Diabetes Nursing Care

Nursing Care: Diabetes Mellitus

Diabetes

Normal Pathophysiology Need to consider how insulin works insulin continuously released: during “fasting

periods”, the pancreas continuously releases a small amount of insulin along with glucagon. Together a constant level of glucose in the blood is maintained by stimulating the release of glucose from the liver.

Diabetes

In diabetes the body’s ability to respond to insulin may

decrease the pancreas may stop producing insulin. This

in turn leads to hyperglycemia leads to other acute metabolic complications

Diabetes is a heterogeneous group of diseases involving disruption of metabolism of carbohydrates, fats, and protein.

Diabetes

What population of patients would be at risk for developing diabetes?

Classification of diabetes mellitus Type I

• may occur at any age• usually thin• abrupt onset• family history?

Diabetes

Classification Type II

• >age 30

• often obese

• few classic symptoms

• insulin resistant Impaired glucose tolerance

• plasma glucose levels higher than normal, but not diagnostic for diabetes 2 hr plasma glucose >140 mg/dl & < 200 mg/dl

Diabetes

Classification Impaired fasting glucose

• fasting plasma glucose > 110 mg/dl & < 126 mg/dl Gestational diabetes

• has onset or discovery of glucose tolerance during pregnancy

Diabetes

Clinical Manifestations Insulin deficiency or decreased insulin activity glucose not used

properly osmotic effect on intracellular and interstitial fluid results in frequent urination (polyuria), and thirst (polydipsia) without insulin the patient may experience hunger (polyphagia)

• the body will turn to other energy sources besides glucose: first fat and then protein

Diabetes

Diagnostic studies diabetes is a multisystem, multiproblem

disease, all laboratory studies must be examined with assessment findings

normal blood glucose range: 70-110 mg/dl urine tests not sufficient for a dx of diabetes fasting blood glucose of > 126 mg/dl glycosylated hemolobin

Diabetes

Nutritional therapy Goals of nutritional therapy

• maintenance of as near-normal blood glucose levels

• achievement of optimal serum lipid levels

• provision of adequate calories for maintaining or attaining reasonable weights, normal growth & development rates

• prevention and treatment of acute complications

• improvement of overall health through optimal nutrition

Diabetes

Nutritional therapy Type I

• based on patient’s usual food intake with insulin therapy

• eat at consistent times, synchronized with the action of their insulin

• monitor blood glucose levels and adjust as needed

Diabetes

Nutritional therapy Type II

• achieving glucose, lipid, and blood pressure goals

• weight loss is desirable

• regular exercise

• monitor blood glucose level

Nutritional therapy

Food composition calorie distribution glycemic index simple sugars and complex carbohydrates

Areas of concern alcohol dietetic foods

Diabetes

Drug therapy 4 types of insulin; things to consider

• how soon the insulin starts working (onset)

• when it works the hardest (peak time)

• how long it lasts in your body (duration) The nurse may find that different sources list different

numbers of hours for onset, peak, duration of action of the main types of insulin, and the patient’s reactions may vary. The nurse should focus on which meals and snacks are being covered by which insulin dose.

Insulin

Rapid-acting insulin: onset: 15 minutes after injection peak: 30-90 minutes later duration: may last as long as 5 hours

Short-acting: onset: 30 minutes after injection peak:2 to 4 hours duration: 4 to 8 hours

Insulin

Intermediate-acting onset: 2 to 6 hours peak: 4 to 14 hours duration: 14 to 20 hours

Long-acting onset: 6 to 14 hours peak: 10 to 16 hours duration: 20 to 24 hours

Insulin

StrengthAdditivesStorage and safetyAdministrationInsulin therapyInsulin delivery

Insulin and Oral Agents

Problems with insulin therapy allergic reactions lipodystrophy Somogyi effect and dawn phenomenon

Oral medicationsOther drugs affecting blood glucose levelsThings to consider…

exercise, self-monitoring

Nursing Management: Diabetes

Assessment: Subjective data

• past health information

• family history

• medications

• surgery and other treatments Health-perception-health management

• + family history, malaise


Nutritional-metabolic weight thirst and hunger Nausea and vomiting poor healing compliance with diet

