NUR 201 Diabetes Powerpoint

7/29/2019 NUR 201 Diabetes Powerpoint

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Nursing 201ursing 201

LPN Transition to RNPN Transition to RN

Nursing 201ursing 201

LPN Transition to RNPN Transition to RN

Assessment and Management of Patients Assessment and Management of Patients

WithWith

Diabetes MellitusDiabetes Mellitus



Diabetes Mellitus Clinical Manifestationsiabetes Mellitus Clinical Manifestations Classic symptoms: Classic symptoms:

---polyuria, polydipsia, polyphagia,---polyuria, polydipsia, polyphagia,

---increased frequency of infections & fatigue ---increased frequency of infections & fatigue

Diabetes Mellitus Clinical Manifestationsiabetes Mellitus Clinical Manifestations Classic symptoms: Classic symptoms:

---polyuria, polydipsia, polyphagia,---polyuria, polydipsia, polyphagia,

---increased frequency of infections & fatigue ---increased frequency of infections & fatigue

Type Iype I Weight LossWeight Loss

Rapid onsetRapid onset

Insulin dependentInsulin dependent

Early onset- before age 15Early onset- before age 15

Type IIype II Sedentary lifestyleSedentary lifestyle

Familial tendencyFamilial tendency

Weight increaseWeight increase

Slow onsetSlow onset

Average age 50 years Average age 50 years

History of high BPHistory of high BP



Diabetes Mellitusiabetes Mellitus

Type I Diabetesype I Diabetes

Pancreas doesPancreas does notnot produce any insulinproduce any insulin Insulin- dependent diabetes mellitus (IDDM)- insulinInsulin- dependent diabetes mellitus (IDDM)- insulin

must be administered to control complicationsmust be administered to control complications Onset age usually < 30 years; usually thin atOnset age usually < 30 years; usually thin at

diagnosis; with recent weight lossdiagnosis; with recent weight loss Etiology- genetic, immunologic, or environmentalEtiology- genetic, immunologic, or environmental

factorsfactors Clinical findings: Polyuria, polyphagia, polydipsia,Clinical findings: Polyuria, polyphagia, polydipsia,

weaknessweakness Ketones proneKetones prone when insulin absentwhen insulin absent Acute complication: Acute complication: DiabeticDiabetic KetoacidosisKetoacidosis (DKA)(DKA)



Body does not produceBody does not produce enoughenough insulin or the cellsinsulin or the cellsignoreignore the insulinthe insulin

Non-insulin dependent diabetes (NIDDM)-Non-insulin dependent diabetes (NIDDM)- notnotdependent upon insulin for survival,dependent upon insulin for survival, but may havebut may haveinsulin orderedinsulin ordered

Onset age > 30 years; usually obese at diagnosisOnset age > 30 years; usually obese at diagnosis Etiologies usually includes obesity, heredity, orEtiologies usually includes obesity, heredity, or

environmentalenvironmental Blood glucose usually controlled by diet and exerciseBlood glucose usually controlled by diet and exercise Ketosis rareKetosis rare, except in stress or infection, except in stress or infection Acute complication: Acute complication: Hyperglycemic hyperosmolarHyperglycemic hyperosmolar

nonketotic syndrome (HHNK)nonketotic syndrome (HHNK)

Diabetes Mellitus

Type II Diabetes



Gestational Diabetesestational Diabetesestational Diabetesestational Diabetes

Any degree of glucose intolerance with its onset Any degree of glucose intolerance with its onset

during pregnancyduring pregnancy Recommended screening between 24th and 28thRecommended screening between 24th and 28th

weeks of gestationweeks of gestation

Criteria:Criteria:

– 25 years of age or older25 years of age or older

– Younger than 25 years of age and obese Younger than 25 years of age and obese

– Family history of DM in first-degree relativesFamily history of DM in first-degree relatives

– Member of an ethnic/racial group with a high prevalence of DMMember of an ethnic/racial group with a high prevalence of DM



Impaired Glucose ToleranceImpaired Glucose Tolerance

Borderline, subclinical, asymptomatic diabetesBorderline, subclinical, asymptomatic diabetes

Oral glucose tolerance value between 140 to 200Oral glucose tolerance value between 140 to 200

mg/dlmg/dl Impaired fasting plasma glucose between 110 to 126Impaired fasting plasma glucose between 110 to 126

mg/dlmg/dl

May be obese or nonobese- should reduce weightMay be obese or nonobese- should reduce weight

Should be screened for diabetes periodicallyShould be screened for diabetes periodically



Risk Factors for Diabetes Mellitusisk Factors for Diabetes Mellitusisk Factors for Diabetes Mellitusisk Factors for Diabetes Mellitus

Family history of diabetesFamily history of diabetes

ObesityObesity

Race/ ethnicityRace/ ethnicity

Age = or > 45 years Age = or > 45 years

Previously identified impaired fasting glucosePreviously identified impaired fasting glucose

or impaired glucose toleranceor impaired glucose tolerance HypertensionHypertension

History of gestational diabetes or delivery of History of gestational diabetes or delivery of

babies over 9 lbs.babies over 9 lbs.



Diagnostic Testingiagnostic Testingiagnostic Testingiagnostic Testing

Fasting Blood Sugar (FBS)Fasting Blood Sugar (FBS) – Diagnose new DM & monitor glucose levelDiagnose new DM & monitor glucose level

– Blood obtained by venipunctureBlood obtained by venipuncture – NPO for least 8 hours (water permitted)NPO for least 8 hours (water permitted)

– If already diabetic- blood obtained before insulin or oralIf already diabetic- blood obtained before insulin or oral

antidiabetic agents administeredantidiabetic agents administered

– Diagnosis of diabetes- two separate test results > 126 mg/dlDiagnosis of diabetes- two separate test results > 126 mg/dl



Oral Glucose Tolerance Testral Glucose Tolerance Testral Glucose Tolerance Testral Glucose Tolerance Test

