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AH 1108 Diabetes.

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Presentation on theme: "AH 1108 Diabetes."— Presentation transcript:

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.

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