Diabetes

Types of Diabetes

Type I

Type II

Latent Onset

Gestational Diabetes

Medication Induced Hyperglycemia or Secondary

Pathophysiology of diabetes

Need to review the pathophysiology

This high blood sugar produces the classical symptoms of polyuria (frequent urination), polydipsia (increased thirst) and polyphagia (increased hunger).

DKA

State of metabolic dysregulation characterized by the smell of acetone; a rapid, deep breathing known as Kussmaul breathing; nausea; vomiting and abdominal pain; and an altered state of consciousness.

Hyperosmolar Hyperglycemic NonKetonic

Complications: Infection, Renal, Vascular, Vision, Hypoglycemia, Peripheral Neuropathy may be on Elavil or Neurotonin for neuropathy

Check the oral area, can have Thrush/Candidiasis

Yeast infection treated commonly with Diflucan (Fluconazole)

Some diabetic patients may have cholesterol problems may be on Lipitor

Testing

Hemoglobin A1C

Fasting Glucose

2 Hour Post Prandial

Nursing Care Planning

Risk for infection

Ineffective Health Maintenance

Ineffective therapeutic regimen management

Risk for non-compliance

Imbalanced nutrition (more than body requirements)

Imbalanced fluid volume (fluid volume deficit)

Risk for peripheral neurovascular dysfunction

Acute pain

Knowledge deficit

Nursing Care Plan NANDA Nursing Diagnosis (problem statement)

Imbalanced nutrition r/t excessive intake of nutrients as evidenced by Type II Diabetes:

Nursing Care Plan Goal Statements:

1. Patient will acknowledge his or her behaviors / feelings that exacerbate imbalanced nutrition (excessive) within 8 hours. (this is a great example of a short term goal statement).

2. Patient will design a realistic dietary plan which will assist him / her with decreasing caloric intake, within 24 hours. (the key word in this statement is REALISTIC, to increase compliance).

3. Patient will incorporate at least 30 minutes of well tolerated exercise into daily schedule by the end of 48 hours. (another short term goal statement, a lifestyle change in the longterm).

Nursing Interventions for Imbalanced Nutrition (Excessive):

The Nurse shall explain and have patient verbalize the relationship of diabetes and diet, and the patient shall give a return explanation is his / her own words. (this nursing intervention will help clear up and misconceptions and reinforce the medical value of a healthy diabetic diet).

Patient will consult with a dietician to find out what an optimal caloric intake for her size, activity level and goal of weight loss is, so that she knows where to start in planning her dietary needs. (initial education and working knowledge).

Patient will keep a journal of total intake every time food is consumed and mark where improvement can be made. (accountability, ongoing education experience)

Patient will display (you choose how) a working knowledge of how to read a food label after nurse demonstrates (you choose method according to patient's best way of learning)

Promote family member or caregiver participating in the above mentioned 30 minute exercise program. (increases compliance through a support system, motivation).

The nurse shall have patient record an exercise log. (accountability)

The patient should have a list of goals and reward for those goals related to reducing overall caloric intake. (will increase compliance).

Comments: The most important fact to remember in dealing with type 2 diabetes is well thought out diet can completely negate the diabetic disease process. The Diabetic diet can be strict, but some "cheating" in moderate, planned ways are actually a GOOD idea. Human behavior dictates, and research has shown, a strict diet is rarely followed. With type 2 diabetes the diet is a lifetime diet and overall adherence to the diet is the overall goal. Lack of a regulated diet can easily lead to type 1 diabetes and more severe medical problems such as neuropathy, vision loss, and premature death related to diabetic complications.

The nurse should closely monitor the patient. Ongoing monitoring of blood glucose levels is crucial. Doing so would let the nurse know if the levels are too high or too low so that they can take the appropriate action depending on the levels. The vital signs should also be monitored closely. Is the patient’s blood pressure too high or low? Does the patient have a temperature? The answer to these questions will determine what course, if any, need to be taken for the well being of the patient. Skin and foot care test should be done to see if any breakdown of the skin and to assure that the feet are getting enough circulation. Monitoring the mental status of the patient is important too. The information that the caregiver gathers during their observation of the patient is important to the patient care.