Performed to diagnose DM when serum glucose isPerformed to diagnose DM when serum glucose is

between 126 to 140 mg/dlbetween 126 to 140 mg/dl

Not routinely used except in diagnosis of gestationalNot routinely used except in diagnosis of gestationalDMDM

FBS drawn; client drinks a glucose solution; bloodFBS drawn; client drinks a glucose solution; blood

samples obtained at 30 minutes intervals for 2 hourssamples obtained at 30 minutes intervals for 2 hours

Diagnosis of DM- blood glucose > 200 mg/dl at 120Diagnosis of DM- blood glucose > 200 mg/dl at 120

minutesminutes



Glycosolated Hemoglobin (HbA1c)lycosolated Hemoglobin (HbA1c)lycosolated Hemoglobin (HbA1c)lycosolated Hemoglobin (HbA1c)

Best indicator of average blood glucose level-Best indicator of average blood glucose level-

overview over previous 3 monthsoverview over previous 3 months

Used to assess long-term glycemic control & predictUsed to assess long-term glycemic control & predict

risk for development of chronic complicationsrisk for development of chronic complications

Not influenced by recent food intake, exercise, orNot influenced by recent food intake, exercise, or

stressstress

Valuable to determine compliance with prescribed Valuable to determine compliance with prescribed

medical regimenmedical regimen

ADA recommends testing: twice yearly for stable BS ADA recommends testing: twice yearly for stable BS

& quarterly on clients who therapy has changed& quarterly on clients who therapy has changed



Urine Testing for Ketones Bodiesrine Testing for Ketones Bodiesrine Testing for Ketones Bodiesrine Testing for Ketones Bodies

Abnormal in urine Abnormal in urine

Presence in urine may indicate impendingPresence in urine may indicate impending

ketoacidosisketoacidosis

ADA recommend testing: ADA recommend testing: – acute illness or stressacute illness or stress

– when BS level consistently > 300 mg/dlwhen BS level consistently > 300 mg/dl

– during pregnancyduring pregnancy

– when symptoms of ketoacidosis are presentwhen symptoms of ketoacidosis are present

Recommended for DM clients participating in aRecommended for DM clients participating in a

weight loss programweight loss program



Criteria for the Diagnosis ofriteria for the Diagnosis of

Diabetes Mellitusiabetes MellitusCriteria for the Diagnosis ofriteria for the Diagnosis of

Diabetes Mellitusiabetes Mellitus

Symptoms of diabetes + casual plasma glucoseSymptoms of diabetes + casual plasma glucose

level > or = 200 mg/dllevel > or = 200 mg/dl

Fasting plasma glucose > or = 126 mg/dlFasting plasma glucose > or = 126 mg/dl

2-hour postload glucose > or = 200 mg/dl2-hour postload glucose > or = 200 mg/dlduring an oral glucose tolerance testduring an oral glucose tolerance test



5 Components ofComponents of

Management of Diabetesanagement of Diabetes5 Components ofComponents of

Management of Diabetesanagement of Diabetes

I.I. NutritionNutrition

II.II. ExerciseExerciseIII.III. Blood Glucose MonitoringBlood Glucose Monitoring

IV.IV. Pharmacological TherapyPharmacological Therapy

V. V. EducationEducation



I. Nutritional Therapy. Nutritional Therapy. Nutritional Therapy. Nutritional Therapy

Goals:Goals: – Balance food intake with insulin or oral diabetic medsBalance food intake with insulin or oral diabetic meds

– Achieve optimal serum lipid levels Achieve optimal serum lipid levels – Enough calories to maintain or attain reasonable weightEnough calories to maintain or attain reasonable weight

– Prevent & treat acute complicationsPrevent & treat acute complications

– Improve overall health through optimal nutritionImprove overall health through optimal nutrition

Individualize the nutritional interventionIndividualize the nutritional intervention

Be realistic & flexible in developing a nutritional planBe realistic & flexible in developing a nutritional plan Be consistent in timing of meals & Be consistent in timing of meals & proportions of proportions of

CHO, protein, and fatCHO, protein, and fat



Typical diet consists of : CHO, Fat, Protein, & Typical diet consists of : CHO, Fat, Protein, &

Dietary FibersDietary Fibers

Exchange Lists for Meal PlanningExchange Lists for Meal Planning – Each 6 lists contains foods similar amounts of protein, fat, CHO, & Each 6 lists contains foods similar amounts of protein, fat, CHO, &

caloriescalories

starch/bread, meat, vegetable, fruit, milk, & fatstarch/bread, meat, vegetable, fruit, milk, & fat – A food on the list can be traded or exchanged for any other food A food on the list can be traded or exchanged for any other food

on that liston that list

– However, foods from one list or exchange cannot be substituted forHowever, foods from one list or exchange cannot be substituted for

foods from another list or exchangefoods from another list or exchange

Nutritional Therapy

Cont’d:

Nutritional Therapy

Cont’d:



II. ExerciseI. ExerciseI. ExerciseI. Exercise

– Primary benefit- increase glucose utilization by the tissues, therebyPrimary benefit- increase glucose utilization by the tissues, thereby

lowering blood glucose concentrationlowering blood glucose concentration

– Facilitate weight loss, which will decrease peripheral resistanceFacilitate weight loss, which will decrease peripheral resistance

– Several factors influence blood glucose response to exercise:Several factors influence blood glucose response to exercise:

timingtiming

amountamount

intensity of exerciseintensity of exercise



ADA Recommendations forDA Recommendations for

Diabeticsiabetics

Who Exerciseho Exercise

ADA Recommendations forDA Recommendations for

Diabeticsiabetics

Who Exerciseho Exercise

Use appropriate footwearUse appropriate footwear Monitor feet closely before & after exercise for injuryMonitor feet closely before & after exercise for injury

Ensure proper hydration before & during exerciseEnsure proper hydration before & during exercise

Avoid exercising in extremely hot or cold conditions Avoid exercising in extremely hot or cold conditions



Exercise-Induced Hypoglycemiaxercise-Induced Hypoglycemiaxercise-Induced Hypoglycemiaxercise-Induced Hypoglycemia

