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PEDIA

DIABETES MELLITUS

Type I DM(Insulin Dependent DM)

-partial/complete lack of secretory capacity of thebeta cells of pancreas,insulin deficiency

Normal bld glucose:70-110 mg/dL

Assessment:1.3 Ps,enuresis(more common in type I DM)

2.Wt. loss

3.vaginitis(candida)4.dehydration

5.hypo/hyperkalemia-complication

Diet:

-3 meals/day

-Midafternoon CHO snack-Bedtime CHON snack

Exercise:

-dietary adjustment when exercising-extra food for activity(10-15 g CHO every 30-45

mins of activity)

-monitor bd glucose before exercising

Insulin:

-Diluted insulin for infants to provide small enoughdoses to avoid hypoglycemia.

-Glycosylated Hgb-tests every 3 mos

-should not withheld during stress-hyperglycemiaand ketoacidosis result-Glucagon-IM/SQ if unable to consume P.O.

Bld glucose monitoring:-more accurate than urine testing

-finger prick

Urine testing:

-tests ketones and glucose

-2nd voided urine is most accurate

ACUTE COMPLICATION:

1.Hypoglycemia

-too much insulin-too much oral hypoglycemic agent

-not enough food

-excessive activityIntervention:

-complex CHO and CHON(slice of bread or peanut

butter cracker)

-extra snack,if next meal not planned for >30 mins

or activity is planned.-if become UNCONCIOUS:

>squeeze cake frosting or glucose paste onto the

gums and retest bld glucose level>if does not improve w/in 15-20 mins and if reading

remains low,administer additional sugar:

Carbonated beverage

3-4 hard candies2 or 3 glucose tabs

Life savers

1 tsp honey>if child remains unconscious,administer

GLUCAGON>Hosp setting:dextrose IV.

2.HyperglycemiaNotify physician if child unable to take food or

fluids.Sick day rules:

-always give insulin even if child does not have anappetite

-test bld glucose level at least q 4 hrs.

-test for urinary ketones w/ each voiding-calorie-free liquids to aid in clearing ketones

-rest esp. if ketones are present

3.Diabetic Ketoacidosis

-life-threatening condition

-metabolic acidosis-bld glucose level:>300 mg/dlInterventions:

-correct dehydration:IV 0.9% or 45% saline

-correct hyperglycemia:IV Reg insulin-monitor potassium:potassium replacement

-IV dextrose added when bld glucose reaches

appropriate level.

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ADULT

DIABETES MELLITUS

-chronic disorder of impaired CHO,CHON,and

lipid(fat) metab.caused by deficiency of insulin.

TYPE I:Insulin-dependent diabetes mellitus

-nearly absolute deficiency of insulin

-if insulin not given,fatsmetabolized,=ketonemia(acidosis)

TYPE II:Non-insulin dependent DM-lack of insulin or resistance to action of insulin

-insulin sufficient to stabilize fat and CHON metab

but not to deal with CHO metab.

Microvascular complications:

retinopathy,nephropathy,neuropathy

Assessment:1.3 Ps(more common in type I DM)

2.wt.loss(common in type I DM)3.vaginal infxns

Diet:-food exchange from American Diabetic

Association

-dietary guidelines for Americans(Food GuidePyramid)issued by US Dept. of Agri and Health and

Human Services

Exercise:- blood glucose level

-dietary adjustments when exercising

-monitor bld glucose before exercising-Initially,15 g CHO snack(a fruit exchange) or

complex CHO + CHON before engaging in

moderate exercise to prevent hypoglycemia-if bld glucose >250 mg/dL + urinary ketones(type I

DM)-not to exercise until bld glucose is closer to

normal and urinary ketones are absent

Oral hypoglycemic meds:

-prescribed for DM II

-Type II DM-insulin may be needed duringstress,surgery,or infxn

Insulin:-for Type I DM

-also for Type II DM when diet and weight control

therapy have failed

REGULAR INSULIN-only insulin can be

administered IV in emergency tx of DKA.

-illness,infxn,stress need for insulin and not be

withheld because hypoglycemia and ketoacidosiscan result

Complication of insulin therapy:

1.Local allergic reactions-avoid alcohol to cleanse skin before injxn.

2.Insulin lipodystrophyLipoatrophy-use of HUMAN INSULIN helps to

prevent this complication.

Lipohypertrophy-caused by repeated use of an injxnsite.

3.Insulin resistance-develops immune antibodies that bind

insulin,decreasing insulinTx:Purer Insulin Preparation

4. Dawn Phenomenon

-reduced tissue sensitivity to insulin b/w 5 & 8

AM(prebreakfast hyperglycemia occurs)Tx:evening dose of INTERMEDIATE-ACTING

INSULIN at 10 PM.

