AHI – Diabetes Management

DM Type I
autoimmune disorder where the body does not produce insulin for glucose metabolism; acute and sudden onset, typically manifests at a young age
DM Type 2
a Metabolic Disorder that accounts for 90 to 95 percent of all diabetes cases wherein either the pancreas does not make sufficient insulin or body cells are resistant to its effects (insulin resistance)
*usually occurs in older patients, but is seen increasingly in younger pts
Three Main Types of Diabetes
1) DM Type I
2) DM Type 2
3) Gestational Diabetes
S/S DM Type 1
Polyuria
Polydipsia
Polyphagia
Fatigue
Weakness
Weight loss
Irritability and mood changes
Criteria for Diagnosing Diabetes
1) *A1C = ≥6.5%* (Glycated Hemoglobin, Glycosylated Hemoglobin, Hemoglobin A1c, A1C, HbA1c)
2) Fasting plasma glucose (FPG) = *≥126 mg/dL (7.0 mmol/L)*
3) 2-h plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT
4)A random plasma glucose ≥200 mg/dL (11.1 mmol/L)
Hemoglobin A1C
% of hemoglobin that is coated with glucose, used for diagnosis of diabetes b/c it is not as susceptible for spikes as blood glucose levels are
Prediabetic Criteria
FPG = 100-126
AB1C = 5.7-6.4%
OGTT = 140-199
Normal Lab Values Relevant to Diabetes
A1C = < 6.5% (5%) FPG = 70-110 (<99) pH = 7.35-7.45
Tx for DM Type I
*Insulin therapy*
– Most should be treated with multiple dose injections (3-4 per day of basal and prandial insulin) or continuous subcutaneous insulin infusion
Education: how to match prandial insulin dose to carbohydrate intake, premeal blood glucose, and anticipated activity
Onset, Peak, Duration of Lispro
O = 15 min
P = 0 -1.5 hrs
D = 3-4 hrs
Onset, Peak, Duration of Asparte (Rapid Acting Insulin)
O = immediate
P = 45 min – 1.5 hrs
D = 3-4 hrs
Onset, Peak, Duration of Regular Insulin (Short Acting Insulin)
O = 30 min – 1 hr
P = 2-3 hrs
D = 3-6 hrs
Onset, Peak, Duration of NPH (Intermediate Acting)
O = 2-4 hrs hrs
P = 4-10 hrs
D = 10-16 hrs
Onset, Peak, Duration of Glargine (Long-Acting)
O = 1-2 hrs
P = none (plateaus throughout duration)
D = 24+ hrs
*commonly used as Basal Insulin
Administration of Insulin
Before meals
Blood glucose testing and administration of insulin should occur within 30 minutes of each other
Injection
Proper injection sites
Gently pinch skin and give at 90° angle (if very thin 45°)
Document blood glucose, and insulin administration
Be aware of NPO status, impending tests, and when meals are delivered
A hypoglycemia management protocol should be adopted and implemented by each health care setting
Blood glucose testing should be done within __ minutes of administration.
30
Monitoring Blood Glucose
Important for detecting episodic hyperglycemia and hypoglycemia
Patient training is crucial
Supplies immediate information about blood glucose levels
Continuous Glucose Monitor tests glucose in ____ .
interstitial fluid
Adrenalin can make blood sugar ___ .
go up
Exercise can also have the effect of ____ blood glucose by using the available sugar during activity.
lowering.
Order of NI for Diabetic Pt
1) Vital Signs
2) Fingerstick
3) Administer Insulin
4) Complete Bedside Assessment
5) AM Care
6) Education
Beta cell dysfxn begins ___ years before presentation of DM Type 2.
10-12
Etiology of DM Type 2
The overabundance of free fatty acids contributes to insulin resistance.
As the progression to type 2 diabetes continues, pancreatic insulin-producing cells become exhausted from
overwork and damage occurs.
Non-modifiable Risk Factors for DM Type 2
Increased age
Certain ethnicities (Native Americans, African Americans, Hispanic and/or Asian)
Genetic factors
Modifiable Risk Factors for DM Type 2
Overweight
Sedentary lifestyle
Dietary components
Perinatal factors, nutrition in utero
As one’s ___ goes up, their risk for Diabetes Type 2 also increases.