Instructions to minimize risk: Instructions to minimize risk: avoid injecting Insulin into body areas involved inavoid injecting Insulin into body areas involved in

exerciseexercise monitor BS before & after activitymonitor BS before & after activity

consistent in timing of Insulin injections & activityconsistent in timing of Insulin injections & activity

take pre-exercise snack if BS <100 to 120 mg/dl & if take pre-exercise snack if BS <100 to 120 mg/dl & if

> 90 minutes passed since last meal> 90 minutes passed since last meal

carry fast-acting CHO while exercisingcarry fast-acting CHO while exercising

wear diabetes identificationwear diabetes identification

exercise with someone who knows how to recognizeexercise with someone who knows how to recognize

& treat hypoglycemia& treat hypoglycemia



IV. Pharmacological TherapyV. Pharmacological Therapy

-Insulin TherapyInsulin TherapyIV. Pharmacological TherapyV. Pharmacological Therapy

-Insulin TherapyInsulin Therapy

Short-acting Insulinhort-acting Insulin Regular InsulinRegular Insulin

Onset- 30 minutes to 1 hourOnset- 30 minutes to 1 hour Peak- 2 to 3 hoursPeak- 2 to 3 hours Duration- 4 to 6 hoursDuration- 4 to 6 hours Action - covers meals eaten within 30-60 minutes Action - covers meals eaten within 30-60 minutes Clear in appearanceClear in appearance Usually administered 20 to 30 minutes before a meal,Usually administered 20 to 30 minutes before a meal,

either alone or in combination with a longer-acting Insulineither alone or in combination with a longer-acting Insulin



Intermediate-Acting Insulinntermediate-Acting Insulin NPH Insulin (neutral protamine Hagedorn) or Lente InsulinNPH Insulin (neutral protamine Hagedorn) or Lente Insulin

Onset- 3 to 4 hoursOnset- 3 to 4 hours

Peak- 4 to 12 hoursPeak- 4 to 12 hours Duration- 16 to 20 hoursDuration- 16 to 20 hours Action - covers Insulin needs for about 1/2 the day or overnight Action - covers Insulin needs for about 1/2 the day or overnight White and cloudy in appearanceWhite and cloudy in appearance If NPH or Lente Insulin is taken alone-If NPH or Lente Insulin is taken alone- notnot critical that it becritical that it be

taken a half-hour before the mealtaken a half-hour before the meal Important for the patient to have eaten some food around theImportant for the patient to have eaten some food around the

time of onset and peak of these Insulinstime of onset and peak of these Insulins

IV. Pharmacological Therapy-Insulin Therapy




Long-acting Insulins and Fixed Combinationsong-acting Insulins and Fixed Combinations

1.1. Ultralente InsulinUltralente Insulin Onset- 6 to 8 hoursOnset- 6 to 8 hours

Peak- 12 to 16 hoursPeak- 12 to 16 hours Duration- 20 to 30 hoursDuration- 20 to 30 hours Action- provides a low level of Insulin support for 24 hours Action- provides a low level of Insulin support for 24 hours

2.2. Fixed combinationsFixed combinations Human 50/50 (50% NPH Insulin and 50% Regular Insulin)Human 50/50 (50% NPH Insulin and 50% Regular Insulin) Humulin 70/30 (70% NPH Insulin and 30% Regular Insulin)Humulin 70/30 (70% NPH Insulin and 30% Regular Insulin) Novolin 70/30Novolin 70/30





Rapid-Acting Insulinsapid-Acting Insulins

-Humalog or Novolog-Humalog or Novolog

Onset- 10 to 15 minutesOnset- 10 to 15 minutes Peak- 1 to 2 hours after injectionPeak- 1 to 2 hours after injection Duration- 3 hoursDuration- 3 hours Action - covers meals eaten at same time Action - covers meals eaten at same time

Patient should be instructed not to wait the usual 30 minutesPatient should be instructed not to wait the usual 30 minutesafter injection to eatafter injection to eat Due to short duration of action of Humalog & Novolog -Due to short duration of action of Humalog & Novolog -

patients with Type I diabetes also require a long-acting Insulinpatients with Type I diabetes also require a long-acting Insulinto maintain glucose controlto maintain glucose control





The Newest InsulinThe Newest Insulin ---Lantus---Lantus

Human Insulin analogHuman Insulin analog Basal InsulinBasal Insulin No pronounced peak No pronounced peak Duration of action- up toDuration of action- up to 2424 hourshours

Clear solutionClear solution NeverNever mix with any Insulin (separate syringe)mix with any Insulin (separate syringe) Administered SQ once a day at bedtime Administered SQ once a day at bedtime Can be used as part of regimen of combinationCan be used as part of regimen of combination

therapytherapy





Client receiving Regular Insulin at 0730?Client receiving Regular Insulin at 0730? – The nurse should observe the client most closely for symptomsThe nurse should observe the client most closely for symptoms

associated with an insulin reaction at : (time frame???)associated with an insulin reaction at : (time frame???)

Client receiving NPH Insulin at 0730?Client receiving NPH Insulin at 0730? – The nurse should observe for symptoms of insulin reaction at :The nurse should observe for symptoms of insulin reaction at :

(time frame??)(time frame??)

Client receiving 70/30 NPH/Regular Insulin premix atClient receiving 70/30 NPH/Regular Insulin premix at

0730?0730? – The nurse expects insulin reaction due to regular Insulin betweenThe nurse expects insulin reaction due to regular Insulin between

(time frame???)(time frame???)