Elimination constipation or diarrhea frequent urination, incontinence, nocturia skin infections


Activity-exercise muscle weakness, fatigue

cognitive-perceptual abdominal pain, headache, blurred vision,

numbness or tingling of extremities, pruritis

Sexuality-reproductive impotence, frequent vaginal infections,

decreased libido


Coping-stress depression apathy irritability

Value-belief commitment to lifestyle changes involving diet,

medication, and activity patterns


Objective data eyes integumentary respiratory cardiovascular gastrointestinal neurologic musculoskeletal diagnostic findings


Insulin therapy assessment of patient’s use of and response to

insulin therapy education of the patient regarding

administration, adjustment to, and side effects of insulin

The “new” diabetic Stress of acute illness and surgery


Oral agents nursing responsibilities similar to those taking

insulin

Personal hygiene dental skin care

Medical identification and travelFollow-up nursing management

Intermission

Complications of Diabetes

Diabetic Ketoacidosis Etiology

• undiagnosed diabetes

• inadequate treatment of existing diabetes

• insulin not taken as prescribed

• change in diet, insulin, or exercise regimen


Diabetic Ketoacidosis Assessment

• dry mouth, thirst, abdominal pain, N & V, confusion, lethargy, flushed dry skin, eyes appear sunken, breath odor of ketones, rapid, weak pulse, labored breathing, fever, urinary frequency, serum glucose > 300 mg/dl, glucosuria and ketonuria


Diabetic Ketoacidosis Nursing interventions

• initial– ensure patent airway

– O2

– establish IV access and begin fluid resuscitation

– begin continuous IV insulin

– identify history of diabetes, time of last food, and time/amount of last insulin injection


Diabetic Ketoacidosis Nursing interventions

• ongoing monitoring– monitor VS, LOC, cardiac rhythm, O2 saturation, and

urine output

– assess breath sounds

– monitor serum glucose and serum potassium

– anticipate possible administration of sodium bicarb with severe acidosis (pH < 7.0)


Hyperglycemic Hyperosmolar Nonketosis occurs in a patient who has some insulin to

prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion

usually is a history of inadequate fluid intake, increasing mental depression and polyuria

HHNK constitutes a medical emergency


Hyperglycemic Hyperosmolar Nonketosis nursing management

• administration of a rapid-acting insulin

• administration of IV fluid

• assessment of mental status

• I & O

• assessment of blood glucose levels

• assessment of blood and urine for ketones

• electrocardiogram monitoring


Hypoglycemia clinical manifestations

• blood glucose <50 mg/dl

• cold, clammy skin

• numbness of fingers , toes, mouth

• emotional changes, HA, nervousness, seizures, coma, faintness, dizziness

• changes in vision

• hunger

• unsteady gait, slurred speech


Hypoglycemia causes

• alcohol intake with food

• too little food - delayed, omitted, inadequate intake

• diabetic medication or food taken at wrong time

• loss of weight with change of medication

• use of B-blockers


Hypoglycemia nursing management

• immediate ingestion of 5-20 g of simple carbohydrates

• ingestion of another 5-20 g of simple carbohydrates in 15 min if no relief obtained

• contact physician if no relief obtained

• collaborate with physician

• prevention is the key


Hyperglycemia clinical manifestations

• elevated blood sugar

• increase urination

• increase in appetite followed by lack of appetite

• weakness, fatigue

• blurred vision, HA

• nausea and vomiting, abdominal cramps

• glycosuria

• progression to DKA or HHNK


Hyperglycemia causes

• too much food

• too little or no diabetes medication

• inactivity

• emotional, physical stress

• poor absorption of insulin


Hyperglycemia nursing management

• notify physician

• continuance of diabetes medication as ordered

• frequent checking of blood and urine specimens and recording of results

• prevention is key

Chronic Complications

MacroangiopathyMicroangiopathyPeripheral Vascular DiseaseDiabetic RetinopathyNephropathyNeuropathySkin changes

Question

A diabetic patient has a serum glucose level of 824 m/dl and is sleepy and unresponsive. Following assessment of the patient the nurse suspects DKA rather than HHNK based on the finding of

a) polyuria b) severe dehydration c) rapid, deep respirations d) decreased serum potassium

Diabetes Nursing Care

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