Maximin A.

Pomperada, RN, MAN Pomperada,

Diabetes Mellitus
 Affects

the metabolism of carbohydrate, protein, and fat Result : HYPERGLYCEMIA

 End

Review A&P

Role of Insulin


Insulin:
Counters metabolic activity that would increase blood glucose levels Enhances transport of glucose into body cells Lowers blood glucose levels

Physiology Cont: Insulin

 

Basal (continuous) Prandial (Bolus)

*Blood glucose increases within 10 minutes of the beginning of a meal*

Physiology Cont: Glucose Control

Patho: DM Type 1

Patho Cont: DM Type 2

Normal Physiology

PathophysiologyPathophysiology-Cont.:DM Type 2

DM 1&2: THE BIG DIFFERENCEu

DM TYPE 1 NO ENDOGENOUS INSULIN TX REQUIRES INSULIN INJECTIONS Usually < age 30 yrs. KETOSIS PRONE (DKA) Former names: IDDM (Juvenile) Diabetes Type I Thin to normal body weight ACUTE METABOLIC COMPLICATIONS (DKA)

DM TYPE 2
Some endogenous insulin Tx diet and exercise 1st, then pills and /or insulin Usually over 30 yrs. (peaks at 50) NO KETOSIS NIDDM (maturity/adult- onset) (maturity/adultDiabetes Type II Usually Overweight CHRONIC VASCULAR COMPLICATIONS

Diabetes: Clinical Manifestations

THE 3 POLYs POLYDYPSIA

POLYURIA

POLYPHAGIA

13

Diabetes Clinical Manifestations Cont: Signs and Symptoms

Early signs  3 Polys  Weight loss  Fatigue/Always tired  Visual Blurring Late signs  Any of the 3 Polys  Infections  Numbness/ tingling of feet or leg pain  Slow healing wounds  Chronic Complications

Diabetes: Dx Tests


Fasting Blood Glucose (FBS): <100 mg/dL mg/dL

70-110 mg/dL 70mg/dL

Check MD orders or agency protocol for frequency of BS Monitoring In General: AC&HS if pt able to eat; Q4-6 hours if NPO or tube feedings

*Random/Casual Blood Glucose*:<200 mg/dL mg/dL



Oral Glucose Tolerance Test (OGTT): < 140 mg/dL mg/dL Glycosylated Hemoglobin (HgbA1C): 4-6% 4-

Diabetes: Diagnostic Tests Cont.

 Glycosylated

hemoglobin test Hemoglobin A1C (HbA1c)

measures the amount of glycosylated hemoglobin (hemoglobin that is chemically linked to glucose) in blood.
Normal -4-6% Target range DM patient <7%

HbA1C Control

Criteria for the Diagnosis of Diabetes Mellitus

Diabetes- positive findings from any two of the following tests on different days: Symptoms of diabetes mellitus* plus casual (random) plasma glucose concentration >=200 mg / dL or FBS >=126 mg per dL or 2hr GTT >=200 mg per dL after a 75-g glucose load

Diagnostic Tests Cont. Is it Diabetes Yet?

>126 >200 >6

100-125 140-200

Impaired Fasting Glucose Impaired Glucose Tolerance

<100 <140 <6

Acute Complications
Diabetic Ketoacidosis (DKA)  BS > 300 mg/dL mg/dL  Classic symptoms  Ketosis


HyperglycemicHyperglycemicHyperosmolar Nonketotic Syndrome (HHNS)  BS > 800 mg/dL mg/dL  Similar symptoms  No Ketosis


Check urine for ketones

(ADA)

Chronic Complications of DM

Effects on Blood Vessels

Blood Vessel Lumen

Chronic Complications - Macrovascular

 Cardiovascular

heart disease
 Cerebrovascular

Stroke
DM pts have heart disease and stroke risks 2 to 4 X higher than non-DM pts

 Peripheral

vascular

disease

Long Term Complications

Cardiovascular:


increases occurrence of hypertension and decreased perpherial circulation

Chronic ComplicationsComplicationsMicrovascular :
 Diabetic

Retinopathy

The leading cause of new cases of blindness in adults ages 20 - 74

Chronic ComplicationsComplicationsMicrovascular
Nephropathy
The leading cause of end-stage renal disease (ESRD), occurs in about 20 40% of patients with diabetes

Long Term Complication

Nephropathy  affects microcirculation of kidneys  can cause kidney failure Hemodialysis

