Nur 105Adult Health I

DIABETES MELLITUSJackie C. Williams, RN-C, MSN

Shelton State Community College

DEFINITIONDIABETES MELLITUS

An endocrine disorder in which there is insufficient amount or lack of insulin secretion to metabolize carbohydrates.

It is characterized by hyperglycemia, glycosuria and ketonuria.

Diabetes MellitusPathophysiology

The beta cells of the Islets of Langerhan of the Pancreas gland are responsible for secreting the hormone insulin for the carbohydrate metabolism.

Remember the concept - sugar into the cells.

Diabetes MellitusTypes

Type 1 - IDDM little to no insulin

produced 20-30% hereditary Ketoacidosis

Gestational overweight; risk for

Type 2

Type 2 - NIDDM some insulin

produced 90% hereditary

Other types include Secondary Diabetes : Genetic defect beta cell

or insulin Disease of exocrine

pancreas Drug or chemical

induced Infections-pancreatitits Others-steroids,

Absence of Insulin Hyperglycemia Polyuria Polydipsia Polyphagia Hemoconcentration, hypervolemia,

hyperviscosity, hypoperfusion, and hypoxia

Acidosis, Kussmaul respiration Hypokalemia, hyperkalemia, or normal

serum potassium levels

Assessment History Blood tests

Fasting blood glucose test: two tests > 126 mg/dL

Oral glucose tolerance test: blood glucose > 200 mg/dL at 120 minutes

Glycosylated hemoglobin (Glycohemoglobin test) assays

Glucosylated serum proteins and albumin FSBS – (finger stick) monitoring blood sugar

Urine Tests

Urine testing for ketones Urine testing for renal function Urine testing for glucose

Diabetes MellitusClinical Manifestation

Hyperglycemia Three P’s -

Polyuria

Polyphagia

Polydispsia

Gradual Onset

Hypoglycemia Weak, diaphoretic,

sweat, pallor, tremors, nervous, hungry, diplopia, confusion, aphasia, vertigo, convulsions

Treatment - OJ with sugar, or IV glucose

Sudden onset

Hyperglycemia - Clinical Manifestations

Three P’s – polyuria, polydypsia,

polyphagia Glycosuria Dehydration Hypotension Mental Changes

Fever Hypokalemia Hyponatremia Seizure Coma

Life Threatening!!!

Risk for Injury Related to Hyperglycemia

Interventions include: Dietary interventions, blood glucose

monitoring, medications Oral Drugs Therapy

(Continued)

Risk for Injury Related to Hyperglycemia (Continued)

Oral therapy Sulfonylurea agents Meglitinide analogues Biguanides Alpha-glucosidase inhibitors Thiazolinedione antidiabetic agents

Oral HypoglcemiasKey Points

Monitor serum glucose levels Teach patient signs and symptoms of

hyper/hypoglycemia Altered liver, renal function will affect

medication action Avoid OTC meds without MD approval Assess for GI distress and sensitivity Know appropriate time to administer med

Diet Therapy Goals of diet therapy Principles of nutrition in diabetes

Protein, fats and carbohydrates, fiber, sweeteners, fat replacers

Alcohol Food labeling Exchange system, carbohydrate

counting Special considerations for type 1 and

type 2 diabetes

Diabetes MellitusDiet

American Diabetic Association

Food groups/ exchanges

Carbohydrates - 60%

Fats - 30% Protein - 12-20%

Diabetes - Monitoring Glucose Levels

Urine - Ketones

FSBS

Wear ID Bracelet

Diabetes - TreatmentExercise

Purpose - controls blood glucose and lowers blood glucose

Purpose - reduce the amount of insulin needed

Exercise Therapy

Benefits of exercise Risks related to exercise Screening before starting exercise

program Guidelines for exercise Exercise promotion

Drug Therapy Drug administration Drug selection Insulin therapy:

Insulin analogue Short-acting insulin Concentrated insulin Intermediate

(Continued)

Drug Therapy (Continued)

Fixed-combination Long-acting Buffered insulins

Insulin Regimens

Single daily injection protocol Two-dose protocol Three-dose protocol Four-dose protocol Combination therapy Intensified therapy regimens

Pharmacokinetics of Insulin

Injection site Absorption rate Injection depth Time of injection Mixing insulins

Complications of Insulin Therapy

Hypoglycemia Lipoatrophy Dawn phenomenon Somagyi's phenomenon

Alternative Methods of Insulin Administration

Continuous subcutaneous infusion of insulin

Implanted insulin pumps Injection devices New technology includes:

Inhaled insulin Transdermal patch (being tested)

Client Education

Storage and dose preparation Syringes Blood glucose monitoring Interpretation of results Frequency of testing Blood glucose therapy goals

