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Assessment and Management of PT W DM
Assessment and Management of PT W DM
Diabetes Mellitus
A group of metabolic disease characterized by increased levels of glucose in
the blood resulting from defects in insulin secretion, insulin action or both
Classification
Type 1 diabetes
Type 2 diabetes
Gestational diabetes
Diabetes mellitus associated w/ other conditions or syndromes
Different types of DM may vary in :
o
o
o
Cause
Clinical course
Treatment
Pathophysiology
Insulin
form of glycogen
Signals the liver to stop the release of glucose
Enhances storage of dietary fat in adipose tissue
Accelerates transport of amino acids w/c derived from
dietary protein into cells
Glucagon
Glycogenolysis
Gluconeogenesis
Type 1 diabetes
5 % to 10 % of all diabetes
Previously classified as :
o
Juvenile diabetes
o
Juvenile-onset diabetes
o
Ketosis-prone diabetes
o
Brittle diabetes
o
Insulin-dependent diabetes mellitus (IDDM)
Onset any age, but usually young (<30 y)
Characterized by destruction of pancreatic beta cells
Possible contributors to beta cell destruction :
o
Genetic
o
Immunologic
o
Environmental (eg. viral)
Genetic susceptibility is a common underlying factor
People do not inherit type 1 itself but rather a genetic predisposition toward
development of type 1
The genetic tendency has been found in people w/ certain human leukocyte
antigen (HLA) types
There is also evidence of autoimmune response in w/c antibodies are
directed against normal tissues of the body
Destruction of beta cells results in :
o
Decreased insulin production
o
Unchecked glucose production by the liver
o
Fasting hyperglycemia
Glucose derived from food cannot be stored in the liver but instead remains
in the bloodstream and contributes to postprandial (after meals)
hyperglycemia
If the high risk women do not have GDM at initial screening , they should
retested bet. 24 and 28 weeks of gestation
All women of average risk should be tested at 24 to 28 weeks of gestation
Women considered to be at high or average risk should have either an oral
glucose tolerance test (OGTT) or a glucose challenge test (GCT)
Initial management include dietary modification and blood glucose monitoring
Goals for blood glucose levels during pregnancy :
o
105 mg/dL or less before meals
o
130 mg/dL or less 2 hr after meals
After delivery , blood glucose usually return to normal , however many
develop type 2 later in life
Prevention
Type 2 diabetes
90 % to 95 % of all diabetes
Previously classified as :
o
Adult-onset diabetes
o
Maturity-onset diabetes
o
Ketosis-resistant diabetes
o
Stable diabetes
o
Non-insulin dependent diabetes (NIDDM)
Onset any age, usually over 30 y & obese
2 main problems are insulin resistance (decreased tissue sensitivity) and
impaired insulin secretion
Increased amount of insulin must be secreted to maintain normal glucose
level
DKA does not typically occur
Gestational diabetes
Any degree of glucose intolerance
Secretion of placental hormones causes insulin resistance
High risk :
o
Obese
o
Personal history of GDM
o
Glycosuria
o
Strong family history of diabetes
High risk ethnic groups :
o
Hispanic Americans
o
Native Americans
o
Asian Americans
o
African Americans
o
Pacific Islanders
Clinical Manifestations
Depend on the pts level of hyperglycemia
Classic clinical manifestations of all types of DM include 3 Ps :
o
Polyuria (increased urination)
o
Polydipsia (increased thirst) as a result of excess loss of fluid
o
Medical Management
200 mg/dL
. Casual is defined as any time of the day without regard to time since
last meal
Fasting plasma glucose 126 mg/dL . Fasting is defined as no caloric intake
for at least 8 hours
Two-hour postload glucose
stored
Altered insulin secretion
Increase in fat tissue w/c increases insulin resistance
neuropathic complications
Intensive glucose control / therapy :
o
3 or 4 insulin injections per day
o
Continuous SQ insulin infusion
o
Insulin pump therapy
o
Frequent blood glucose monitoring
o
Weekly contact c the diabetes educators
5 components of DM management
I. Nutritional Therapy
Foundations of DM management :
o
Nutrition
o
Meal planning
o
Weight control
Most important objective in dietary and nutritional management of DM :
o
Control of total caloric intake to attain or maintain a reasonable
body weight
o
Control of blood glucose levels
o
Normalization of lipids and BP to prevent heart disease
A registered dietitian has the major responsibility for designing and
teaching therapeutic plan
For obese pt c diabetes , weight loss is the key treatment
Overweight is considered to be a BMI of 25 to 29
Obesity is defined as 20 % above ideal body weight or BMI
30
First step in preparing a meal plan is a thorough review of the pts diet