IV. Pharmacological Therapy-Insulin Therapy Time Frame Questions

IV. Pharmacological Therapy-Insulin Therapy Time Frame Questions



Teaching Self Administration of Insulineaching Self Administration of Insulineaching Self Administration of Insulineaching Self Administration of Insulin

Administered into SQ tissue with special insulin syringe Administered into SQ tissue with special insulin syringe Syringes matched with Insulin concentration (i.e. U-100)Syringes matched with Insulin concentration (i.e. U-100) Most insulin syringes- 27 to 29 gauge needle- approximately 0.5Most insulin syringes- 27 to 29 gauge needle- approximately 0.5

inch longinch long Short-acting clear in appearanceShort-acting clear in appearance Long-acting cloudy and white- must be mixed gently inverted orLong-acting cloudy and white- must be mixed gently inverted or

rolled in the hands before userolled in the hands before use Draw upDraw up Regular Insulin firstRegular Insulin first if mixing insulinif mixing insulin Debate regarding storage of insulin bottle either in theDebate regarding storage of insulin bottle either in the

refrigerator or kept at room temperaturerefrigerator or kept at room temperature



Sliding Scale InsulinSliding Scale Insulin – Unstable glucose levels requiring supplemental insulin, in additionUnstable glucose levels requiring supplemental insulin, in addition

to usual insulin coverageto usual insulin coverage – Use short-acting Insulin- Regular InsulinUse short-acting Insulin- Regular Insulin

– Usually given before mealsUsually given before meals

– Dose dependent on level of blood glucose at time of administrationDose dependent on level of blood glucose at time of administration

IV. Pharmacological Therapy

-Insulin Therapy




Complications of Insulin Therapyomplications of Insulin Therapyomplications of Insulin Therapyomplications of Insulin Therapy

Local Allergic ReactionsLocal Allergic Reactions – redness, swelling, tenderness, & induration at injection site 1 to 2redness, swelling, tenderness, & induration at injection site 1 to 2

hours after injection administeredhours after injection administered

– usually occurs in beginning stage & disappears with continued use of usually occurs in beginning stage & disappears with continued use of InsulinInsulin

Systematic Allergic ReactionsSystematic Allergic Reactions – rare; local skin reaction gradually spreads entire bodyrare; local skin reaction gradually spreads entire body

LipodystrophyLipodystrophy – localized reaction due tolocalized reaction due to repeated use of same injection siterepeated use of same injection site

– loss of SQ fat (appears as slight dimpling)loss of SQ fat (appears as slight dimpling) – important to rotate injection site & use of Human Insulin- almostimportant to rotate injection site & use of Human Insulin- almost

eliminates this complicationeliminates this complication



Insulin ResistanceInsulin Resistance – immune antibodies develop & bind to insulin- decreasing insulinimmune antibodies develop & bind to insulin- decreasing insulin

available for useavailable for use

– treatment- administer purer insulin & occasionally Prednisonetreatment- administer purer insulin & occasionally Prednisone

– need to monitor for hypoglycemianeed to monitor for hypoglycemia

Dawn PhenomenonDawn Phenomenon – relatively normal BS level until 0300; result from nighttime release of relatively normal BS level until 0300; result from nighttime release of

growth hormone that causes increase BS at 0500 to 0700growth hormone that causes increase BS at 0500 to 0700

– not preceded by an episode of hypoglycemianot preceded by an episode of hypoglycemia

– diagnosis: measurement of BS levels at 0300- level normal & FBS atdiagnosis: measurement of BS levels at 0300- level normal & FBS at0700 is high0700 is high

– treated by changing evening dose of insulin- giving intermediate-treated by changing evening dose of insulin- giving intermediate-acting insulin at 2200 instead of beforeacting insulin at 2200 instead of before dinner at 1800dinner at 1800

Complications of Insulin TherapyComplications of Insulin Therapy



Somogyi EffectSomogyi Effect – periods of nocturnal hypoglycemia followed by reboundperiods of nocturnal hypoglycemia followed by rebound

hyperglycemia (BS levels increase despite increasing doses of hyperglycemia (BS levels increase despite increasing doses of insulin)insulin)

– causes: excessive insulin therapy & release of stress hormonescauses: excessive insulin therapy & release of stress hormones – patient awakes with H/A, c/o restless sleep, nightmares, orpatient awakes with H/A, c/o restless sleep, nightmares, or

unexplained N & Vunexplained N & V

– insulin peaks at 0200 to 0300- blood glucose levels may beinsulin peaks at 0200 to 0300- blood glucose levels may belower- decrease in metabolismlower- decrease in metabolism

– diagnosis: BS levels at 0200, 0400, & 0700- if 1st measurementdiagnosis: BS levels at 0200, 0400, & 0700- if 1st measurement

between 50 to 60 mg/dl & 0700 measurement > 180 to 200between 50 to 60 mg/dl & 0700 measurement > 180 to 200mg/dlmg/dl

– treated by decreasing insulin dosages - nocturnal hypoglycemiatreated by decreasing insulin dosages - nocturnal hypoglycemiadoes not occur & bedtime snack of does not occur & bedtime snack of proteinprotein

Complications of Insulin TherapyComplications of Insulin Therapy



Alternative Methods of Insulin Deliverylternative Methods of Insulin Deliverylternative Methods of Insulin Deliverylternative Methods of Insulin Delivery

Insulin PensInsulin Pens

Jet InjectorsJet Injectors

Insulin PumpsInsulin Pumps Implantable and Inhalant Insulin DeliveryImplantable and Inhalant Insulin Delivery

TransplantationTransplantation



1.1. SulfonylureasSulfonylureas Drugs:Drugs: Diabinese, Micronase, Glucatrol, Orinase, AmarylDiabinese, Micronase, Glucatrol, Orinase, Amaryl Action: Action: Stimulates beta cells of pancreas to secrete moreStimulates beta cells of pancreas to secrete more of of

its own insulinits own insulin Functioning pancreas necessary & Functioning pancreas necessary & cannot be used in Type Icannot be used in Type I

DMDM Peak- 3 to 4 hrs; duration- 6 to 12 hrs (varies with type)Peak- 3 to 4 hrs; duration- 6 to 12 hrs (varies with type) Hypoglycemia occurs: excessive doses, meals omitted orHypoglycemia occurs: excessive doses, meals omitted or

delayed, food intake decreased, or activity is increaseddelayed, food intake decreased, or activity is increased Some meds may increase or decrease BS levelsSome meds may increase or decrease BS levels Common side effects: GI symptoms & dermatologicalCommon side effects: GI symptoms & dermatological

reactionsreactions

IV. Pharmacological Therapy-Oral Antidiabetic Agents: Classifications




2.2. BiguanidesBiguanides – Drug:Drug: GlucophageGlucophage

– Action: increase Insulin sensitivity of liver cells, thus reducing liver Action: increase Insulin sensitivity of liver cells, thus reducing liver

cell production of sugarcell production of sugar – no effect on pancreatic beta cellsno effect on pancreatic beta cells

