Care Conference Diabetes
-
Upload
cikbungazafieya-zawani -
Category
Healthcare
-
view
37 -
download
0
Transcript of Care Conference Diabetes
PATIENT BIODATA• Mr G• M/47• Businessman• ∆ DM, IHD, hyperlipidemia, HPT• Admission – 27/9/16 @ 2305HRS• Consultant – Dr M
PATIENT BIODATA
• Med History – HPT, DM, IHD (2008) & peripheral vascular disease (2010)
• Surg History – Angioplasty (2008), peripheral angiogram (2010)
• Family History – DM, HPT (mother)• Allergic – Unknown• Mode of Admission – Trolley
ASSESSMENT
• VITAL SIGN : Temperature – 37.4˚C Heart Rate – 98 bpm Respiration – 22 bpm Pain Score - 2/10 DM - 12.7 mmol/L Weight – 67 kg
ACTIVITY DAILY LIVING
• C/O extreme fatigue, giddiness and loss of appetite X 1/12 and SOB X 1/7.
• Conscious, anxious.
• Chest tightness & cough with whitish phlegm
• Heavy smoker 10 years ago
ACTIVITIES DAILY LIVING
• Frequent urination
• Insomnia
• Ambulate with assistant
• Side rail
PHYSICAL EXAMINATION
• Dry skin• Dry and flaky skin at both lower legs and
foots• IV branula 18G at left hand• Oxygen 2L nasal prong in progress
17KS, Trop T, CE, CKMB ECG CT Brain ECHO CXR (PA) TDS glucometer
S/B Dr M at casualty at 2215Hrs :
PANCREAS HORMONES :
• INSULIN BY BETA CELLS
• GLUCAGON BY ALPHA CELLS
Insulin PRODUCTION
Pancreas produce insulin according to the blood
glucose level
• Pancreas secretes 40-50 units of insulin daily in two steps:– Secreted at low levels during
fasting ( basal insulin secretion)– Increased levels after eating
(prandial)– An early burst of insulin occurs
within 10 minutes of eating– Then proceeds with increasing
release as long as hyperglycemia is present
Insulin • Insulin allows glucose to move into
cells to make energy• Inhibits glucagon activity
Diabetes mellitus (DM) is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin production, insulin action, or both.
The term diabetes mellitus describes a metabolic disorder of multiple aetiology characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both.
The effects of diabetes mellitus include long–term damage, dysfunction and failure of various organs.
What is diabetes?
Diabetes
• Diabetes describes a group of metabolic diseases in which the person has high blood glucose (blood sugar), either because insulin production is inadequate, or because the body's cells do not respond properly to insulin, or both.
• Type 1 Diabetes Mellitus • Type 2 Diabetes Mellitus• Gestational Diabetes
TYPES OF DIABETES
Types1.Type I
formerly known as Insulin – Dependent Diabetes Mellitus (IDDM)Autoimmune (Islet cell antibodies)•Early introduction of cow’s milk and cereals•Intake of medicine during pregnancy •Indoor smoking of family members
destruction of beta cells of the pancreas little or no insulin productionrequires daily insulin admin. may occur at any age, usually appears below age 15
• Type 1 Diabetes:Type 1 diabetes is usually diagnosed in children and young adults. Only 10% of people with diabetes have this form of the disease.
• In type 1 diabetes, the body does not produce insulin.
• Patients with type 1 diabetes will need to take insulin injections for the rest of their life. They must also ensure proper blood-glucose levels by carrying out regular blood tests and following a special diet.
2. Type II formerly known as Non Insulin–Dependent
Diabetes Mellitus (NIDDM) probably caused by:
disturbance in insulin reception in the cells number of insulin receptors loss of beta cell responsiveness to glucose
leading to slow or insulin release by the pancreas
occurs over age 40 but can occur in children common in overweight or obese w/ some circulating insulin present, often do
not require insulin
• Type 2 diabetes:• The body does not produce enough insulin for
proper function, or the cells in the body do not react to insulin.
Approximately 90% of all cases of diabetes worldwide are of this type.
• Overweight and obese people have a much higher risk of developing type 2 diabetes compared to those with a healthy body weight.
• The risk of developing type 2 diabetes is also greater as we get older.
• Men whose testosterone levels are low have also been found to have a higher risk of developing type 2 diabetes.
Gestational Diabetes This type affects females during pregnancy. The majority of gestational diabetes patients can
control their diabetes with exercise and diet. Undiagnosed or uncontrolled gestational diabetes can raise the risk of complications during childbirth. The baby may be bigger than he/she should be.
What causes diabetes?
• Diabetes causes vary depending on your genetic makeup, family history, ethnicity, health and environmental factors.
• There is no defined diabetes cause because the causes of diabetes vary depending on the individual and the type.
Who are at risk? ?
Risk Factors• Obesity • Race • History of CVD• HPT • Physical inactivity• Familial history • Polycystic Ovary Syndrome• Gestational Diabetes
? ? ? ? ? ? ?
What happens if there is a problem with the production of insulin?
• Glucose in blood is not able to go into the cells.
