NURSING MANAGEMENT:

DIABETES MELITUS

NURSING MANAGEMENT
A. Assessment

assess for level of knowledge &
ability to perform self care
ask clients whether they take
vitamin, mineral or herbal
supplements to decrease blood
glucose
Fluid volume deficit RT polyuria
and dehydration

Administer IVF
Encourage patient to increase oral fluid
intake
Monitor I&O
Monitor V/S

B. Nursing Diagnoses

Provide health teachings regarding the
following:
the disease & its treatment modalities
recognition & prevention of complications
appropriate preventive behaviors (foot care)
inspect feet on a daily basis
wear well-fitting, closed-toe shoes
avoid walking bare-footed, using heat pads &
shaving calluses
Trim toenails straight across without rounding
the corners

Knowledge deficit RT lack of information about the
disease & treatment
Readiness for Enhanced Therapeutic
Regimen Management

Explain the pathophysiology of diabetes
Plan an exercise program
Prevent complications from exercise
should be adequately hydrated
should eat 15-30g CHO if blood glucose
< 100 mg/dl
should carry CHO snack & DM
identification

Plan nutrition therapy to achieve target
blood glucose
balanced meal plan
calories = restrict 250-500 calories per day
than usual
CHON = 10% of daily calories
Fat = decrease total dietary fat to 30% or
less & limit saturated fat intake to 10%
CHO = 50-60%

Dietary management for clients
with Type 1 DM

Breakfast should be taken within 1
hr after morning insulin dose & CHO
eaten about 3 hrs later
Lunch should be taken 4-5 hrs after
morning insulin dose
Risk for Ineffective Therapeutic Regimen

Provide instruction on blood glucose
monitoring
provide instruction on urine testing
provide instruction on insulin administration
insulin concentrations
insulin syringes= 100 u in 1 ml
insulin storage= refrigerators
Avoid temperature extremes >36F/>86F
Vials can be stored at room temperature for 1
month
Inspect for flocculation

insulin preparation & injection
NPH & Lente should be agitated
vigorously
pre-filled syringes= chemically stable for up
to 3 weeks in refrigerator
Mixing regular & NPH in 1 syringe
site selection & rotation
abdomen, posterior arms, anterior thighs, hips
give injection in one area about an inch apart until
whole area has been used
avoid sites above muscles that will be exercised
heavily
rotate injection sites to decrease variability of
absorption


SURGICAL MANAGEMENT
Pancreas and Pancreas-Kidney
Transplantation
clients own pancreas is left intact and the
new pancreas is anastomosed to the iliac
artery and vein, through which insulin can
enter the systemic pathway.
The new pancreas is placed in the lower
pelvic cavity and the duct is connected to
the urinary bladder
ACUTE COMPLICATIONS OF DIABETES
MELLITUS
DIABETIC KETOACIDOSIS (DKA)
complication of Type 1 DM
commonly caused by:
taking too little insulin
skipping doses of insulin
inability to meet increased need for
insulin
developing insulin resistance
involves ketosis, dehydration &
electrolyte imbalance
Relative/absolute lack of insulin
Stress/infection/surgery
Depletion of carbohydrates for energy
Secretion of glycogen, catecholamine, cortisol, growth hormones
Lipolysis of adipose tissue
Ketogenesis
Release of ketones
Antagonizes the effect of insulin
Severe hyperglycemia
Ketosis
Acidosis
Nausea & vomiting Kussmauls respiration
Hyperosmolality of the blood
Hemoconcentration
Glucose uptake
Impaired renal threshold
Osmotic diuresis Glycosuria Hydrogen in the blood
H from the blood replaces K in the cell
K moves to the blood
Hyperkalemia
Dehydration
MANIFESTATIONS:(DKA)
NAVA
Dehydration
Fruity odor or
ketones on
breath
Hyperpnea
Hypotension
Impaired level of
consciousness


Polyuria
Tachycardia
Thirst
Visual
disturbances
Weakness
Weight loss


MANAGEMENT
Rehydrate
PNSS 1 L during the first hour, followed
by additional 2000 to 8000 ml of solution
over the next 24 hours
NGT insertion
Monitor I&O

Reverse Shock

administer blood, albumin or other
plasma volume expanders (Dextran)
alternately with PNSS


Restore Potassium Balance

Frequently assess and measure urine
output
Assess for hyperkalemia/hypokalemia
Replace potassium carefully
Resume intake of potassium-rich
foods if the client has recovered
Monitor Na, Cl and phosphate levels