Chronic Complications-Microvascular ComplicationsDiabetic Neuropathy - the poor blood supply

will cause the nervous system to malfunction

Long Term Complications

Neuropathy:  causes pain in legs, then no feeling  Ensue safety issues

Chronic Complications

Amputation of Toes

Chronic ComplicationsComplicationsMicrovascular


Sexual problems for men

erectile dysfunction retrograde ejaculation



Sexual problems for women

decreased vaginal lubrication decreased sexual response



Urologic problems for men and women

urinary tract infections neurogenic bladder

Complications: Lipodystrophy
indurated areas of subcutaneous tissue  injecting cold insulin or not rotating sites


Complications: Hyperglycemic hyperosmolar nonketotic coma (HHNK)

Extremely high glucose levels  Caused by dehydration  No ketosis; elevated BUB  Treatment: replace fluids and electrolytes, insulin


Long Term Complications

Infection
Increased sugar in body fluids is an ideal medium for growth of microorganisms  urinary tract infections, etc.


Cellulitis

Chronic ComplicationsComplicationsMicrovascular
 Gastroparesis

Nerve damage to the digestive system most commonly causes constipation. Damage can also cause the stomach to empty too slowly

Long Term Complications

Nursing Interventions  Assess for each complication early
 Teach

patient to maintain control of the illness & to consistently keep blood sugar within normal ranges

MANAGEMENT OF DM
 Regular

Blood Glucose Monitoring

DRUG THERAPY

DIET

39

EXERCISE

Management: Diet & Exercise

Diet : Diabetes Food Pyramid

Diet Cont: What to do???

Diet Cont. CarbCarb-Counting

Diet Cont: Glycemic Index

Diet Cont.: Getting the balance right

Get your portions right!!

Management: Exercise


Helps regulate blood glucose

Increases insulin effectiveness and sensitivity in the body. Must monitor insulin and food intake to match exercise regimen.

Drug Therapy
Insulin & Oral Antidiabetic Agents

Interventions: Insulin
Insulin therapy:
 Opens

the door for glucose to enter the cell & be used for energy

Drug Therapy: Insulin Types



Fast-acting insulin
Rapid Acting Insulin Analogs


Aspart, Lispro, Glulisine

Regular Human Insulin

BOLUS Used to lower blood sugar after eating a meal

Intermediate-acting insulin
NPH Human Insulin Pre-Mixed Insulin


Humulin 70/30, Humalog 75/25

Long-acting insulin
Insulin Glargine, Insulin Detemir

BASAL Used to lower blood sugar throughout the day and night

Drug Therapy Cont.: Insulin

 Onset - how soon it starts to work in the blood  Peak - when the insulin has the greatest effect on blood sugar levels  Duration how long it keeps working

Drug Therapy Cont:

Goal of Insulin Therapy

Basal and Bolus Insulin Coverage

Sample Insulin Regimen (NPH & Regular insulin)

Drug Therapy-Insulin Cont: Therapy-

Rapid Acting Logs Logs

Humalog Humalog (insulin lispro) Novolog Novolog (insulin aspart) Bolus insulin  Onset 15 min; peaks 1-2 hrs; lasts 4-6 4hours  Ideal for meal coverage


Give the shot while the plate is hot! hot!

Drug Therapy-Insulin Cont: Therapy-

Short Acting: Regular Insulin Regs

Bolus insulin  Onset -1 hr; peaks 2-4 hrs; lasts 6-8 hrs


Give 30 minutes to 1 hour before a meal

Drug Therapy-Insulin Cont: Therapy-

Short Acting: Regular Insulin

Its time give you your regular insulin Its time to give it 30 minutes before your plate is in Come back to check you in 2 (hours) Watch out for shakes and sweats too If your lucky youll have no clue!!!!

Drug Therapy-Insulin Cont: TherapyRapid Acting (Humalog/Novolog) VS. Short Acting (Regular Insulin)
Delayed onset Peaks in 2-4 hr Lasts 6-8 hours

Rapid onset 1-2 hour peak Limited duration

Drug Therapy-Insulin Cont: Therapy-

Intermediate acting: NPH Insulin



Basal insulin: covers blood sugar between meals Satisfies overnight insulin requirement Onset 1-2 hrs, peaks 6-10 hrs, lasts 12+ hrs Need snack if NPH given at 5 pm (only) Ideal to be given at 9 pm (HS) to address Dawn Phenomenon

Drug Therapy-Insulin Cont: Therapyongong-Acting: Peakless Insulins!!! Insulins!!!