5.Somogyi Phenomenon

-normal or elevated bld glucose present at

BEDTIME-hypoglycemia 2-3 AM-hyperglycemic 7 AM

Tx:

a.decreasing evening(predinner or bedtime)dose ofINTERMEDIATE OR LONG ACTING INSULIN

b.increasing BEDTIME SNACK

6.Insulin Waning

-progressive rise in bld glucose level from

BEDTIME to MORNING

Tx:a.increasing evening(predinner or bedtime)dose of

INTERMEDIATE OR LONG ACTING INSULIN

b.instituting dose of INSULIN before evening mealif one is not already prescribed.

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Insulin Pumps

-externally worn device contains syringe attached tolong,thin,narrow-lumen tube w/ needle or Teflon

catheter attached to end.

-inserts needle or Teflon catheter into SQ(abdomen)-worn on a belt or in a pocket

-needle/Teflon catheter changed every 3 days

-delivers bolus of REGULAR INSULIN before

each meal.

Pancreas transplants

-performed on a limited number of clients(mostlyclients receiving kidney transplantations

simultaneously)

-immunosuppressive therapy to treat rejection.

Bld glucose monitoring:

-more accurate than urine testing-finger prick

-caution with diabetic retinopathy and neuropathy

Urine testing:-tests ketones and glucose

-2nd voided urine is most accurate

Urine ketone testing:

-should be performed during illness

-whenever TYPE I DM has glycosuria and with bldglucose level of >240 mg d/L for 2 consecutive

periods.

ACUTE COMPLICATIONS OF DM:1.Hypoglycemia

-too much insulin

-too much oral hypoglycemic agent-not enough food

-excessive activity

*High-fat foods slow absorption of glucose andhypoglycemic symptoms may not resolve quickly.

a.Mild hypoglycemia-10 to 15 g FAST-ACTING SIMPLE CHO:

Glucose tablet

6-10 life savers or hard candy4 tsp sugar

4 sugar cubes

1 tbs honey/syrup cup fruit juice/regular (nondiet softdrink)

6 saltine crackers

3 graham crackers>retest bld glucose in 15 mins.

b.Moderate-15-30 g FAST-ACTING SIMPLE CHO

>low-fat milk or cheese after 10-15 mins.

c.Severe-

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-K level fall rapidly w/in 1st hr of tx as dehydrationand acidosis are treated

-K administered IV in diluted solution(when Kreaches normal to prevent hypokalemia)

Guidelines during illness:

-test bld glucose,test urine for ketones every 3-4 hrs

-if usual meal plan cannot be followed,substitute soft

foods 6-8 x per day-vomiting/diarrhea/fever:consume liquids every to 1

hr. to prevent dehydration and to provide calories.

3.HYPERGLYCEMIC HYPEROSMOLAR

NONKETOTIC SYNDROME(HHNS)

-extreme hyperglycemia w/o ketosis and acidosis-occurs most often with TYPE II DM

Assessment:-bld glucose 600-1200 mg/dL

-low BP,low HR-dehydration

-seizures

Interventions:-Tx similar to DKA

-Insulin plays less critical role in tx of HHNS becauseinsulin is not needed for reversal of acidosis in HHNS.

CHRONIC COMPLICATIONS OF DM

1.Retinopathya.Photocoagulation(laser therapy):removes

hemorrhagic tissue to scarring.

b.Vitrectomy:removes vitreous hemorrhages thus tension on retina,preventing detachmentc.Cataract removal w/ lens implant

2.Nephropathy

-microalbuminuriaInterventions:

-restrict CHON,Na,K-prepare for dialysis

-prepare for kidney transplant

-prepare for pancreas transplant

3. Neuropathy-erectile dysfunction/impotence-loss sensation in CN III,IV,V,VI

-dyspareunia r/t yeast infxnInterventions:

-dont treat corns,blisters, ingrown toenails

-dont wear same pair of shoes 2 days in a row

-estrogen-containing lubricants for female

OPERATIVE CAREPreop care:

-Long-acting oral antidiabetic meds are d/c 24-48 hrs.before surgery.

-Insulin may be adjusted/withheld if IV insulinadministration during surgery is planned.

Postop care:

-IV glucose and Reg.insulin infusion until client cantolerate oral feedings

-supplemental short-acting insulin-monitor bld glucose if client receiving TPN.

MEDICATIONS FOR DIABETES MELLITUS

A.INSULIN

-prescribed for clients with Type I DM- glucose transport into cells and promotes

conversion of glucose to glycogen, serum glucose

levels.

-primarily acts in the liver,muscle,and adiposetissue by attaching to receptors on cellular

membranes and facilitating passage of

glucose,K,and Mg.