Correct pH and administer insulin

administer sodium bicarbonate to
clients with a blood pH of 7.1 or
less
administer low-dosage insulin
therapy (5-10 units/hr)

Prevent recurrence - instruct
clients to:

Take insulin in appropriate doses at
appropriate times
Monitor blood glucose frequently
Monitor urine ketone levels
Schedule regular appointments to
review blood glucose levels


HYPERGLYCEMIC, HYPEROSMOLAR, NONKETOTIC
SYNDROME (HHNS)
Characterized by:
Extreme hyperglycemia (600 to 2000 mg/dl)
Profound dehydration (10-15% loss of body
water)
Mild or undetectable ketonuria
Hyperosmolality of plasma & elevated BUN.
Higher mortality than DKA
Interventions
infusion of PNSS over a 2-hour period, followed
by administration of hypotonic (0.45%)
saline solution
administration of K, Na, Cl, PO4, insulin

HYPOGLYCEMIA
Blood glucose level below 50-60
mg/dl
Results from:
Insulin overdose
Omitting a meal/eating less food than usual
Overexertion without additional CHO
compensation, nutritional & fluid
imbalances d/t N/V, alcohol intake
HYPOGLYCEMIA cont
Manifestations:
Adrenergic
Shakiness
Irritability
Nervousness
Tachycardia
Palpitations



Hunger
Tremor
Diaphoresis
Pallor
Paresthesias
HYPOGLYCEMIA cont
Neuroglycopenic
H/A
Mental illness
Irritability
Slurred speech


Blurred vision
Lethargy
Loss of
consciousness
Coma
Death
Management: (Hypoglycemia)
Return blood glucose to normal levels
give 15g of simple carbohydrate
administer IV glucose to unconscious client
administer glucagon 1mg IM/SQ
in severe cases, give 10-25g of IV glucose (as
50% or 25% dextrose) over 1-3 minutes
followed by infusion of 5% dextrose at 5-10g/hr
Prevent hypoglycemia


CHRONIC COMPLICATIONS OF DIABETES
MELLITUS
MACROVASCULAR COMPLICATIONS
Coronary Artery disease
Common in clients younger than age 40
years if diabetes is of long duration
Cerebrovascular disease
Atherothromboembolic infarctions
manifested by TIA & CVA
Hypertension
40% increase rate
CHRONIC COMPLICATIONS OF DIABETES MELLITUS cont
Peripheral vascular disease
carotid bruit, absent pedal pulses,
intermittent claudication & ischemic
gangrene
Infections
caused by impaired polymorphonuclear
leukocyte function
diabetic neuropathies and vascular
insufficiency
more common types of infection include
UTI & diabetic foot infections


MICROVASCULAR
COMPLICATIONS
Diabetic retinopathy
major cause of blindness among clients with
diabetes
80% have some form of retinopathy 15 yrs after
diagnosis
Nephropathy
single most common cause of End-Stage Renal
Disease (ESRD)
involves damage to and eventual obliteration of
the capillaries that supply the glomeruli of the
kidney

NEUROPATHY
Most common chronic complication of
DM (60%)
Caused by:
Vascular insufficiency
Chronic elevations in blood glucose level
Hypertension
Cigarette smoking.
NEUROPATHY cont
Mononeuropathy/focal neuropathy
usually involves a single nerve or group of
nerves; produce sharp & stabbing pains

Polyneuropathy/diffuse neuropathy
involves sensory & autonomic nerves; sensory is
more common & is bilateral, symmetrical &
affecting the lower extremities


Autonomic neuropathy
Pupillary interferes with the pupils ability
to adapt to the dark
Cardiovascular evidenced by abnormal
response to exercise (fixed heart with
orthostatic hypotension)
Gastrointestinal - dysphagia, abdominal
pain, N/V, malabsorption, postprandial
hypoglycemia, gastroparesis
Genitourinary bladder hypotonicity or
neurogenic bladder

Destruction of alpha and beta cells of the pancreas
Failure to produce insulin and/or insulin resistance
Elevated blood glucose
Chronic elevations in blood glucose
Glycoprotein cell wall deposits
Irritates the blood vessel
Permeability Elasticity of capillaries
Retinal edema
Microaneurysm & Retinal hemorrhage
Progression of hemorrhage
Visual acuity Blindness
Destruction of renal capillaries
Glomerular destruction
Renal impairment
ESRD
Reduced blood and nutrient
supply to the peripheral
nerves
Loss of sensation
Risk of break in the skin integrity
Poor healing
O2 & nutrients transport
Amputation