ADVANCED MEDICAL-SURGICAL MS3
Diabetes Mellitus INSULIN SECRETION AND FUNCTION 1. Insulin is a hormone secreted by the beta cells of the islet of Langerhans in the pancreas. 2. Small amounts of insulin are released into the bloodstream in response to changes in blood glucose levels throughout the day. 3. Increased secretion or a bolus of insulin, released after a meal, helps maintain euglycemia. 4. Through an internal feedback mechanism that involves the pancreas and the liver, circulating blood glucose levels are maintained at a normal range of 60 to 110 mg/dL. 5. Insulin is essential for the utilization of glucose for cellular metabolism as well as for the proper metabolism of protein and fat. a. Carbohydrate metabolismâ€”insulin affects the conversion of glucose into glycogen for storage in the liver and skeletal muscles, and allows for the immediate release and utilization of glucose by the cells. b. Protein metabolismâ€”amino acid conversion occurs in the presence of insulin to replace muscle tissue or to provide needed glucose (gluconeogenesis). c. Fat metabolismâ€”storage of fat in adipose tissue and conversion of fatty acids from excess glucose occurs only in the presence of insulin. 6. Glucose can be used in the endothelial and nerve cells without the aid of insulin. 7. Without insulin, plasma glucose concentration rises and glycosuria results. a. Absolute deficits in insulin result from decreased production of endogenous insulin by the beta cell of the pancreas. b. Relative deficits in insulin are caused by inadequate utilization of insulin by the cell. CLASSIFICATION OF DIABETES A. Type 1 Diabetes Mellitus Type 1 diabetes mellitus was formerly known as insulin dependent diabetes mellitus and juvenile diabetes mellitus. 1. Little or no endogenous insulin, requiring injections of insulin to control diabetes and prevent ketoacidosis. 2. Five to 10% of all diabetic patients have type 1. 3. Etiology: autoimmunity, viral, and certain histocompatibility antigens as well as a genetic component. 4. Usual presentation is rapid with classic symptoms of polydipsia, polyphagia, polyuria, and weight loss. 5. Most commonly seen in patients under age 30 but can be seen in older adults. B. Type 2 Diabetes Mellitus Type 2 diabetes mellitus was formerly known as noninsulin dependent diabetes mellitus or adult onset diabetes mellitus. 1. Caused by a combination of insulin resistance and relative insulin deficiencyâ€”some individuals have predominantly insulin resistance, whereas others have predominantly deficient insulin secretion, with little insulin resistance. 2. Approximately 90% of diabetic patients have type 2. 3. Etiology: strong hereditary component, commonly associated with obesity. 1
HbA1c) Description 2
. Usual diet and exercise pattern must be followed for 3 days before OGTT. Found primarily in adults over age 30. Blood Glucose Description Fasting blood sugar (FBS). make sure that patient has maintained 8-hour fast overnight.ADVANCED MEDICAL-SURGICAL MS3
4. phenytoin. weight gain. During OGTT. 4. are still referred to as having type 2 diabetes. Advise patient that for accuracy in results. Oral Glucose Tolerance Test Description The oral glucose tolerance test (OGTT) evaluates insulin response to glucose loading. For fasting glucose. For random blood glucose. 2.
2. Oral contraceptives. 3. note the time and content of the last meal. Random blood sugar greater than or equal to 200 mg/dL and presence of classic symptoms of diabetes (polyuria. b. 1. may be seen in younger adults and adolescents who are overweight. Patients with this type of diabetes.
Nursing and Patient Care Considerations 1.and long-term glucose control. the patient must refrain from smoking and remain seated. For postprandial test. 2. Glycated Hemoglobin (Glycohemoglobin. nonfasting. drawn after at least an 8-hour fast. Interpret blood values as diagnostic for diabetes mellitus as follows: a. Fasting blood glucose result of greater than or equal to 100 mg/dL demands close follow-up and repeat monitoring. however. Diagnostic for diabetes mellitus if 2-hour value is 200 mg/dL or greater. but who eventually may be treated with insulin. DIAGNOSTIC TESTS LABORATORY TESTS Laboratory tests include those tests used to make the diagnosis as well as measures to monitor short. salicylates. 6. and 3 hours (may be 4. certain instructions must be followed: a. and recurrent infection. 5. diuretics.or 5-hour sampling). 1. to evaluate circulating amounts of glucose. postprandial test. FBS greater than or equal to 126 mg/dL on two occasions b. Advise patient to refrain from smoking before the glucose sampling because this affects the test results. drawn at any time. 2. to evaluate glucose metabolism. and weight loss) 6. polyphagia. Usual presentation is slow and typically insidious with symptoms of fatigue. poor wound healing. and nicotinic acid can impair results and may be withheld before testing based on the advice of the health care provider.
