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Nursing 201

Assessment and Management of Patients With Diabetes Mellitus

Diabetes Mellitus Clinical Manifestations

Classic symptoms: ---polyuria, polydipsia, polyphagia, ---increased frequency of infections & fatigue
Type I Weight Loss Rapid onset Insulin dependent Early onset- before age 15 Type II Sedentary lifestyle Familial tendency Weight increase Slow onset Average age 50 years History of high BP

Type I Diabetes

Diabetes Mellitus

Pancreas does not produce any insulin Insulin- dependent diabetes mellitus (IDDM)- insulin must be administered to control complications Onset age usually < 30 years; usually thin at diagnosis; with recent weight loss Etiology- genetic, immunologic, or environmental factors Clinical findings: Polyuria, polyphagia, polydipsia, weakness Ketones prone when insulin absent Acute complication: Diabetic Ketoacidosis (DKA)

Type II Diabetes

Diabetes Mellitus

Body does not produce enough insulin or the cells ignore the insulin Non-insulin dependent diabetes (NIDDM)- not dependent upon insulin for survival, but may have insulin ordered Onset age > 30 years; usually obese at diagnosis Etiologies usually includes obesity, heredity, or environmental Blood glucose usually controlled by diet and exercise Ketosis rare, except in stress or infection Acute complication: Hyperglycemic hyperosmolar nonketotic syndrome (HHNK)

Gestational Diabetes

Any degree of glucose intolerance with its onset during pregnancy Recommended screening between 24th and 28th weeks of gestation Criteria:
25 years of age or older Younger than 25 years of age and obese Family history of DM in first-degree relatives Member of an ethnic/racial group with a high prevalence of DM

Impaired Glucose Tolerance

Borderline, subclinical, asymptomatic diabetes Oral glucose tolerance value between 140 to 200 mg/dl Impaired fasting plasma glucose between 110 to 126 mg/dl May be obese or nonobese- should reduce weight Should be screened for diabetes periodically

Risk Factors for Diabetes Mellitus

Family history of diabetes Obesity Race/ ethnicity Age = or > 45 years Previously identified impaired fasting glucose or impaired glucose tolerance Hypertension History of gestational diabetes or delivery of babies over 9 lbs.

Diagnostic Testing

Fasting Blood Sugar (FBS)

Diagnose new DM & monitor glucose level Blood obtained by venipuncture NPO for least 8 hours (water permitted) If already diabetic- blood obtained before insulin or oral antidiabetic agents administered Diagnosis of diabetes- two separate test results > 126 mg/dl

Oral Glucose Tolerance Test

Performed to diagnose DM when serum glucose is between 126 to 140 mg/dl Not routinely used except in diagnosis of gestational DM FBS drawn; client drinks a glucose solution; blood samples obtained at 30 minutes intervals for 2 hours Diagnosis of DM- blood glucose > 200 mg/dl at 120 minutes

Glycosolated Hemoglobin (HbA1c)

Best indicator of average blood glucose leveloverview over previous 3 months Used to assess long-term glycemic control & predict risk for development of chronic complications Not influenced by recent food intake, exercise, or stress Valuable to determine compliance with prescribed medical regimen ADA recommends testing: twice yearly for stable BS & quarterly on clients who therapy has changed

Urine Testing for Ketones Bodies

Abnormal in urine Presence in urine may indicate impending ketoacidosis ADA recommend testing:
acute illness or stress when BS level consistently > 300 mg/dl during pregnancy when symptoms of ketoacidosis are present

Recommended for DM clients participating in a weight loss program

Criteria for the Diagnosis of Criteria for the Diagnosis of

Diabetes Mellitus

Symptoms of diabetes + casual plasma glucose level > or = 200 mg/dl Fasting plasma glucose > or = 126 mg/dl 2-hour postload glucose > or = 200 mg/dl during an oral glucose tolerance test

5 Components of

Management of Diabetes
Nutrition Exercise Blood Glucose Monitoring Pharmacological Therapy Education

