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
● 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
• >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
● Gestational diabetes
• has onset or discovery of glucose tolerance during
pregnancy
Diabetes
❧ Clinical Manifestations
● 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
● 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
● 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
• 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
● 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
● 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