Nursing and Patient Care Considerations 1. 5. sips of water are allowed. and random glucose. drawn usually 2 hours after a well-balanced meal.to 200-g glucose load (usual amount is 75 g). polydipsia. and blood samples are drawn at Â½. advise patient that no food should be eaten during the 2-hour interval. FBS is obtained before the ingestion of a 50. c.
B. Evening or bedtime dosage can be helpful in controlling early-morning hyperglycemia.
. BLOOD GLUCOSE MONITORING Accurate determination of capillary blood glucose assists patients in the control and daily management of diabetes mellitus. short-. Test results can be affected by red blood cell disorders (eg. No prior preparation. NPH/Regular or NPH/Lispro 1. Short-acting regular insulin can also be given I. Many methods exist for performing the test. lispro. Typically. About 20 types of insulin are available in the United States. 3. 3. making it necessary to consult the laboratory for normal values
GENERAL PROCEDURES AND TREATMENT MODALITIES 1. such as fasting or withholding insulin.or immediate-acting insulin added to morning NPH controls glucose elevations after breakfast. or aspart insulin given before breakfast and before supper is termed a â€œsplitmixâ€• regimen. and ambient blood glucose values. 2/3 to Â¾ of the daily dosage is given before breakfast and 1/3 to Â¼ is given at bedtime. 2. NPH can also be given twice daily (morning and bedtime) to eliminate afternoon hypoglycemia yet provide nighttime coverage. Traditionally given as a morning dosage to assist with normalization of glucose during the afternoon and evening. Short. Insulin Regimens NPH Only 1.to 120-day period by measuring the irreversible reaction of glucose to hemoglobin through freely permeable erythrocytes during their 120-day lifecycle. NPH and regular. reflects glucose excursion after meals. Blood glucose monitoring helps evaluate effectiveness of medication. Used alone only in type 2 diabetes when patients are capable of producing some exogenous insulin as a supplement for better glucose control. 2. or long-acting insulin at various times to achieve the desired effect.V. 2. Combination Oral Agent and Insulin Therapy 1. Only about 6% of diabetics are still using beef or pork insulin due to problems with immunogenicity. Short-acting regular insulin or immediate-acting lispro (Humalog) or aspart (Novolog) insulin is added to NPH to promote postprandial glucose control. 4. assesses glucose response to exercise regimen. sickle cell anemia). and assists in the evaluation of episodes of hypoglycemia and hyperglycemia to determine appropriate treatment 2. providing 24-hour insulin coverage for type 1 diabetes. thalassemia. A. room temperature.ADVANCED MEDICAL-SURGICAL MS3
Measures glycemic control over a 60. ionic charges. 3.or immediate-acting insulin before supper. Appropriate only in type 2 diabetes. 4. Increased blood glucose levels after supper can be controlled by the addition of short.
Nursing and Patient Care Considerations 1. most of these are human insulin manufactured synthetically. INSULIN THERAPY Insulin therapy involves the subcutaneous injection of immediate-. intermediate-. is necessary.