I. II. III. IV. V.

I. Nutritional Therapy

Goals:

Balance food intake with insulin or oral diabetic meds Achieve optimal serum lipid levels Enough calories to maintain or attain reasonable weight Prevent & treat acute complications Improve overall health through optimal nutrition

Individualize the nutritional intervention Be realistic & flexible in developing a nutritional plan Be consistent in timing of meals & proportions of CHO, protein, and fat

Nutritional Therapy Contd:

Typical diet consists of : CHO, Fat, Protein, & Dietary Fibers Exchange Lists for Meal Planning
Each 6 lists contains foods similar amounts of protein, fat, CHO, & calories starch/bread, meat, vegetable, fruit, milk, & fat A food on the list can be traded or exchanged for any other food on that list However, foods from one list or exchange cannot be substituted for foods from another list or exchange

II. Exercise
Primary benefit- increase glucose utilization by the tissues, thereby lowering blood glucose concentration Facilitate weight loss, which will decrease peripheral resistance Several factors influence blood glucose response to exercise:

timing amount intensity of exercise

ADA Recommendations for Diabetics Who Exercise

Use appropriate footwear Monitor feet closely before & after exercise for injury Ensure proper hydration before & during exercise Avoid exercising in extremely hot or cold conditions

Exercise-Induced Hypoglycemia

Instructions to minimize risk:

avoid injecting Insulin into body areas involved in exercise monitor BS before & after activity consistent in timing of Insulin injections & activity take pre-exercise snack if BS <100 to 120 mg/dl & if > 90 minutes passed since last meal carry fast-acting CHO while exercising wear diabetes identification exercise with someone who knows how to recognize & treat hypoglycemia

IV. Pharmacological Therapy -Insulin Therapy

Short-acting Insulin Regular Insulin

Onset- 30 minutes to 1 hour Peak- 2 to 3 hours Duration- 4 to 6 hours Action - covers meals eaten within 30-60 minutes Clear in appearance Usually administered 20 to 30 minutes before a meal, either alone or in combination with a longer-acting Insulin

IV. Pharmacological Therapy -Insulin Therapy

Intermediate-Acting Insulin

NPH Insulin (neutral protamine Hagedorn) or Lente Insulin Onset- 3 to 4 hours Peak- 4 to 12 hours Duration- 16 to 20 hours Action - covers Insulin needs for about 1/2 the day or overnight White and cloudy in appearance If NPH or Lente Insulin is taken alone- not critical that it be taken a half-hour before the meal Important for the patient to have eaten some food around the time of onset and peak of these Insulins

IV. Pharmacological Therapy -Insulin Therapy

Long-acting Insulins and Fixed Combinations

1. Ultralente Insulin

Onset- 6 to 8 hours Peak- 12 to 16 hours Duration- 20 to 30 hours Action- provides a low level of Insulin support for 24 hours

2. Fixed combinations

Human 50/50 (50% NPH Insulin and 50% Regular Insulin) Humulin 70/30 (70% NPH Insulin and 30% Regular Insulin) Novolin 70/30

IV. Pharmacological Therapy -Insulin Therapy

Rapid-Acting Insulins

-Humalog or Novolog

Onset- 10 to 15 minutes Peak- 1 to 2 hours after injection Duration- 3 hours Action - covers meals eaten at same time Patient should be instructed not to wait the usual 30 minutes after injection to eat Due to short duration of action of Humalog & Novolog patients with Type I diabetes also require a long-acting Insulin to maintain glucose control

IV. Pharmacological Therapy -Insulin Therapy

The Newest Insulin

---Lantus

Human Insulin analog Basal Insulin No pronounced peak Duration of action- up to 24 hours Clear solution Never mix with any Insulin (separate syringe) Administered SQ once a day at bedtime Can be used as part of regimen of combination therapy

IV. Pharmacological Therapy -Insulin Therapy Time Frame Questions

Client receiving Regular Insulin at 0730?