Storing insulin:

-avoid exposing insulin to extremes in temp.-shoud not be frozen or kept in direct sunlight.

-before injxn,should be at room temp.

-if vial of insulin will be used up in a month,may bekept at room temp;otherwise,vial should be

refrigerated.

Insulin injxn site:a.abdomen-may absorb more evenly and rapidly

than the other sites.

b.arms(posterior surface)c.thighs(anterior surface)

d.hips

-systematic rotation w/in 1 anatomical area isrecommended to prevent lipodystrophy

-dont use same site more than once in a 2-3 wk

period.

-injxns should be 1.5 inches apart within theanatomical area.

-heat,massage,&exercise of injected area can

absorption rates and may result in hypoglycemia.

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Administering insulin:

Usual concentration:U 100(100 units/mL)-most insulin syringes have 27-29 gauge needle,0.5

inch long.

-before use,roll bottle to ensure ingredients aremixed.

-dont shake may cause bubbles.

-premixed insulin:Humulin 70/30-most commonly

used.-mixtures of insulin in prefilled syringes should be

kept in the refrigerator,stable for 1 wk.

-prefilled syringes should be kept flat or with needlein upright position to avoid clogging of needle.

-inject air into the insulin bottle(vacuum makes it

difficult to draw up the insulin)-when mixing,Regular(short-acting)insulin first.

-Regular insulin may be mixed with any other type

of insulin.-Insulin zinc suspension only mixed with each other

and regular insulin.-administer mixed dose of insulin w/in 5-15 mins of

prep,after this time regular insulin binds with NPHand action is reduced.

-aspiration is not recommended with self-injxn.

-administer at 45-90 degree/45-60 degree in thinpersons.

Remember:Regualr insulin is the only type of

insulin that can be administered IV.

B.ORAL HYPOGLYCEMIC MEDICATIONS

-Prescribed for Type 2 DM-stimulate pancreas to produce more insulin- sensitivity of peripheral receptors to insulin

- hepatic glucose output or delay intestinal

absorption of glucose ,thus serum glucose levels.

1.Sulfonylureas

-stimulate beta cells to produce more insulin-can affect cardiac function and 02

consumption=cardiac dysrhythmias.

Side effects:GI sx & dermatological rxns

Ex:a.Chlorpropamide(Diabenese)-can cause

disulfiram(Antabuse) type of rxn wen alcohol is

ingested.b.Tolbutamide(Orinase)

2.Nonsulfonylureas-affect hepatic & GI production of glucose

-used alone or with sulfonylurea

Ex:

Acarbose(Precose)Metformin(Glucophage)

Rosiglitazone(Avandia)

Contraindications and concerns:

*Hypoglycemic meds+-adrenergic blocking

agents=masks s/sx of hypoglycemia

Meds that cause of hypoglycemia:

Anticoagulants

ChloramphenicolSalicylates

Propranolol(Inderal)

MAOIPantamidine(pentam 300)

Sulfonamides

Meds that cause hyperglycemia:

CorticosteroidsThiazide diuretics

Phenytoin(Dilantin)Throid preps

Oral contraceptives

Estrogen compounds

C.GLUCAGON

-hormone secreted by alpha cells of the islets ofLangerhans in pancreas

- bld glucose by stimulating glycogenolysis in

liver.-by SQ,IM,IV-used to treat insulin-induced hypoglycemia when

client is semiconscious or unconscious and unable

to ingest liquids.-bld glucose level begins to w/in 5-20 mins after

admin.

D.DIAZOXIDE(Proglycem)

- bld glucose by inhibiting insulin release from

beta cells and stimulating release of epinephrine

from adrenal medulla-used to treat chronic hypoglycemia caused by

hyperinsulinism resulting from islet cell cancer or

hyperplasia.-not used for hypoglycemic rxns from insulin.

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GLUCOSE STUDIES

1.Fasting Blood Glucose

>70-110 mg/dL

Int:-fast for 8-12 hrs before the test

-DM patient:withhold morning insulin or oral hypoglycemic med.

2.Glucose tolerance test>70-110 mg/dL

-if glucose levels peak at higher than normal at 1 and 2 hrs after injxn or ingestion of glucose,and slower than

normal to return to fasting level,DM is confirmed.Int:

-eat high-CHO(200-300g)diet for 3 days before test

-fast for 10-16 hrs before the test-avoid strenuous exercise for 8 hrs before and after test.

-DM patient:withhold morning insulin or oral hypoglycemic med

-test takes 3-5 hrs-IV or oral admin of glucose,and multiple bld samples

3.Glycosylated hemoglobin

Hemoglobin A1c-reflection of how well bld glucose levels have been controlled for up to the prior 4 mos.-fasting not required before the test.

>good control:7.5% or less

4.Glucose,2hr postprandial

Value: