing Judgment
Professional Identity
Spirit of Inquiry
Patient-Centered Care
Teamwork and Collaboration
Evidence-based Practice
Quality Improvement
Safety
Holistic Care
Health Promotion & Education
Growth & Development- adult stages
Age-appropriate Care
Culturally Competent Care
Therapeutic Communication
Informatics
Content Mastery
Patient-centered Care
Evidence-Based Practice
Nursing Process
Ethics & Legal Implications
Prioritization
Delegation
Knowledge Synthesis (from nursing and non-nursing courses) – A&P, nutrition, micro, psychology
Professionalism
Nursing Roles
Self-Care & Awareness
Critical Thinking

4. Content for Focus Pathophysiology Pharmacology Assessment
Developmental considerations
Nursing management
Cultural needs
Plans of care
Diagnostic Studies
Heath promotion & patient teaching
Evidence-based practice guidelines

5. Pathophysiology Multisystem disorder
Abnormal insulin production, impaired insulin utilization, or both
Theories-linked to genetic, autoimmune, environmental factors (obesity, viruses, toxins)
Insulin-a hormone is normally produced in small increments into the bloodstream when food is ingested.
There are receptors on muscle and adipose tissue that when insulin unlocks, glucose can enter the cell for energy.
Insulin lowers glucose and keeps levels in normal rage.
mg/dL (70-99 mg/dL)

6. Classes of Diabetes (4) Prediabetes
Impaired glucose levels but not high enough to dx DM
Increased risk for developing type 2 DM

7. Type I DM
1. Type 1 DM
Formally known as juvenile onset or insulin dependent DM
Autoimmune disorder-body develops antibodies against B-cells
To little insulin to survive
Genetic
Virus exposure triggers destruction of the B-cells either directly or through the autoimmune process
Idiopathic DM
Type 1 DM not related to autoimmunity
Occurs only in small number of people
Idiopathic (strongly inherited)-Type I Diabetes affects a small number-Hispanic-African, or Asian ancestry.
Latent autoimmune (LADA) slowly progressing type I DM-occurs in adults-mistaken for DM Type II

8. Type 2 DM 2. Type 2 DM Used to be referred to as AODM, or NIDDM
Most prevalent type 90-95% of pts.
Contributing factors
Overweight or Obesity
Family hx of type 2
Becoming more prevalent in children
More prevalent in some ethnic populations d/t-genetic predispositions, environmental factors, and dietary choices.
African Americans
Asian Americans
Hispanics
Hawaiians or other Pacific Islanders
Native Americans

9. Gestational Diabetes 3. Gestational Diabetes
Woman who are obese or advanced maternal age
Increased risk of developing Type II DM within 16 years

10. Other specific types of DM
Results from another medical condition or as a result of tx causing elevated glucose
Cushing syndrome
Hyperthyroidism
Pancreatitis
Cystic fibrosis
Hemochromotosis
Parenteral nutrition
What about medications?
Corticosteroids
Phenytoin
Thiazides
Antipsychotics-clozapine

11. Nursing Assessment Prediabetes Gestational Nursing Assessment
No s/s
Impaired glucose tolerance or fasting glucose
If 2 hr OGTT levels mg/dL
Fasting BG levels are mg/dL
Long term damage occurring-like what?
Type I DM
Polydipsia
Polyuria
Polyphagia
Weakness, fatigue
Weight loss
Ketoacidosis most common in type 1
Type II DM
Fatigue
Recurrent infections, vaginal yeast or candidal infections
Prolonged wound healing
Weight gain
Visual changes
Why all the changes?
Gestational Diabetes
Typically resolves within 6 weeks of delivery
Gestational

12. Interprofessional Care
Reduce symptoms
Promote well-being
Prevent complications form hyperglycemia or hypoglycemia
Prevent or delay onset and progression of long term complications.
Goals are more likely to be met when BG is stable and near normal levels.
Requires daily decisions about nutrition, BG, medication, and exercise.
Include the patient in decisions and care

13. Pharmacology Pharmacology 3 major types of glucose lowering agents
Insulin (exogenous)
OA-Oral agents
Non-insulin injectable agents
Insulin
Bolus -uses rapid or short acting insulin before meals
Basal-intermediate or long acting
Optimal glucose before meals mg/dL