BMI
Clinical Manifestations of DM Type 2
Feeling tired and weak
Passing large volumes of urine, especially during the night
Having frequent infections (ex. yeast infections –> high blood sugar)
Having blurred eyesight
Weight loss
Excessive hunger and thirst
Factors Affecting BG Levels in Hospital Setting
• Changing IV glucose rates
• TPN and enteral feedings
• Lack of physical activity
• Unusual timing of insulin injections
• Use of glucocorticoids
• Unpredictable or inconsistent food intake
• Fear of hypoglycemia
• Cultural acceptance of hyperglycemia
Some non-diabetic medications may _____ blood glucose levels in pts.
increase or decrease
Nursing Care for Diabetic Pts
• 24-hour coverage by nursing
• Nursing often coordinates, and is aware of, the multiple
services required by patient
– Travel off unit, (eg, physical therapy, X-ray)
– Amount of food eaten (carbohydrates)
– Patient’s day-to-day concerns
– Order changes (by various providers)
Goals of Care for DM Pts
Maintain steady control of blood glucose
Decrease symptoms
Promote well-being
Prevent acute complications
Delay onset and progression of chronic complications
Nursing Assessment for DM
Past health history (Table 49-13)
Infections
Medications
Recent surgery
Positive health history
Obesity
Current management strategies
– How often they see their PCP
– Education level
– Nutritional habits
Important Education for Pts with DM
Symptoms
Diagnosis
Prevention
Treatment
Self-care
Foot Care
Exercise
Nutrition
Storage and dose preparation
Syringes
Blood glucose monitoring
Interpretation of results
Frequency of testing
Blood glucose therapy goals
Nursing Diagnosis for DM
Knowledge Deficit:
Pathophysiology
Normal levels
Effect of insulin & exercise
Effects of stress, illness & infections
Drugs, alcohol
Self testing
Signs/Symptoms of Hypoglycemia/
Hyperglycemia
Oral Drug Therapy for DM
Work to improve mechanisms by which insulin
and glucose are produced and used by the body.
Sulfonylureas
increase insulin production from the pancreas
1) Glipizide (Glucotrol)
2) Glyburide (Micronase)
3) Glimepiride (Amaryl)
Biguanides
reduce glucose production by the liver, enhances insulin sensitivity and improves glucose transport
1) Metformin (Glucophage)
– Temporarily discontinue metformin before IV contrast, resume after 48 hours and normal creatinine
– Used for weight loss & lowering Cholesterol as well
– CI for pts with liver disease or ETOH abuse
Nutritional Therapy for DM
+ Protein, – fats and carbohydrates, + fiber, – sweeteners, + replacers
Less Alcohol
Food labeling
Exchange system, carbohydrate counting
– ALL ABOUT BALANCE
– Loss of 1-2 lbs a week does drastic improvement for HbAC1 %
Exercise Therapy for DM
Benefits of exercise (*decreases insulin resistance*)
Risks related to exercise
Screening before starting exercise program
Guidelines for exercise
– 30min/day moderate
– 150 min/ week
Exercise promotion
Acute Complications of DM
1) Diabetic ketoacidosis (DKA)
2) Hyperosmolar hyperglycemic syndrome (HHS)
3) Hypoglycemia
– Too much insulin
– Too little glucose
Hypoglycemia
*Blood glucose level < 70 mg/dL* Diet therapy: carbohydrate replacement Drug therapy: glucagon, 50% dextrose Prevention strategies for: - Insulin excess - Deficient food intake - Exercise - Alcohol consumption
What can cause hypoglycemia?
Insulin > demand
Change in type of insulin
Oral hypoglycemia
Decreased caloric intake
Increase in activity
Decreased metabolism
Excessive ETOH
Adrenal insufficiency
Glucagon IM has precautions for ___ .
aspiration, as it can cause emesis (N/V)
Hypoglycemia can lead to ….
– LOC
– seizures
– coma
– death
Treat hypoglycemia with ___ carbs.
simple -> absorbed faster!
After giving glucose re hypoglycemic protocol, recheck after ___ .
20 min
S/S Hypoglycemia
mood changes, tremor, pallor, diaphoresis, dizziness, blurred vision, HA, fatigue, hunger
Clinical Manifestations of Diabetic Ketoacidosis (DKA)
Dehydration (poor skin turgor, tachycardia,
orthostatic hypotension)
Lethargy and weakness
Abdominal pain with anorexia and vomiting
Kussmaul respirations (Body’s attempt to reverse metabolic acidosis)
Acetone on breath (sweet, fruity odor)
*Typically occurs in DM Type 1 that is poorly managed or undiagnosed*
DKA Lab Findings
BG > 250mg/dL (super high blood glucose)
Arterial blood pH < 7.30 (low pH) Bicarb < 15mEq/L ( low HCO3) Urine +++ketones (keytones + in urine!)
