Ms2 Finals Project Dka

Diabetes Mellitus  Is a chronic disorder of carbohydrate, protein, and lipid metabolism that is caused by deficiency of insulin  A deficiency of insulin results in hyperglycemia  Type I diabetes mellitus is a nearly absolute deficiency of insulin; if insulin is not given fats are metabolized, resulting in ketonemia (acidosis)  Type II diabetes mellitus is a relative lack of insulin or resistance to the action of insulin; usually insulin is sufficient to stabilized fat and protein metabolism but not to deal with carbohydrate metabolism ASSESSMENT Polyuria, polydipsia, polyphagia (more common in type I DM) Hyperglycemia Weight loss Blurred vision Slow wound healing Vaginal infections Weakness and paresthesias Sign of inadequate circulation to the feet Signs of accelerated atherosclerosis DIET  The total number of calories is individualized based on the client’s current or desired weight and the presence of other existing health problems EXERCISE Lowers blood glucose level Reduces cardiovascular risk Improves circulation and muscle tone Decrease total cholesterol and triglyceride levels Encourages weight loss Instruct the client to monitor blood glucose level before exercising; if the clients plans to participate in extended period of exercise, blood glucose level should be checked before, during and after exercise period  If the blood glucose level is greater than 250mg/dL and urinary ketones (type I DM) are present, the client is instructed not to exercise until the blood glucose is closer to normal and urinary ketones are absent.      

ORAL HYPOGLYCEMIC MEDICATIONS Oral medications are prescribed with type II DM Assess vital signs and blood glucose levels Assess the medications that the client is currently taking Aspirin, alcohol, sulfonamides, oral contraceptives, and monoamine oxidase inhibitors increase the hypoglycemic effect, causing a decrease in blood glucose levels Glucocorticoids, thiazide diuretics, and estrogen increase blood glucose levels Teach the client to recognize symptoms of hypoglycemia and hyperglycemia Teach the client to avoid over the counter medications unless prescribed by the physician Teach the client to avoid alcohol if taking sulfonylureas Inform the client with type II DM that insulin may be neede during stress, surgery or infection. INSULIN Insulin is used to treat type I DM and type II DM when diet and weight control therapy have failed to maintain satisfactory blood glucose levels The peak action time of insulin is important because of the possibility of hypoglycemic reactions occurring during that time COMPLICATIONS OF INSULIN THERAPY Local allergic reactions  Redness, swelling, tenderness, and induration or a wheel at the site of injection may occur 1 to 2 hours after administration  Reactions usually occur during the early stages of insulin therapy  Instruct the client to avoid the use of alcohol to cleanse the skin before injection  The physician may prescribe an antihistamine to be taken 1 hour before injection Insulin lipodystrophy  Lipoatrophy is loss of subcutaneous fat and appears as slight dimpling or more serious pitting of subcutaneous fat; the use of human insulin helps prevent this complication  Lipohypertrophy is the development of fibrous fatty masses at the injection site and is caused by repeated use of an injection site  Instruct the client about the importance of rotating insulin injection sites

INSULIN ADMINISTRATION  Insulin pens  A device that uses a small, prefilled insulin cartridge that is loaded into a penlike holder; a disposable needle is attached to the device for injection  The clients inserts the needle for injection, and the insulin delivered by dialing in a dose or pushing a button for every 1 to 2 unit increment administered  Jet injectors  A device that delivers insulin through the skin under pressure in an extremely fine stream  Insulin administered by this device usually absorbs faster  The injector can cause bruising at the site of insulin delivery  Insulin Pumps  Continuous subcutaneous insulin infusion is administered by an externally worn device that contains a syringe attached to a long, thin, narrow-lumen tube with a needle or Teflon catheter attached to the end  The client inserts the needle or Teflon catheter into the subcutaneous tissue (usually on the abdomen) and secures it with tape or a transparent dressing; the pump is worn on a belt or in a pocket, the needle is changed at least every 3 days  Implantable insulin delivery  An insulin pump is implanted in the peritoneal cavity, where insulin can be absorbed in a more physiological manner  Implants are not widely used because of mechanical problems associated with the pump, the catheter, and the insulin delivery  Pancreas transplant  The goal of pancreatic transplantation is to halt or reverse the complication of diabetes mellitus  Immunosuppressive therapy is prescribed to prevent and treat rejection COMPLICATIONS OF DIABETEIC MELLITUS ACUTE COMPLICATIONS: Hypoglycemia DIABETIC KETOACIDOSIS Hyperglycemic hyperosmolar nonketotic syndrome CHRONIC COMPLICATIONS Diabetic retinopathy

Diabetic nephropathy Diabetic neuropathy DIABETIC KETOACIDOSIS (DKA) Is a serious complication of diabetes. Develops when you have too little insulin in your body. Without enough insulin, sugar (glucose) can't enter your cells for energy. Your blood sugar level rises and your body begins to break down fat for energy. This produces toxic acids known as ketones. most common in people who have type 1 diabetes, but people who have type 2 diabetes may develop diabetic ketoacidosis, too. In fact, in a few cases diabetic ketoacidosis is the first sign that a person has diabetes.

