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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