1. Chapter 51 Assessment and Management of Patients With Diabetes

2. Diabetes
A group of diseases characterized by hyperglycemia caused by defects in insulin secretion, insulin action, or both
Affects nearly 25.8 million people in the United States; one third of cases are undiagnosed
Prevalence is increasing
Minority populations and older adults are disproportionately affected

3. Functions of Insulin Transports and metabolizes glucose for energy
Stimulates storage of glucose in the liver and muscle as glycogen
Signals the liver to stop the release of glucose
Enhances storage of fat in adipose tissue
Accelerates transport of amino acids into cells
Inhibits the breakdown of stored glucose, protein, and fat

4. Type 1 Diabetes
Insulin-producing beta cells in the pancreas are destroyed by an autoimmune process
Requires insulin because little or no insulin is produced
Onset is acute and usually before 30 years of age
5% to 10% of persons with diabetes

5. Type 2 Diabetes
Decreased sensitivity to insulin (insulin resistance) and impaired beta cell function result in decreased insulin production
90% to 95% of person with diabetes, onset over age 30 years, increasing in children, obesity
Slow, progressive glucose intolerance
Treated initially with diet and exercise
Oral hypoglycemic agents initially may need to convert to insulin or use both

6. Risk Factors
Type 1: early onset, familial, genetic predisposition, possible immunologic or environmental (viral or toxins) factors
Refer to Chart 51-1
Type 2: obesity, age, previous identified impaired fasting glucose or impaired glucose tolerance, hypertension ≥140/90 mm Hg, HDL ≤35 mg/dL or triglycerides ≥250 mg/dL, history of gestational diabetes or babies over 9 pounds

7. Clinical Manifestations
“Three Ps”
Polyuria
Polydipsia
Polyphagia
Fatigue, weakness, vision changes, tingling or numbness in hands or feet, dry skin, skin lesions or wounds that are slow to heal, recurrent infections
Type 1 may have sudden weight loss

8. Diagnostic Findings Fasting blood glucose 126 mg/dL or more
Random glucose exceeding 200 mg/dL
Gerontologic considerations: age-related elevation of blood glucose
A1-C

9. Treatment Goal: Maintain Normal Blood Glucose Levels (Hgb A1c <7%)
Intensive control, defined as three or four insulin injections per day or continuous subcutaneous insulin infusion, insulin pump therapy plus frequent blood glucose monitoring, and weekly contacts with diabetic educators, dramatically decreases development and progression of complications such as retinopathy, nephropathy, and neuropathy.

10. Dietary Management Goals
Maintain the pleasure of eating; include personal and cultural preferences
Promote exercise and activity
Achieve and maintain BMI <25
Prevent wide fluctuations of blood glucose levels
Decrease serum lipids, if elevated

11. Role of the Nurse Be knowledgeable about dietary management
Communicate important information to the dietician or other management specialists
Reinforce patient understanding
Support dietary and lifestyle changes

12. Glycemic Index
Combining starchy foods with protein and fat slows absorption and glycemic response.
Raw or whole foods tend to have lower responses than cooked, chopped, or pureed foods.
Eat whole fruits rather than juices; this decreases glycemic response because of fiber (slowing absorption).

13. Other Dietary Concerns
Alcohol
Nutritive and nonnutritive sweeteners
Reading labels

14. Exercise Lowers blood sugar Aids in weight loss
Lowers cardiovascular risk

15. Educating Patients in Insulin Self-Management
Use and action of insulin
Symptoms of hypoglycemia and hyperglycemia
Required actions
Blood glucose monitoring
Self-injection of insulin
Insulin pump use

16. Oral Antidiabetic Agents
Used for patients with type 2 diabetes who require more than diet and exercise alone
Combinations of oral drugs may be used
Major side effect: hypoglycemia
Nursing interventions: monitor blood glucose for hypoglycemia and other potential side effects
Patient education

17. Acute Complications of Diabetes
Hypoglycemia
DKA
Hyperglycemic hyperosmolar syndrome (HHS)
Comparison of DKA and HHS: refer to Table 51-7

18. Hypoglycemia
Abnormally low blood glucose level (below 50–60 mg/dL); too much insulin or oral hypoglycemic agents, excessive physical activity, and not enough food
Adrenergic symptoms: sweating, tremors, tachycardia, palpitations, nervousness, hunger
Central nervous system symptoms: inability to concentrate, headache, confusion, memory lapses, slurred speech, drowsiness
Severe hypoglycemia: disorientation, seizures, loss of consciousness, death

19. Management of Hypoglycemia
Give 15 g of fast-acting, concentrated carbohydrate
Three or four glucose tablets
4 to 6 oz of juice or regular soda (not diet soda)
Retest blood glucose in 15 minutes; retreat if >70 mg/dL or if symptoms persist more than 10 to 15 minutes and testing is not possible
Provide a snack with protein and carbohydrate unless the patient plans to eat a meal within 30 to 60 minutes

20. Emergency Measures If the patient cannot swallow or is unconscious:
Subcutaneous or intramuscular glucagon (1 mg)
25 to 50 mL of 50% dextrose solution IV

21. Diabetic Ketoacidosis (DKA)
Absence or inadequate amount of insulin resulting in abnormal metabolism of carbohydrate, protein, and fat
Clinical features
Hyperglycemia
Dehydration
Acidosis
Refer to Figure 51-7
“Sick day rules”: refer to Chart 51-9

22. Assessment of DKA Blood glucose levels >300 to 1,000
Severity of DKA not only due to blood glucose level
Ketoacidosis is reflected in low serum bicarbonate, low pH; low PCO2 reflects respiratory compensation (Kussmaul’s respirations)
Ketone bodies in blood and urine
Electrolytes vary according to degree of dehydration; increase in creatinine, Hct, BUN

23. Treatment of DKA Rehydration with IV fluid
IV continuous infusion of regular insulin
Reverse acidosis and restore electrolyte balance
Note: rehydration leads to increased plasma volume and decreased K; insulin enhances the movement of K+ from extracellular fluid into the cells
Monitor blood glucose, renal function and urinary output, ECG, electrolyte levels, VS, lung assessments for signs of fluid overload

24. Hyperglycemic Hyperosmolar Syndrome
Hyperosmolar hyperglycemia is caused by a lack of sufficient insulin; ketosis is minimal or absent
Hyperglycemia causes osmotic diuresis, loss of water and electrolytes, hypernatremia, and increased osmolality
Manifestations include hypotension, profound dehydration, tachycardia, and variable neurologic signs caused by cerebral dehydration
High mortality rate

25. Treatment of HHS Rehydration Insulin administration
Monitor fluid volume and electrolyte status
Prevention
BGSM
Diagnosis and management of diabetes
Assess and promote self-care management skills

26. Long-Term Complications of Diabetes
Macrovascular: accelerated atherosclerotic changes, coronary artery disease, cerebrovascular disease, and peripheral vascular disease
Microvascular: diabetic retinopathy (refer to Figure 51- 8), and nephropathy
Neuropathic: peripheral neuropathy, autonomic neuropathies, hypoglycemic unawareness, neuropathy, sexual dysfunction