– Peak- unknown; duration- 6 to 12 hoursPeak- unknown; duration- 6 to 12 hours

– Interacts with anticoagulants, Corticosteroids, diuretics, & oralInteracts with anticoagulants, Corticosteroids, diuretics, & oral

contraceptivescontraceptives

– contraindicated in patients with renal impairments & who drink contraindicated in patients with renal impairments & who drink alcohol heavilyalcohol heavily

– should be discontinued for 2 days before any diagnostic testingshould be discontinued for 2 days before any diagnostic testing

requiring use of contrast agent- potential risk for Lactosis Acidosisrequiring use of contrast agent- potential risk for Lactosis Acidosis





3.3. Oral Alpha Glucosidase InhibitorsOral Alpha Glucosidase Inhibitors – Drug:Drug: PercosePercose

– Action: reduces digestion of starch into sugar in the intestines; Action: reduces digestion of starch into sugar in the intestines;

less sugar is absorbed into the blood after mealsless sugar is absorbed into the blood after meals – Peak- 1hr; duration- unknownPeak- 1hr; duration- unknown

– Does not enhance insulin secretionDoes not enhance insulin secretion

– Can be used with dietary treatment or conjunction with other oralCan be used with dietary treatment or conjunction with other oralantidiabetic meds (when used in conjunction- hypoglycemia mayantidiabetic meds (when used in conjunction- hypoglycemia mayoccur)occur)

– Work on food absorption- must be taken immediately before aWork on food absorption- must be taken immediately before amealmeal

– Side effects: diarrhea & flatulence (GI problems)Side effects: diarrhea & flatulence (GI problems)





4.4. ThiazolidinedionesThiazolidinediones – Drug:Drug: Rezulin, AvandiaRezulin, Avandia

– Action: increases insulin receptor sensitivity on muscles and Action: increases insulin receptor sensitivity on muscles andadipose (fat) cellsadipose (fat) cells

– Increases insulin uptake from blood into target cellsIncreases insulin uptake from blood into target cells

– Makes insulin more effective & less is requiredMakes insulin more effective & less is required

– Peak- 2 to 3 hrs; duration- unknownPeak- 2 to 3 hrs; duration- unknown

– Approved as first-line agent to treat Type II DM, in conjunction Approved as first-line agent to treat Type II DM, in conjunctionwith dietwith diet





5.5. MeglitinidesMeglitinides – Drug:Drug: Prandin, StarlixPrandin, Starlix

– Action: stimulates beta cells of the pancreas to secrete more of its Action: stimulates beta cells of the pancreas to secrete more of its

own insulinown insulin – Contraindicated in patients with Type I DMContraindicated in patients with Type I DM

– Fasting action & short durationFasting action & short duration

– Help manage BS changes after specific mealsHelp manage BS changes after specific meals

– Indicated for useIndicated for use in conjunction with Glucophagein conjunction with Glucophage (patients who(patients who

hypoglycemia cannot be controlled by diet, exercise, & eitherhypoglycemia cannot be controlled by diet, exercise, & eitherGlucophage or Prandin alone)Glucophage or Prandin alone)

– Principle side effect: hypoglycemiaPrinciple side effect: hypoglycemia





Nursing Care for Patients with Diabetes Mellitusursing Care for Patients with Diabetes Mellitus

ADPIE -AssessmentPIE -AssessmentNursing Care for Patients with Diabetes Mellitusursing Care for Patients with Diabetes Mellitus

ADPIE -AssessmentPIE -Assessment

– obtain full history; include info re: ongoing treatment for knownobtain full history; include info re: ongoing treatment for knowndiabetesdiabetes

– peripheral pulsesperipheral pulses

– skin changes at injection sitesskin changes at injection sites

– temperature of extremitiestemperature of extremities – sensation losssensation loss

– visual acuityvisual acuity

– muscle atrophymuscle atrophy

– weaknessweakness



Diagnostic EvaluationDiagnostic Evaluation – glucose tolerance testglucose tolerance test

– urinalysisurinalysis

– blood glucose testsblood glucose tests

Clinical ManifestationsClinical Manifestations – increased hunger (polyphagia)increased hunger (polyphagia)

– weight lossweight loss

– excess thirst (polydipsia)excess thirst (polydipsia)

–excess urination (polyuria)excess urination (polyuria)

– fatiguefatigue

– weaknessweakness

Nursing Care for Patients with Diabetes Mellitus

ADPIE –Assessment Cont’d:Nursing Care for Patients with Diabetes Mellitus

A DPIE –Assessment Cont’d:



– Knowledge deficit- medication and dietary regimen r/t self-careKnowledge deficit- medication and dietary regimen r/t self-care

skills aeb ????skills aeb ????

– Anxiety r/t fear of diabetic complications aeb ??? Anxiety r/t fear of diabetic complications aeb ??? – Altered nutrition, more than body requirements, r/t failure to follow Altered nutrition, more than body requirements, r/t failure to follow

diet and exercise plan aeb ???diet and exercise plan aeb ???

– Fluid volume deficit r/t loss of fluids aeb diarrhea, vomiting, andFluid volume deficit r/t loss of fluids aeb diarrhea, vomiting, and

osmotic diuresis from hyperglycemiaosmotic diuresis from hyperglycemia

– Impaired skin integrity r/t decreased tissue perfusion or infectionImpaired skin integrity r/t decreased tissue perfusion or infectionaeb ???aeb ???

