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Control of Blood Glucose – Diabetes Mellitus

Ann MacLeod, RN, BScN, MPH

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Objectives

Understand pathophysiology of diabetes Describe the following relating to diabetes

• Assessment• Nursing diagnoses• Management

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Diabetes Mellitus

Definition: a metabolic disorder characterized by glucose intolerance

an imbalance between insulin supply and demand

not enough insulin, or insulin isn’t effective

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Pathophysiology

BS urine glucose glycosuria

H20 loss due to

hyperosmolarity polyuria

Usable fat combustion ketoacidosis resp

glucose metab. Acidosis

brain starvation coma

tissue food for bacteria infections

glucose

serum atherosclerosis miocardial infarcts

cholesterol gangrene

? small vessel disease kidney damage, retinopathy, neuropathy

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Types of Diabetes

Type 1: IDDM: insulin dependent

Type 2: NIDDM: not insulin dependent Associated with other conditions:

Gestational

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Type 1 diabetes - IDDM

Diseased pancreatic beta cells not producing insulin Genetic? Environmental? Autoimmune? Recall insulin

• Inhibits glycogenolysis (breakdown of stored glucose in the liver)

• Inhibits gluconeogenesis (making new glucose from nutrients)

• Inhibits fatty acid breakdown into glucose(ketones & acid & glucose products)

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Type II diabetes - NIDDM

Cells receptors not sensitive or resistant to insulin insulin unable to glucose transport into cell

Insulin still being produced Risk factors obesity & sedentary

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Gestational diabetes

Hyperglycemia due to excretion of hormones during pregnancy

Usually return to normal after delivery At risk for Type II

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Risk Factors for Diabetes

Heredity: Does someone in the family have the disease? Black, Aboriginal Obesity Age > 45 Stress hypertension HDL < 35 mg/dl gestational diabetes or large babies Sex: 3x more women viral infections of pancreas

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Diagnostic tests

Random Blood Sugar > 11mmol/l Fasting Blood Sugar (FBS) > 7 2 hr. pc. Blood sugar Glucose tolerance test Urine testing for sugar and acetone

(diabetic protocol) HgbA 1c

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Further Assessment

Polydypsia

polyuria

polyphagia

Glucosuria

weakness, fatigue

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Nursing Diagnoses

Risk for fluid volume deficit r/t polyuria Altered nutrition r/t imbalance of insulin, food and

physical activity Knowledge deficit r/t self-care Potential self-care deficit r/t blindness neuropathy Anxiety Altered coping

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Collaborative Management

Diet: based on body wt. And activity: 50-60% CHO, 12-20% protein, 20-30% fat BMI <30

typically 3 meals /day with an eve. snack

Monitoring of blood glucose, glucometers

oral hypoglycemic agents: stimulate beta cells to produce insulin

injectable insulin excercise

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Nursing Interventions

Close monitoring for hypoglycemia especially when blood glucose levels are low ie. Fasting for tests, surgery, meal skipping, nausea, vomiting, other short lived illnesses

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Insulin

Hormone secreted by the pancreas when blood glucose rises.

Needed to transport glucose from the blood into the cells of fat and muscle

most common source is beef/pork now largely biosynthetic sources ( anything

ending with “lin” made with recombinant DNA in a lab

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Insulins

Humulin R ClearCan be IV5-20 u ac

Onset .5hPeak 2-3h

Duration 5-7

NPH, Humulin N

Novolin N LenteHumulin LNovolin L

CloudyGiven qd,bid

Onset 1- 1.5Peak 8-12

Duration 18-24

Humulin U,Ultralente

Cloudy,hypoglyc.during sleep

Onset 4-8Peak 10-30 h

Duration 36+

NPH/Regular70/30 or 50/50Most common

Cloudy Varies withdose

Varies withdose

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Oral Hypoglycemics Sulphonylureas eg. glyburide

• stimulate b cells to secrete insulin

• do not use with renal impairment, no etoh Alpha-Glucosidase inhibitors

• inhibit absorption of Sugars (blocks amylase etc. Biguanide eg. Metaformin

liver gluconeogenesisintestinal absorption of glucose

• geriatric risk for DKA, monitor renal function or liver disease

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Insulin

Various insulin delivery systems are being manufactured, including insulin pens, sq ports, sq infusions, IV infusions