The nurse should observe the client most closely for symptoms associated with an insulin reaction at : (time frame???)

Client receiving NPH Insulin at 0730?

The nurse should observe for symptoms of insulin reaction at : (time frame??)

Client receiving 70/30 NPH/Regular Insulin premix at 0730?

The nurse expects insulin reaction due to regular Insulin between (time frame???)

Teaching Self Administration of Insulin

Administered into SQ tissue with special insulin syringe Syringes matched with Insulin concentration (i.e. U-100) Most insulin syringes- 27 to 29 gauge needle- approximately 0.5 inch long Short-acting clear in appearance Long-acting cloudy and white- must be mixed gently inverted or rolled in the hands before use Draw up Regular Insulin first if mixing insulin Debate regarding storage of insulin bottle either in the refrigerator or kept at room temperature

IV. Pharmacological Therapy -Insulin Therapy

Sliding Scale Insulin

Unstable glucose levels requiring supplemental insulin, in addition to usual insulin coverage Use short-acting Insulin- Regular Insulin Usually given before meals Dose dependent on level of blood glucose at time of administration

Complications of Insulin Therapy

Local Allergic Reactions

redness, swelling, tenderness, & induration at injection site 1 to 2 hours after injection administered usually occurs in beginning stage & disappears with continued use of Insulin

Systematic Allergic Reactions

rare; local skin reaction gradually spreads entire body

Lipodystrophy
localized reaction due to repeated use of same injection site loss of SQ fat (appears as slight dimpling) important to rotate injection site & use of Human Insulin- almost eliminates this complication

Complications of Insulin Therapy Insulin Resistance

immune antibodies develop & bind to insulin- decreasing insulin available for use treatment- administer purer insulin & occasionally Prednisone need to monitor for hypoglycemia relatively normal BS level until 0300; result from nighttime release of growth hormone that causes increase BS at 0500 to 0700 not preceded by an episode of hypoglycemia diagnosis: measurement of BS levels at 0300- level normal & FBS at 0700 is high treated by changing evening dose of insulin- giving intermediateacting insulin at 2200 instead of before dinner at 1800

Dawn Phenomenon

Complications of Insulin Therapy

Somogyi Effect

periods of nocturnal hypoglycemia followed by rebound hyperglycemia (BS levels increase despite increasing doses of insulin) causes: excessive insulin therapy & release of stress hormones patient awakes with H/A, c/o restless sleep, nightmares, or unexplained N & V insulin peaks at 0200 to 0300- blood glucose levels may be lower- decrease in metabolism diagnosis: BS levels at 0200, 0400, & 0700- if 1st measurement between 50 to 60 mg/dl & 0700 measurement > 180 to 200 mg/dl treated by decreasing insulin dosages - nocturnal hypoglycemia does not occur & bedtime snack of protein

Alternative Methods of Insulin Delivery

Insulin Pens Jet Injectors Insulin Pumps Implantable and Inhalant Insulin Delivery Transplantation

IV. Pharmacological Therapy -Oral Antidiabetic Agents: Classifications

1.

Sulfonylureas

Drugs: Diabinese, Micronase, Glucatrol, Orinase, Amaryl Action: Stimulates beta cells of pancreas to secrete more of its own insulin Functioning pancreas necessary & cannot be used in Type I DM Peak- 3 to 4 hrs; duration- 6 to 12 hrs (varies with type) Hypoglycemia occurs: excessive doses, meals omitted or delayed, food intake decreased, or activity is increased Some meds may increase or decrease BS levels Common side effects: GI symptoms & dermatological reactions

IV. Pharmacological Therapy -Oral Antidiabetic Agents: Classifications

Biguanides
Drug: Glucophage Action: increase Insulin sensitivity of liver cells, thus reducing liver cell production of sugar no effect on pancreatic beta cells Peak- unknown; duration- 6 to 12 hours Interacts with anticoagulants, Corticosteroids, diuretics, & oral contraceptives contraindicated in patients with renal impairments & who drink alcohol heavily should be discontinued for 2 days before any diagnostic testing requiring use of contrast agent- potential risk for Lactosis Acidosis

2.