maintenance
In most instances, people c type II DM require weight reduction
Initial education addresses :
o
Importance of consistent eating habits
o
Relationship of food and insulin
o
Provision of an individualized meal plan
Caloric Requirements
o
Constipation if fluid intake is inadequate
If fiber is added in the meal plan , it should be done gradually and in
consultation c dietitian
weight
To promote a 1 to 2 pound weight loss per week, 500 to 1000 calories
are subtracted from the daily total
The calories are distributed into CHO, CHON, and fats and a meal plan
Soluble
is then developed
The priority for a young pt c type I DM should be a diet c enough
insoluble fiber
Slows stomach emptying and movement of food through upper digestive
tract
glucose control
Caloric Distribution
grains)
20 % to 30 % from fats
10 % to 20 % from CHON
Insoluble
glucose levels
Foods high in CHO such as sucrose (concentrated sweets) are not
CHON
Use of some non animal sources of protein to help reduce saturated fat
Fiber
Exchange Lists
Nutrition Labels
Several systems have been developed in w/c foods are organized into
groups c common characteristics such as :
o Number of calories
o Composition of foods (amount of CHO, CHON, fats in the food)
o Effect on blood glucose levels
CHO
hypoglycemia
Other problems may include :
o
Abdominal fullness
o
Nausea
o
Diarrhea
o
Increased flatulence
Fats, oils, and sweets should be used sparingly to obtain weight and
foods
Glycemic Index
Used to describe how much a given food increases the blood glucose
response
Eating foods that are raw and whole results in a lower glycemic
absorbed
Pt can create their own glycemic index by monitoring their blood
glucose level after ingestion of a particular food
diabetes
Alcohol is absorbed before other nutrients and does not require insulin
for absorption
Large amounts can be converted to fats increasing the risk for DKA
Moderation is recommended
May lead to :
o
Excessive weight gain (from the high caloric content of alcohol)
o
Hyperlipidemia
o
Elevated glucose levels
Lower calorie or less sweet drinks and food intake along c alcohol
consumption are advised
Hypoglycemia
Sweeteners
Nutritive sweeteners
Contain calories
Include fructiose , sorbitol, and xylitol , all of w/c provide calories in
Nonnutritive sweeteners
II. Exercise
Extremely important in DM management because of its effects :
o
Lowers blood glucose levels by increasing the uptake of glucose by
o
o
metabolic rate
Alters blood lipid concentrations, increasing HDL and decreasing
encouraged
Must be altered as necessary for pt c diabetic complications
Avoiding trauma to lower extremities is esp. important in pt c numbness
r/t neuropathy
Increased BP associated c exercise may aggravate diabetic retinopathy
encouraged
For pt older than 30 y/o and who have 2 or more risks factors for
heart disease , an exercise stress test is recommended
Exercise Precautions
Pt who have blood glucose levels exceeding 250 mg/dL and who have
ketones in their urine should not begin exercising until the urine test
results are negative for ketones and blood glucose level is closer to
normal
Exercising c elevated blood glucose level increases the secretion of
glucagon, GH, and catecholamines . Liver then releases more glucose
Gerontologic considerations
o
Decrease in hyperglycemia
o
General sense of well being
o
Better use of ingested calories resulting in weight reduction
Because there is an increased incidence of cardiovascular problems, a
detect patterns
To evaluate the need for dosage adjustments :
o
Testing is done at the peak action time of the medication
To evaluate basal insulin and determine bolus insulin doses :
o
Testing is done before meals
To determine bolus doses of regular or rapid acting insulin :
o
Testing is done 2 h after meals
Pt c type II DM :
o
Encouraged to test daily before and 2 h after the largest meal
ketone levels
Laboratory methods measure plasma glucose
o
Plasma glucose values are 10 % to 15 % higher than whole blood
glucose values
It is important for pt c DM to know whether their monitor and
Pt are asked to keep a record of blood glucose levels so that they can
reagent strip and allowing the blood to stay on the strip for
o
o
techniques
Some common causes of error in SMBG :
o
Improper application of blood (e.g drop too small)
o
Damage to the reagent strips caused by heat or humidity
o
Use of outdated strips
o
Improper meter cleaning and maintenance
Nurses play an important role in providing initial teaching about SMBG
techniques
Q 6 to 12 mos. Pt should conduct a comparison of their meter result c a
Also referred to as :
o
Glycosylated hemoglobin
o
HgbA1C
o
A1C
Blood test that reflects ave. blood glucose levels over a period of app.
