Chapter 36

Alpha - glucogon - glucogen - glucose

Beta - insulin

Delta - stomatostatin, balance

Diabetes MellitusDefinition: Lack of or resistance to Insulin

ClassificationsType 1 DiabetesType 2 DiabetesGestational

Impact of Diabetes6th leading cause of deathleading cause of renal failuremajor cause of blindnessmost frequent cause of non-trauma

amputationsaffects 17 millionincreasing prevalence of type 2

Historical FactsDiabetes is from the Greek word “to siphon” Mellitus is from Latin word “sweet”

Usually died within 2-3 years from starvation

1921 - Insulin discoveryincreased life span experiencing long term effects of diabetes

1979 - self monitoring with glucometers

Diabetes Mellitus - HistoricalChildren died of starvation

Diabetes and your nursing practiceImpact?Opportunity?

TeachingFollow-up

Future?

Diabetes Type 1Beta cells no longer produce insulin

hyperglycemiafats and protein are broken downdevelopment of ketosis

accounts for 10-15% of all casesoccurs in childhood or adolescence

juvenile onset or insulin dependent diabetes

Clinical ManifestationsHyperglycemia leads to

polyuriaglycosuriapolydipsiapolyphagiaweight lossmalaise and fatigueblurred vision

Diabetic Ketoacidosis DKAResults from a breakdown of fatoccurs when undiagnosed or known diabetic

has an increased energy needblood sugar >250mg/dLpH < 7.3ketones and glucose in the blood and urine

DKA - TreatmentRegular insulin - sub q or IV

Restore fluid balance - .9NS IV

Correct electrolyte imbalances - K+

Diabetes Type 2Definition - when fasting hyperglycemia

occurs despite endogenous insulinalso known as adult onset diabetesRisk Factors

family historyobesityrace - African American, Hispanic or Am.

IndianWomen - gestational diabetes, birth wt>9lbs

Cellular Resistance

Not enough insulin

Type 2 Diabetes - Clinical ManifestationsClient - usually unaware, doesn’t experience

wt. losshyperglycemiapolyuria, polydipsia, blurred visionfatigueparesthesiasskin infections

Hyperosmolar Hyperglycemia State - HHSLife threatening complication of type 2Characterized by increase in plasma

osmolarity, blood glucose and ALCPrecipitating factors

infection, therapeutic agent/procedure, acute or chronic illness

slow onset

HHSClinical Manifestations

altered level of consciousnessneurological

hyperthermia, motor/sensory impairment, seizuredehydration

TreatmentICU, correct fluid and electrolyte imbalances,

regular insulin

Complications of DiabetesHyperglycemia

DKA - associated with Diabetes Type 1HHN - associated with Diabetes Type 2Dawn phenomenon - rise in b.s. 4-8amSomogyi effect - hypoglycemia at night with re-

bound morning hypergylcemia

Complications of DiabetesHypoglycemia - b.s. 45-60mg/dLManifestations

early signs - cool clammy skin, rapid heart beat, hunger, nervousness, tremor, faintness, dizziness

late signs - unsteady gait, incoherent, vision changes, seizures, coma

HypoglycemiaTreatment

15gms of rapid acting sugar (1/2 cup of fruit juice, 8oz skim milk, 3 glucose tablets, 3 life savers)

15/15 rule, if still low, repeat 15 grams of sugar

IV - 25-50% of glucose

Why do you need to know about diabetes?

How would you feel if diagnosed with Diabetes today?

Tell us about Diabetes Type 1

pathoincidenceclinical

manifestationsDKA?

Tell us about Type 2 Diabetesrisk factors

clinical manifestations

hyperosmolar hyperglycemia state?

Tell us about complications, signs and symptoms and treatment

hyperglycemia

hypoglycemia

Complications of DiabetesCoronary Artery DiseaseHypertensionStrokePeripheral Vascular DiseaseDiabetic Retinopathy

retinal ischemialeading cause of blindness ages 25-74

Diabetic Retinopathy

Complications of Diabetes

Diabetic nephropathyglomerular changes in kidneys

leading to impaired renal function microalbuminuria

most common cause ESRD in America

Renal Involvement

Complications of DiabetesPeripheral and Autonomic Nervous System

changes in the blood vessels that supply nerves and result in impaired nerve conduction

peripheral neuropathies distal paresthesias - numbness/ tingling in

toes/feet pain, aching, burning feelings of cold impaired sensation

visceral neuropathies sweating G.I.

