DIABETES MELLITUS

STATE UNIVERSITY OF NEW YORK AT STONY BROOK

1 YEAR NURSING PROGRAM

SUMMER 2008 HNI 364

The story of patient S.S.

Who is S.S.?: Case History

• White female, 5’ tall, 87 lbs.

• Active, thin 14 year-old

• General good health, occasional cold/flu

• Never been hospitalized

• Family history: maternal grandmother has hyperthyroidism

History of Present Illness (HPI)

• Late fall, Mrs. S. noticed that S.S. was pale and less active

• S.S. felt tired and began to avoid friends and activities (wanted to resign from cheerleading!)

• S.S. was constantly hungry, but still thin.• S.S. noticed she had to use the bathroom after

almost every class.• S.S. was irritable, had difficulty concentrating• Due to these symptoms, Mrs. S. took S.S. to

family physicians

S.S.’s current status

• S.S. has lost 7 lbs in last week, despite eating 5-6 meals /day.

• Skin is pale and dry• VS are within normal limits, but respirations and

ulse rates are higher than on previous physical exams.

• Voiding lg. amounts of urine q 1-2 hrs• Constantly hungry, thirsty, fatigued• Fasting glucose level = 396 mg/dl• Urine acetone +

S.S. is diagnosed with Type 1 diabetes and hospitalized to regulate her insulin!

Conclusions

• S.S. and her family demonstrated technical competence and understanding in:– Blood glucose monitoring– Urine testing– Diet activity– Sick day management– Reason for urine testing

S.S. released from hospital!!

Question 1A:

What was the most likely cause of S.S.’s polyuria and weight loss before

her hospitalization?

Diabetes Type 1 No insulin formed by pancreas

No uptake of glucose by body’s cells

Accumulation of glucose in bloodstream

(Hyperglycemia)

Increased solute concentration in blood due to excess glucose

H20 moves from highto low solute concentration:

from cells to intravascular space

Cell dehydration

Body excretes excess H20, glucose, and electrolytes in urine

Why did S.S. lose weight?

When your body cannot utilize

glucose for energy it will

begin to breakdown

adipose tissue or fat and use that

for energy, which explains the weight loss.

Question 1B:

What are normal blood glucose levels?

Normal blood glucose

• Normal blood glucose levels, before meals, should be less than 100 mg/l.

• Normal blood glucose levels, 2 hours after meals, should be less than 140 mg/l.

• Realistic target levels for people on medication is 70 – 140 before meals and less than 180 after meals.

Question 2:

Compare and contrast the signs and symptoms of diabetic

ketoacidosis and insulin shock. Explain why each occurs.

The DIFFERENCES between

ketoacidosis &

insulin shock

Lab tests

Ketoacidosis• High blood glucose

levels (> 250 mg/dL)• Accumulation of

ketones in urine and blood

Insulin shock• Low blood glucose

levels (< 45 mg/dL)

Symptoms

KetoacidosisExtreme thirstDehydrationDry mouth

Frequent urinationFatigue

Nausea/VomitingDifficulty breathing

Difficulty concentrating

Insulin shockConfusion

Difficulty concentratingIrritability

WeaknessTremorsAnxietyHunger

What’s the deal with ketoacidosis?

• When the body cannot use glucose for energy due to the lack of insulin, the glucose is converted into fat for energy.

• Excess fat is broken down by the liver and produces ketone bodies, which end up in the urine (ketouria).

• Polyuria further increases the concentration of ketone bodies in the urine.

• Breakdown of protein in the body also produces ketone bodies, contributing to ketoacidosis.

What causes insulin shock?

• Too much insulin in the blood due to overdose during an insulin shot.

• Since insulin is responsible for uptake of glucose into body’s cells, too much insulin results in too little blood glucose.

• Immediate intake of sugar will counteract insulin shock.

Similarities between ketoacidosis & insulin shock

• Both ketoacidosis and insulin shock are severe, emergency situations.

• If left unaddressed they can both lead to coma.

• The best way to prevent either one is to constantly monitor blood glucose levels.

Question 3: Why must insulin be injected? Discuss the various types of

insulin, their time of onset, peak of action and duration of action. Do persons with

Type II diabetes ever require insulin injections? If so, when and why?

Why must insulin be injected?

• Insulin is a protein made up of two peptide chains linked together by disulfide bonds.