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Complications of Diabetes Diabetic Ketoacidosis: a life-threatening syndrome onset: hours>>days severe hyperglycemia and acidosis resulting from

insulin deficiency or absence associated with failure to take insulin, new Dx.,

infection Hyperglycemia acts like an osmotic diuretic and

causes severe fld. And electrolyte loss

( K+)

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Assessment Diabetic Ketoacidosis Are a result of

hyperglycemia and fluid and electrolyte losses

alt. LOC kaussmaul resp. tachycardia

Dry flushed skin, poor turgor, dry mucous membranes

polyuria, polydypsia acetone breath weakness

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Assessment DKA cont’d

Blood work: blood glucose can go as high as 25-80 mm/L

electrolyte imbalances severe dehydration

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Collaborative Management

Fluid replacement rapid acting insulin restore electrolyte

levels

Treatment of underlying cause

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Nursing Process

Fluid volume deficit

Risk for Injury

Altered peripheral tissue perfusion

knowledge deficit

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Hypoglycemia

A lowering of blood glucose caused by excessive insulin or hypoglycemic agent

may also be caused by: skipping meals, ++exercise, vomiting

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Hypoglycemia

Sudden onset: typical scenario: hypoglycemia occurs

during the time of peak action of insulin or hypoglycemic agent. Especially at night when ct. is asleep, or hasn’t eaten a bed time snack

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Assessment

For some cts. You will see symptoms when blood glucose drops below 5

pale, cold, clammy, perspiration weak, hunger, tachycardia,headache, double

vision confusion, slurred speech, coma

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Management

Admin. Of rapid acting sugar (fruit juice, cola, hard candy, then follow it with a complex CHO and protein)

50% dextrose IV works in less than 10 min (25-50 mls)

glucagon

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Nursing Process

Alt. Protection r/t risk of seizure and brain damage

knowledge deficit r/t disease process

Knowledge deficit r/t diagnostic testing, indicators of hypoglycemia, theraputic regime

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Hyperosmolar Hyperglycemic, Non ketotic syndrome Life threatening lack of insulin causing

severe hyperglycemia usually elderly cts. With inadequate Tx. Or

undiagnosed DM. Often have pre-existing cardiac or

pulmonary problems

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Assessment

Same as DKA as well as seizures resp. shallow with apneic episodes polyuria, polydypsia, fatigue, weakness hypotension, increased HR. T.

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Risk Factors

Undiagnosed DM gram negative infection over 50 yrs. In age cardiac or lung problems

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Chronic Complications of Diabetes Mellitus Risk factors: ageing, dietary habits, lack of

control of blood sugars, duration of illness, lack of exercise, complicating pre-existing medical conditions, SMOKING

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Complications of Diabetes

Three main types: 1) macrovascular 2) microvascular 3) neuropathy

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Macrovascular

Related to degenerative changes in the large blood vessels

MI: r/t coronary artery disease CVA: r.t cerebral artery disease PVD: r/t peripheral vasc. Disease infection d/t vasc. insufficiency

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Microvascular

Nephropathy: damage to capillaries that supply the glomeruli: early sign is proteinuria, may progress to end stage renal disease

Retinopathy: damage to capillaries of retina>scar tissue>blindness

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Neuropathy

Most common chronic complication of diabetes

when circulation to axons and dendrites is impeded, transmission of impulses slows

Ax. Parestesia: prickling, tingling,may also be autonomic

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Ongoing Assessment Activity diet medication glucose monitoring eyes ( retinopathy) skin and mucous membranes Cardio vascular system BP, tissue perfusion Genitourinary system - infections, difficulty voiding, Neuropathies

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Client Teaching with regards to diabetes Importance of balance

between insulin, diet, exercise

more frequent checks of BS during episodes of brief illness, injury or stress

Never alter insulin dosage unless advised by a MD.

Insulin use:how to give self a SQ injection (begin with simple and work to complex

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Client Teaching

Dietary modifications

exercise

hygiene and safety measures

foot care

Coping skills, with careful consideration of growth and development

techniques for monitoring blood glucose levels