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BSNIII-D Group D16 1. The eight risk factors assoiated with Diabetes Mellitus are obesity, family history (genes), race/ethnicity, age of 45 and above, previously identified impaired fasting glucose or impaired glucose tolerance, having hypertension, HDL cholesterol level of <35mg/dL and triglyceride level of >250mg/dL, history of gestational diabetes or delivery of baby of over 9 lbs. As a nurse, one must educate patient about diet, planning of activities and insulin shots, other medications and CBG monitoring. The nurse must also support the patient through encouragement and healthy coping
2. Current Classification Type 1 -5 to 10% of all diabetes -Previously classified as juvenile diabetes, juvenile-onset diabetes, ketosis-prone diabetes, brittle diabetes, and insulin dependent diabetes mellitus (IDDM) Clinical Characteristics and ClinicalImplications y Onset any age, but usually young (<30 years) y Usually thin at diagnosis; recent weight loss y Etiology includes genetic, immunologic, and environmental factors (e.g. virus) y Often have islet cell antibodies y Often have antibodies to insulin even before insulin treatment y Little or no endogenous insulin y Need insuln to preserve life y Ketosis prone when insulin absent y Acute complication of hyperglycemia: diabetic ketoacidosis y y y y y y y y y y Onset any age, usually over 30 years Usually obese at diagnosis Causes include obesity, heredity, and environmental factors No islet cell antibodies Decrease in endogenous insulin, or increased with insulin resistance Most patients can control blood glucose through weight loss if obese Oral antidiabetic agents may improve blood glucose levels if dietary modification and exercise are unsuccessful May need insulin on a short-term or long-term basis to prevent hyperglycemia Ketosis uncommon, except in stress or infection Acute complication: hyperglycemic hyperosmolar nonketotic syndrome Accompanied by conditions known or suspected to cause the diabetes: pancreatic diseases, hormonal abnormalities, medications such as corticosteroids and estrogen-containing preparations Depending on the ability of the pancreas to produce insulin, the
Type 2 -90 to 95% of all diabetes: obese 80% of type 2; nonobese 20% of type 2 -Previously classified as adult onset diabetes, maturity-onset diabetes, ketosis-resistant diabetes, stable diabetes, and non-insulindependent diabetes (NIDDM)
Diabetes Mellitus -Associated wit other conditions or syndromes -Previously classified as secondary diabetes
patient may require treatments with oral antidiabetic agents or insulin Gestational Diabetes y y y y y y Onset during pregnancy. signals the liver to stop the release of glucose. another pancreatic hormone called glucagon (secreted by the alpha cells of the islets of Langerhans) is released when blood glucose levels decrease and stimulates the liver to release stored glucose. protein and fat. It moves glucose from the blood into muscle. being an anabolic hormone. usually in the second or third trimester Due to hormones secreted by the placenta. during pregnancy or illness) Current normal glucose metabolism Impaired glucose tolerance or impaired fasting glucose screening after age 40 years if tere is a family history of diabetes or if symptomatoc Encourage ideal body weight. The insulin and ther glucagon together maintain a constant level of glucose in the blood by stimulating the release of glucose from the liver.In subsequent pregnancies . stimulates storage of glucose in the liver and muscle. accelerates transport of amino acids into cells and inhibits the breakdown of stored glucose. family history of diabetes. because loss of 10-15 lb may improve glycemic control 3. insulin to strictly maintain normal blood glucose levels Occurs in about 2-5% of all pregnancies Glucose intolerance transitory but may recur: . Insulin. 4. liver and fat cells where it performs all its major activities (written above). enhances storage of dietary fat in adipose tissue. Insulin is very important it transports and metabolizes glucose for energy. increases when a person eats. .30-40% will develop overt diabetes (usally type 2) within 10 years (especially if obese) Risk factors include obesity.and 28-weeks gestation Should be screened for diabetes periodically y y y Prediabetes -Previously classified as previous abnormality of glucose tolerance (Prev AGT) y y y y Previous history of hyperglycemia (eg. if needed. age older than 30 years. During fasting periods (between meals and overnight) the pancreas continuously releases a small amount of insulin (basal insulin). especially macrosomia (abnormally large babies) Treated with diet and. previous large babies (>9 lbs) Screening tests (glucose challenge test) should be perfomed on all pregnant women between 24. which inhibit the action of insulin Above-normal risk for perinatal complications.