– Potential for injury or trauma r/t inability to feel pain secondary toPotential for injury or trauma r/t inability to feel pain secondary toperipheral nerve degenerationperipheral nerve degeneration


ADPIE - Nursing DiagnosesNursing Care for Patients with Diabetes Mellitus

A DPIE - Nursing Diagnoses



Client OutcomesClient Outcomes (before addition of time and measurement(before addition of time and measurementconditions)conditions)

Client will show increasing knowledge base toClient will show increasing knowledge base to

demonstrate self-caredemonstrate self-care by describing ___ by date.by describing ___ by date. Client will verbalize an understanding of common DMClient will verbalize an understanding of common DM

complications and their management bycomplications and their management by listing ____ bylisting ____ bydatedate

Client will follow prescribed diet planClient will follow prescribed diet plan Client will maintain adequate intake of fluids andClient will maintain adequate intake of fluids and

electrolyteselectrolytes Client will maintain skin integrity and avoid injuriesClient will maintain skin integrity and avoid injuries


ADPIE Planning:


ADPIE Planning:



Nursing Care for Patients with Diabetes Mellitusursing Care for Patients with Diabetes Mellitus ADPDPIE –– V. InterventionsV. Interventions

Nursing Care for Patients with Diabetes Mellitusursing Care for Patients with Diabetes Mellitus ADPDPIE –– V. InterventionsV. Interventions

1.1. Encourage to follow practices that promote health & preventEncourage to follow practices that promote health & prevent

injury adhering to prescribed diet, getting sufficient exercise,injury adhering to prescribed diet, getting sufficient exercise,

taking care of feet, inspecting skin daily, checking temperaturetaking care of feet, inspecting skin daily, checking temperature

of bath water before use, and applying heating devices carefullyof bath water before use, and applying heating devices carefully

2.2. Teach to use an appropriate method of self-monitoring of bloodTeach to use an appropriate method of self-monitoring of blood

glucoseglucose

3.3. Teach about types of insulin prescribed for DM self-injectableTeach about types of insulin prescribed for DM self-injectable

InsulinInsulin

4.4. Teach how to treat complications of diabetes causes, symptoms,Teach how to treat complications of diabetes causes, symptoms,& prevention of hypoglycemia, hyperglycemia, diabetic& prevention of hypoglycemia, hyperglycemia, diabetic

ketoacidosis, & hyperglycemia hyperosmolar nonketoticketoacidosis, & hyperglycemia hyperosmolar nonketotic

syndromesyndrome

5.5. Teach diabetic foot careTeach diabetic foot care

6.6. Teach changes that must occur in event of illnessTeach changes that must occur in event of illness



– Client demonstrates self-care skillsClient demonstrates self-care skills

– Client verbalizes understanding of common diabetic complicationsClient verbalizes understanding of common diabetic complications

and their managementand their management

– Client eats prescribed dietClient eats prescribed diet

– Client maintains adequate intake of fluids and electrolytesClient maintains adequate intake of fluids and electrolytes

– Client verbalizes perception of disease, benefits of care, and barriersClient verbalizes perception of disease, benefits of care, and barriers

to careto care

– Client identifies coping patterns and personal strengths to promoteClient identifies coping patterns and personal strengths to promote

effective copingeffective coping

– Client maintains intact skinClient maintains intact skin – Client avoids injury or traumaClient avoids injury or trauma

Nursing Care for Patients with Diabetes Mellitus ADPIE

- Evaluation

Nursing Care for Patients with Diabetes Mellitus ADPIE

- Evaluation



Acute Complications of Diabetes:cute Complications of Diabetes:Hypoglycemiaypoglycemia

Acute Complications of Diabetes:cute Complications of Diabetes:Hypoglycemiaypoglycemia

– BS level falls < 60 to 70 mg/dlBS level falls < 60 to 70 mg/dl – may occur with either types of diabetesmay occur with either types of diabetes – most common causes:most common causes:

too much insulin or oral antidiabetic agenttoo much insulin or oral antidiabetic agent too little food intake (delayed or missed meal)too little food intake (delayed or missed meal)

too much exercise at wrong time of daytoo much exercise at wrong time of day ingestion of alcohol, esp. when not eatingingestion of alcohol, esp. when not eating – onset is rapid - 1 to 3 hrs & if prolonged, coma may resultonset is rapid - 1 to 3 hrs & if prolonged, coma may result – Symptoms: cold & clammy, pallor, perspiration, shaking or tremors, hunger, headache,Symptoms: cold & clammy, pallor, perspiration, shaking or tremors, hunger, headache,

anxious, inability to concentrate, blurred vision, dizzy, fatigue, irritable, & unresponsiveanxious, inability to concentrate, blurred vision, dizzy, fatigue, irritable, & unresponsive – TreatmentTreatment

10 to 15 grams of a fast-acting CHO orally10 to 15 grams of a fast-acting CHO orally

– 3 to 4 commercially prepared glucose tablets, 4 to 6 oz of fruit juice or regular3 to 4 commercially prepared glucose tablets, 4 to 6 oz of fruit juice or regularsoda, 6 to 10 Life Savers or either hard candies, or 2 to 3 tsp.. of sugar orsoda, 6 to 10 Life Savers or either hard candies, or 2 to 3 tsp.. of sugar orhoneyhoney

Recheck BS 15 minutes later- retreat if BS <70 to 75 mg/dlRecheck BS 15 minutes later- retreat if BS <70 to 75 mg/dl Symptoms resolved- snack containing protein & starch unless eat a regular mealSymptoms resolved- snack containing protein & starch unless eat a regular meal Unconscious & cannot swallow- injection of Glucagon 1mg administered either SQ orUnconscious & cannot swallow- injection of Glucagon 1mg administered either SQ or

IM;IM;

Hospital setting- treated with 25 to 50 ml of 50% Dextrose in water (D50)-Hospital setting- treated with 25 to 50 ml of 50% Dextrose in water (D50)-administered IV- immediate effectsadministered IV- immediate effects



– Very high BS level- due to inadequate insulin effect Very high BS level- due to inadequate insulin effect

– Predisposing factors:Predisposing factors:

newly diagnosed DM,newly diagnosed DM,

insufficient education about DM & insufficient education about DM & conditions that increase counterregulatory hormonesconditions that increase counterregulatory hormones

