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DIABETES

DIABETES

A group of diseases characterized by hyperglycemia caused by defects


in insulin secretion, insulin action, or both
Affects nearly 25.8 million people in the United States; one third of
cases are undiagnosed
Prevalence is increasing
Minority populations and older adults are disproportionately affected

What does Insulin do?


Transports and metabolizes glucose for energy
Stimulates storage of glucose in the liver and muscle glycogen
Signals the liver to stop the release of glucose
Enhances storage of dietary fat in adipose tissue
Accelerates transport of amino acids into cells
Inhibits the breakdown of stored glucose, protein, and fat.

Type 1 Diabetes

Insulin-producing beta cells in the pancreas are destroyed by an autoimmune


process
Requires insulin because little or no insulin is produced
Onset is acute and usually before 30 years of age
5% to 10% of persons with diabetes

Risk factors
Family history of diabetes (e.g., parents or siblings with diabetes)
Obesity (i.e., 20% over desired body weight or body mass index 30
kg/m2)
Race/ethnicity (e.g., African Americans, Hispanic Americans, Native
Americans, Asian Americans, Pacific Islanders)
Age 45 years
Previously identified impaired fasting glucose or impaired glucose
tolerance
Hypertension (140/90 mm Hg)
High-density lipoprotein (HDL) cholesterol level 35 mg/dL (0.90 mmol/L)
and/or triglyceride level 250 mg/dL (2.8 mmol/L)
History of gestational diabetes or delivery of a baby over 9 lb

TYPE 2 DIABETES

Decreased sensitivity to insulin (insulin resistance) and impaired beta cell


function result in decreased insulin production
90% to 95% of person with diabetes, onset over age 30 years, increasing in
children, obesity
Slow, progressive glucose intolerance
Treated initially with diet and exercise
Oral hypoglycemic agents initially may need to convert to insulin or use both

Risk factors
obesity, age, previous identified impaired fasting glucose or impaired
glucose tolerance,
hypertension 140/90 mm Hg, HDL 35 mg/dL or triglycerides 250
mg/dL,
history of gestational diabetes or babies over 9 pounds

Symptoms of Diabetes
Common symptoms of diabetes:
Three Ps
Polyuria
Polydipsia
Polyphagia
Extreme fatigue , weakness
Blurry vision
dry skin, skin lesions or wounds that are slow to heal, recurrent
infections
Weight loss - even though you are eating more (type 1)
Tingling, pain, or numbness in the hands/feet (type 2)

DIAGNOSTICS
Fasting Plasma Glucose (FPG): greater than or equal to 126mg/dl
Casual (Random) plasma glucose concentration: Greater than or equal to
200mg/dl
Two-hour postload glucose (Oral Glucose tolerance test): greater than or
equal to 200mg/dl
Hemoglobin A1C

HYPOGLYCEMIA
Abnormally low blood glucose level <70
Causes: too much insulin or oral hypoglycemic agents, excessive physical
activity, and not enough food
Adrenergic symptoms: sweating, tremors, tachycardia, palpitations,
nervousness, hunger
Central nervous system symptoms: inability to concentrate, headache,
confusion, memory lapses, slurred speech, drowsiness
Severe hypoglycemia: disorientation, seizures, loss of consciousness,
death

**Cold and clammy, need some candy!!**

Hypoglycemia: Nursing Interventions:

Give client 15g of fast-acting simple carbohydrates

3 or 4 glucose tablets
4 oz of fruit juice or regular soda
6 to 10 hard candies
2 to 3 tsp of sugar or honey

If the client is unconscious or unable to swallow: Administer


glucagon IM or SQ. Repeat in 10 minutes if client is still
unconscious and notify provider

Follow 15/15/15 rule

Administer 15g of simple carbs


Wait 15 minutes and recheck blood glucose
Administer 15g more of carbs if blood glucose remains less
than 70mg/dl
Give 7g of protein when blood glucose is within normal limit
2 tbs of peanut butter
1 oz of cheese
8 oz of milk

Emergency Measures:
If the patient cannot swallow or is unconscious:
Subcutaneous or intramuscular glucagon (1 mg)
25 to 50 mL of 50% dextrose solution IV

HYPERGLYCEMIA

>110
NEED INSULIN!!!!!!!!!
Look for a reason (i.e- stress, infection, missed medication?)
Symptoms:
dry mouth,
extreme thirst
frequent urination
drowsiness

***"HOT AND DRY , SUGAR HIGH"***

TREATMENT GOAL: Maintain Normal Blood Glucose Levels (Hgb


A1C<7%)
Intensive control, defined as three or four insulin injections per day
or continuous subcutaneous insulin infusion
insulin pump therapy plus frequent blood glucose monitoring, and
weekly contacts with diabetic educators
dramatically decreases development and progression of
complications such as retinopathy, nephropathy, and neuropathy.

TREATMENT

Type 1 diabetics Must use Insulin


Type 2 diabetics
1. Healthy eating and exercise

2. Oral medication
3. Insulin (Syringe, Pen, or Pump)

Blood Glucose Control Agents


Insulin (short acting & long acting)
Insulin- mixtures
Glucose- Elevating agents
Oral Agents- Sulfonylureas, Biguanides, Meglitinides
Oral Agents- Thiazolidinediones, Alpha-glucosidase inhibitors,
oral combination therapy

Oral Antidiabetic Agents


Used for patients with type 2 diabetes who require more than diet
and exercise alone
Combinations of oral drugs may be used
Major side effect: hypoglycemia
Nursing interventions:
monitor blood glucose for hypoglycemia and other potential
side effects
Patient education

BASAL VS. BOLUS INSULIN


Basal insulin -background insulin that is normally supplied by the
pancreas and is present 24 hours a day whether or not the person
eats
Short acting/ Regular Insulin??????