Other Complications from D.M.Increased susceptibility to infection

inflammatory response is diminishedslower than normal healing

Periodontal diseaseFoot ulcer and infections

Collaborative CareKeeping blood glucose levels close to normal

medicationsdietary managementexercise

Futurepancreatic transplant, beta cell transplant

Diagnostic Tests1. Symptoms of diabetes and random b.s.

>200mg/dL2. fasting glucose >126mg/dL3. Oral glucose tolerance test - OGTT

after 2 hrs glucose is >200mg/dL4. Glycosylated hemoglobin - Hemoglobin A1C

average glucose over 2-3 months

Routine accu checks for managementType 1 3x/day, Type 2 prn to reach glucose

goal

What can you tell us about this?

Type

Action

Administration

Nursing Care

MedicationsInsulin

all type 1, some type 2, gestational diabetics, those on TPN

Terms describing insulinonset, peak, duration

Typesrapid acting, short acting, intermediate, long

and combinations

Types of InsulinShort acting – Regular

onset 30 min to 1 hrpeak 2-3 hrsduration 4-6 hrs

Intermediate acting – NPHonset 1-2 hrspeak 6-14 hrsduration 16-24 hrs

Long acting – Lantusonset 2 hrs, peak not definedDuration 24 hours

Insulin AdministrationEquipment

syringecalibrated for U 100insulin pump

Routeparenterally only nasal spray recently approved for useresearch into oral forms

Insulin AdministrationStorage?Gently rollwithdraw without air bubblesclear to cloudyAdministration

subcutaneous tissue differs in absorption rates90 degree angle, no massage, avoid scars

Insulin Sites

Abdomen – most rapid absorption siteArmsThighsButtocks

Insulin AdministrationBest site for injection

Oral Hypoglycemic AgentsUsed to treat Type 2Combination with prescribed diet and

exerciseMany combinations of insulin and

hypoglycemic agentsglucotrol, glucophage

Aspirin therapy

Diet Management

Goalsnear-normal glucose levelsoptimal lipid levelsadequate calories to maintain reasonable wt.

Meal planningconsistent-carbohydrate planexchange list

Diet ManagementSpecifically for type 1

correlate eating with insulin onsetadjust according to self-monitoring

Specifically for type 2includes weight loss plan3 meals spaced 4-5 hours apart

“Sick Day Management Plan”

DM - Weight LossPlays important role

ExerciseIncrease uptake of glucose by muscle cellsDecrease cholesterol and triglyceride levelsADA Recommendations

proper footwear, inspect feetavoid temperature extremesavoid during times of poor glucose control

Diabetic Surgical ClientsMonitor for increased risk of

postoperative infectionsdelayed wound healingfluid and electrolyte imbalanceshypoglycemiaDKA

Diabetic Surgical ClientsPreop Care

insulin - may receive usual dose or 1/2 of the usual dose

early morning surgeryPost op Care

b.s. fluctuate depending on NPO, gastric suctioning

monitor at set intervals

Nursing DiagnosesRisk for Impaired skin integrity:Proper foot

care1. Daily inspection of the feet2. Checking temperature of any water before

washing feet3. Need for lubricating cream after drying but

not between toes4. Quit smoking

Nursing DiagnosesRisk for Infection

1. Frequent hand washing2. Early recognition of signs of infection and

seeking treatment3. Meticulous skin care4. Regular dental examinations and consistent

oral hygiene care

Nursing DiagnosesRisk for Injury: Prevention of accidents, falls

and burns

Sexual dysfunction1. Effects of high blood sugar on sexual

functioning2. Resources for treatment of impotence,

sexual dysfunction

Nursing DiagnosesIneffective coping

1. Assisting with problem solving strategies2. Providing information about diabetic

resources community education program support groups

3. Use all client contact as an opportunity to reinforce management, help coping and prevent complications