2 to 3 mos.
When blood glucose levels are elevated, glucose molecules attach to
hemoglobin in RBC
The hemoglobin-glucose binding is permanent and lasts for the life of
antidiabetic agents
Motivate pt to continue c treatment
c type II DM , SMBG is recommended :
During periods of suspected hyperglycemia or hypoglycemia
When the medication or dosage of medication is modified
Preparations
present
Other strips are available for measuring both urine glucose and
insulin
Appear white and cloudy
If taken alone, it is not crucial that it be taken 30 min. before
the meal
It is important that pt eat some food around the time of the
action
Basal insulin is necessary to maintain blood glucose levels
irrespective of meals
Nurse should emphasize w/c meals are being covered by w/c insulin
doses :
o
Rapid acting and short acting insulins are expected to cover the
increase in glucose levels after meals , immediately after
o
injection
Intermediate acting insulin are expected to cover subsequent
meals
Long acting insulin provide a relatively constant level of insulin
and act as a basal insulin
Species (source)
In the past , all insulins were obtained from beef (cow) and pork (pig)
pancreases
Human insulins are now widely available
Human insulins are preferable to animal source because they are not
Insulin Therapy
acting insulin
There are 2 gen. approaches to insulin therapy : conventional and
intensive
Pt can learn to use SMBG results and CHO counting to vary insulin
doses
Complex insulin regimens require a strong level of commitment ,
Insulin Lipodystrophy
regimen to use
There are not set guidelines as to w/c insulin regimen should be used
for w/c pt
Conventional regimen
Lipoatrophy
Loss of SQ fat
Appears as a slight dimpling or more serious pitting of SQ fat
Use of human insulin has almost eliminated this disfiguring complication
Lipohypertrophy
production in humans
Very few resistant pt develop high levels of antibodies , many of these
and illness
3 to 4 injections of insulin per day
It is found out that Risk of severe hypoglycemia was increased in pt
longer
Treatment consists of administering a more concentrated insulin
regimen
Intensive regimen
Dawn phenomenon
Complications of Insulin Therapy
Local Allergic Reactions
Relatively normal blood glucose level until app 3 am when the level
begins to rise
Result from nocturnal surges in GH secretion w/c create a greater
administration
Usually occur during the beginning stages of therapy and disappear c
Insulin waning
Rare
Somogyi effect
Jet injectors
counterregulatory hormones
Nocturnal hypoglycemia followed by rebound hyperglycemia
first used
Pt should be cautioned that absorption rates, peak insulin activity, and
Insulin pumps
2.0 units/h)
When a meal is consumed , pt calculates a dose of insulin to metabolize
the meal by counting the total amount of CHO for the meal using a
predetermined insulin-to-CHO ratio ( eg. 1 unit of insulin for q 15 g
Possible disadvantages
Unexpected disruptions in the flow of insulin from the pump that may
Insulin pens
Use small (150-to 300unit ) prefilled insulin cartridges that are loaded
administered
People still need to insert the needle for each injection but do not need
or travelling
Also useful for pt c impaired manual dexterity , vision or cognitive
function w/c makes use of traditional syringes difficult
o
o
o
o
phenylalanine derivatives )
o
Thiazolidinediones (glitazones)
o
Dipeptide-peptidase-4 (DPP-4) inhibitors
Sulfonylureas and meglitinides are considered insulin secretagogues
because their action increases the secretion of insulin by the
Secondary failure
App. half of all pt who initially use oral antidiabetic agents eventually
require insulin
Primary failure
mealtimes
Used c insulin , not in place of insulin
Hypoglycemia is an associated risk
Must be injected in the abdomen or thigh because of variable