• Proteins are broken down and digested by proteases (i.e. pepsin in the stomach & trypsin in the small intestines)

• If taken orally, insulin will therefore be broken down and deactivated, never reaching the blood stream

• Insulin must be injected SQ to provide a more direct route of entry into the blood stream

Types of Insulin

• Rapid (Quick-acting) -Insulin Lispro

• Short Acting -Regular (R)

• Intermediate-Acting -NPH (N) or Lente (L)

• Long-Acting -Ultralente (U)

• Pre-mixed

Rapid Insulin

• Onset: 5-15 minutes

• Peak of Action: 1 hour after injection

• Duration of Action: 3-4 hours

Short-Acting (Regular) Insulin

• Onset: 30-45 minutes

• Peak of Action: 2-3 hours after injection

• Duration of Action: 5-8 hours

Intermediate-Acting Insulin

• Onset: 2-4 hours

• Peak of Action: 4-10 hours after injection

• Duration of Action: 10-16 hours

Long-acting Insulin

• Onset: 6-10 hours

• Peak of Action: has a peak, but top speed looks like its normal speed

• Duration of Action: 20 + hours

Pre-mixed Insulin

• Onset: 30 minutes

• Duration: 16-24 hours

Figure 2. Onset of action, peak, and duration of action of exogenous insulin

preparations. (Neutral protamine Hagedorn = NPH)

Reprinted with permission from the American Diabetes Association's Clinical Education Program

"Insulin Therapy for the 21st Century."

Do persons with Type II Diabetes ever require insulin injections? If so, when &

why?

• Type II diabetes occurs when the body produces enough insulin, but the ability to process & use this insulin is lost (the body becomes resistant)

• Injections of insulin should mimic normal release patterns of the body

• Long-acting insulin is usually injected 1-2x a day

• In addition, short-acting or rapid-acting insulin is injected at mealtimes

Type II Diabetes Insulin Requirements

Question #4Goal for a nutrition program for children with Type 1 Diabetes

• Maintain blood glucose levels without causing excessive hypoglycemia

• When hypoglycemia occurs bring levels up to 80 mg/dl

• Foods low on glycemic index do not produce drastic changes in blood glucose levels; i.e. whole grains, oranges and peanuts

• DIET:

- > 50% calories from carbohydrates (1300 kcal/day)

- 10-15% calories from protein (260-390 kcal/day)

- 30-35% calories from fats (780-910 kcal/day)

Tips to help when eating out

• keep a count of calorie intake• eat slowly• eat same portions as you would at home• order foods that are not breaded or fried • choose healthy alternatives• carry diabetes kit with you.• if rapid acting insulin is taken, try to delay

injection until meal is served• talk to doctor about how to adjust insulin

regimen when eating out

#5A How do you prepare the injection?

Why?

•NPH (intermediate-acting) and regular (shortacting) are commonly mixed to produce differently-timed pharmacologic actions with a

single injection.•The regular insulin is prepared first to prevent it from becoming contaminated with the intermediate-acting insulin (NPH).

Steps To Preparing Injection

•Check the patient's name, medication, dosage, route and time of administration.

•Carefully verify insulin labels. •Roll the NPH vial between hands to resuspend the insulin preparation. •If vial did not have cap on top, wipe off with an alcohol swab.

•Verify dosage a second time.

Steps To Preparing Injection (Cont.)

• Take insulin syringe and aspirate volume of air equivalent to the dose of insulin to be withdrawn from the intermediate-acting (NPH) insulin first.

• DO NOT LET THE TIP OF NEEDLE TOUCH THE INSULIN.

• Remove syringe from vial without aspirating the insulin. 

•With the same syringe inject air equal to the dose of insulin to be withdrawn from the short-acting (regular) insulin.

Steps To Preparing Injection (Cont.)

• Withdraw the correct dose into the syringe (10 units of regular). Verify again that the correct dose has been withdrawn.

 • Place the needle of the syringe back into the NPH vial and

withdraw the correct dose (10 units). Verify that the correct dose has been withdrawn.

 • The total amount of insulin in the syringe should be the sum of

the two types (20 units).

• Because short acting insulin was mixed withintermediate-acting insulin, which reduces the action of the faster-acting insulin, administerthe mixture within 5 minutes of preparation.

What Type of Syringe would you use?

• A 50 or 100 unit Insulin syringe would be used• Insulin is measured in units (check the insulin bottle)

* syringe measuring cc's or mL's cannot be used*

Since the total amount to be given is 20 units, a low dose 50 unit syringe is appropriate, but a 100 unit syringe may also be used.

What sites could you use for the injection?