• The cells can’t meet energy needs and energy is tried to be provided from ‘fat’ and protein’.
• Using ‘fat’ as the energy source results the increasing of keton in the body.
Physiology
The symptoms of diabetes
• With the usage of protein as energy source,the patient feels themselves tired and sluggish.
• If blood glucose is to high,It is tried to be thrown away by kidneys so the patients begin to urinate so often.
• As a result, the patients feel thirsty and start to drink a lot.
• On the other hand,despite eating so often and a lot,the patients lose weight.
Fasting Plasma Glucose
Oral Glucose Tolerance Test (OGTT)
Glycoselated Hemoglobin (HbA1c)
• HbA1c is a test that measures the amount of glycated hemoglobin in your blood. Glycated hemoglobin is a substance in red blood cells that is formed when blood sugar (glucose) attaches to hemoglobin.
(HbA1c)
Glycoselated Hemoglobin (HbA1c)
Immediate past month
50%
2nd month 25%3rd month 15%4th month 10%
Urinalysis
• Glycosuria • Ketone bodies
Diagnostic Criteria • Classic signs of HYPERGLYSEMIA with CPG ≥200mg/dL• OGTT ≥200mg/dL• FPG ≥126mg/dL• A1C ≥ 6.5%
• CKMB- 45 (< 25 U/L)• ESR- 20 (0-15 mm/hr)• White blood cell count- 20.2 (4.3 – 10.5 10³/uL)• Neutrophil- 87.3% (40-75%)• Lymphocyte- 5.3% (20-45%• Glucose- 13.9 (3.9 – 6.1mmol/L)
17KS, Trop T, CE, CKMB
• Glucose- 13.9 (3.9 – 6.1mmol/L)• Creatinine- 134 (51 – 124umol/L)• Urea- 6.9 (2.0 – 6.8umol/L)• Sodium- 131 (135 – 155mmol/L)
17KS, Trop T, CE, CKMB
• Total cholesterol- 7.2mmol/L (<5.2)• Triglycerides- 2.04mmol/L (<1.71)• HDL cholesterol- 1.05mmol/L (>1.42)• LDL cholesterol- 5.2mmol/L (<2.6)• Chol/HDL Chol- 6.8 (up to 4.0)
17KS, Trop T, CE, CKMB
• Protein, urine- ++ (Negative)
• Glucose, urine- Trace (Negative)
• Bacteria, urine- Occasional (Nil)
Urine FEME
• Normal
CXR (PA)
• Old infarct of right occipital region.
CT BRAIN
• Old ant/apical MI
ECG
• LV apical deterioration• Moderate LVAD
ECHO
• The major components of the treatment of diabetes are:
Management of DM
Diet is a basic part of management in every case. Treatment cannot be effective unless adequate attention is given to ensuring appropriate nutrition.
Dietary treatment should aim at:◦ ensuring weight control◦ providing nutritional requirements◦ allowing good glycaemic control with blood glucose
levels as close to normal as possible◦ correcting any associated blood lipid abnormalities
Diet
Physical activity promotes weight reduction and improves insulin sensitivity, thus lowering blood glucose levels.
Together with dietary treatment, a programme of regular physical activity and exercise should be considered for each person. Such a programme must be tailored to the individual’s health status and fitness.
People should, however, be educated about the potential risk of hypoglycaemia and how to avoid it.
Exercise
• There are currently four classes of oral anti-diabetic agents:
i. Biguanidesii. Insulin Secretagogues – Sulphonylureasiii. Insulin Secretagogues – Non-sulphonylureasiv. α-glucosidase inhibitorsv. Thiazolidinediones (TZDs)
Oral Anti-Diabetic Agents
Oral Antidiabetic Agents
ORAL HYPOGLYCAEMIC MEDICATIONS
Short-term use:Acute illness, surgery, stress and emergencies Pregnancy Breast-feedingInsulin may be used as initial therapy in type 2 diabetes in marked hyperglycaemia Severe metabolic decompensation (diabetic
ketoacidosis, hyperosmolar nonketotic coma, lactic acidosis, severe hypertriglyceridaemia)
C. Insulin Therapy
Long-term use:If targets have not been reached after optimal
dose of combination therapy, consider change to multi-dose insulin therapy. When initiating this,insulin secretagogues should be stopped and insulin sensitisers e.g. Metformin or TZDs, can be continued.
C. Insulin Therapy
The majority of patients will require more than one daily injection if good glycaemic control is to be achieved. However, a once-daily injection of an intermediate acting preparation may be effectively used in some patients.
Twice-daily mixtures of short- and intermediate-acting insulin is a commonly used regimen.
In some cases, a mixture of short- and intermediate-acting insulin may be given in the morning. Further doses of short-acting insulin are given before lunch and the evening meal and an evening dose of intermediate-acting insulin is given at bedtime.
Other regimens based on the same principles may be used.
A regimen of multiple injections of short-acting insulin before the main meals, with an appropriate dose of an intermediate-acting insulin given at bedtime, may be used, particularly when strict glycaemic control is mandatory.