Exenatide (Byetta)
or sulfonylureas
Derived from a hormone that is produced in the small intestine and has
of the hormone
Hypoglycemia is not a side effect if adjustments are made in the
sulfonylurea dose
Has been shown to result in weight loss because of the increased
satiety produced
Must be injected 2 x a day within 1 h before breakfast and dinner
Not a substitute for insulin in pt who require insulin to control their
DM
inch long
The 1-mL syringes are marked in 1 and 2 unit increments
A small disposable insulin needle 31 gauge , 8 mm long is available for very
insulin
So as not to inject one type of insulin into the bottle containing a
(Lilly)
Combinations w/ a ratio of 75 % NPL (neutral protamine lispro) and 25%
insulin lispro are also available
o
NPL is used only in the mix w/ Humalog
o
NPL action is same as NPH
Prefilled syringes
Nursing Management
V. Education
Storing Insulin
Should
Should
Should
Should
be refrigerated
not be allowed to freeze
not be kept in direct sunlight or in a hot car
be kept at room temperature to reduce local irritation at the
For pt who can inject insulin but who have difficult drawing up a single or
mixed dose
May be done with the help of home care nurses or family and friends
A 3-week supply of insulin syringes may be prepared and kept in ref
Should be stored w/ the needle in an upright position to avoid clogging of
the needle
Should be mixed thoroughly before the insulin is injected
Withdrawing Insulin
rolling it bet. the hands before drawing the solution into a syringe or pen
Bottles of intermediate-acting insulin should also be inspected for
flocculation ,
o
There is a frosted, whitish coating inside the bottle
o
Occurs most commonly w/ human insulins that are exposed to
o
extremes of temp.
If present, some of the insulin is bound and it should not be used
Selecting syringes
Inject air into the bottle of insulin equivalent to the number of units of
Use all available injection sites within one area rather than
randomly rotating sites from area to area (e.g pt may exclusively
use the abdominal area , administering each injection 0.5 to 1 inch
legs)
Few general principles to all rotation patterns :
o
Pt should not try to use the same site more than once in 2 to 3
o
weeks
If pt is planning to exercise, insulin should not be injected into the
limb that will be exercised because this will cause drug to be
o
o
Technique is based on the need for the insulin to be injected into the SQ
tissue
Injection that is too deep or too shallow may affect the rate of absorption
of insulin
A 90 degree angle is the best insertion angle for a normal or overweight
person
Some pt may be taught to insert needle at 45 degree angle
Aspiration is generally not recommended
oTremor
oNervousness
oTachycardia
oHunger
Moderate hypoglycemia
Inability to concentrate
Confusion
Emotional changes
Headache
Memory lapses
Irrational or combative behavior
Lightheadedness
Numbness of lips and tongue
Double vision
Slurred speech
Impaired coordination
Drowsiness
o
o
o
o
o
o
o
o
o
o
o
o
Severe hypoglycemia
Disoriented behavior
Seizures
Difficulty arousing from sleep
Loss of consciousness
o
o
o
o
I. Gerontologic considerations
of hypoglycemia
With decreasing renal function , it takes longer for oral
financial limitations
Decreased visual acuity may lead to errors in insulin
administration
Usually occurs in some pt who have had diabetes for many years
May be r/t autonomic neuropathy
May Contribute to lack of symptoms of hypoglycemia
As the blood glucose level falls, the normal surge in adrenalin
does not occur , and usual adrenergic symptoms do not take place
The hypoglycemia may not be detected until moderate or severe
CNS impairment occurs
IV. Management
Treating w/ CHO
Mild hypoglycemia
SNS is stimulated resulting in a surge of epinephrine and norepinephrine