Bolus insulin - refers to the extra amounts of insulin the pancreas


would naturally make in response to glucose taken in through food.
The amount of bolus insulin produced depends on the size of the
meal

Educating Patients in Insulin Self-Management


Use and action of insulin
Symptoms of hypoglycemia and hyperglycemia
Required actions
Blood glucose monitoring
Self-injection of insulin
Insulin pump use

COMPLICATIONS
Skin Complications (wounds, sugar isn't good for wound healing)
Eye Complications - nerve damage (Retinopathy)
Neuropathy
Foot Complications- (neuropathy) frequent checks, no lotion
between toes
DKA (Ketoacidosis) & Ketones
Hyperosmolar non-ketotic syndrome (HHNS)
Kidney Disease(Nephropathy)- lack of bld flow to kidney
High Blood Pressure (Hypertension)
Stroke
Gastroparesis
Heart Disease
Mental Health

DIABETIC KETOACIDOSIS (DKA)


Absence or inadequate amount of insulin resulting in abnormal
metabolism of carbohydrate, protein, and fat
Clinical features
Hyperglycemia
Dehydration
Acidosis
Refer to Figure 51-7
Sick day rules: refer to Chart 51-9

ASSESSMENT OF DKA
Blood glucose levels >300 to 1,000
Severity of DKA not only due to blood glucose level
Ketoacidosis is reflected in low serum bicarbonate, low pH; low PCO2
reflects respiratory compensation (Kussmauls respirations)
Ketone bodies in blood and urine
Electrolytes vary according to degree of dehydration; increase in
creatinine, Hct, BUN

TREATMENT OF DKA
Rehydration with IV fluid
IV continuous infusion of regular insulin
Reverse acidosis and restore electrolyte balance
Note: rehydration leads to increased plasma volume and decreased
K; insulin enhances the movement of K+ from extracellular fluid into
the cells
Monitor blood glucose, renal function and urinary output, ECG,
electrolyte levels, VS, lung assessments for signs of fluid overload

HYPERGLYCEMIC HYPEROSMOLAR SYNDROME

Hyperosmolar hyperglycemia is caused by a lack of sufficient


insulin; ketosis is minimal or absent
Hyperglycemia causes osmotic diuresis, loss of water and
electrolytes, hypernatremia, and increased osmolality
Manifestations include hypotension, profound dehydration,
tachycardia, and variable neurologic signs caused by cerebral
dehydration
High mortality rate

Treatment of HHS
Rehydration
Insulin administration
Monitor fluid volume and electrolyte status
Prevention
BGSM
Diagnosis and management of diabetes
Assess and promote self-care management skills

Nursing Diagnosis
Risk for infection
Risk for disturbed sensory perception
Powerlessness
Imbalanced nutrition less than body requirements
Deficient fluid volume
Fatigue
Knowledge Deficit

Nursing Interventions
Monitor blood glucose
Administer medications as prescribed
Provide education
Monitor VS and I&O
Refer to a diabetic educator
Monitor for complications

Patient Management Goals


Medication Administration
Insulin Storage & Syringe Safety
Blood Glucose Monitoring
Dawn Phenomenon vs. Somogyi phenomenon
Healthy Eating
Foot Care
Sick Days
Exercise

Dietary Management Goals


Maintain the pleasure of eating; include personal and cultural
preferences
Promote exercise and activity
Achieve and maintain BMI <25
Prevent wide fluctuations of blood glucose levels
Decrease serum lipids, if elevated

MEAL PLANNING
Consider food preferences, lifestyle, usual eating times, and cultural
and ethnic background
Review diet history and need for weight loss, gain, or maintenance
Caloric requirements and calorie distribution throughout the day;
exchange lists
Carbohydrates: 50% to 60% carbohydrates; emphasize whole grains
Fat: 20% to 30%, with >10% from saturated fat and <300 mg
cholesterol; protein: 10% to 20%
Fiber: 25 g daily; refer to Table 51-2

Carbohydrate Counting
Food changes into Blood Glucose!
Carbohydrates= up to 100%
Protein= 50-60%
Fat= less than 10%
DIABETES INSIPIDUS

Disorder of the Posterior Pituitary Gland


Deficiency of Antidiaretic Hormone or ADH Vassopressin
Signs and Symptoms= polydipsia and polyuria
Causes: secondary to head trauma, brain tumor, surgery or
irradiation of pituitary gland, infections of the central nervous
system, or tumors.
Diagnostic Tests: Fluid deprivation test (Plasma and urine
osmolality),
Treatment: Desmopressin (intranasal)

MANIFESTATIONS:
Urine Chemistry (Dilute): Decreased urine specific gravity and
decreased urine osmolality
-Serum Chemistry (concentrated): Hypernatremia, increased serum
osmolality, hypokalemia
-Polyuria and polydipsia: Increased urine output and crave excessive
amounts of water
-Dehydration, weight loss, and dry skin
-Hemoconcentration

Nursing Interventions
weigh daily
monitor urine output and urine specific gravity
assess the clients blood pressure and heart rate
maintain fluid and electrolyte balance
Client Education
lifetime vasopressin replacement therapy
report weight gain or loss, polyuria, or polydipsia
monitor fluid intake and urine output
avoid foods with diuretic action