Lantus (insulin glargine) Levimir (insulin detimir)

 Basal

Insulin  Onset 1.5 hrs; no peak (max effect in 5 hrs); lasts 24 hours  No risk for hypoglycemia  Do not mix with other insulins becomes
inactivated when mixed with other insulins

Lantus

Drug TherapyTherapyInsulin Cont: Hypoglycemia



BS < 60-70 mg/dL 60An acute complication of insulin administration Tx: (15/15 or 20/20 Rule) Give 15/20 g simple carb and recheck BG in 15/20 minutes

Preparing Insulin for Injection

When mixing insulin:  Clear to cloudy  Do not mix long acting insulin with any other insulin or solution.  If giving at the same time as a rapid acting insulin, the nurse must use a separate syringe and a different site

Synthetic injectables
 Byetta:

Synthetic incretin mimetic hormone

Indicated for patients with type 2 diabetes who dont use insulin

 Symlin:

Synthetic analogue of human amylin

Approved for use with insulin in adults with type 1 and type 2 diabetes

Other Methods of Insulin Administration

For Uncontrolled DM 1 0r 2

Rapid-acting insulin

Continuous IV insulin infusion



Used to maintain glycemic control in hospitalized patients with high blood glucose levels; in DKA and HHNS Regular insulin may be used IV May also be given preoperatively or postoperatively More frequent BS monitoring ( q12 hours per agency protocol)

Drug Therapy Cont: Oral Antidiabetic agents

New Oral Med

 Januvia

(Sitagliptin)

An oral drug that reduces blood sugar levels in patients with type 2 diabetes. Sitagliptin is the first approved member of a class of drugs that inhibit the enzyme, dipeptidyl peptidase-4 (DPP-4).

Acute Complication of Insulin and (some) Oral Meds Hypoglycemia

Hyperglycemia

Diabetic Teaching Needs

Disease process S/S of hyperglycemia and hypoglycemia Blood sugar monitoring Diet Exercise Drug therapy Sick Day Rules Complications (acute and chronic) Prevention: Foot care, eye exam etc.

Health Teaching

Health Teaching: Foot Care

 Daily

cleanse feet in warm soapy water  Rinse and dry carefully  Inspect, dont break blisters  Trim nails to follow natural curve of toe

 Always

wear breathable shoes such as leather  No crossing of the legs  No cream between toes  Inspect visually daily

Health Teaching


Storage & dose preparation Syringes Blood glucose monitoring

Interpretation of results Frequency of testing

Health Teaching
 Injection

techniques ( intrasite

rotation)
 Dietary

management

 Quit

smoking

 Stress

Management (stress increases blood sugar)

DIABETES can be controlled!!!

THANK YOU NURSES!

Diabetes Mellitus
Practice Questions

The client, an 18-year old female, 18comes to the clinic with a wound on her left lower leg that has not healed for 2 weeks. Which disease process would the nurse suspect that the client developed?
A. B. C. D. Type 1 DM Type 2 DM Gestational DM Secondary DM

The client diagnosed with Type 1 DM has a glycosylated Hgb (A1C) of 8.1%. Which interpretation should the nurse make based on this result?
A. B. C. D. This This This This result result result result is is is is below normal levels within acceptable range above recommended levels dangerously high

The nurse administered 28 units of Humulin N, an intermediate acting insulin, to a client diagnosed with Type 2 DM at 1700. Which action should the nurse implement?
A. Determine how much food the client ate at lunch B. Perform a glucometer reading at 0700 C. Ensure the client eats a bedtime snack D. Offer the client protein after administering insulin

client diagnosed with Type 2 DM is receiving Humalog, a rapid-acting insulin, Humalog, rapidby sliding scale.  The order reads blood glucose level: <150, give 0 units 151-200, give 3 units 151201201-250, give 6 units >251, contact MD  The clients BS is 189 mg/dL. mg/dL.
 The

How much insulin should you administer? What is the most important follow-up followassessment for this patient and when?

76 year old client with Type 2 DM that must be controlled with 70/30 combination insulin. Which intervention should be included in the plan of care?
A. Assess the clients ability to read small print B. Monitor the clients coagulation studies C. Teach the client how to perform a HgbA1C test daily D. Instruct the client to check the feet weekly.