PATHOPHYSIOLOGY Progressive hyperglycemia occurs due to inadequate circulating insulin, preventing cellular uptake of glucose – leading to a state of 'cellular starvation' This induces pancreatic glucagon secretion and release of other stress hormones such as catecholamine, corticol and GH These humoral factors encourage glycogenolysis and gluconeogenesis, further raising plasma glucose The stress response encourages proteolysis and lipolysis, forming free fatty acids, which are then converted to the ketoacids acetoacetate, beta-hydroxybutyrate and acetone, (due to absence of intracellular glucose required for their metabolic conversion) leading to acidosis The very high glucose levels cause a huge osmotic diuresis and gross dehydration Dehydration may reduce tissue perfusion and further derange metabolism by causing lactic acidosis A vicious cycle of progressive metabolic disruption is set in train, continuing until rehydration and insulin therapy are given

SIGNS AND SYMPTOMS Diabetic ketoacidosis symptoms often develop quickly, sometimes within 24 hours. You may notice: Excessive thirst Frequent urination Nausea and vomiting Abdominal pain Loss of appetite Weakness or fatigue Shortness of breath Fruity-scented breath Confusion More specific signs of diabetic ketoacidosis — which can be detected through home blood and urine testing kits — include:  

High blood sugar level High ketone level in your urine

CAUSES Diabetic ketoacidosis is usually triggered by:  An infection or other illness can cause your body to produce certain hormones, such as adrenaline. Unfortunately, these hormones work against insulin — sometimes triggering an episode of diabetic ketoacidosis  A problem with insulin therapy missed insulin treatments or inadequate insulin therapy can leave you with too little insulin in your system, triggering an episode of diabetic ketoacidosis. Other possible triggers of diabetic ketoacidosis may include: Stress Physical or emotional trauma High fever Surgery Heart attack Stroke

Alcohol or drug abuse RISK FACTOR  Those who have type I diabetic mellitus  Younger than age of 19 WHEN TO SEEK MEDICAL ADVICE Contact your doctor if: You're vomiting and unable to tolerate any food or liquid Your blood sugar level is higher than your target range and doesn't respond to home treatment Your urine ketone level is moderate or high Seek emergency care if: Your blood sugar level is consistently higher than 300 milligrams per deciliter (mg/dL) or 16.5 millimoles per liter (mmol/L) You have excess ketones in your urine You have multiple symptoms of diabetic ketoacidosis — excessive thirst or urination, nausea and vomiting, abdominal pain, loss of appetite, shortness of breath, fruityscented breath, confusion

SCREENING AND DIAGNOSIS  Blood sugar level if there isn't enough insulin in your body to allow sugar to enter your cells, your blood sugar level will rise (hyperglycemia). As your body breaks down fat and protein for energy, your blood sugar level will continue to rise.  Ketone level when your body breaks down fat and protein for energy, toxic acids known as ketones enter your bloodstream.  Blood acidity If you have excess ketones in your blood, your blood will become acidic (acidosis). This can damage organs throughout your body.

COMPLICATIONS 

Low blood sugar (hypoglycemia) insulin allows sugar to enter your cells. This causes your blood sugar level to drop. If your blood sugar level drops too quickly, you may develop low blood sugar.  Low potassium (hypokalemia) the fluids used to treat diabetic ketoacidosis may cause your potassium level to drop too low. A low potassium level can impair the activities of your heart, muscles and nerves.  Swelling in the brain (cerebral edema) adjusting your blood sugar level too quickly can produce swelling in your brain. This complication appears to be more common in children, especially those who have newly diagnosed diabetes.

TREATMENT  Fluid replacement will replace those you've lost through excessive urination, as well as help dilute the excess sugar in your blood.  Electrolyte replacement you'll receive electrolytes through your veins to help keep your heart, muscles and nerve cells functioning normally.  Insulin therapy Insulin reverses the processes that cause diabetic ketoacidosis. Along with fluids and electrolytes, you'll receive insulin therapy — usually through a vein. When your blood sugar level falls below 250 mg/dL (14 mmol/L) and your blood is no longer acidic, you may be able to stop intravenous insulin therapy and resume your normal insulin therapy.