NURSING CARE MANAGEMENT OF CLIENTS WITH CHRONIC COMPLICATIONS

DIABETES
What is an important question to ask Diabetics?
Acute – sudden and short-term onset that requires immediate - “How long have you been a Diabetic?”
medical and nursing interventions; can lead to death
if not resolved properly ANGIOPATHY (BLOOD VESSEL DISEASE)

Chronic – occurs after a long period of time Macroangiopathy

- Affects large or medium-sized blood vessels
ACUTE COMPLICATIONS - EXAMPLE: CVA, Cardiovascular Disease,
Diabetic Ketoacidosis (DKA), Diabetic Acidosis, Diabetic Coma Peripheral Vascular Disease

1. Caused by too little insulin accompanied by: Microangiopathy

• High caloric intake - Affects small / minute / microscopic, fine blood
• Physical/ emotional stress vessels
• Undiagnosed DM (most likely Type 1) - EXAMPLE: Retina of the eye (Diabetic retinopathy),
Glomerulus of kidneys (Diabetic nephropathy),
Level of Consciousness Blood vessels of the skin (Diabetic dermopathy),
A. Awake Blood vessels of neurons (Diabetic neuropathy)
B. Lethargic – sleeping most of the time but responds to
verbal stimuli PERIPHERAL VASCULAR DISEASE
C. Stupor – sleeping most of the time but respond to
painful stimuli • Combination of Macro + Microangiopathy + clotting
D. Coma – unable to respond to verbal and painful abnormality
stimuli • The legs and feet are most often affected
• Accounts for diabetic hospitalizations
• Sequelae: TRIAD → Infection, Gangrene, Amputation

Classic Signs and Symptoms:

- Intermittent claudication (muscle pain that happens
when active, but stops when at rest)
- Pain at rest
- Cold feet
- Delayed capillary refill
- Dependent rubor

*If client has PVD + these 5 classic signs, there is

inadequate oxygenation to the tissues and poor
circulation.

Diagnostic test:
- Doppler study
- Peripheral angiography

Management:
- Control and reduction of risk factors:
1. Smoking
2. High cholesterol
3. Hypertension
- Proper care of feet (seek Podiatrist)
- Antibiotic therapy

DIABETIC RETINOPATHY

• A disease of the retina in the eye due to:

- Damaged capillaries
- Capillary drop-out
- Abnormal blood vessel growth on the surface of
the retina
• Manifested by Glaucoma, Cataracts, and Blindness

DIABETIC NEPHROPATHY

1. The microangiography causes diffuse nodular

glomerulosclerosis.
2. The basement membrane of the glomerulus become
thickened and leaking, and can progress to renal failure.
3. It can proceed to end-stage renal disease (ESRD) that
requires dialysis or kidney transplant.

*Diabetes is the #1 reason why patients undergo

hemodialysis. The #2 is Hypertension.

DIABETIC NEUROPATHY

• Results from
- Reduced nerve conduction
- Demyelinization (myelin sheath destroyed)
• Results in symmetrical peripheral polyneuropathy
Symmetrical – “affects both” POSTERIOR PITUITARY GLAND DISORDER
Peripheral – “both hands and feet”
Polyneuropathy – “many neurons” * Syndrome of Inappropriate Anti-Diuretic Hormone (SIADH)
* Diabetes Insipidus
Classic Signs and Symptoms:
3P: Pain even at rest
Paresthesias (tingling, numbing, needle-like pricking,
tearing, burning, cramping, crushing)
Partial loss of sensation to touch / temperature

Fine Needle Test – pricking at the foot to test sensation

ANTERIOR PITUITARY GLAND DISORDER

HYPERPITUITARISM

Hyperpituitarism
- Growth hormone excess
- Clinical conditions: Gigantism / Acromegaly
SIADH & DIABETES INSIPIDUS
***GIGANTISM
↓
- Onset occurs before the closure of the epiphyses
and while the long bones are still capable of Brain Pathology
longitudinal growth - Brain tumors
- Onset is early childhood or puberty - Brain / CNS infections (encephalitis,
- Children can grow as tall as 8FT and weigh over
meningitis)
300lbs
- These children are usually not healthy and die at - Head trauma
a young age - Brain vascular disorder (CVA)

