1. Caring for Clients With Diabetes Mellitus36
Caring for Clients With Diabetes Mellitus

2. Directory
Classroom Response System
Lecture Note Presentation

3. NCLEX-PN® Question 1
A client is taught self-monitoring of blood glucose (SMBG) in order to check his blood glucose before meals and administer insulin according to a sliding scale. The nurse will teach the client to use which type of insulin?

4. NCLEX-PN® Question 1 Choices
Humulin N
Humulin R
Lantus
Humulin 70/30

5. NCLEX-PN® Question 1 Choices
Humulin N
Humulin R
Lantus
Humulin 70/30

6. NCLEX-PN® Rationale
Outcome 2, 3, 6. The sliding scale permits periodic monitoring of blood glucose levels to provide better control. Fast-acting insulin (regular insulin) is used with the sliding scale to best mimic the natural action of the pancreas. Humulin N is an intermediate-acting insulin that takes longer to have an effect. Lantus is a long-acting insulin that takes 2 hours to have an effect. Humulin 70/20 is an intermediate-acting insulin that takes longer to have an effect than Humulin N.

7. NCLEX-PN® Question 4
Which one of the following clients has the highest risk factors for developing type 2 diabetes mellitus?

8. NCLEX-PN® Question 4 Choices
16-year-old Native American who plays basketball in high school.
30-year-old Caucasian with a family history of diabetes mellitus.
52-year-African American with a history of thyroid disease.
68-year-old Hispanic female who is overweight.

9. NCLEX-PN® Question 4 Choices
16-year-old Native American who plays basketball in high school.
30-year-old Caucasian with a family history of diabetes mellitus.
52-year-African American with a history of thyroid disease.
68-year-old Hispanic female who is overweight.

10. NCLEX-PN® Rationale
Outcome 1. Risks for type 2 DM include adults over 65, obesity, sedentary lifestyle, and Hispanic or African American women, and Native Americans. The 16-year-old has lower risk due to physical activity. Family history plays a more important role in the development of type 1 than type 2 DM. Thyroid disease does not increase risk for DM.

11. NCLEX-PN® Question 7
A client is admitted to the medical unit with a diagnosis of diabetic ketoacidosis. Which of the following clinical manifestations should the nurse expect to find?

12. NCLEX-PN® Question 7 Choices
Cool, clammy skin
Acetone breath odor
Slurred speech
Radial pulse 70, bounding

13. NCLEX-PN® Question 7 Choices
Cool, clammy skin
Acetone breath odor
Slurred speech
Radial pulse 70, bounding

14. NCLEX-PN® Rationale
Outcome 4. Diabetic ketoacidosis is characterized by hyperglycemia and spillage of ketones in the urine, which causes the classic acetone breath. The skin is very warm and dry as a result of dehydration, not cool and clammy. Slurred speech occurs with hypoglycemia, not hyperglycemia. The pulse is usually rapid and weak, not bounding.

15. NCLEX-PN® Question 9
A conscious client arrives in the emergency department with a blood glucose of 50 mg/dL. What nursing intervention should the nurse anticipate doing for this client?

16. NCLEX-PN® Question 9 Choices
Give lispro (Humalog) injection.
Give crackers and cheese.
Give glucagon injection.
Give a half cup regular soda.

17. NCLEX-PN® Question 9 Choices
Give lispro (Humalog) injection.
Give crackers and cheese.
Give glucagon injection.
Give a half cup regular soda.

18. NCLEX-PN® Rationale
Outcome 4. Regular soda, a rapid-acting glucose source, is given immediately to a conscious client with hypoglycemia. Giving insulin would decrease glucose levels further. Glucagon is only used with an unconscious client. Crackers and cheese are given after glucose levels have returned to normal because they take longer to act.

19. Learning Outcomes
Differentiate risk factors, pathophysiology, and clinical manifestations between type 1 and type 2 diabetes mellitus.
Identify the diagnostic tests used to diagnose and monitor selfmanagement of diabetes mellitus.

20. Learning Outcomes
Discuss the nursing implications for insulin and oral antidiabetic agents ordered for clients with diabetes mellitus.
Compare and contrast the causes, manifestations, and interdisciplinary care of diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic state (HHS), and hypoglycemia.

21. Learning Outcomes
Explain the interdisciplinary care of chronic complications for clients with type 1 and type 2 diabetes mellitus.
Reinforce teaching guidelines to clients with diabetes mellitus regarding self-management of medications, diet, exercise, and foot care.

22. Learning Outcomes
Use the nursing process to collect data, establish outcomes, provide individualized care, and evaluate responses for the client with diabetes mellitus.

