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 ●

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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 • • • •

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>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

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Gestational diabetes • has onset or discovery of glucose tolerance during pregnancy

Diabetes ❧ Clinical Manifestations ●

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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 ●

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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 ●

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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 ❧ Strength ❧ Additives ❧ Storage and safety ❧ Administration ❧ Insulin therapy ❧ Insulin delivery

Insulin and Oral Agents ❧ Problems with insulin therapy ● ● ●

allergic reactions lipodystrophy Somogyi effect and dawn phenomenon

❧ Oral medications ❧ Other drugs affecting blood glucose levels ❧ Things to consider… ●

exercise, self-monitoring

Nursing Management: Diabetes ❧ Assessment: ●

Subjective data • • • •

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past health information family history medications surgery and other treatments

Health-perception-health management • + family history, malaise

Nursing Management: Diabetes ❧ Nutritional-metabolic ● ● ● ●

weight thirst and hunger Nausea and vomiting poor healing compliance with diet

❧ Elimination ● ● ●

constipation or diarrhea frequent urination, incontinence, nocturia skin infections

Nursing Management: Diabetes ❧ 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

Nursing Management: Diabetes ❧ Coping-stress ● ● ●

depression apathy irritability

❧ Value-belief ●

commitment to lifestyle changes involving diet, medication, and activity patterns

Nursing Management: Diabetes ❧ Objective data ● ● ● ● ● ● ● ●

eyes integumentary respiratory cardiovascular gastrointestinal neurologic musculoskeletal diagnostic findings

Nursing Management: Diabetes ❧ Insulin therapy ●

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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

Nursing Management: Diabetes ❧ Oral agents ●

nursing responsibilities similar to those taking insulin

❧ Personal hygiene ● ●

dental skin care

❧ Medical identification and travel ❧ Follow-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

Complications of Diabetes ❧ 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

Complications of Diabetes ❧ 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

Complications of Diabetes ❧ 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)

Complications of Diabetes ❧ Hyperglycemic Hyperosmolar Nonketosis ●

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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

Complications of Diabetes ❧ 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

Complications of Diabetes ❧ 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

Complications of Diabetes ❧ 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

Complications of Diabetes ❧ 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

Complications of Diabetes ❧ 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

Complications of Diabetes ❧ Hyperglycemia ●

causes • • • • •

too much food too little or no diabetes medication inactivity emotional, physical stress poor absorption of insulin

Complications of Diabetes ❧ 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 ❧ Macroangiopathy ❧ Microangiopathy ❧ Peripheral Vascular Disease ❧ Diabetic Retinopathy ❧ Nephropathy ❧ Neuropathy ❧ Skin 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