***ACROMEGALY
- More common in the 3rd or 4th decade of life
THYROID GLAND DISORDER
- Physical features: enlargement of hands and
HYPERTHYROIDISM
feet, enlarged paranasal & frontal sinuses,
coarse facial features, diaphoresis (sweating),
Hyperthyroidism
abdominal distension, oily skin
- Excessive circulating levels of T3, T4, or both
- More common in women
HYPOPITUITARISM
- Affects ages 30-40 years of age
Hypopituitarism
Clinical Conditions:
- Growth Hormone deficit = decreased in 1 or
➢ Grave’s Disease
more of APG Hormones
- Multisystem, autoimmune syndrome marked by
↑ production of TH
Symptoms (non-specific):
- Precipitating factors: INSUFFICIENT IODINE
• Weakness
SUPPLY
• Fatigue ➢ Multinodular Goiter
• Headache - Characterized by small, discrete, autonomously
• Diminished tolerance to stress functioning nodules that secret TH
• Poor resistance to infection - These nodules may be benign or malignant
In women: ➢ Exopthalmus / Exophthalmus
• Menstrual irregularities - Eyeballs protrude from their orbit
• Diminished libido - Upper lids are retracted & eyeballs are forced
• Changes in secondary characteristics outward
• ↓ breast size - The sclera is visible → CHARACTERISTIC
In men: STARE & PROTRUSION
• Testicular atrophy
• Loss of libido HYPOTHYROIDISM
• Impotence
• ↓ muscle mass Hypothyroidism
- Hypofunction of the thyroid
Management: - ↓ TH secretion
• Replacement of hormones - Slowing of metabolic processes
• EXAMPLE: Corticosteroids, Thyroid
Hormones, Sex Hormones Clinical Conditions:
➢ Cretinism (children)
***DWARFISM - very slow mental process in children
- Failure to grow ➢ Myxedema (adults)
- Slow but proportional growth - Moon face (puffy)
- Except for their small size, they appear
completely normal
 - IATROGENIC: prolonged use of steroids due to
medical treatment

Corticosteroid Therapy:
• Common preparations:
- Cortisone, Hydrocortisone, Dexamethasone,
Prednisone, Betamethasone
- Can be oral tablet, liquid, injectables, ointment,
lotion, cream, inhaler puff
• Therapeutic effects / indications:
- Anti-inflammatory agents (SAID):
inflammation, allergic, immunoreactive,
edematous, skin problems, malignancies,
degenerative, chronic conditions
• Adverse effects:
- Na+H2o retention: edema, wt. gain, increased
BP, congestive heart failure
- GIT symptoms: nausea & vomiting, gastritis, GI
ulcer, GI bleeding
- Endocrine changes: menstrual irregularities,
Cushingoid appearance
- Immunologic response: mask infection,
increased susceptibility to infection

Characteristics of Cushing Syndrome

➢ Central Obesity
- Weight gain
- Pendulous abdomen
- Supraclavicular fat pad
- Buffalo hump
- Moon face
➢ Protein Wasting
- Thin extremities with muscle wasting or muscle
atrophy
- Thinning of hair
- Slow wound healing
- Ecchymosis from easy bruising
- Purple striae
- Increased body and facial hair

SIMPLE GOITER

Simple Goiter
- Enlargement of the Thyroid gland not caused by
inflammation or neoplasm

a. Endemic
- Caused by nutritional iodine deficiency
b. Sporadic
- Caused by ingestion of large amounts of Alternative Management:
goitrogenic agents: cabbage, soy beans, - Gradual discontinuance
peanuts, peaches, peas, strawberries, spinach, - Reduction of steroid dose
radish (low thyroxine production) - Conversion to an alternate day regimen (MWF
or TTHS)
THYROIDITIS
*We cannot stop steroid therapy.
Thyroiditis
- Inflammatory process in the thyroid
- Thyroid tissue is replaced by fibrous tissue NURSING DIAGNOSIS OF ENDOCRINE PROBLEMS
- Stress aggravates these autoimmune process
- Hashimoto’s thyroiditis → popular among Body image disturbance; Altered self-concept/ self-
Japanese males (workaholic + stress) esteem
High risk for infection
ADRENAL CORTEX DISORDER Activity intolerance
CUSHING SYNDROME Altered nutrition
Sensory-perceptual alterations
Cushing Syndrome Fluid and electrolyte imbalance
- A spectrum of clinical abnormalities caused by High risk for injury
excess glucocorticoids, particularly
corticosteroids
- Occurs more in women