Assist the patient to maintain their diet. Communicating with the patient is very important here. If the doctor has ordered a special diet, then the caregiver should

explain to the patient why it is important to maintain the special diet. The caregiver should also assure that the patient be directed to a dietitian.

Medications should be administered as prescribed. The medication may be prescribed by the doctor to be taken by injection or orally. Not all diabetics are insulin dependent diabetics. Sometimes other type of medication is prescribed to help maintain diabetes. The nursing care plan for diabetes should include carefully carrying out the doctor’s orders and charting all medications that are given.

Educate the patient in accordance with the doctor’s orders. A patient may need to be shown how to administer his or her own insulin shots. They also may need to be educated on the special skin and cueing needs of a diabetic. It also may be important to discuss an exercise routine if they physician feels that the patient needs this. The family and or caregivers may also need to be educated in these areas.

Continue to observe the patient for signs and symptoms. This is very important in the nursing care plan for diabetes. Signs to look for would be blurred vision, excessive thirst, slurred speech, frequent urination, mental alertness and is the patient lethargic. These are common symptoms to monitor in a diabetic patient. Changes in any of these areas could indicate that emergency measures may need to be taken. The caregiver needs to be alert to these signs and be prepared to treat the patient’s symptoms.

1.Monitoring in Special Circumstances

1. Blood Sugar at 3 am 1. Obtain prior to adjusting overnight Insulin 2. Obtain if morning Hyperglycemia

1. Hyperglycemia (Dawn Phenomena) 2. Nocturnal Hypoglycemia (Somogyi Phenomena)

2. Protocol: Basic Carbohydrate Counting 1. Each 15 gram serving of carbohydrate raises BG 50 mg/dl 2. Each meal has 3-4 carbohydrate servings (45-60 grams)

1. Weight loss needed 1. Women: 2-3 carbs/meal 2. Men: 3-4 carbs/meal

2. Weight maintenance (1500-2000 cals) 1. Women: 3-4 carbs/meal 2. Men: 4-5 carbs/meal

3. Very active 1. Women: 4-5 carbs/meal 2. Men: 4-6 carbs/meal

3. Examples of 15 gram carbohydrate servings 1. One slice bread (1 oz) 2. One half cup peas 3. One cup squash 4. One half-cup potato

4. Examples of foods with high carbohydrates counts 1. One 4 oz bagel is worth 4 carbohydrates (60 grams) 2. Low fat yogurt (8 oz), sweetened, fruit: 2-3 carbs 3. Bean burrito is worth 3 carbohydrates (45 grams)

5. Plate method (9 inch plate) 1. 50% of plate can be carbohydrates

1. Grains, beans and starches 2. Milk and yogurt

2. 25% of plate is composed of vegetables 3. 25% of plate is composed of meat, fish, eggs, cheese

3. Protocol: Carbohydrate Counting special topics 1. Fiber content

1. Subtract fiber carbohydrate grams if > 5 grams 2. Glycemic Index

1. Some value, but all carbohydrates raise blood sugar 2. Low Glycemic Index diets lower Hemoglobin A1C by 0.4%

3. Sugar Alcohols (poor absorption) 1. Fewer calories than sugar (2 calories per gram) 2. GI upset if more than 10 grams in food item 3. Subtract 1/2 sugar Alcohol grams 4. No Alcohol

4. Agents: Most effective 1. Obese patients

1. Thiazolidinedione s (e.g. Rosiglitazone) 2. Metformin (Glucophage)

2. Lean patients 1. Sulfonylurea or other secretagogue

5. Agents: Available 1. General

1. Lifestyle changes can lower A1C by 1-2% 2. Efficacy Example: Weight loss, diet and Exercise 3. Insulin is very cost effective (consider early)

1. Lowers HBA1C an unlimited amount 1. Can be used with oral medications

2. Insulin Secretagogue s (early Type II Diabetes) 1. Older agents (rarely used in United States)

1. Chromium Picolinate 2. First Generation Sulfonylurea (e.g. Tolbutamide)

2. Newer Agents 1. Second Generation Sulfonylurea (e.g. Glipizide)

1. Lowers HBA1C by 1.5% 2. Meglitinide s (e.g. Nateglinide, Repaglinide)

1. Lowers HBA1C by 1.5% 3. Insulin Resistance Agents

1. Biguanide s (e.g. Glucophage) 1. Decreases hepatic glucose release

2. Lowers HBA1C by 1.5% 2. Thiazolidinedione s (e.g. Rosiglitazone)

1. Increases muscle and fat Insulin sensitivity 2. May also independently reduce cardiovascular risk 3. Lowers HBA1C by up to 1.4%