Interventions for DKA
Monitoring for clinical manifestations
*Assessment of airway, level of consciousness, hydration status, blood glucose level*
Management of fluid and electrolytes
Drug therapy goal: to lower serum glucose by 75 to
150 mg/dL/hr
Management of acidosis
Client education and prevention
– Severity of s/s will dictate treatment
– Pt can end up on NG tube or respirator
Hyperosmolar Hyperglycemic Syndrome (HHS)
Severe hyperglycemia w/ serum glucose *>600mg/dL*
Plasma osmolarity > 315 mOsm/kg
Bicarb > 15
Arterial pH > 7.3
Serum ketones – negative or mildly elevated
*HHNS occurs less often than DKA, but has a much higher
mortality*
– Patients >60, Type 2 DM, infections

End result – hyperglycemia and volume depletion
through osmotic diuresis.
– Total body water losses can reach 8-12 liters

BG levels can rise as high as ___ before s/s of HHS begin, because there is enough insulin in the body to combat the glucose levels before ketosis begins.
600-800
Typically, with pts who get HHS, an acute illness has impaired their ____.
thirst mechanism
Nursing Interventions for HHS
Monitoring for clinical manifestations
Fluid therapy: to rehydrate the client and restore
normal blood glucose levels within 36 to 72 hr
Continuing therapy with IV regular insulin at 10
units/hr often needed to reduce blood glucose levels
Client education and prevention
DKA vs HHS
– usually < 40 y/o - S/S last under 2 days - Glucose levels 600-800 mg/dL - Sodium = normal or low - Potassium = irrelevant - BiCarb = low - Ketones = present - Serum Osmolality = < 350 mOsm/kg - Prognosis = 3-10% mortality
HHS vs DKA
– usually >60 y/o
– S/S usually last > 5 days
– Glucose levels = > 800 mg/dL
– Sodium = normal or high
– Potassium = irrelevant
– BiCarb = normal
– Ketones = not present
– Serum Osmolality = > 350 mOsm/kg
– Prognosis = 10-20% mortality
Chronic Complications of Diabetes
Cardiovascular disease (Primary cause of death in patients with DM) *silent ischemia*
Cerebrovascular disease (Diabetic patients have at least twice the risk of CVA)
Retinopathy (vision) problems
– damage to blood vessels in retina
– Leading cause blindness
– *Need annual eye exams*
Diabetic neuropathy
Diabetic nephropathy
Male erectile dysfunction due to nerve impairment
*Complications for feet and lower extremities*
– due to sensory neuropathy
– and peripheral arterial disease
Primary cause of death for pts with DM
Cardiovascular Disease
Diabetic Retinopathy
– starts with “dirty lens” spots, “floaters”
– damage to blood vessels in retina
– can lead to blindness
– annual eye exams necessary
Interventions for DM Risk for Delayed Surgical Recovery
Preoperative care
– Careful assessment of cardiac risk factors –> EKG
– May be relatively asymptomatic
Intraoperative care
– Glycemic control
Postoperative care and monitoring includes care of:
– Cardiovascular
– Renal
– Nutritional
Contributing Factors to Risk for Complications of Feet and Lower Extremities in DM
Risk factors
Sensory neuropathy
Peripheral arterial disease- 2x more common in diabetics
Other contributors:
*Smoking*
Clotting abnormalities.
Impaired immune function
Autonomic neuropathy
1 in __ diabetics will develop a foot ulcer in their lifetime.
4
Foot ulcers can become a big problem in DM pts because of …
delayed healing that can lead to necrosis or amputation
It is recommended that DM pts go to ____ annually.
a podiatrist
Interventions for Foot Care
•Testing for sensation (monofilament, vibration)
•Annual visit with comprehensive foot examination
•Every visit if high risk
•Appropriate foot wear
•Teach patient daily skin assessment, may need mirror
•Wash/dry daily
•Avoid hot water; dry thoroughly between toes
•Lubricate daily (not between toes)
•Trim toes properly after bathing
•No self-cutting of nails if:
•Neuropathy, PAD, poor vision
•Report nonhealing breaks in skin or any other concerns
Interventions for Nursing Dx for DM: Risk of Injury Related to Disturbed Sensory Perception: Visual
Blood glucose control
Environmental management
Incandescent lamp
Clock method for meals
Syringes with magnifiers
Large-print reading materials
Hand-held magnifiers
DM and Infection
Diabetic individuals more susceptible to infection
Defect in mobilization of inflammatory cells
Impairment of phagocytosis by neutrophils and
monocytes
Loss of sensation may delay detection.
Treatment must be prompt and vigorous.
(frequent yeast infections, neuropathy can delay awareness of s/s of infection, impaired wound healing)
DM Gero Considerations
Prevalence increases with age
Hypoglycemic unawareness more common
Presence of delayed psychomotor function
could interfere with treating hypoglycemia
Strict glycemic control may be difficult to
achieve
– cognitive dysfxn can interfere with Tx as well
Some medications may _____ blood glucose levels.
increase or decrease