14. Insulins Drug Therapy-lists insulins-p. 1125 Onset p.1126
Meal-time insulin-15 minutes (most closely resembles natural insulin secretion in response to meals)
Rapid (Onset 10-30) Meal within 15minutes
Lispro
Aspart
Glulisine
Short (Onset min)
Regular
Intermediate (Onset hours)
NPH
Long acting ( hours)
Glargine
Detemir
Combination Therapy
NPH/Reg 70/30
NPH/Reg 50/50
More concentrated Insulin
Toujeo U-300 (Insulin glargine)
Humulin R U-500
Inhaled Insulin (Onset minutes)
Affrezza-Not recommended for DKA, in pts that smoke, copd, or asthma-bronchospasm

15. Insulin Pump Insulin Pump Continuous subcutaneous infusion
Use rapid acting insulin-loaded in reservoir or cartridge and connected by plastic catheter inserted into sq tissue
Programmed to deliver rapid acting insulin 24 hrs/day (basal rate)
Can be temporarily increased or decreased depending on carbs, activity, illness, preprandial or postprandial glucose levels
Drug Therapy-oral and noninsulin injectables
Table 48-7, p. 1131
What about herbal supplements- a-lipoic acid, cinnamon, chromium, garlic, ginseng, (may affect blood glucose)

16. Complications of Insulin Therapy
Allergic reactions-inflammatory
Urticaria
Anaphylactic
d/t zinc or protamine used as preservative-latex rubber stoppers?
Lypodystrophy -atrophy-wasting indentation
Hypertrophy-thickening sq tissue-avoid 6mths
Hyperglycemia-am
Somoygi-high dose insulin-low night-time BG-rebounds in am because of counterregulatory hormones
Check BG between 2-4am for hyoglycemia
Reduce nighttime insulin
Dawn Phenomenon-hyperglycemia 2-4am
Increase insulin
Insulin Storage
Insulin storage 4 wks room temp
Avoid exposure to direct sunlight
May prefill syringes with 2 diff insulin-good for 1 wk when refrigerated
One type of insulin-30 days

17. Patient Teaching-Insulin
Insulin absorption-abd fastest
Followed by arm, thigh, buttock
Rotate injections between sites
Different insulin syringe sizes
Different needle lengths and gauges
Administer degree angle
Insulin pens
Administration
Wash hands
Inspect insulin bottle-agitate-gently roll- cloudy
Cleanse vial top with alcohol
Always draw up clear before cloudy
Select appropriate injection site
Cleanse accordingly
Push plunger all the way down (leave in place 5 seconds)
Dispose
Clear before cloudy
Insulin differences
U100
Concentrated insulin
U300
U500
A physician orders 95 units of concentrated insulin (U500)
Does the insulin get drawn up in:
An insulin syringe or a tuberculin syringe?
How much do you give?

18. Plan of Care Surgery Plan of Care Bariatric surgery-DM 2
Pancreas transplant-DM 1
End stage renal disease, kidney transplant & pancreas
Requirements:
Hx of frequent, acute, severe metabolic complications (hyperglycemia, hypoglycemia, dka) requiring medical attention.
Incapacitating emotional and clinical problems managing exogenous insulin
Consistent failure of insulin based management
Pancreatic islet transplant-potential treatment

19. Health Promotion, Nursing Interventions, Patient Teaching
Monitoring blood glucose
Administration of insulin
Nutrition-my plate
Carbs, protein, fiber, fats, alcohol
Diabetes exchange list
Exercise-activity affects glucose levels
Nurse role
Identify patients at risk
Obesity is primary risk factor
Educate
Modest wgt loss 5-7% of body wgt & regular exercise of 30 minutes 5 x wk, lowers risk of developing DM 58%
Routine screening for overwt or obese adults with BMI = or > 25 kg/m2
Identify people at risk and include factors such as ethnicity, obesity, having large birthweight babies.
Acute Illness & Surgery
Increases glucose levels
DM 1 BG > 240 check urine ketones q 3-4 hrs
If BG levels are 300 mg/dL twice in a row, or urine ketones are moderate to high insulin may need increased to prevent DKA
DM 2-may require insulin in hyperglycemia
During illness if pts eat less than normal-continue OA & Insulin
Carb containing fluids low sodium soup, juice, regular sugar sweetened decaff drinks
If eating normally continue regular diet plan, OA or insulin as directed
Surgery-IVF's, Insulin before during and after surgery
DM 2-temporary measure