• Insulin should be administered subcutaneously

• There are 4 main sites:abdomen, posterior arms, anterior and lateral thighs and posterior hips

• The insulin is absorbed faster in the abdomen and the rate of absorption decreases in the arms, thighs and hips

Education

• Teach the patient what treatments are used, how the treatments work and how to administer the drugs

• The patient should be aware of the effects of continuously injecting into the same site

• They should know that it is important to rotate the injection site

• They shouldn’t inject into a limb that is to be exercised because it will be absorbed faster and may result in hypoglycemia.

Question #5: Lipodystrophy and What are some of the long term complications of diabetes and

why do they occur?

Researchers: J Strasheim & M. Valerio

Ppt. Preparer: Stefany Cimino

Presenter: Nancy Yang

Lipodystrophy: Localized Disturbance of Fat Metabolism Below Skin Surface

Causes: Not Rotating Insulin Injection Sites

2 Forms:

1. Lipoatrophy

2. Lipohypertrophy

Lipoatrophy: Loss of Subcutaneous Fat Under the Skin Surface Resulting in

Small Dents

• Appears as Slight Dimpling

• Appears as Pitting (more serious)

Lip hypertrophy: Buildup of Fat

Below the Skin Surface Causing lumps

• Appears as Fibro-Fatty Masses.

• Absorption is Delayed at these Sites.

• Avoid these Sites Until Hypertrophy Disappears.

Question 5d:

• What are Some of the Long Term Complications of Diabetes and Why Do They Occur?

Diabetes: Long Term Complications

• Affects the Metabolism of Every Cell in the Body

• Adversely Affects the Body’s Blood Supply

• Can Lead to Life-Threatening and Disabling Complications Over Time

• Therapeutic Management can Prevent or Delay the Onset of Various Complications

3 General Categories of Long Term Diabetes Complications

1. Macrovascular Disease

2. Microvascular Disease

3. Neuropathy

Macrovascular Disease

• Atherosclerotic Changes in Larger Blood Vessels

• Diabetics are more Prone to Develop than non-diabetics, but No clear-cut explanation Why

• There is No Direct Link Between Hyperglycemia and Artherosclerosis

• Diabetes is Seen as an Independent Risk Factor

Macrovascular Examples

1. Coronary Artery Disease (CAD)

2. Peripheral Vascular Disease (PVD)

Coronary Artery Disease

• Artherosclerotic Changes in Coronary Arteries

• Leads to MI and an Increased Chance of a 2nd MI

Peripheral Vascular Disease

• Atherosclerotic Changes in Large Blood Vessels of Lower Extremities

• Decreased Peripheral Pulses

• Intermittent Claudication

• Increased Chance of Gangrene, Amputation

Microvascular Disease

• Changes Unique to Diabetics

• Characterized by Capillary Basement Membrane Thickening

• Increased Blood Glucose Levels React through a Series of Biochemical Responses to Thicken the Basement Membrane

Microvascular Examples

1. Diabetic Retinopathy

2. Neuropathy

Diabetic Retinopathy

• Changes in Small Blood Vessels in Retina

Neuropathy: Conditions Affecting the Nerves

1. Renal Disease

2. Foot and Leg Problems

Renal Disease

• Diabetics comprise 25% of the patients with End-Stage Renal Disease (ESRD) requiring dialysis or transplantation

• Diabetics have a 20-40% chance of developing Renal Disease

• Type I Diabetics show signs after 15-20 years

• Type II Diabetics show signs within 10 years of diagnosis

Renal Disease: After Onset

• The Kidney’s filtration mechanism is stressed, allowing blood proteins to leak into urine

• Kidney Blood Vessel Pressure Increases-thought to serve as the stimulus for development of Nephropathy

• As Renal failure progresses, catabolism of insulin decreases, and frequent hypoglycemic episodes result, requiring a change in insulin

DIABETIC NEPHROPATHY

Foot and Leg Problems

• 50-75% of all Lower Extremity Amputations are performed on Diabetics

• Increased risk of foot infections

Three Contributing Factors

1. Neuropathy

2. PVD

3. Immunocompromised Status

Neuropathy

• Loss of pain and pressure sensation, increased dryness and fissuring due to decreased sweating

PVD

• Poor Circulation in lower extremities, causes poor wound healing and increased risk of gangrene

Immunocompromised Status

• Hyperglycemia Impairs the ability of specialized Leukocytes to destroy bacteria

• Decreased Resistance to Infections

Prevention

• Daily Foot Checks

What will you teach Ms. S.S. regarding the

following situations she may encounter ?

Question #6A.