– Clinical Findings:Clinical Findings:

polyuria, polydipsia, weakness, light-headness, weight loss,polyuria, polydipsia, weakness, light-headness, weight loss,

polyphagia, & blurred visionpolyphagia, & blurred vision

– Treatment:Treatment: control of DM through medication, exercise & dietcontrol of DM through medication, exercise & diet

Acute Complications of Diabetes:Hyperglycemia

Acute Complications of Diabetes:Hyperglycemia



– Type of metabolic acidosis with hyperglycemia & dehydration- leads toType of metabolic acidosis with hyperglycemia & dehydration- leads to

excessive levels of ketones in the bodyexcessive levels of ketones in the body

– Major life-threatening complication; occurs inMajor life-threatening complication; occurs in Type I DMType I DM – Causes:Causes:

absence or markedly inadequate amount of insulin, illness orabsence or markedly inadequate amount of insulin, illness or

infection, treatment error, steroid therapy, stress, & infection, treatment error, steroid therapy, stress, &

undiagnosed & untreated diabetesundiagnosed & untreated diabetes

– Cardinal signs of DKA Cardinal signs of DKA HyperglycemiaHyperglycemia, metabolic, metabolic acidosisacidosis, osmotic, osmotic diuresisdiuresis

(dehydration & electrolyte loss)(dehydration & electrolyte loss)

– Blood sugar levels varies-Blood sugar levels varies- 300 to 800300 to 800 mg/dlmg/dl

– Onset slow 4 -10 hoursOnset slow 4 -10 hours

Acute Complications of Diabetes:Diabetic Ketoacidosis (DKA)

Acute Complications of Diabetes:Diabetic Ketoacidosis (DKA)



Clinical ManifestationsClinical Manifestations – polyuria, polydipsia, blurred vision, weakness, headache,polyuria, polydipsia, blurred vision, weakness, headache,

orthostatic hypotension, anorexia, N & V, abd. pain,orthostatic hypotension, anorexia, N & V, abd. pain, classic-classic-

acetone breath, hyperventilation (Kussmaul respiration),acetone breath, hyperventilation (Kussmaul respiration), & mental& mental

status changesstatus changes InterventionsInterventions

– HyperglycemiaHyperglycemia

Monitor BS levels, VS, airway patency & LOC along withMonitor BS levels, VS, airway patency & LOC along with

UO & mental status every hourUO & mental status every hour

– HydrationHydration IV fluid- 0.9% NS at high rate, usually 0.5 to 1 liter perIV fluid- 0.9% NS at high rate, usually 0.5 to 1 liter per

hour for 2 to 3 hourshour for 2 to 3 hours (IV rate ???)(IV rate ???) Monitor VS, lung assessment, I & O, andMonitor VS, lung assessment, I & O, and signs for fluidsigns for fluid

overload!overload!

When BS reaches 300 or <- IV fluid may be changed to D5WWhen BS reaches 300 or <- IV fluid may be changed to D5W

Acute Complications of Diabetes:Diabetic Ketoacidosis (DKA) Cont’d.




Electrolyte LossElectrolyte Loss – Monitor K+Monitor K+ level b/c insulin pushes K into cells; caution but timelylevel b/c insulin pushes K into cells; caution but timely

K+ replacement to avoid dysrhythmiasK+ replacement to avoid dysrhythmias

– Frequent EKG readings and lab measurements of K+ esp. during 1stFrequent EKG readings and lab measurements of K+ esp. during 1st8 hours of treatment8 hours of treatment

Acidosis Acidosis – Insulin infused IVInsulin infused IV at a slow, continuous rateat a slow, continuous rate

– Hourly BS monitoringHourly BS monitoring

– Dextrose added to IV fluidsDextrose added to IV fluids (NS)- BS level reach 250 to 300 mg/dl(NS)- BS level reach 250 to 300 mg/dl – IV Insulin continued 12 to 24 hrs- until serum bicarbonate levelIV Insulin continued 12 to 24 hrs- until serum bicarbonate level

improves & client can eatimproves & client can eat



l f b



– Life-threatening; emergency situation more common in elderly TypeLife-threatening; emergency situation more common in elderly Type

II DM or undiagnosed DM clientsII DM or undiagnosed DM clients

– Dehydration, hyperglycemia & alterations of sense of awarenessDehydration, hyperglycemia & alterations of sense of awareness

(coma)(coma)

– Results from insulin deficiency; onset gradual;Results from insulin deficiency; onset gradual; Ketosis & acidosisKetosis & acidosis

does not occurdoes not occur

– Causes:Causes:

acute illness or infection, fluid loss from osmotic diureticacute illness or infection, fluid loss from osmotic diuretic

2nd to hyperglycemia, severe burns, severe diarrhea,2nd to hyperglycemia, severe burns, severe diarrhea,

hemodialysis & pharmacological agentshemodialysis & pharmacological agents

– Assessment Assessment

electrolyte & BUN (clinical picture of severe dehydration),electrolyte & BUN (clinical picture of severe dehydration),

mental status changes, neurologic deficits, & posturalmental status changes, neurologic deficits, & postural

hypotensionhypotension

Acute Complications of Diabetes:Hyperglycemia Hyperosmolar NonketoticSyndrome (HHNK)

Acute Complications of Diabetes:Hyperglycemia Hyperosmolar NonketoticSyndrome (HHNK)

l f bA C li i f Di b



Clinical ManifestationsClinical Manifestations – hypotension, severe dehydration, tachycardia, depressed mentalhypotension, severe dehydration, tachycardia, depressed mental

status to coma, severe weakness & lethargystatus to coma, severe weakness & lethargy

– Blood glucose level-Blood glucose level- 600 to 1200 mg/dl600 to 1200 mg/dl, osmolarity > 350 mOsm/kg,, osmolarity > 350 mOsm/kg,elevated serum Na+,elevated serum Na+, ketones negativeketones negative

InterventionIntervention – IV fluid- 0.9% or 0.45% NS;IV fluid- 0.9% or 0.45% NS; K+K+ added to IV fluids (UO adequateadded to IV fluids (UO adequate

with EKG monitoring)with EKG monitoring)

– Careful monitor for complications:Careful monitor for complications: CHFCHF, electrolyte imbalance,, electrolyte imbalance,seizuresseizures

– Insulin administered at low rateInsulin administered at low rate & Dextrose to replace fluids& Dextrose to replace fluids

– May take 3 to 5 days for neurologic symptoms to resolveMay take 3 to 5 days for neurologic symptoms to resolve

– Can control DM with diet or with diet & oral antidiabetic agentsCan control DM with diet or with diet & oral antidiabetic agents

Acute Complications of Diabetes:Hyperglycemia Hyperosmolar NonketoticSyndrome (HHNK) Cont’d.