It is caused due to fluctuations of the hormonal level during pregnancy. but it may be beneficial. which can be y y y . and induration or a 2. tenderness. insulin binds to special receptors on cell surfaces and initiates a series of reactions involved in glucose metabolism. Asian Americans. Type I diabetes is treated with insulin which is injected using an insulin pump. y Local Allergic Reactions. The effects of use of the glycemic index on blood glucose levels and on long-term patient outcomes are unclear. there is an immediate local skin reaction that gradually spreads into generalized urticatia (hives).to 4-cm wheal) may appear at the injection site 1 to 2 hours after the insulin administration. Normally. has a personal history of GDM. GDM occurs among pregnant women. It may be that the beta cells have been damaged by a viral infection or an autoimmune disease (in which the body's own immune system generates secretion of substances that attack the beta cells of the pancreas )and so their functioning is seriously impaired. Providing that the condition is diagnosed quickly and the diabetic controls their diet and insulin injections then there is no reason why they can t continue life as normal. glycosuria. it appears as slight dimpling or more serious pitting of subcutaneous fat. which causes insulin resistance. The physician may prescribe an antihistamine to be take 1 hour before the injection if such a local reaction occurs. Systemic Allergic Reactions. 7. Most patients have some degree of insulin resistance at one time or another. 6. The treatment is desensitization. swelling. occurring at the site of insulin injections. are becoming rare because of the increased use of human insulins. which usually occur during the beginning stages of therapy and disappear with continued use of insulin. Resistance to Injected Insulin.5. Gestational diabetes occurs in as many as 14% of pregnant women and increases their risk for hypertensive disorders during pregnancy. Native Americans. in the form of either lipoatrophy or lipohypertrophy. Insulin-dependant diabetes mellitus (IDDM) or Dm type 1 is caused by a lack of insulin secretion from the beta cells of the pancreas which cannot synthesize enough amount of insulin hormone as required by the body. A local allergic reaction (redness. Systemic allergic reactions to insulin are rare. African Americans and Pacific Islanders. Lipoatrophy is loss of subcutaneous fat. Hyperglycemia develops during pregnancy because of the secretion of placental hormones. or a strong family history of diabetes should be checked for GDM. Lipodystrophy refers to a localized reaction. Insulin Lipodystrophy. The term glycemic index is used to describe how much a given food increases the blood glucose level compared wit an equivalent amount of glucose. 8. rapid increase in blood glucose levels after eating. with small dose of insulin administered in gradually increasing amounts using a desensitization kit. Women who are marked obesity. These reactions. When they do occur. It utilized to avoid sharp. the most common being obesity. making insulin less effective at stimulating glucose uptake by the tissues and at regulating glucose release by the liver. This may occur for various reasons. The use of human insulin has almost eliminated this disfiguring complication. High-risk ethnic groups include Hispanic Americans. It is also used to describe how much a given food increases the blood glucose level compared with an equivalent amount of glucose. It is any degree of glucose intolerance with its onset during pregnancy. In type 2 diabetes. Type II diabetes is also called non-insulin dependant diabetes mellitus (NIDDM) and is caused by decreased sensitivity of target tissues to the metabolic effects of insulin and affects approximately 90% to 95% of people with the disease This reduced sensitivity is often referred to as insulin resistance which is commonly secondary to obesity. these intracellular reactions are diminished. These rare reactions are occasionally associated with generalized edema or anaphylaxis.