23. Diabetes Mellitus Chronic disease Not a single disorder
Group of metabolic disorders
Characterized by hyperglycemia

24. Overview Large number of individuals are not diagnosed Cannot be cured
Can be controlled in efforts to control complications

25. Complications Affects: Eyes Kidneys Nervous system
Cardiovascular system

26. Type 1 DM Usually occurs in children and adolescents
Results from an autoimmune disorder that destroys the beta cells of islets of Langerhans

27. Type 1 DM Insulin no longer produced
Leads to hyperglycemia and breakdown of body fat and protein
Cells starve
Burning of fat leads to “ketosis”
Ketone bodies accumulate

28. Type 1 DM - Pathophysiology
Elevated blood glucose
Excess spills into the urine leading to glycosuria
Once hyperglycemia and glycosuria occur, three manifestations of diabetes are seen:
Polyuria
Polydipsia
Polyphagia

29. Type 2 DM
Characterized by hyperglycemia due to insufficient insulin production and insulin resistance
Not enough insulin to lower blood glucose levels
Enough insulin to prevent the breakdown of fats; ketosis does not develop

30. Type 2 DM Risk factors: Heredity Obesity Increasing age
High-risk ethnic group

31. Type 2 DM – Role of Obesity
Reduces available insulin receptor sites, leading to insulin resistance
Three-quarters of older adults with type 2 are overweight
All older adults develop insulin resistance
Weight loss through diet and exercise can reduce insulin resistance
With enough weight loss, may not need oral medications

32. Type 2 DM - Diagnosis Often undiagnosed for years
Less severe hyperglycemia
Only polyuria and polydipsia are present
Breeding ground for bacterial infections
Cloudiness of eye lens leading to blurred vision

33. Type 2 DM - Diagnosis
Destruction of peripheral nerves leading to paresthesias
Fatigue due to tissue starvation

35. Diabetes insipidus (DI)
is a condition characterized by excessive thirst and excretion of large amounts of severely diluted urine, with reduction of fluid intake having no effect on the latter.
There are several different types of DI, each with a different cause. The most common type in humans is central DI, caused by a deficiency of arginine vasopressin (AVP), also known as antidiuretic hormone (ADH).
The second common type of DI is nephrogenic diabetes insipidus, which is caused by an insensitivity of the kidneys to ADH. It can also be an iatrogenic artifact of drug use

36. Laboratory Tests Plasma glucose (PG) level
Fasting blood glucose level (FBG)
Oral glucose tolerance test (OGTT)

37. Routine Screening Should Be Done If: Obese
First-degree relative with DM
High-risk ethnic population
Delivered baby > 9 lb or gestational diabetes history

38. Routine Screening Should Be Done If: Hypertensive HDL < 35 mg/dL
Triglycerides > 250 mg/dL
Impaired glucose tolerance or fasting glucose in the past

39. Self-Monitoring Blood Glucose
Monitor and achieve metabolic control
Useful if ill or pregnant
Useful if symptomatic with hypo- or hyperglycemia
On insulin: three or more times per day
Not on insulin: two to three times per week

40. Equipment Lancet Blood glucose monitoring machine Test strips
Follow manufacturer’s instructions for use

41. Noninvasive Blood Glucose Monitoring
GlucoWatch Biographer: worn as a watch
Measures glucose value in perspiration

42. Urine Testing for Ketones and Glucose
Has unpredictable results
Should be done with type 1 diabetes
Either Acidtest or Ketostix
Normal result is no glucose in urine

43. Insulin Pork or synthetic
Strengths: rapid-acting, short-acting, intermediate-acting, long-acting

45. Insulin Strengths Insulin Strengths 100 U per mL or 500 U per mL
Administered in a sterile, single-use, disposable syringe
All insulin given parenterally
Regular insulin: either subcutaneous or intravenous

46. Alternative Delivery Methods
Insulin pen
Jet injector
Continuous subcutaneous infusion pump

47. Figure 36-2 Sites of insulin injection.

48. Injection Sites Process: pinch skin, inject needle at 90-degree angle
Do not inject into muscle; do not massage after injecting
Rotate injection sites
Minimize painful injections

50. Problems with Insulin Injections
Lipodystrophy: is a medical condition characterized by abnormal or degenerative conditions of the body's adipose tissue
Lipoatrophy: is the term describing the localized loss of fat tissue.

52. Insulin Regimen Individualized Mix short and longer acting
Timing depends on feed, exercise, glucose level, type of insulin
Tight glucose control results in fewer long-term complications
Oral Antidiabetic Agents

53. Diabetes Ketoacidosis (DKA)
Life-threatening illness in type 1
Hyperglycemia, dehydration, coma
Excess glucose leads to dehydration, sodium and potassium loss
Burning of fat leads to ketosis
Kidneys unable to excrete ketones, leads to ketoacidosis

54. DKA Treatment Hospital admission
Treatment: fluids, insulin, electrolytes

55. Hyperosmolar Hyperglycemic State (HHS)
Seen in type 2 diabetes
Severely elevated blood glucose
Extreme dehydration
Altered LOC
Develops slowly over hours to days
Life-threatening emergency

56. HHS
Treatment
Correct fluid and electrolyte imbalances; provide insulin

58. Hypoglycemia Type 1 or type 2 diabetes Causes
Too much insulin
Overdose of oral antidiabetic agents
Too little food
Excess physical activity
Sudden onset; blood glucose < 50 mg/dL