Acute Complications of Diabetes:Hyperglycemia Hyperosmolar NonketoticSyndrome (HHNK) Cont’d.



Long-term Degenerative Changesong-term Degenerative Changes

of Diabetes Mellitusof Diabetes MellitusLong-term Degenerative Changesong-term Degenerative Changes

of Diabetes Mellitusof Diabetes Mellitus

1.1. Macrovascular DiseaseMacrovascular Disease – Coronary artery disease, cerebrovascular disease, & peripheralCoronary artery disease, cerebrovascular disease, & peripheral

vascular diseasevascular disease

– Results from changes in medium to large blood vessels- bloodResults from changes in medium to large blood vessels- blood

vessels walls thicken & become occluded by plague- eventuallyvessels walls thicken & become occluded by plague- eventually

blood flow becomes blockedblood flow becomes blocked

– Increased risk for myocardial infarction- typical ischemic symptomsIncreased risk for myocardial infarction- typical ischemic symptoms

may be absentmay be absent

– Management:Management:

prevention & treatment of risk factors forprevention & treatment of risk factors foratherosclerosisatherosclerosis

diet & exercise in managing obesity, HTN & diet & exercise in managing obesity, HTN &

hyperlipidemiahyperlipidemia

medication & close control of BS levelsmedication & close control of BS levels

smoking cessationsmoking cessation



2.2. Microvascular DiseaseMicrovascular Disease – Diabetic RetinopathyDiabetic Retinopathy

deterioration of small blood vessels that nourish thedeterioration of small blood vessels that nourish theretinaretina

Clinical Manifestations:Clinical Manifestations: – painless, blurred vision, hemorrhaging- floaters orpainless, blurred vision, hemorrhaging- floaters or

cobwebs in visual field or sudden visual changes-cobwebs in visual field or sudden visual changes-spotty or hazy vision or complete loss of visionspotty or hazy vision or complete loss of vision

DiagnosisDiagnosis

– direct visualization with ophthalmoscope ordirect visualization with ophthalmoscope orfluorescent anigographyfluorescent anigography ManagementManagement

– maintenance of BS levelmaintenance of BS level – advanced cases- Argon Laser Photocoagulationadvanced cases- Argon Laser Photocoagulation

Long-term Degenerative Changesof Diabetes Mellitus




3.3. Diabetic NeuropathiesDiabetic Neuropathies – affects all types of nerves including peripheral, autonomic, & affects all types of nerves including peripheral, autonomic, &

spinal nervesspinal nerves – Two common types:Two common types:

Sensorimotor polyneuropathySensorimotor polyneuropathy Autonomic neuropathy Autonomic neuropathy

– Clinical Manifestations:Clinical Manifestations: paresthesias (prickling, tingling sensation); burningparesthesias (prickling, tingling sensation); burning

sensations (esp. at night); progression- the feetsensations (esp. at night); progression- the feet

become numb; decrease awareness of posture & become numb; decrease awareness of posture & movement of body & decrease sensation lead tomovement of body & decrease sensation lead tounsteady gaitunsteady gait

– ManagementManagement intensive insulin therapy & control of BS; painintensive insulin therapy & control of BS; pain

management with analgesics, antidepressants or TENSmanagement with analgesics, antidepressants or TENS

unitunit





4.4. Diabetic NephropathyDiabetic Nephropathy – Renal disease 2nd to diabetic microvascular changes in the kidney;Renal disease 2nd to diabetic microvascular changes in the kidney;

3rd most common listed diagnosis of pts treated for ESRD3rd most common listed diagnosis of pts treated for ESRD

– Clinical Manifestations:Clinical Manifestations:

signs of renal dysfunction (proteinuria, edema, & renalsigns of renal dysfunction (proteinuria, edema, & renal

insufficiency) along with multiple system failureinsufficiency) along with multiple system failure

(declining visual acuity, impotence, feet ulcerations & (declining visual acuity, impotence, feet ulcerations &

CHF)CHF)

– ManagementManagement

control HTN, prevent & treat UTIs, & avoidance of control HTN, prevent & treat UTIs, & avoidance of

nephrotoxic substances, adjust meds as renal functionnephrotoxic substances, adjust meds as renal function

changes, low Na+ and low protein dietchanges, low Na+ and low protein diet

Renal failure; hemodialysis or peritoneal dialysis & renalRenal failure; hemodialysis or peritoneal dialysis & renal

transplantationtransplantation





Older Adult Alertlder Adult Alertlder Adult Alertlder Adult Alert

Type II DM more common in older adult clientType II DM more common in older adult client

Greatest risk for complications associated with DM that wouldGreatest risk for complications associated with DM that would

require hospitalizationrequire hospitalization

Symptoms commonly associated with DM may be masked bySymptoms commonly associated with DM may be masked by

other illnessother illness

Many older adults have unusual or erratic eating patterns thatMany older adults have unusual or erratic eating patterns that

must be considered when planning a dietmust be considered when planning a diet

Older adults may have decreased visual acuity or manualOlder adults may have decreased visual acuity or manual

dexterity that may decrease their ability to prepare anddexterity that may decrease their ability to prepare andadminister insulinadminister insulin

Proper foot care may not be possible with their decreasedProper foot care may not be possible with their decreased

mobility and visual acuitymobility and visual acuity

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NUR 201 Diabetes Powerpoint

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