3. Alpha-glucosidase Inhibitor s (e.g. Acarbose) 1. Decreases gastrointestinal carbohydrate absorption 2. Lowers HBA1C by 0.5 to 1%

4. Combination agents 1. Glucophage and Insulin secretogogue (e.g. Glucovance) 2. Thiazolidinedione s with Insulin secretogogue 3. Basal Insulin (e.g. Lantus) with Glucophage 4. Contrast Glucophage + Glitizone + Glipizide: 5. Insulin with Glucophage and Glitazone

6. Protocol: Sample Template for Prescribing Combination Oral Agents 1. General

1. Use a combination of agents (consider from onset) 2. Treat Insulin Resistance and Insulin shortage

2. Example of Oral Hypoglycemic regimen for obese patient 1. Initial Management: Decrease hepatic glucose release

1. Glucophage (Metformin) 2. Next Management: Insulin Secretion

1. Recent onset Type II Diabetes: Sulfonylurea 2. Prolonged Type II Diabetes: Consider Insulin

3. Next Management: Insulin Resistance 1. Thiazolidinedione s (e.g. Rosiglitazone) or 2. Alpha-glucosidase Inhibitor : (e.g. Acarbose)

3. Example of Oral Hypoglycemic regimen for lean patient 1. Initial Management: Insulin Secretion

1. Recent onset Type II Diabetes: Sulfonylurea 2. Prolonged Type II Diabetes: Consider Insulin

2. Next Management 1. Alpha-glucosidase Inhibitor : (e.g. Acarbose)

4. Examples based on timing of hyperglycemia 1. Pre-meal fasting hyperglycemia

1. Sulfonylurea (most effect is on pre-meal glucose) 2. Insulin Resistance agents

1. Glucophage (Metformin) 2. Thiazolidinedione s (e.g. Rosiglitazone)

2. Postprandial hyperglycemia (Insulin deficiency) 1. Meglitinide s (e.g. Repaglinide) 2. Alpha-glucosidase Inhibitor s

7. Adverse Effects: Oral Agents 1. Hypoglycemia

1. Associated with Diabetics on ACE Inhibitors 2. Higher risk with Captopril than Enalapril

3. Higher risk for Sulfonylureas 4. May account for 14% DM admissions for Hypoglycemia

2. Weight gain 1. Sulfonylurea s

3. Gastrointestinal side effects 1. Biguanide s (Glucophage) 2. Alpha-glucosidase Inhibitor s (Acarbose, Miglitol)

4. Lactic Acid osis 1. Biguanide s (Glucophage)

5. Liver toxicity 1. Thiazolidinedione s (e.g. Actos or Avandia*****concern about the use of

Avandia) 6. Edema (avoid in Congestive Heart Failure)

1. Thiazolidinedione s (e.g. Actos or Avandia) 8. See Also

1. Sitagliptin (Januvia) 2. Dipeptidyl Peptidase-4 Inhibitor (DPP-4 Inhibitor)

9. Indications 1. Type II Diabetes Mellitus 2. Insulin deficiency and Insulin Resistance

1. Adjunct to Glucophage, Sulfonylureas, Glitazones 10. Contraindications

1. Type I Diabetes Mellitus (no oral medications, will need insulin)2. Concurrent Insulin use 3. Renal Failure : Creatinine Clearance <30 ml/min

11. Mechanism 1. Synthetic form of exendin-4

1. Originally identified in Gila Monster Saliva 2. Peptide with 39 amino acids

2. Incretin Mimetic 1. Incretin analogue that mimics endogenous hormone 2. Incretin released from GI tract following meals

3. Incretin effects 1. Increases glucose dependent Insulin secretion 2. Delays gastric emptying 3. Decreases food intake (improves satiety)

12. Insulin Selection 1. New Insulin anologues are preferred

1. More consistent absorption than traditional Insulin 2. Bolus analogues have more rapid onset 3. Basal agents release at more constant rate 4. Only disadvantage is anologues double price