Etiology of type 1 diabetes is not well understood. No oral antidiabetic agent is given at bedtime. Defects at the cell level. 2. Diabetes can be diagnosed in any of the following ways (and should be confirmed on a different day by any of these tests): a. FBS of greater than or equal to 126 mg/dL b. 4. Some patients may require regular/NPH insulin injected before supper to assist with elevated postprandial evening glucoses. Etiology of type 2 diabetes involves heredity. polydipsia. and increased nocturnal hepatic glucose production (gluconeogenesis) are seen in type 2 diabetes. 3. Clinical Manifestations Onset is abrupt with type 1 and insidious with type Hyperglycemia Weight loss. impaired secretory response of insulin to rises in glucose. metformin (Glucophage). 3. Random blood glucose of greater than or equal to 200 mg/dL with classic symptoms (polyuria. resulting in hyperglycemia. polyphagia. along with diet and exercise. Combination therapy may also include the use of a thiazolidinedione (pioglitazone [Actos]. weight loss) c. viral. rosiglitazone [Avandia]). Intermediate-acting insulin (NPH) is given in the evening and an oral sulfonylurea agent in the morningâ€”called BIDS therapy (Bedtime Insulin. or utilization. genetics. Daytime antidiabetic agent (usually sulfonylurea). secretion. Daytime Sulfonylurea). autoimmune. d. or other agents. Pathophysiology and Etiology 1. c. and environmental theories are under review. OGTT greater than or equal to 200 mg/dL on the 2-hour sample 4
. fatigue Polyuria. controls daytime blood glucose levels. Controlling hepatic glucose production overnight with evening insulin helps to start the day with a lower FBS. a. There is an absolute or relative lack of insulin produced by the beta cell. and obesity. polyphagia Blurred vision Altered Tissue Response Poor wound healing Recurrent infections.ADVANCED MEDICAL-SURGICAL MS3
2. DIABETES AND RELATED DISORDERS DIABETES MELLITUS Diabetes mellitus is a metabolic disorder characterized by hyperglycemia and results from defective insulin production. particularly of the skin Diagnostic Evaluation 1. polydipsia. b.
including stimulation of insulin secretion from functioning beta cells. Medication 1. if < 60 kg. micronized (Glynase) 0. Act by a variety of mechanisms.5-40 mg in single dose or divided dose with meals Glipizide (Glucotrol XL) 5-20 mg in single dose before breakfast Glimepiride (Amaryl) Biguanides Metformin (Glucophage) 500-2. Diet a.75-12 mg in single or divided dose Glipizide (Glucotrol) 2.25-20 mg in single or divided dose with meals Glyburide. and meglitinide analogues may cause significant flatus and GI adverse effects. if meal is skipped. c. b. maximum dose 50 mg tid Miglitol (Glyset) 150-300 mg in 3 divided doses with meals Meglitinide Analogue Repaglinide (Prandin) 0. The goal of meal planning is to control blood glucose and lipid levels 2. and improves cardiovascular fitness. enhances the action of insulin. enhancement of peripheral sensitivity to insulin. These tests are not used for diagnosis.000 mg daily with evening meal Alpha-Glucosidase Inhibitors Acarbose (Precose) 150-300 mg in 3 doses with meals. Exercise Regularly scheduled. do not take dose Amino Acid Derivative Nateglinide (Starlix) 120-360 mg in 3 divided doses within 30 minutes of starting meal. DiaBeta) 1.550 mg in 2-3 divided doses with meals Metformin (Glucophage XR) 500-2. Oral Antidiabetic Agents Second-Generation Sulfonylureas Glyburide (Micronase. Tests for glucose control over time are glycated hemoglobin and fructosamine assay (see pages 911 to 912). moderate exercise performed for at least 30 minutes most days of the week promotes the utilization of carbohydrates. if meal is skipped. reduction of hepatic glucose production. do not take dose Thiazolidinediones 5
. Management 1.5-16 mg in 2-4 divided doses within 30 minutes of starting meal. b. Sulfonylureas and meglitinide analogues may cause hypoglycemic reactions. 3. assists with weight control. Dietary control with caloric restriction of carbohydrates and saturated fats to maintain ideal body weight. Oral antidiabetic agents for patients with type 2 diabetes who do not achieve glucose control with diet and exercise only. and reduced absorption of carbohydrates from the intestine. alpha-glucosidase inhibitors. a.ADVANCED MEDICAL-SURGICAL MS3