IV. Pharmacological Therapy -Oral Antidiabetic Agents: Classifications

3.

Oral Alpha Glucosidase Inhibitors

Drug: Percose Action: reduces digestion of starch into sugar in the intestines; less sugar is absorbed into the blood after meals Peak- 1hr; duration- unknown Does not enhance insulin secretion Can be used with dietary treatment or conjunction with other oral antidiabetic meds (when used in conjunction- hypoglycemia may occur) Work on food absorption- must be taken immediately before a meal Side effects: diarrhea & flatulence (GI problems)

IV. Pharmacological Therapy -Oral Antidiabetic Agents: Classifications

4.

Thiazolidinediones
Drug: Rezulin, Avandia Action: increases insulin receptor sensitivity on muscles and adipose (fat) cells Increases insulin uptake from blood into target cells Makes insulin more effective & less is required Peak- 2 to 3 hrs; duration- unknown Approved as first-line agent to treat Type II DM, in conjunction with diet

IV. Pharmacological Therapy -Oral Antidiabetic Agents: Classifications

Meglitinides
Drug: Prandin, Starlix Action: stimulates beta cells of the pancreas to secrete more of its own insulin Contraindicated in patients with Type I DM Fasting action & short duration Help manage BS changes after specific meals Indicated for use in conjunction with Glucophage (patients who hypoglycemia cannot be controlled by diet, exercise, & either Glucophage or Prandin alone) Principle side effect: hypoglycemia

5.

Nursing Care for Patients with Diabetes Mellitus A DPIE -Assessment

obtain full history; include info re: ongoing treatment for known diabetes peripheral pulses skin changes at injection sites temperature of extremities sensation loss visual acuity muscle atrophy weakness

Nursing Care for Patients with Diabetes Mellitus

ADPIE Assessment Contd:

Diagnostic Evaluation
glucose tolerance test urinalysis blood glucose tests

Clinical Manifestations
increased hunger (polyphagia) weight loss excess thirst (polydipsia) excess urination (polyuria) fatigue weakness

Nursing Care for Patients with Diabetes Mellitus

ADPIE - Nursing Diagnoses

Knowledge deficit- medication and dietary regimen r/t self-care skills aeb ???? Anxiety r/t fear of diabetic complications aeb ??? Altered nutrition, more than body requirements, r/t failure to follow diet and exercise plan aeb ??? Fluid volume deficit r/t loss of fluids aeb diarrhea, vomiting, and osmotic diuresis from hyperglycemia Impaired skin integrity r/t decreased tissue perfusion or infection aeb ??? Potential for injury or trauma r/t inability to feel pain secondary to peripheral nerve degeneration

Nursing Care for Patients with Diabetes Mellitus

ADPIE Planning:
conditions)

Client Outcomes (before addition of time and measurement

Client will show increasing knowledge base to demonstrate self-care by describing ___ by date. Client will verbalize an understanding of common DM complications and their management by listing ____ by date Client will follow prescribed diet plan Client will maintain adequate intake of fluids and electrolytes Client will maintain skin integrity and avoid injuries

Nursing Care for Patients with Diabetes Mellitus Nursing Care for Patients with Diabetes ADP I E V. Interventions V. Interventions 1. Encourage to follow practices that promote health & prevent injury adhering to prescribed diet, getting sufficient exercise, taking care of feet, inspecting skin daily, checking temperature of bath water before use, and applying heating devices carefully 2. Teach to use an appropriate method of self-monitoring of blood glucose 3. Teach about types of insulin prescribed for DM self-injectable Insulin 4. Teach how to treat complications of diabetes causes, symptoms, & prevention of hypoglycemia, hyperglycemia, diabetic ketoacidosis, & hyperglycemia hyperosmolar nonketotic syndrome 5. Teach diabetic foot care 6. Teach changes that must occur in event of illness