Insulin regimens
Overview of Insulin and Action
Insulin Insulin injection injection
sites sites
Factors that influence the body’s need for insulin
11 need : trauma, infection, fever, severe psychological or physical stress, other illnesses
2. need : active exercise
DRUGS DATE ORDERED
IV Nootropil 1gm TDS 27/9/16
Janumet (50/500) 1/1 BD 27/9/16
Diamicron MR 1/1 BD 27/9/16
IV Cefrex 1gm STAT & BD 27/9/16
Brilinta 11/11 STAT & 1/1 BD 27/9/16
Vasteral MR 1/1 BD 27/9/16
Vytorin (10/20) 1/1 ON 27/9/16
Tanakan 1/1 TDS 27/9/16
Bioquinol 1/1 TDS 27/9/16
Diabetes Management
Algorithm
• Hypoglycemia low blood glucose (usually
below 60mg/dl) results from too much insulin,
not enough food, and/or excessive physical activity
may occur 1-3 hrs after regular insulin injection
Management of Hypoglycemia
1.Give simple sugar orally if pt. is conscious and can swallow – orange juice, candy, glucose tablets, lump of sugar2.Give Glucagon (SQ or IM) if pt. is unconscious or cannot take sugar by mouth3.As soon as pt. regains consciousness, he should be given carbohydrate by mouth4.If pt. does not respond to the above measures, he is given 50 ml of 50% glucose I.V. or 1000 ml of 5%-10% glucose in water I.V.
Preventing Hypoglycemic Reactions Due to Insulin
Instruct the pt. as follows:1.Hypoglycemia may be prevented by maintaining regular exercise, diet and insulin2.Early symptoms of hypoglycemia should by recognized and treated3.Carry at all times some form of simple carbohydrate (orange juice, sugar, candy)4.Extra food should be taken before unusual physical activity or prolonged periods of exercise5.Between-meal and bedtime snacks may be necessary to maintain a normal glucose level.
CHRONIC COMPLICATIONS OF DM• Degenerative changes in the vascular
system– Undernourishment– Atherosclerosis
• Neuropathy from:– Vascular insufficiency–Hyperglycemia
• Eye complications from anoxia– Cataract–Diabetic retinopathy– Retinal detachment
• Nephropathy– Damage & obliteration of capillaries
supplying the kidney• Heart disease–Mi from atherosclerosis
• Skin changes– DIABETIC DERMOPATHY –
HYPERPIGMENTED & SCALY PRETIBIAL AREAS (acanthosis nigricans)
• Liver changes– Enlargement & fatty infiltration
CHRONIC COMPLICATIONS OF DM
SOME COMPLİCATİONS LİNKED TO BADLY CONTROLLED DİABETES:
Eye complications - glaucoma, cataracts, diabetic retinopathy, and some others.
Foot complications - neuropathy, and sometimes gangrene which may require that the foot be amputated
Heart problems - heart disease when the blood supply to the heart muscle is diminished
Hypertension - common in people with diabetes, which can raise the risk of kidney disease, eye problems, heart attack and stroke
Mental health - uncontrolled diabetes raises the risk of suffering from depression, anxiety and some other mental disorders
• Hearing loss - diabetes patients have a higher risk of developing hearing problems
• Gastroparesis - the muscles of the stomach stop working properly• Stroke - if blood pressure, cholesterol levels, and blood glucose
levels are not controlled, the risk of stroke increases significantly
D.K.A.PATHOPHYSIOLOGY
NO INSULIN
MARKED HYPERGLYCEMIA
GLUCOSURIA
WEIGHT LOSS
OSMOTICDIURESIS
POLYURIA
CELLULAR HUNGER
POLYPHAGIA
POLYDIPSIA
LIPOLYSIS
OSMOTICDEHYDRATION
D.K.A.S/SX:• S/SX OF DM +• KETONURIA• METABOLIC ACIDOSIS• KUSSMAUL’S RESPIRATION• ACETONE BREATH• DHN• FLUSHED FACE• TACHYCARDIA• CIRCULATORY COLLAPSE COMA DEATH
D.K.A.
MANAGEMENT:
• ADEQUATE VENTILATION• FLUID REPLACEMENT• INSULIN – RAPID ACTING• ECG
GENERAL STRATEGY• Assessment• Analysis• Planning and
Implementation/Intervention• Evaluation and Ongoing monitoring• Documentation
ASSESSMENT• Primary and secondary
assessment• Focused assessment –Subjective data collection–Objective data collection
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
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.
Risk for Impaired Skin Integrity
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–Analgesics –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
Health Teaching
• Assessing learning needs• Assessing physical, cognitive, and
emotional limitations• Explaining survival skills• Counseling• Psychosocial preparation• Home care management• Health care resources
Patients should be educated to practice self-care. This allows the patient to assume responsibility and control of his / her own diabetes management. Self-care should include:
◦ Blood glucose monitoring◦ Body weight monitoring◦ Foot-care◦ Personal hygiene◦ Healthy lifestyle/diet or physical activity◦ Identify targets for control◦ Stopping smoking
Self-Care