Physical education classes

and

cheerleading practice

Physical education classes and

cheerleading practice

Exercise is an important part of any diabetes treatment plan.

Exercise can actually increase your body’s insulin sensitivity, which means your body requires less insulin to guide sugar into your cells.

Before and after physical education/ cheerleading practice:

– Check glucose levels

You're good to go. For most people, this is a safe pre-exercise

blood sugar range.– Eat a healthy meal– Hydrate yourself

100-200 mg /dL

Bring snacks and enough water or Gatorade-type drinks to physical

education or cheerleading

If blood sugars are low try:

½ cup of juice or

few pieces of candy

If you feel lightheaded or dizzy at any time

– Take a break– Eat and drink

something to bring up glucose levels

Always take breaks to hopefully avoid feeling lightheaded, dehydrated or

dizzy

Check glucose levels after

if planning on exercising long

30 minutes

Wear cotton socks

Wear appropriate footwear(i.e. no flip flops or sandals)

– You need support and cushion

– Check feet daily, especially plantar surface (bottom of foot)

What will you teach Ms. S.S. regarding the

following situations she may encounter:

Question 6B.

Illness e.g. colds and the flu, episodes of diarrhea and

vomiting?

Diabetes management:

Creating your

sick-day plan

Diabetes management can be especially challenging when you're struggling with a cold or other illness.

Proper planning can help you prevent complications.

You don't feel well. Your temperature is high, you're tired and

you've lost your appetite.

Having diabetes only adds to your

concerns.

When you're sick, your body produces hormones to help fight the illness.

These hormones raise your blood sugar by preventing insulin from working effectively.

In people without diabetes, the additional sugar promotes healing.

But when you have diabetes, the fluctuations can result in potentially serious diabetes complications.

To prevent complications,

make a sick-day plan

part of your diabetes

management.

Start with your health care teamTalk to your doctor and other members of your diabetes care team

about your sick-day plan. Make sure your sick-day plan includes:

What medications to take How often to measure your blood sugar and urine

ketones How to adjust your insulin dosage, if you need insulin How to manage any other conditions you may have When to call your doctor

Also identify a loved one or friend who can contact your doctor or help you seek emergency care if you experience diabetes complications.

Keep close track of your blood sugar and urine ketone levels:

Continue taking your diabetes medication when you're sick, and remember to test your blood sugar often. You may need to adjust your insulin doses or other medications. Here are some general guidelines:

Type 1 diabetes. Check your blood sugar and urine ketone levels every four hours.

Excessively high blood sugar can lead to ketoacidosis, especially in people who have type 1 diabetes.  e conditions can be fatal.

Excessively high blood sugar can lead to ketoacidosis,

especially in people who have type 1 diabetes.  

These conditions can be fatal.

Stick to your diabetes meal plan

With a minor illness such as a cold, you may be able to stick to your diabetes meal plan — which will help ensure blood sugar stability. Remember to

check the sugar content of any over-the-counter medications you take.

Many cough syrups and other liquid cold preparations are high in sugar.

If you have nausea, vomiting or diarrhea, you may not be able to eat your regular foods. But it's still

important to get enough carbohydrates. Try these foods, which contain about 10 to 15 grams of

carbohydrates each:1 double-stick frozen fruit pop

1 cup milk 1/2 cup fruit juice 1/2 cup regular (not diet) soda 6 saltine crackers 3 graham crackers 1 slice dry toast 1/2 cup regular (not artificially sweetened) gelatin

In addition to sipping fruit juice or sweetened beverages, drink at least 8 ounces of water or other calorie-free liquid every hour you're awake.

If you're not able to keep anything down, it's especially important to monitor your blood sugar closely.

Know when to contact your doctor

Diabetes complications can quickly become dangerous. Contact your doctor if:

Your blood sugar level is higher than 300 mg/dL Your blood sugar level is higher than 240 mg/dL for more than 24

hours Your urine ketone level is moderate to high You feel sleepier than usual or can't think clearly You're unable to keep fluids down or vomit for more than six hours You have diarrhea for more than six hours You feel confused and can't think clearly Your lips and tongue appear dry and cracked

Think prevention

High blood sugar can weaken your immune system. This makes you more likely to get a cold or the flu — and more vulnerable to serious effects of common illnesses. To reduce the risk of getting sick, wash your hands often and avoid crowds during flu season.

Think prevention

Ask your doctor about

vaccination for flu

and pneumococcal

pneumonia.

If you do get sick,

feel confident in your ability

to manage your diabetes by following

your sick-day plan.