60. Hypoglycemia Unawareness
May develop in some people with long-standing type 1 diabetes
No symptoms of hypoglycemia in the presence of a low blood glucose level

61. Hypoglycemia Treatment Mild Severe Immediate treatment
15 g rapid-acting sugar
Severe
Hospitalized
Intravenous glucose

62. Macrovascular Complications
Macrocirculation
Large blood vessels undergo changes due to atherosclerosis
Complications
Coronary artery disease
Stroke
Peripheral vascular disease

63. Complication: CAD Risk factor for an MI
High cholesterol and high triglycerides

64. Complication: Stroke Two to six times more likely to occur in type 2
Hypertension plays a role

65. Complication: Peripheral Vascular Disease
Greater in type 2
Diabetes-induced arteriosclerosis
Can lead to leg ulcers and gangrene

66. Microvascular Complications
Microcirculation
Eyes
Kidneys
Nerves

67. Complication: Diabetic Retinopathy
Changes in the retinal capillaries; lead to retinal ischemia, retinal hemorrhage, or detachment
Retinopathy stages: nonproliferative and proliferative
Leading cause of blindness in people ages 20 to 74
Yearly eye exams are recommended

68. Complication: Diabetic Nephropathy
Disease of the kidneys
Characterized by albumin in the urine, hypertension, edema, renal insufficiency
Most common cause of renal failure
First indication: microalbuminuria
Treatment: ACE inhibitors

69. Complication: Diabetic Neuropathy
Disorder of the peripheral nerves and autonomic nervous system
Results: sensory and motor impairments, postural hypotension, delayed gastric emptying, diarrhea, impaired genitourinary function
Result from the thickening of the capillary membrane and destruction of myelin sheath

70. Complication: Diabetic Neuropathy
Bilateral sensory disorders
Appear first in toes, feet, and progress upward to fingers and hands
Treatment
None specific
Focus on controlling neuropathic pain with tricyclic antidepressants or topical cream capsaicin (Zostrix)

71. Complication: Autonomic Neuropathy
Involves numerous body systems such as cardiovascular, gastrointestinal, genitourinary

72. Teaching Plan Contents
Medications
Diet
Exercise
Foot care

73. Client Teaching - Medications
Type of medication
Oral or insulin
Insulin
Type, dosage, mixing instructions, times of onset and peak, obtaining and care of equipment, self-injections, locations for injections, timing of injections with meals

74. Click here to view an animation on glipizide.
Glipizide Animation
Click here to view an animation on glipizide.

75. Client Teaching - Diet
Role of diet with control of blood glucose levels
Complex carbohydrates and food high in fiber
Limit sugar, fat, sodium, alcohol
How to read food labels

76. Client Teaching – Diet Personal food preferences Eating away from home
Relationship between diet, exercise, medication

77. Client Teaching - Exercise
Purpose
Importance
Types
Personal exercise choices

78. Client Teaching - Foot care
Wash feet daily
Inspect feet daily

79. Figure Ulceration after trauma to the foot of a person with diabetes. (Source: Courtesy of Harry Przekop/Medichrome/The Stock Shop, Inc.)

80. Client Teaching - Concerns for Young Adults
Assess the young adult’s lifestyle including eating habits/patterns, exercise
Provide teaching to address the need for scheduled eating patterns and exercise regime

81. Client Teaching - Concerns for Middle-Aged Adults
Assess the client’s lifestyle to include eating habits/patterns, exercise
Provide teaching to address the need for scheduled eating patterns and exercise regime.

83. Client Teaching - Concerns for Older Adults
If obese, might need diet, exercise, and weight reduction program
Consider: dietary likes/dislikes, eating habits, meal preparation, age-related changes in taste and smell, dental health
Consider: age-related decline in calorie needs and reduced physical activity
Might be on a fixed income

84. Client Teaching - Concerns for Older Adults
Coexisting illnesses and multiple medications can decrease appetite and reduce energy to plan, cook, or eat
Dietary restrictions can lead to avoidance of social gatherings
Decreased thirst mechanism can lead to dehydration

85. Client Teaching - Concerns for Older Adults
Exercise should be individualized depending on physical limitations
Withdrawal from social situations can lead to depression
Visual and fine motor skill deficits can make insulin administration, glucose monitoring, food preparation, exercise and foot care difficult or impossible.

86. The Nursing Process
Used to assess, diagnose, plan, implement, and evaluate care for the client with diabetes mellitus.

88. Nursing Diagnoses Imbalanced Nutrition Impaired Skin Integrity
Risk for Infection
Risk for Injury
Ineffective Coping

89. Evaluation Collect data related to chronic complications
Identify frequency of DKA, HHNS, hypoglycemia
Document VS, LOC, skin integrity, complications

90. Evaluation Notify MD of client’s response to treatment
Reinforce teaching related to medications, diet, and self-care
Document