In most patients with diabetes wo take insulin. A constant level of insulin is required at all times. An elevated blood glucose level on arising in the morning is caused by an insufficient level of insulin. immune antibodies develop and bind the insulin. Administration of mixtures of rapid. y y y y y y Patients who are well controlled on a particular mixed-insulin regimen should maintain their standard procedure for preparing their insulin doses. there is no blunting of the onset of action of the rapid-acting insulin.y overcome by weight loss. Insulin glargine should not be mixed with other forms of insulin due to the low pH of its diluent. however. No other medication or diluent should be mixed with any insulin product unless approved by the prescribing physician. binding equilibrium may y . 9. Because of their rapid onset. physicochemical changes in the mixture may occur (either immediately or over time).or short. Currently available NPH and short-acting insulin formulations when mixed may be used immediately or stored for future use. Use of commercially available premixed insulins may be used if the insulin ratio is appropriate to the patient s insulin requirements. There are varying opinions regarding which type of insulin (short. the postprandial blood glucose response was similar when rapid-acting insulin was mixed with either NPH or ultralente. Longer. On mixing. Intermediate-acting insulins function as basal insulins but may have to be split into two injections to achieve 24-hour coverage. and human insulins to lesser degree. Mixing of short-acting and lente insulins is not recommended except for patients already adequately controlled on such a mixture. The formulations and particle size distributions of insulin products vary. cause antibody production in humans.acting insulin must be mixed thoroughly before drawing into the syringe.or long-acting insulins will produce a more normal glycemia in some patients than use of a single insulin. y Patients should not inject one type of insulin into the bottle containing a different type of insulin. As a result. the patient should be instructed to eat no more than 5 to 15 minutes after injection. Zn2+ present in lente insulins (e.and intermediate. but not the total bioavailability. Because of the short duration of action of these insulin analogues. The ADA recommends that the regular insulin be drawn up first. so as not to draw up the wrong dose in error or the wrong type of insulin. But we must keep in mind that the most important issue with regards to this are: y Patients should be consistent in the technique that they use. the Somogyi effect.or long-acting insulin. Rapid-acting insulins produce a more rapid effect that is of shorter duration than regular insulin. Injecting cloudy insulin into a vial of clear insulin contaminates the entire vial of clear insulin and alters its action. or insulin warning. is seen when rapid-acting and protamine-stabilized insulin (NPH) are mixed. thereby decreasing the insulin available for use.g. When rapid-acting insulin is mixed with either an intermediate.. the mixture should be injected within 15 min before a meal. Basal insulin is necessary to maintain blood glucose levels irrespective of meals. In clinical trials. A slight decrease in the absorption rate. When rapid-acting and ultralente insulins are mixed. The degree and rate of binding varies with the ratio and species of the two insulins. the physiological response to the insulin mixture may differ from that of the injection of the insulins separately.acting or rapid acting) should be drawn up first into the syringe when they are going to be mixed. Clinical insulin resistance has been defined as a daily insulin requirement of 200 units or more. All animal insulins. which may be caused by several factors: the dawn phenomenon. Morning Hyperglycemia. Upon mixing. lente and ultralente) will bind with the short-acting insulin and delay its onset of action. patients with type 1 diabetes and some patients with type 2 or gestational diabetes also require a long-acting insulin (basal insulin) to maintain glucose control.
Press cotton ball over injection site for several seconds. the needle should be embedded within the skin for 5 s after complete depression of the plunger to ensure complete delivery of the insulin dose. Patients should be aware that air bubbles in an insulin pen can reduce the rate of insulin flow from the pen. f. Injecting insulin at room temperature. If short-acting and lente mixtures are to be used. even if the needle remains under the skin for as long as 10 s after depressing the plunge If an injection seems especially painful or if blood or clear fluid is seen after withdrawing the needle. e. Follow state regulations for disposal of syringes and needles Disposal . If the patient suspects that a significant portion of the insulin dose was not administered. Pull the needle straight out of skin. welts. g. y y y y y With on hand stabilize the skin by spreading it or pinching up a large area. Making sure no air bubbles remain in the syringe before injection. soreness. b.g. Insert the needle straight in to the skin. the patient s injection technique should be reviewed by a physician or diabetes educator. d. Routine aspiration (drawing back on the injected syringe to check for blood) is not necessary. underdelivery of insulin can occur when air bubbles are present. Proper technique for self-injection of insulin and disposal of syringe Injections are made into the subcutaneous tissue. Penetrating the skin quickly. If bruising. Most individuals are able to lightly grasp a fold of skin and inject at a 90° angle.. especially in the thigh area. Particularly with the use of insulin pens. therefore. To inject the insulin. or pain occur at the injection site. NPH insulin) should not be mixed with lente insulins.y y not be reached for 24 h. the patient should apply pressure for 5 8 s without rubbing. Blood glucose monitoring should be done more frequently on a day when this occurs. Not reusing needles. push the plunger all the way in. the patient should standardize the interval between mixing and injection. Thin individuals or children can use short needles or may need to pinch the skin and inject at a 45° angle to avoid intramuscular injection. c. and the longer-acting insulin will convert to a short-acting insulin to an unpredictable extent. Waiting until topical alcohol (if used) has evaporated completely before injection. Insulin formulations may change. 10. when injecting. Phosphate-buffered insulins (e. redness. Painful injections may be minimized by the following: a. blood glucose should be checked within a few hours of the injection. not tense. Use disposable syringe only once and discard into hard plastic container (with a tight-fitting top) such as empty bleach or detergent container. Not changing direction of the needle during insertion or withdrawal. the manufacturer should be consulted in cases where its recommendations appear to conflict. Keeping muscles in the injection area relaxed. Zinc phosphate may precipitate. Pick up syringe with the other hand and hold it as you would a pencil.