Nursing Care for Patients with Diabetes Mellitus ADPIE

- Evaluation

Client demonstrates self-care skills Client verbalizes understanding of common diabetic complications and their management Client eats prescribed diet Client maintains adequate intake of fluids and electrolytes Client verbalizes perception of disease, benefits of care, and barriers to care Client identifies coping patterns and personal strengths to promote effective coping Client maintains intact skin Client avoids injury or trauma

Acute Complications of Diabetes:

Hypoglycemia
BS level falls < 60 to 70 mg/dl may occur with either types of diabetes most common causes: too much insulin or oral antidiabetic agent too little food intake (delayed or missed meal) too much exercise at wrong time of day ingestion of alcohol, esp. when not eating onset is rapid - 1 to 3 hrs & if prolonged, coma may result Symptoms: cold & clammy, pallor, perspiration, shaking or tremors, hunger, headache, anxious, inability to concentrate, blurred vision, dizzy, fatigue, irritable, & unresponsive Treatment 10 to 15 grams of a fast-acting CHO orally 3 to 4 commercially prepared glucose tablets, 4 to 6 oz of fruit juice or regular soda, 6 to 10 Life Savers or either hard candies, or 2 to 3 tsp.. of sugar or honey Recheck BS 15 minutes later- retreat if BS <70 to 75 mg/dl Symptoms resolved- snack containing protein & starch unless eat a regular meal Unconscious & cannot swallow- injection of Glucagon 1mg administered either SQ or IM; Hospital setting- treated with 25 to 50 ml of 50% Dextrose in water (D50)administered IV- immediate effects

Acute Complications of Diabetes:

Hyperglycemia
Very high BS level- due to inadequate insulin effect Predisposing factors:

newly diagnosed DM, insufficient education about DM & conditions that increase counterregulatory hormones polyuria, polydipsia, weakness, light-headness, weight loss, polyphagia, & blurred vision control of DM through medication, exercise & diet

Clinical Findings:

Treatment:

Acute Complications of Diabetes:

Diabetic Ketoacidosis (DKA)

Type of metabolic acidosis with hyperglycemia & dehydration- leads to excessive levels of ketones in the body Major life-threatening complication; occurs in Type Causes:

I DM

absence or markedly inadequate amount of insulin, illness or infection, treatment error, steroid therapy, stress, & undiagnosed & untreated diabetes Hyperglycemia, metabolic acidosis, osmotic diuresis (dehydration & electrolyte loss)

Cardinal signs of DKA

Blood sugar levels varies- 300 to 800 mg/dl Onset slow 4 -10 hours

Acute Complications of Diabetes:

Diabetic Ketoacidosis (DKA) Contd.

Clinical Manifestations
polyuria, polydipsia, blurred vision, weakness, headache, orthostatic hypotension, anorexia, N & V, abd. pain, classicacetone breath, hyperventilation (Kussmaul respiration), & mental status changes

Interventions
Hyperglycemia

Monitor BS levels, VS, airway patency & LOC along with UO & mental status every hour IV fluid- 0.9% NS at high rate, usually 0.5 to 1 liter per hour for 2 to 3 hours (IV rate ???) Monitor VS, lung assessment, I & O, and signs for fluid overload!
When BS reaches 300 or <- IV fluid may be changed to D5W

Hydration

Acute Complications of Diabetes:

Diabetic Ketoacidosis (DKA) Contd.