NPH 70%) 0. The American Diabetes Association (2003) recommends the following goals of treatment. NPH 70%) 0.5-1 hour 5 hours Short-acting (regular. semilente) 0. Glycemic control 1.5 hour 3-5 hours 24 hours (Lispro 25%.000 mg/day in single dose or divided doses Glipizide/metformin (Metaglip) Up to 20/2. aspart) 0. Commonly results in increased appetite and weight gain.000 mg/day in divided doses 2.25 hour 0. Insulin Onset.5-1.25 hour 0. exercise.ADVANCED MEDICAL-SURGICAL MS3
Rosiglitazone (Avandia) 4-8 mg in a single dose or 2 divided doses Pioglitazone (Actos) 15-45 mg in single dose Combination Agents Glyburide/metformin (Glucovance) Up to 20/2. b. NPH 75%) 0.25 hour 1-4 hours 24 hours General Health Rigid prevention and management guidelines have been established for glycemic control. c. Lipid control Low-density lipoprotein < 100 mg/dL High-density lipoprotein > 40 mg/dL Triglycerides < 150 mg/dL 3.5 hour 2-12 hours 24 hours (Regular 50%. and kidney function to prevent complications. NPH 50%) 0.000 mg/day in single dose or divided doses Rosiglitazone/metformin (Avandamet) Up to 8/2. HbA1c < 7% Preprandial glucose 90 to 130 mg/dL Peak postprandial glucose < 180 mg/dL 2. Insulin therapy for patients with type 1 diabetes who require replacement a.5 hours 24 hours (Aspart 30%.5-1 hour 2-4 hours 5-7 hours Intermediate-acting (NPH. Microalbumin (spot urine) < 30 mcg/mg creatinine 6
. and oral antidiabetic therapy. and Duration INSULIN ONSET PEAK DURATION Immediate-acting (lispro. blood pressure (BP). BP < 130/80 mm Hg 3. Hypoglycemia may result as well as rebound hyperglycemia (Somogyi effect). lipid values. May also be used for type 2 diabetes when unresponsive to diet. lente) 1-3 hours 6-12 hours 18-24 hours Long-acting (ultralente) 4-6 hours 10-30 hours 24-36 hours (insulin glargine) 1 hour none 24+1 hours Mixed (Regular 30%. Peak.
polydipsia. infections. Cardiovascular: orthostatic hypotension. dehydration. and insulin/oral antidiabetic agent. their subsequent treatment. hunger or thirst g. Obtain a history of current problems. impotence. glaucoma d. 2. Peripheral Vascular Disease 4. halos. and presence of complications. and general health history. a. general health of patient. Eyes: changes in visionâ€”floaters. Impotence/Sexual Dysfunction 10. and complications 2. Diarrhea 9. Diabetic ketoacidosis (DKA) occurs primarily in type 1 diabetes during times of severe insulin deficiency or illness. Hypoglycemia occurs as a result of an imbalance in food. 3. Hyperosmolar hyperglycemic nonketotic syndrome (HHNKS) affects patients with type 2 diabetes. causing severe dehydration. bloating. periodontal disease e. Genitourinary (GU): increased urination. weak pedal pulses. decreased pain and temperature perception. Number of years since diagnosis of diabetes c. cataracts. Mouth: gingivitis. Nephropathy 6. Skin: skin lesions. Perform a review of systems and physical examination to assess for signs and symptoms of diabetes. leg claudication f. Coronary Artery Disease (CAD) 3. Cerebrovascular Disease 2. Chronic 1. activity. nocturia. a. ketonuria. GI: diarrhea. evidence of poor wound healing c. Peripheral Neuropathy 7. dry or burning eyes. Has the patient experienced polyuria. Neurologic: numbness and tingling of the extremities. blurred vision. anxiety b. Gastroparesis 8. increased fatigue. changes in gait and balance Nursing Diagnoses Imbalanced Nutrition: More than Body Requirements related to intake in excess of activity expenditures Fear related to insulin injection Risk for Injury (hypoglycemia) related to effects of insulin. producing severe hyperglycemia. and any other symptoms? b. polyphagia. inability to eat Activity Intolerance related to poor glucose control 7
. family history. Family members diagnosed with diabetes. vaginal discharge h. constipation. cold extremities. Orthostatic Hypotension Nursing Assessment 1. dehydration. and acidosis. Retinopathy 5. hyperglycemia. increased flatulence. hyperosmolarity. tiredness. early satiety. and stupor. General: recent weight loss or gain.ADVANCED MEDICAL-SURGICAL MS3
Complications Acute 1.