Diabetic Education - Preventive Medicine

Proper skin and foot care

Proper Eye Exam

Proper diet and fluids

Diabetic Neuropathy

Diabetic Retinopathy

Diabetic Nephropathy

Diabetic gastroparesis

Diabetes MellitusComplications

Hyperglycemia

Hypoglycemia

Diabetic Ketoacidosis

Hyperosmolar Hyperglycemic

Nonketotic Syndrome

Acute Complications of Diabetes

Diabetic ketoacidosis Hyperglycemic-hyperosmolar-

nonketotic syndrome Hypoglycemia from too much

insulin or too little glucose

Diabetic Ketoacidosis

Potential for Diabetic Ketoacidosis

Interventions include: Monitoring for manifestations Assessment of airway, level of

consciousness, hydration status, blood glucose level

Management of fluid and electrolytes(Continued)

Potential for Diabetic Ketoacidosis (Continued)

Drug therapy goal: to lower serum glucose by 75 to 150 mg/dL/hr

Management of acidosis Client education and prevention

Complication – KetoacidosisTreatment

Patent airway Suctioning Cardiac monitoring Vital Signs Central venous

pressure Blood work – ABG,

BS, chemistry panel

Administration of Na Bicarb

Foley – monitor urinary output

I & O Frequent

Repositioning

Complication – HHNCHyperosmolar Hyperglycemic

Non-Ketotic Coma Fluid moves from

inside to outside cell vausing diuresis and loss of Na+ and K+

Treatment - Give insulin and correct fluid and electrolytes imbalance

Signs and Symptoms Hypotension Mental changes Dehydration Hypokalemia Hyponatremia

Life Threatening!!!

Chronic Complications of Diabetes

Cardiovascular disease Cerebrovascular disease Retinopathy (vision) problems Diabetic neuropathy Diabetic nephropathy Male erectile dysfunction

Diabetes MellitusNursing Process

Assessment – Medicines, Allergies, Symptoms, Family Hx

Nursing Diagnosis- Anxiety and Fear, Altered

Nutrition, Pain, Fluid Volume Deficit

Planning – Address the nursing diagnosis

Implementation – Prevent complications, monitor

blood sugars, administer meds and diet, teach diet

and meds, Asess , Assess, Assess

Evaluation- Goals, EOC’s

Whole-Pancreas Transplantation

Operative procedure Rejection management Long-term effects Complications Islet cell transplantation hindered by

limited supply of beta cells and problems caused by antirejection drugs

Risk for Delayed Surgical Recovery

Interventions include: Preoperative care Intraoperative care Postoperative care and monitoring

includes care of: Cardiovascular Renal Nutritional

Risk for Injury Related to Sensory Alterations

Interventions and foot care practices: Cleanse and inspect the feet daily. Wear properly fitting shoes. Avoid walking barefoot. Trim toenails properly. Report nonhealing breaks in the skin.

Wound Care

Wound environment Debridement Elimination of pressure on infected

area Growth factors applied to wounds

Chronic Pain

Interventions include: Maintenance of normal blood glucose

levels Anticonvulsants Antidepressants Capsaicin cream

Risk for Injury Related to Disturbed Sensory Perception: Visual

Interventions include: Blood glucose control Environmental management

Incandescent lamp Coding objects Syringes with magnifiers Use of adaptive devices

Ineffective Tissue Perfusion: Renal

Interventions include: Control of blood glucose levels Yearly evaluation of kidney function Control of blood pressure levels Prompt treatment of UTIs Avoidance of nephrotoxic drugs Diet therapy Fluid and electrolyte management

Potential for Hypoglycemia Blood glucose level < 70 mg/dL Diet therapy: carbohydrate

replacement Drug therapy: glucagon, 50%

dextrose, diazoxide, octreotide Prevention strategies for:

Insulin excess Deficient food intake Exercise Alcohol

Potential for Hyperglycemic-Hyperosmolar Nonketotic Syndrome and Coma

Interventions include:MonitoringFluid therapy: to rehydrate the client and restore normal blood glucose levels within 36 to 72 hrContinuing therapy with IV regular insulin at 10 units/hr often needed to reduce blood glucose levels

Health Teaching Assessing learning needs Assessing physical, cognitive, and

emotional limitations Explaining survival skills Counseling Psychosocial preparation Home care management Health care resources

Diabetes MellitusSummary

Treatable, but not curable. Preventable in obesity, adult client. Diagnostic Tests Signs and symptoms of hypoglycemia and

hyperglycemia. Treatment of hypoglycemia and

hyperglycemia – diet and oral hypoglycemics. Nursing implications – monitoring, teaching

and assessing for complications.