oSweating
oPalpitation
or IM
Glucagon is a hormone produced by alpha cells to
o
o
regain consciousness
For awakened pt :
o
A concentrated source of CHO followed by a snack
should be given to prevent recurrence of hypoglycemia
o
administered IV
Pt may complain of headache and pain at injection site
Assessing patency of IV line is essential because
hypertonic solutions such as D50W are very irritating
to veins
Providing pt education
Hypoglycemia is prevented by :
o
Consistent pattern of eating
o
Administering insulin
o
Exercising
Routine blood glucose tests are performed so that changing
of hypoglycemia
Autonomic neuropathy or beta blockers such as propranolol
symptoms
Pt may subsequently eat more of the foods mentioned when
symptoms do not resolve rapidly w/c may cause very high blood
glucose levels for several hours and may contribute to weight gain
Polyuria
Polydipsia
Blurred vision
Weakness
Headache
Mental status varies widely
(alert, lethargic, comatose)
Diabetic Ketoacidosis
I. Definition
Caused by an absence or inadequate amount of insulin
Insulin deficiency results in disorders in the metabolism of CHO,
volume depletion
insulin q 3 to 4 h
If you cannot follow you usual meal plan, substitute soft foods 6 to
8 x per day
Orthostatic hypotension
Vomiting
Abdominal pain
Acetone breath (fruity odor)
Kussmaul respiration
Frank hypotension
Weak, rapid pulse
Blood glucose levels may vary bet. 300 and 800 mg/dL
Evidence of ketoacidosis Low serum bicarbonate (0 to 15 mEq/L) ,
30 mm Hg)
Metabolic acidosis - Kussmaul respirations
Accumulation of ketone bodies Blood and urine ketone
measurements
Sodium & potassium concentrations may be low, normal or high
III. Prevention
Nausea
Anorexia
Pt w/ marked intravascular
manifestation of diabetes)
Insulin deficit may result from :
o
Insufficient dosage of insulin prescribed
o
Errors in insulin dosage
o
Pt error in drawing up or injecting insulin
o
Intentional skipping of insulin doses
o
Equipment problems
o
Illness and Infection are associated w/ insulin resistance
o
Stress hormones (glucagon, epinephrine, norepinephrine,
VI. Management
Rehydration
resumed
Any interruption in administration may result in the reaccumulation of
ketone bodies
Even if blood glucose levels are decreasing and returning to normal ,
continued rehydration
Moderate to high rates of infusion (200 to 500 mL/h) may be needed
Restoring Electrolytes
The major electrolyte of concern during treatment of DKA is potassium
Serum level of potassium decreases as potassium reenters the cells
2. Insulin administration
Enhances the movement of potassium from the extracellular fluid into
the cells
Potassium replacement
is normal
Frequent (q 2 to 4 hr initially) ECGs and laboratory measurements of
Reversing Acidosis
added to IV solutions
Nurse must convert hourly rates of insulin infusion (units/hr) to IV
drip rates i.e 1 unit of insulin = 5 mL
(5 units/h = 25 mL/h)
insulin drip must not be stopped until SQ insulin therapy has been
started . Rather the rate or concentration of the dextrose infusion
should be increased
IV insulin may be continued for 12 to 24 hr until serum bicarbonate
Laboratory Tests
Assessment
I. Definition
resistance
Persistent hyperglycemia causes osmotic diuresis w/c results in loss
IV. Management
replacement
Potassium is added to IVF when urinary output is adequate and
Hypotension
Dehydration
Dry mucous membranes
Poor skin turgor
Tachycardia
Variable neurologic signs (alteration of sensorium, seizures,
hemiparesis )
potassium
Extremely elevated blood glucose concentration decrease as the
pt is rehydrated , Insulin is not needed
Macrovascular Complications
Myocardial infarction
Cerebrovascular disease
People w/ diabetes have twice the risk
Recovery from stroke may be impaired in pt who have elevated blood