20. Personal Hygiene, Medical ID, & Travel
Diligent skin and dental hygiene
Routine bathing, foot care -table (p. 1151)
Don't go barefoot, inspect feet daily
Wear comfortable well fitting shoes
Wash feet with soap and warm water (Test temp with elbow) why?
Don't scrub vigorously
Dry thoroughly
May use lanolin (never between toes)
Cut toenails - do not trim down corners
Report skin infections/sores promptly
Wear clean cotton/wool socks
Watch circulation
Treat cuts and scrapes promptly
Medical ID & Travel
Carry identification bracelet, card
Type of diabetes, insulin or noninsulin agents
Sedentary elevated glucose level and dvt risk
Keep snacks handy
Involve pt and caregiver in care

21. Diabetic Complications DKA & HHS
Diabetic Ketoacidosis (DKA)
Deficient insulin, hyperglycemia, ketones, acidosis, dehydration
Acetone breath
BG = or > 250 mg/dL, pH < 7.30serum bicarbonate <16 mEq/L, mod to lg ketones in serum or urine
Ensure patent airway O2
IV access-lg bore
IVF's 0.45% to 0.9% saline to restore volume and u/o mL/hr
Insulin 0.1 unit/kg/hr
What about electrolytes?
What about fluid volume?
Avoid rapid decreases of BG or over-infusion of hypotonic solution
Cardiac Monitor
Hyperosmolar Hyperglycemic syndrome (HHS)
Life-threatening-occurs in pt >60 y.o. with DM 2
Common causes UTI, Pneumonia, sepsis, impaired thirst mechanism
Enough insulin production to prevent DKA
Severe hyperglycemia
Dehydration
BG = or > 600 mg/dL
IV Insulin
IVF's .45% to 0.9% saline
Avoid overload
Cardiac monitor

22. Hypoglycemia & Hyperglycemia
Hypoglycemia-BG <70 mg/dL
Shaky
Palpitations
Nervousness
Diaphoresis
Pallor
Hunger
Interventions-rule of 15
4-6oz fruit juice or regular soft drink
Wait 15 minutes-recheck BG
<70mg/dL repeat treatment (15g of carbohydrate)
Once BG is stable, If meal is more than 1 hr away—carb with protein or fat (peanut butter crackers)
Notify HCP
Hyperglycemia-elevated BG
Increased urination
Weakness, fatigue
Blurred vision
N/V
Dehydration?

23. Complications continued
Angiopathy-damaged blood vessels
Macrovascular -lg vessels
Microvascular-small vessels
Diabetic retinopathy-damage to the retina
Nephropathy-damage to the kidneys
Neuropathy-damage to the nerves
Complications of the lower extremities and feet-foot ulcers
Integumentary-skin lesions
Infection-increased risk of infections-defect in the mobilization of WBC's

24. Psychological conditions
Psychological considerations
Depression
Anxiety
Eating disorders-bulimia-anorexia
More common in females
May decrease or omit insulin dose-called diabulimia-leads to wt loss, hyperglycemia, glycosuria, because food ingested cannot be used for energy
Eating disorders and insulin omission can lead to retinopathy, neuropathy,
lipid abnormalities, DKA, death
Open communication, MH professionals

25. Developmental considerations
Gerontologic concerns
DM more difficult to dx because of physiologic changes from aging
Symptoms similar to DM, decreased energy, falls, dizziness, confusion,, chronic urinary tract infections
25% of persons over 65 y.o. fastest growing population with DM
Higher rates of death, disability
Coexisting illness HTN, & stroke
More likely to take medications that impair insulin action
i.e., corticosteroinds, antihypertensives, phenothiazines
Hypoglycemic unawareness more common in older adults
Delayed psychomotor function to treat hypoglycemia
Monitor for hypoglycemia and renal and liver dysfunction in those taking sulfonylurea drugs
MSK changes-functional changes
Visual changes, cognitive changes
Economic constraints

26. Cultural needs Cultural needs
Dietary preferences and meal preparation practices
Health hx-meal planning, preferences
Cultural disparities-economic restraints
Culturally competent care

27. Fructosamine Diagnostic studies Diagnostic studies to diagnose
A1C measures glycosylated hemoglobin as a percentage of total hemoglobin measures the amt of hgb with glucose attached.
1. A1C 6.5% or higher-RBC Glucose
2. 8 hr fasting FPG = or > 126 mg/dL or higher
3. Two hr plasma glucose level = or > 200 mg/dL
Fructosamine_add to outline
is another way to assess glucose levels. Fructosamine is formed by a chemical reaction of glucose with plasma protein. It reflects glycemia in the previous 1 to 3 weeks. Fructosamine levels may show a change in blood glucose levels before A1C does.
Islet cell autoantibody testing is ordered primarily to help distinguish between autoimmune type 1 diabetes and diabetes due to other causes.

28. Evidence-based practice guidelines
Use of text messaging-electronic education-BG levels-physical activity
Physical activity, healthy eating
Informatics-what about smart apps?

29. Evaluation Evaluation
Demonstrate knowledge of the disease and treatment plan.
Describe self care measures that prevent or slow the progression of chronic complications
Maintain balance-nutrition, activity, insulin availability that results in safe, healthy blood glucose levels
Experience no injury
Resulting from decrease sensation in feet
Implement measures to increase peripheral circulation

30. Teamwork & Collaboration
Teamwork and collaboration
LPN's and UA (in some states) may administer OA & Insulin-stable pts (Under the direction of RN) RN
Assess for risk factors for prediabetes, DM 1, DM 2
Teach pt and caregiver about self management including SMBG
Noninsulin injectables
OA, nutrition, exercise
Recognition and management of hypoglycemia
Develop a plan to avoid blood sugar swings in illness and surgery
Assess for complications such as hypoglycemia, DKA, HHS
Assess for chronic complications:
Cardiovascular disease
Retinopathy
Nephropathy
Neuropathy
Foot complications
LPN
Administer OA, Insulin
Monitor for s/s of hypoglycemia, DKA, HHS
In the ambulatory or home setting monitor pt self management of insulin
OA, nutrition, physical activity
Report concerns with self management to RN
UAP
Check BG after being trained
Report values to RN
Report changes in pt VS, UO, behavior or LOC to RN
In community or home care setting administer OA, insulin to stable pt (state and agency policy)
Dietician
Assess pt knowledge of DM
Provide teaching about disease process PRN
Teach pt and caregiver about nutrition, diet, to self-manage DM and avoid complications

31. Ethical & Legal Dilemmas
Ethical and legal dilemmas
• The Patient Self-Determination Act (1990) advance directives allowing individuals to state their preferences or refusals of health care in the event that they are incapable of consenting for themselves.
• Durable Power of Attorney for health care is one type of advance directive in which people, when they are competent, identify someone else to make decisions for them, should they lose their decision-making ability in the future.
• The Living Will, another type of advance directive, permits individuals to state their own preferences and refusals.
• Many HCPs mistakenly think that proxies must be family members or blood relatives. Lesbian, gay, bisexual, and transgender (LGBT) individuals often have difficulty having their partnership recognized as valid, especially if the patient's family disputes their rights.
• Some families are deeply divided on decisions for their loved ones, and sometimes difficulties occur when money and property are also disputed. The passage of time may be an issue where the original documents were executed and then changes occurred (e.g., divorce, death or disability of the proxy, inability to contact the proxy, inability to find a valid original of the advance directive).
• Within your scope of nursing practice (depending on state laws)
(1) Teach patients and their families about advance directives
(2) make sure that HCPs are aware of and follow advance directives
(3) Assist the patient and
(4) Assist a conflicted family in obtaining appropriate counseling whenever necessary.
• Counsel LGBT patients on the importance of having a health care proxy and a will to legally protect their end-of-life choices.