2. Combination agents are discouraged unless noncompliant 1. Reduces flexibility in meal and activity timing

13. Agents: Bolus Insulins (Meal-time Insulin) _Make sure that you review the peak, etc as listed in your textbook

1. Traditional Insulins 1. Regular Insulin (Novolin R, Humulin R)

1. Onset: 15 to 30 minutes 2. Peak: 2.5 to 5 hours 3. Duration: 6 to 8 hours

2. Analogue Insulins (Rapid, consistent absorption) 1. Glulisine (Apidra)

1. Onset: 5 to 15 minutes 2. Peak: 1 to 2 hours 3. Duration: 3 to 5 hours 4. Similar to other bolus analogues 5. FDA approved to take after meal

1. Other analogues expected with same effect 2. Lispro (Humalog)

1. Onset: 5 to 15 minutes 2. Peak: 1 to 2 hours 3. Duration: 3 to 5 hours

3. Aspart (Novolog) 1. Onset: 5 to 15 minutes 2. Peak: 1 to 2 hours 3. Duration: 3 to 5 hours

14. Agents: Basal Insulins 1. Traditional Insulins

1. NPH Insulin, Novolin N, Humulin N, Humulin L (Lente) 1. Onset: 1 to 2 hours 2. Peak: 6 to 8 hours

1. Peak time is higher risk of hypoglcemia 2. Consider snack at 6 hours after dose

3. Duration: 10 to 16 hours (Lente slightly longer) 4. Humulin L (Lente) discontinued in U.S. in 2006

2. Ultralente Insulin (extended Insulin zinc suspension) 1. Discontinued in U.S. in 2006 2. Significant inconsistent effect even in same person 3. Onset: 6-10 hours 4. Peak: No peak 5. Duration: 18 to 24 hours

2. Analogue Insulins 1. Detemir (Levemir)

1. Onset: 1 to 2 hours 2. Peak: No peak (flat action curve) 3. Duration: 12 to 20 hours (varies by dosage)

2. Glargine (Lantus) 1. Onset: 1 hour 2. Duration: 21 to 24 hours 3. Peak: No peak (flat action curve mimics continuous Insulin

Infusion)

15. Combination Agents (Type II Diabetes if poor compliance) 1. NPH 50/Regular 50 2. NPH 70/Regular 30 (Humulin 70/30 or Novolin 70/30) 3. NPL 75/Lispro 25 (Humalog Mix 75/25) 4. NPH 70/Aspart 30 (Novolog Mix 70/30)

16. Adverse Effects 1. Hypoglycemia

1. Increased risk when Hemoglobin A1C <7.4% 2. Decreased risk with analogue Insulins

2. Weight gain (Excess of 4 kg over 10 years) 1. Countered with Metformin in type 2 diabetics 2. Countered with diet and Exercise 3. Benefits of glucose control outweigh weight risks

3. Lipohypertrophy 1. Localized fat hypertrophy when sites not rotated 2. Prevent by rotating injection sites (see below) 3. Medical providers should examine injection sites

4. Variable Insulin absorption 1. Insulin absorption varies by body site

1. Abdomen (best absorption) 2. Arms 3. Thigh 4. Buttocks (least absorption)

2. Site rotation (prevents lipohypertrophy - see above) 1. Rotate injections within same body region

1. Avoids Insulin absorption variability 2. Rotate to widely different sites within region

1. Example: Abdomen rotate to LUQ, RUQ, LLQ, RLQ

Review Sliding Scale Procedures

Hypoglycemia Management

17. Review Glucagon and Dextrose Management. Also should be able to know difference in conscious patient versus unconscious patient.

18. Indications for Glucagon1. Hypoglycemia

19. Physiology 1. The brain needs glucose

20. Dosing 1. Dextrose 12.5% in water 2. Dextrose 25% in water

21. Precautions 1. Peripheral vein sclerosis

1. Occurs with concentrated Dextrose 2. Poor outcomes related to repeated glucose bolus in:

1. Severe Head Injury (poor neurologic outcome) 2. Submersion 3. Hypovolemic Shock

Best wishes to you as you prepare for the exam.

Feel free to send an email if not clear about what has been discussed.

Information from online resources and class discussion.