Electrolyte Loss
Monitor K+ level b/c insulin pushes K into cells; caution but timely K+ replacement to avoid dysrhythmias Frequent EKG readings and lab measurements of K+ esp. during 1st 8 hours of treatment

Acidosis
Insulin infused IV at a slow, continuous rate Hourly BS monitoring Dextrose added to IV fluids (NS)- BS level reach 250 to 300 mg/dl IV Insulin continued 12 to 24 hrs- until serum bicarbonate level improves & client can eat

Acute Complications of Diabetes:

Hyperglycemia Hyperosmolar Nonketotic Syndrome (HHNK)

Life-threatening; emergency situation more common in elderly Type II DM or undiagnosed DM clients Dehydration, hyperglycemia & alterations of sense of awareness (coma) Results from insulin deficiency; onset gradual; Ketosis & acidosis does not occur Causes:

acute illness or infection, fluid loss from osmotic diuretic 2nd to hyperglycemia, severe burns, severe diarrhea, hemodialysis & pharmacological agents electrolyte & BUN (clinical picture of severe dehydration), mental status changes, neurologic deficits, & postural hypotension

Assessment

Acute Complications of Diabetes:

Hyperglycemia Hyperosmolar Nonketotic Syndrome (HHNK) Contd.

Clinical Manifestations
hypotension, severe dehydration, tachycardia, depressed mental status to coma, severe weakness & lethargy Blood glucose level- 600 to 1200 mg/dl, osmolarity > 350 mOsm/kg, elevated serum Na+, ketones negative

Intervention
IV fluid- 0.9% or 0.45% NS; K+ added to IV fluids (UO adequate with EKG monitoring) Careful monitor for complications: CHF, electrolyte imbalance, seizures Insulin administered at low rate & Dextrose to replace fluids May take 3 to 5 days for neurologic symptoms to resolve Can control DM with diet or with diet & oral antidiabetic agents

Long-term Degenerative Changes of Diabetes Mellitus

1.

Macrovascular Disease
Coronary artery disease, cerebrovascular disease, & peripheral vascular disease Results from changes in medium to large blood vessels- blood vessels walls thicken & become occluded by plague- eventually blood flow becomes blocked Increased risk for myocardial infarction- typical ischemic symptoms may be absent Management:

prevention & treatment of risk factors for atherosclerosis diet & exercise in managing obesity, HTN & hyperlipidemia medication & close control of BS levels smoking cessation

Long-term Degenerative Changes of Diabetes Mellitus

2.

Diabetic Retinopathy deterioration of small blood vessels that nourish the retina Clinical Manifestations: painless, blurred vision, hemorrhaging- floaters or cobwebs in visual field or sudden visual changesspotty or hazy vision or complete loss of vision Diagnosis direct visualization with ophthalmoscope or fluorescent anigography Management maintenance of BS level advanced cases- Argon Laser Photocoagulation

Microvascular Disease

Long-term Degenerative Changes of Diabetes Mellitus

3.

Diabetic Neuropathies

affects all types of nerves including peripheral, autonomic, & spinal nerves Two common types:

Sensorimotor polyneuropathy Autonomic neuropathy

Clinical Manifestations:

paresthesias (prickling, tingling sensation); burning sensations (esp. at night); progression- the feet become numb; decrease awareness of posture & movement of body & decrease sensation lead to unsteady gait intensive insulin therapy & control of BS; pain management with analgesics, antidepressants or TENS unit

Management

Long-term Degenerative Changes of Diabetes Mellitus

4.

Diabetic Nephropathy
Renal disease 2nd to diabetic microvascular changes in the kidney; 3rd most common listed diagnosis of pts treated for ESRD Clinical Manifestations:

signs of renal dysfunction (proteinuria, edema, & renal insufficiency) along with multiple system failure (declining visual acuity, impotence, feet ulcerations & CHF) control HTN, prevent & treat UTIs, & avoidance of nephrotoxic substances, adjust meds as renal function changes, low Na+ and low protein diet Renal failure; hemodialysis or peritoneal dialysis & renal transplantation

Management

Older Adult Alert

Type II DM more common in older adult client Greatest risk for complications associated with DM that would require hospitalization Symptoms commonly associated with DM may be masked by other illness Many older adults have unusual or erratic eating patterns that must be considered when planning a diet Older adults may have decreased visual acuity or manual dexterity that may decrease their ability to prepare and administer insulin Proper foot care may not be possible with their decreased mobility and visual acuity