g. Unless the syringe will be reused. Local trash disposal authorities should be consulted to determine the appropriate disposition of such containers. 150 or 300 units) of insulin are available. The phenomenon is thought to result from nocturnal surges in growth hormone secretion. placement of containers of used syringes. It is important to teach the patient on what to eat and what to avoid like smoking. Dawn Phenomenon is characterized by a relatively normal blood glucose level until approximately 3am. Recapping. It is treated by Decreasing evening (predinner or bedtime) dose of intermediate-acting insulin. First.Then i will eduate patient about CBG and he importance of monitoring. improve glycemic control.Regulations in some states require the destruction of used insulin syringes and needles. I will encourage the patient and his family to have a regular exercise that can improve the functioning of the cardiovascular system. After all of the insulin has been used. diet and administration of insulin and other oral medications and the importance of taking medications exactly as prescribed. . It is treated by Changing the time of injection of evening intermediate-acting insulin from dinnertime to bedtime. I will teach patients about further complications that may happen for DM patients and ask them to takes steps to prevent eye disease. i will discuss their illness. low-fat dairy products. Disposable insulin pens that contain a limited capacity (e. controlling and maintaining the level of their blood glucose. ). and poultry. the pen device can be discarded in the garbage can with regular trash. bending. in the appropriate dose. improve strength and flexibility. Proper skin and foot care is needed to avod bruising and sores. The likelihood of reuse of a syringe by another person is decreased if the plunger is separated from the barrel at the time of disposal. when blood glucose levels begin to rise. 12. . I will help the patient plan their daily activities. Patients should be taught specific directions for obtaining an adequate blood sample and what to do with the numbers that they receive. In areas with container-recycling programs. its causes and prevention. and lancets with materials to be recycled is prohibited. which create a greater need for insulin in the early morning hours in patients wit type 1 diabetes. I will show the patient how to properly administer insulin by themselves. and improve quality of life and self-esteem. which retains the clipped needle in an inaccessible compartment. vegetables. improve lipid levels. needles. whole grains. lean meats. Patients whould also be aware of cholesterol and lipid management. help decrease weight. 11. or breaking a needle increases the risk of needle-stick injury. The patient will be taught to take and monitor CBG and symptoms felt with time and date indicated. based on how their bodies are responding to specific foods. Patients should be provided with a list of signs and symptoms of hypoglycemia and hyperglycemia and actions to take in each situation. fish. inject the insulin. it should be placed in a puncture-resistant disposal container or needle-clipping device. or increase bedtime snack. a decrease at 2-3am to hypoglycemic levels and a subsequent increase caused by the production of counterregulatory hormones. blood pressure monitoring and management and management of other disease processes. The patient should test blood glucose levels pre-meal and post-meal can help the patient with diabetes make better food choices (Patients with diabetes need to maintain a healthy diet consisting of multiple servings of fruits. The Somigyi Effectis characterized by normal or elevated blood glucose at bedtime.. Inform the patient to report any signs or symptoms instantly so that action can be started. Users select the dose. and then discard the needle according to local regulations.
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