The client with Type 2 DM controlled with biguanide oral diabetic medication is scheduled for a computed tomography with contrast of the abdomen to evaluate pancreatic function. Which intervention should the nurse implement? A. Provide a high fat diet 24 hours prior to test B. Hold the biguanide medication for 48 hours to test C. Obtain an informed consent for the test D. Administer pancreatic enzymes prior to test

The diabetic educator is teaching a class on diabetes Type 1 and is discussing sicksickday rules. Which interventions should the educator include in the discussion?

A. Take diabetic medication even if unable to eat the clients normal diabetic diet B. If unable to eat, drink liquids equal to clients normal caloric intake C. It is not necessary to notify health care provider if ketones are present in urine D. Test blood glucose levels frequently and test urine for ketones once a day and keep a record

 

The client received 10 units of Humulin R, a fast acting insulin, at 0700. At 1030, the unlicensed nursing assistant tells the nurse the client has a headache and is asking for his lunch tray early because he is feeling very hungry. Which action should the nurse implement first?
A. Order the clients lunch tray from the kitchen and give it to him early B. Have the client drink 8 ounces of orange juice C. Go to the clients room and assess the client for hypoglycemia D. Prepare to administer 1 amp of 50% Dextrose intravenously E. Instruct the nursing assistant to obtain a blood glucose level

The client diagnosed with Type 1 DM is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first?
A. B. C. D. Notify the physician Check the serum glucose level Administer 50% dextrose IVP Move the client to the ICU

The nurse is discussing ways to prevent DKA with the client diagnosed with Type 1 DM. Which instruction would be most important to discuss with the client? A. Refer the client to American Diabetes Association B. Do not take any over the counter medications C. Take the prescribed insulin even when unable to eat because of illness D. Be sure to get you annual flu and pneumonia vaccines

Your patient will initially be taking Humulin N/Humulin N/Humulin R 70/30 insulin subcutaneously q a.m., a sliding-scale dose of regular insulin slidingsubcutaneously before lunch and dinner, and Humulin N insulin at bedtime.  Which statement made by a client indicates that she correctly understands selfselfadministration of insulin?


A) "My daily dose of 70/30 insulin is based on how much I ate the day before." B) "The amount of short-acting insulin I take shortevery day is based on my blood sugar readings." C) "I should store my insulin in the refrigerator and remove it thirty minutes before I need it." D) "I will alternate my injection sites from leg to abdomen each day to avoid overuse." 11.

An hour before the next dose of slidingslidingscale insulin is scheduled, the client tells the nurse, "I guess Im really nervous about giving myself insulin injections. Look how shaky and sweaty I am. What is the priority nursing action? A) Obtain Laras vital signs. B) Check Laras blood glucose. C) Assure Lara that she will be able to give herself the injections. D) Offer to bring Lara an orange so she can practice giving injections.
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After discharge, Lara is scheduled for a followfollowup evaluation at the outpatient clinic. A glycosylated Hgb level is drawn, and the results were 11%.  Which statement by Lara reflects understanding of glycosylated Hgb? Hgb?


A) "The results of the test are probably high, because I was not fasting before my blood was drawn this morning." B) "The results of my test are probably high, because I went to a party last night and did not follow my diet." C) "I know that I need to check my glycosolated Hgb before each meal and at bedtime, but I dont always have time." D) "At least I won't have this done again for 3 months. I will really work at following my diet between now and then." 21.

Lara tells the nurse that her 15-year-old sister 15-yearhad a fasting blood glucose test last week, because she felt that she had some of the same symptoms that Lara had before being diagnosed with diabetes.  Lara states her sister's results were 135 mg/dl.


How should the nurse respond? A) "She needs a second test performed before a diagnosis is made." B) "Since her value is high, it sounds like both of you have diabetes." C) "Her value is low and indicates that she does not have diabetes." D) "She is too young to develop Type 1 diabetes. She may have Type 2."

22.

Lara talks to the nurse about what to do if she gets sick. She states, "It just doesnt make sense to take my insulin when I feel sick, knowing I wont want to eat anything.  How should the nurse respond?


A) "You are right. You should not take your insulin if you are feeling sick." B) "Take only sliding-scale insulin, not your slidingregular dose, if you are feeling sick." C) "Being sick increases your blood sugar. Taking your usual insulin dose is important." D) "When you are sick, you should test your urine and only take insulin if ketones are present."
23.

 Which

finding indicates that Lara is experiencing a complication of diabetes? A) Burning sensation in her toes. B) Visual acuity of 60/20. C) Lack of protein in her urine. D) Blood pressure of 110/60.