1. Managing Diabetes Mellitus

2. Review What is the chief characteristic of diabetes mellitus? What is the cause of the chief characteristic? What are the primary pancreatic hormones and their function? What is the primary goal of treatment? Differentiate between the pathophysiology of type 1 and type 2 diabetes mellitus.

3. Osmotic Diuresis When there is not enough insulin glucose can not enter cells. The liver will increase production and release of glucose. Excess blood glucose increases serum osmolality. The kidney’s respond by increasing glucose excretion; water and electrolytes follow. Polyuria results in dehydration and marked electrolyte loss.

4. More Questions Glucose from food can not be stored in the liver. What is the implication of this? What is considered the target blood sugar value? What is a renal threshold? When is the renal glucose threshold reached? Why should the presence of glucose in the urine not be used to guide treatment?

5. And More Questions What is the body’s source of energy when glucose is not available? What is the implication of this? Differentiate between the primary treatment for type 1 and type 2 diabetes mellitus. What does the treatment regimen depend upon?

6. And Even More Questions What are clinical manifestations dependent upon? What are the classical symptoms? What are additional symptoms?

7. Manifestations

8. Diagnostic Findings Indicating Diabetes Mellitus Fasting Blood Glucose > 126 mg/dL Random plasma glucose > 200 mg/dL on more than one occasion Hgb A 1C (glycated hemoglobin) – Normal 4-6%

10. Nutritional Therapy Cornerstone of treatment Includes: nutrition, meal planning, and weight control Distribution of nutrients – 50-60% CHO (majority whole grains) – 20-30% Fat – 10-20% Protein – 25 g fiber/day

11. Exercise Another cornerstone of treatment Lowers glucose and decreases cardiovascular risks Should not be initiated until glucose levels are < 250 mg/dL Recommendations: – Exercise same time each day – Start slow, gradually increase duration – If > 30 y/o with 2 CV risks, exercise stress test – Elderly- realistic and consistent

12. Measures to Aid Self-Management Blood glucose monitoring – Intermittent – continuous Urine glucose testing no longer standard of care Ketone testing – If consistently ↑ serum glucose or glycosuria, during illness, in pregnant diabetic, and in gestational diabetes

13. Pharmacologic Therapy Compare and contrast the pharmacologic treatment of type 1 and type 2 diabetes mellitus. Insulin regimens – Variable – Goal: mimic normal pattern of insulin secretion in response to food intake and activity patterns Two approaches – Conventional – Intensive

14. Sliding Scale Insulin Mrs. J has an order for insulin to be given at 0730. The order reads NPH insulin 24 units and Regular insulin 8 units subcutaneously. She is also on sliding scale insulin coverage. Her 0700 blood sugar is 351. How will you proceed. What must you ensure? When would you expect a hypoglycemic reaction? Fingerstick (BSBS) Blood Sugar mg/dL: < 70call MD 201-2504 units subcutaneously 251-3006 units subcutaneously 301-3508 units subcutaneously 351- 40010 units subcutaneously 401-45012 units subcutaneously 451-50014 units subcutaneously > 500call MD

15. Nursing Management What is one of the most essential aspects of nursing management of diabetes mellitus? What must be done before initiating this activity? What should be included in this activity?

16. Hypoglycemia Immediate treatment: – 15 g of fast acting CHO – Retreat in 15 min if glucose < 70-75 mg/dL – Follow with protein/starch snack Emergency measures: – 1 mg Glucagon – 25-50 mL Dextrose in water IV

17. Diabetic Ketoacidosis ↓ serum HCO3, pH ↑ creatinine, BUN ↓, normal, or ↑ Na+, K+ + Urine and blood ketones Sick Day rules – Don’t eliminate insulin – Contact MD if can’t take fluids without vomiting or if ketones are present

18. DKA: Nursing Management Monitor fluid, electrolyte and hydration status Monitor blood glucose, VS, ABGs Prevent fluid overload– VS and lung assessments I&O Monitor urine output before staring K+ Documentation: lab values, frequent changes in fluids and meds, patient response to treatment

19. Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS) Characterized by alterations in awareness Minimal to absent ketosis Lack of effective insulin Persistent hyperglycemia → osmotic diuresis→ loss of water and electrolytes. Water shifts from intracellular to extracellular space→ hypernatrimia and ↑ osmolality. Polyuria Precipitating event

20. Management HHNS Medical: Fluid replacement – 0.9 or 0.45% saline – Change to D5W when glucose < 250-300 mg/dL Correct electrolytes – K+ if adequate urine Insulin – Continuous Nursing: Closely monitor VS, fluids, labs Maintain safety Monitor I&O and hydration status Care for underlying condition Careful cardiovascular, pulmonary and renal assessments

21. Complications of Diabetes Mellitus Macrovascular – Cardiovascular disease – Cerebrovascular disease – Peripheral vascular disease Microvascular – Retinopathy – Nephropathy Neuropathy – Peripheral – Autonomic – Spinal

22. Diabetic Nephropathy Renal disease secondary to microvascular changes Filtration mechanism damaged→ proteinuria and ↑ pressure in kidney vessels Manifestations: – Same as other renal disease; – Progressive renal failure Assessments and diagnostics – Albumin in urine is earliest sign

23. Diabetic Nephropathy Medical Management Control HTN (ACEI) Prevention or vigorous UTI Rx Avoid nephrotoxic substances Adjust meds as renal function decreases ↓ Na+ and protein diet Nursing Management Orthostatic Hypotension – ↑ Na diet, d/c meds that impede ANS response, sympathomimetics, mineralcorticoids, lower body elastic garments Decreased GI motility – Low fat diet, freq. sm. meals, close glucose monitoring; Reglan Diarrhea – Bulk forming lax, antidiarrheals Constipation – Fiber, fluids, meds, laxatives, enemas

24. Hypoglycemia Unawareness Autonomic nephropathy that affects the adrenal medulla is responsible for diminished or absent adrenergic symptoms of hypoglycemia. – Shakiness, sweating, nervousness, palpitations Frequent blood sugar monitoring needed. Risk for developing extreme hypoglycemia. Goals for blood sugar levels may need to be changed.

25. Foot and Leg Problems Neuropathy, PVD, and immunocompromise are contributing factors. Diabetic ulcer development begins with a soft tissue injury. Risk of developing these problems increases with age, duration of diabetes, and development of complications

26. Management Teaching proper foot care Good hygiene and skin care – So not put lotions between toes Shoes must fit well Trim nails straight across – Do not trim toenails of a diabetic patient Reduce risk factors Avoid home remedies, OTC agents, and self- medicating to treat foot problems.