glucose levels at the time & immediately after stroke
Symptoms of CVA may be similar to symptoms of acute diabetic
complications , it is very important to assess blood glucose level rapidly
Peripheral vascular disease
walking)
Severe form is largely responsible for increased incidence of gangrene
Management
o
o
o
Microvascular Complications/Microangiopathy
normal thickness
Two areas affected are retina and kidneys
angiography
Fluorescein angiography
Diabetic Retinopathy
I. Definition
brain
Changes in the microvasculature :
o
Microaneurysms
o
Intraretinal hemorrhage
o
Hard exudates
o
Focal capillary closure
3 Main Stages :
itching
Generally safe
Nonproliferative retinopathy
Photocoagulation
Macular edema is a complication w/c occurs in app. 10 % of people w/ type 1
or type 2 diabetes
May lead to visual distortion and loss of central vision
Preproliferative retinopathy
bearing down
Usually an anesthetic eye drop is all that is needed during the
treatment
Focal photocoagulation
V. Nursing Management
Teaching pt self care
Continuing care
Nephropathy
I. Definition
15 yrs
Pt w/ type 2 develop renal disease within 10 yrs after the diagnosis of
diabetes , many of them have had diabetes for many years before
diabetes is diagnosed and treated . Therefore , they may have evidence
of nephropathy at the time of diagnosis
Kidneys filtration
IV. Management
NEPHROPATHY
II. Clinical manifestations
Catabolism / breakdown of both exogenous and endogenous insulin decreases
Frequent hypoglycemic episodes
As renal function decreases , pt commonly have multiple-system failure :
o
Declining visual acuity
o
Impotence
o
Foot ulcerations
o
Heart failure
o
Nocturnal diarrhea
Albumin is one of the most important blood proteins that leaks into
the urine
Clinical nephropathy develops in more than 85 % of people w/
microalbuminuria
If microalbumin exceeds 30 mg/24 hours on 2 consecutive random
surgery
Creates additional stress on pt w/ CV disease
Peritoneal dialysis
Diabetic Neuropathies
Peripheral Neuropathy
Gastrointestinal symptoms
I. Definition
Urinary retention
Decreased sensation of bladder fullness
Risk for UTI
Hyperglycemia impairs resistance to infection
Urinary symptoms
Hypoglycemic Unawareness
w/ hypoglycemia :
o
Shakiness
o
Sweating
o
Nervousness
o
Palpitations
Frequent blood glucose monitoring is recommended for these pt
Their inability to detect and treat the warning signs of hypoglycemia
Alcohol-induced
Vitamin-deficiency neuropathies
III. Management
diabetes
Transcutaneous electrical nerve stimulation (TENS)
Sexual Dysfunction
Diabetic Male pt
Erectile dysfunction
Impotence
Some may have normal erectile function and can experience orgasm but
Autonomic Neuropathies
I. Clinical Manifestations
o
o
o
Cardiovascular symptoms
Tachycardic HR
Orthostatic hypotension
Silent or painless MI
Antihypertensive agents
Psychological factors
Other medical conditions
Diabetic Female pt
Lack of orgasm
Vaginal infection may be associated w/ decreased lubrication
Vaginal pruritus
Tenderness
UTI and Vaginitis may affect sexual function
II. Management
Avoiding strenuous exercise
Orthostatic hypotension may respond to a diet high in sodium
Discontinuation of medications that impede autonomic nervous system
response
Use of sympathomimetics
Mineralocorticoid therapy
Treatment of delayed gastric emptying :
o Low fat diet
o Frequent small meals
o Frequent blood glucose monitoring
o Use of agents that increase gastric motility (metoclopramide
Increased dryness
Fissuring of skin s/t decreased sweating
Immunocompromise
Development of a diabetic foot ulcer begins w/ a soft tissue injury of
o
o
o
Bed rest
Antibiotics
Debridement
o
o
o
traumatic)
if pt is not in the habit of
Swelling
Redness of the leg from cellulitis
Gangrene
toes)
History of previous foot ulcers or amputation
III. Management