activity. Emphasize that lifestyle changes should be maintainable for life. Carryover of enhanced metabolic rate and efficient food utilization 6. Discuss the goals of dietary therapy for the patient. 3. 4. 8
. tachycardia. nervousness from the release of adrenalin when blood glucose falls rapidly b. Strategize with patient to address the potential social pitfalls of weight reduction. Explain the importance of exercise in maintaining/reducing body weight. c. Assist patient to identify problems that may have an impact on dietary adherence and possible solutions to these problems. Treat hypoglycemia promptly with 15 to 20 g of fast-acting carbohydrates. confusion. Preventing Injury Secondary to Hypoglycemia Closely monitor blood glucose levels to detect hypoglycemia. 1. 2. and bedtime based on patient's individualized insulin regimen. a. pallor. 2. lack of coordination. 3. fad diets or diet plans that stress one food group and eliminate another are generally not recommended. 4. Reducing intake of carbohydrates may benefit some patients. Assist patient to reduce fear of injection by encouraging verbalization of fears regarding insulin injection. 7. staggering gait from depression of central nervous system as glucose level progressively falls 4. and identifying supportive coping techniques. 5. 2. Instruct patient in filling syringe when he or she expresses confidence in self-injection procedure. irritability. palpitations. Caloric expenditure for energy in exercise b. Adrenergic (early symptoms)â€”sweating. Demonstrate and explain thoroughly the procedure for insulin self-injection (see page 914). Teaching About Insulin 1. Assist patient to establish goals for weekly weight loss and incentives to assist in achieving them. Improving Nutrition 1. 3. Neurologic (later symptoms)â€”light-headedness. Assess current timing and content of meals. however. 3. Assess patient for the signs and symptoms of hypoglycemia. Help patient to master technique by taking a step-by-step approach. a. b. tremor. Teach self-injection first to alleviate fear of pain from injection. 2.ADVANCED MEDICAL-SURGICAL MS3
Deficient Knowledge related to use of oral hypoglycemic agents Risk for Impaired Skin Integrity related to decreased sensation and circulation to lower extremities Ineffective Coping related to chronic disease and complex self-care regimen
Nursing Interventions 1. Allow patient time to handle insulin and syringe to become familiar with the equipment. Instruct patient in the importance of accuracy in insulin preparation and meal timing to avoid hypoglycemia. Setting a goal of a 10% (of patient's actual body weight) weight loss over several months is usually achievable and effective in reducing blood sugar and other metabolic parameters. Review dosage and time of injections in relation to meals. Advise patient on the importance of an individualized meal plan in meeting weight-loss goals. conveying a sense of empathy. a. slurred speech. headache.
Identification bracelet can be obtained from MedicAlert Foundation International. Improving Activity Tolerance 1. Encourage patients to wear an identification bracelet or card that may assist in prompt treatment in a hypoglycemic emergency. hypotension.medicalert. warmth. Assess for trends in blood glucose and other laboratory results 9. Make sure that appropriate insulin dosage is given at the right time and in relation to meals and exercise 10. weight loss. stupor. 9
. Get help immediately for patient presenting with signs of either ketoacidosis (nausea and vomiting. b. Family member or staff must administer injection. c. Assess patient for cognitive or physical impairments that may interfere with ability to accurately administer insulin. Encourage patient to carry a portable treatment for hypoglycemia at all times. polydipsia. Half cup (4 oz) juice. and exercise regimen 5. Get help immediately for signs of hypoglycemia that do not respond to usual glucose replacement 13. hypothermia. four sugar cubes. tenderness. five to six pieces of hard candy may be taken orally. nervousness. http://www. 6. medication treatment. blurred vision 6. monitoring procedures. three glucose tablets. Perform thorough skin and extremity assessment for peripheral neuropathy or peripheral vascular disease and any injury to the feet or lower extremities 8. Kussmaul respirations. light-headedness. tremor. polyphagia. exercise. 1 cup skim milk. 2. Make sure patient has adequate knowledge of diet. When caring for patients with diabetes mellitus: 3. tachycardia. b. a. Assess for signs of hypoglycemia: sweating. 5.M. Instruct patient to plan exercises on a regular basis each day. 8. swelling.org. http://www. Used after hypoglycemia treated with fact-acting carbohydrate. fruity breath odor. may prevent relapse. and medication treatment 11. 7. and protein sources with some fat to delay gastric emptying and prolong effect. Advise patient to assess blood glucose level before and after strenuous exercise. starch. d. seizures.diabetes. Assess for signs of hyperglycemia: polyuria. Glucagon 1 mg (subcutaneously or I. confusion 7. Identification card may be requested from the American Diabetes Association. I. Assess adherence to diet therapy.) is given if the patient cannot ingest a sugar treatment. Between-meal snacks as well as extra food taken before exercise should be encouraged to prevent hypoglycemia. muscle weakness.V. Immediately report to health care provider any signs of skin or soft tissue infection (redness. coma). Nutrition bar specially designed for diabeticsâ€”supplies glucose from sucrose. bolus of 50 mL of 50% dextrose solution can be given if the patient fails to respond to glucagon within 15 minutes. and altered level of consciousness) or hyperosmolar hyperglycemic nonketotic syndrome (nausea and vomiting. Assess level of knowledge of disease and ability to care for self 4.ADVANCED MEDICAL-SURGICAL MS3
a. 4. drainage) 12.org. fatigue. STANDARDS OF CARE GUIDELINES 1. Caring for Patients With Diabetes Mellitus 2.