Infections

Respiratory Infections

People with diabetes face a higher risk for influenza and its complications, including pneumonia, possibly because

the disorder neutralizes the effects of protective proteins on the surface of the lungs. In fact, deaths among people with diabetes increase by 5 - 15% during flu epidemics, and they are six times more likely to be hospitalized with

complications from flu than non-diabetic patients who have flu. Everyone with diabetes should have annual

influenza vaccinations and a vaccination against pneumococcal pneumonia.

Infections

Urinary Tract Infections

Women with diabetes face a significantly higher risk for urinary

tract infections, which are likely to be more complicated and difficult to treat

than in the general population.

#6C Glycosylated Hemoglobin testing

Introduction

• Hemoglobin on red blood cells combine with blood glucose to make glycosylated hemoglobin

• Red blood cells store glycosylated hemoglobin slowly over their 120-day life span

What is it?

• A laboratory test also known as the Hemoglobin A1C

• Analyzes the concentration of glycosylated hemoglobin within the body’s circulation

• Determines blood glucose levels

• High blood glucose levels – Result in red blood cells storing large

amounts of glycosylated hemoglobin

• Normal or near normal blood glucose levels– Result in normal or near normal amounts of

glycosylated hemoglobin

Why is it important?

• High Glycosylated Hemoglobin puts you at risk for:– eye disease – kidney disease – nerve damage – heart disease and stroke

*especially true if the glycosylated hemoglobin remains high for a long period

How is the glycosylated hemoglobin test used?

• Diagnostic tool used by doctors for diabetic patients since 1976

• Offers a good estimate of disease management over a 2 to 3 month period, in contrast to other tests that give a onetime snapshot

• Used in the routine monitoring of patients with diabetes mellitus

• How well patient is responding to treatment – Low test values reduce risk for having

complications from diabetes mellitus

How is the test performed?

• Venipuncture

• Some may feel moderate pain, or only a prick or stinging sensation.

• Afterward, there may be some throbbing

Examples of glycosylated hemoglobin

• A glycosylated hemoglobin level of 7% is considered to be good

» 6% Very Good» 8% Not too bad» 10% Not good» 13% Dangerous

Benefits S.S. will derive from having the test done

• safely monitor her blood glucose levels

• newly diagnosed pt’s may have to monitor levels closely over several 2-3 week periods

Disadvantages to using this test

• Results require interpretation by a physician with knowledge of person’s clinical condition

• False high or low may result – Some medical conditions such as

splenectomies falsely increase levels

Any Questions?

References

• Potter, P.A., & Perry, A.G. (2009). Fundamentals of Nursing (7th edition). St. Louis, MO: Mosby, INC.

• Smeltzer, S.C & Bare, B.G. (1996). Medical-Surgical Nursing (8th edition). Philadelphia, PA: Lippincott-Raven Publishers.

• McCance, Huether et al. Pathophysiology. 4th Edition.• Abraham , E.C., Schwartz, M.K., (1985) Glycosylated Hemoglobins –

Mehtods of Anmalysis and Clinical Applications..• http://www.fda.gov/diabetes/glucose.html• http://www.endocrinologist.com• http://healthlibrary.epnet.com• http://www.healthatoz.com• http://www.labtestsonline.org/understanding/analytes/a1c/test.html• http://www.nlm.nih.gov/medlineplus/ency/article/003640.htm• http://www.mdconsult.com/• http://mayoclinic.com/

Question

Intorduction

.PPT Creator

Sharon Jaffin

Presenter

Renee Brown

1: Alexis Galetta

Kim Barressi

2:Nicole Cariello

Cynthia McCreight

Sharon Jaffin Linda Rampil

3: Ron Casella

Natalie De Roche

4:Amar Singh

Christina DeRosa

Christina Barbuto

Emily Gerbert

Bridget Erwin

Jennifer Dixon

5: Jamie Strasheim

Marisol Valerio

1st ½ of Q#5

Christine Abrams

Kevin Budway

5: Jamie Strasheim

Marisol Valerio

2nd ½ of Q#5

Stef Cimino

Nancy Yang

6: Katrina Stephano

Karen Broomes-James

Melinda Torey

Q6 A&B

Ari Vigborn

Stefanie Florio

6: Katrina Stephano

Karen Broomes-James

Melinda Torey

Q #6 & Finalization of .PPT

Marissa Gonzalez

Renee Brown

Game

Alex Nee

Marissa Lutzer

Ashley Taylor

Rose Massana