. d. such as glucose and fructose. Liver function tests should be monitored periodically. use. Sulfonylurea compounds promote the increased secretion of insulin by the pancreas and partially normalize both receptor and postreceptor defects. Meglitinide analogues (repaglinide [Prandin]) and amino acid derivatives (nateglinide [Starlix]) stimulate pancreatic release of insulin in response to a meal. Metformin (Glucophage). Advise patient that prolonged strenuous exercise may require increased food at bedtime to avoid nocturnal hypoglycemia. so patient should alert all health care providers of use. Discuss with the patient the perceived effect of diabetes on lifestyle. pulses. weight gain. They should be used cautiously in patients with renal and hepatic dysfunction. anemia. and elevation in serum transaminases. GI upset. 5. 2. Assess feet and legs for skin temperature. Many drug interactions exist. dryness. a. Encourage patient to eat a carbohydrate snack before exercising to avoid hypoglycemia. Ovulation may occur in anovulatory premenopausal women. calluses. It decreases hepatic glucose production and intestinal reabsorption of glucose and increases insulin reception and glucose transport in cells. and lactic acidosis (rare). such as visual or hearing impairments. deep tendon reflexes. Counsel patient to inject insulin into the abdominal site on days when arms or legs are exercised. metallic taste. 4. appears to diminish insulin resistance. conditions that may cause dehydration. Metformin must be used cautiously in renal insufficiency. cholestatic jaundice. thereby lowering postprandial and fasting glucose levels. b. 2. They have a more rapid onset and shorter duration than sulfonylureas. Many drug interactions exist. Adverse reactions include edema. family life. corns. distractive environment. They should not be taken when a meal is skipped or missed. a biguanide compound. they reduce hepatic glucose production. soft tissue injuries. Potential adverse reactions include hypoglycemia. Teach the action. finances. low literacy. allergic reaction. hair distribution. e. Patient should contact health care provider if levels remain elevated. so patient should alert all health care providers of its use. 7. Explore previous coping strategies and skills that have had positive effects. Alpha-glucosidase inhibitors (acarbose [Precose] and miglitol [Glyset]) delay the digestion and absorption of complex carbohydrates (including sucrose or table sugar) into simple sugars. and blood dyscrasias.ADVANCED MEDICAL-SURGICAL MS3
3. occupation. They should be used cautiously in liver disease and heart failure. 6. and hepatic impairment. Encourage active participation of the patient and family in the educational process. and may cause hypoglycemia. Potential adverse reactions include GI disturbances. Maintaining Skin Integrity a. Improving Coping Strategies 1. 3.
6. reaction to alcohol. sensation. Instruct patient to avoid exercise whenever blood glucose levels exceed 250 mg/day and urine ketones are present. hammer toe or bunion deformation. 5. 1. Secondarily. Thiazolidinedione derivatives (rosiglitazone [Avandia] and pioglitazone [Actos]) primarily decrease resistance to insulin in skeletal muscle and adipose tissue without increasing insulin secretion. c. Providing Information About Oral Antidiabetic Agents Identify barriers to learning. photosensitivity. and adverse effects of oral antidiabetic agents.
5. Assist family in providing emotional support.ADVANCED MEDICAL-SURGICAL MS3
3. Identify available support groups to assist in lifestyle adaptation.
. Encourage patient and family participation in diabetes self-care regimen to foster confidence. 4.