ATI Med-Surg: Chp 83: Diabetes Mellitus Management

Diabetes mellitus
Diabetes mellitus is characterized by chronic hyperglycemia due to inadequate insulin secretion and/or the effectiveness of endogenous insulin (insulin resistance).

● Diabetes mellitus is a contributing factor to development of cardiovascular disease, hypertension, kidney disease, neuropathy, retinopathy, peripheral vascular disease, and stroke as individuals age.

● Diabetes mellitus is significantly more prevalent in African Americans, American Indians, and Hispanic populations, possibly due to obesity and inactivity.

Type 1 diabetes mellitus
Type 1 diabetes mellitus is an autoimmune dysfunction involving the destruction of beta cells, which produce insulin in the islets of Langerhans of the pancreas. Immune system cells and antibodies are present in circulation and may also be triggered by certain genetic tissue types or viral infections.

● Type 1 diabetes mellitus usually occurs at a young age, and there are no successful interventions to prevent the disease.

Type 2 diabetes mellitus
Type 2 diabetes mellitus is a progressive condition due to increasing inability of cells to respond to insulin (insulin resistance) and decreased production of insulin by the beta cells. It often occurs later in a client’s life due to obesity, inactivity, and hereditary.
Health Promotion and Disease Prevention: Diabetic Screening
◯ Determine risk factors – obesity, hypertension, inactivity, hyperlipidemia, cigarette smoking, genetic history, elevated C-reactive protein (CRP), ethnic group, and women who have delivered infants weighing more than 9 lb

◯ American Diabetes Association (ADA) recommends screening a client who has a BMI greater than 24 and age greater than 45 years, or if a child is overweight and has additional risk factors.

◯ Test urine for glucose and ketones during routine examinations to evaluate the need for further testing.

Health Promotion and Disease Prevention: Client Education
◯ Teach the client that exercise and good nutrition are necessary for preventing or controlling diabetes.

◯ Instruct the client to limit calories and decrease total fat intake to 30% of total daily calories.

◯ Encourage a diet low in saturated fats to decrease low-density lipoprotein (LDL), assist with weight loss for secondary prevention of diabetes, and reduce risk of heart disease.

◯ Modify diet to include omega-3 fatty acids and fiber to lower cholesterol levels, improve blood glucose for clients who have diabetes, for secondary prevention of diabetes, and to reduce the risk of heart disease.

Risk Factors
◯ Obesity, physical inactivity, high triglycerides (greater than 250 mg/dL), and hypertension may lead to the development of insulin resistance and type 2 diabetes.
◯ Pancreatitis and Cushing’s syndrome are secondary causes of diabetes.
◯ Vision and hearing deficits may interfere with the understanding of teaching, reading of materials, and preparation of medications.
◯ Tissue deterioration secondary to aging may impact the client’s ability to prepare food, care for self, perform ADLs, perform foot/wound care, and perform glucose monitoring.
◯ A fixed income may mean that there are limited funds for buying diabetic supplies, wound care supplies, insulin, and medications. This may result in complications.
◯ Older adult clients may not be able to drive to the provider’s office, grocery store, or pharmacy. Assess support systems available for older adult clients.
◯ The older adult is at risk for altered metabolism of medication due to decreased kidney and liver function because of the aging process.
◯ The older adult may have visional alterations (yellowing of lens, decreased depth perception, cataracts), which can affect ability to read information and attend to medication administration.
Clinical Manifestations
◯ Hyperglycemia – blood glucose level usually greater than 250 mg/dL
◯ Polyuria (excess urine production and frequency) from osmotic diuresis
◯ Polydipsia (excessive thirst) due to dehydration
■ Loss of skin turgor, skin warm and dry
■ Dry mucous membranes
■ Weakness and malaise
■ Rapid weak pulse and hypotension
◯ Polyphagia (excessive hunger and eating) caused from inability of cells to receive glucose (cells are starving)
■ Client may display weight loss.
■ Ketones accumulate in the blood due to breakdown of fatty acids when insulin is not available, resulting in metabolic acidosis.
■ Kussmaul respirations – increased respiratory rate and depth in attempt to excrete carbon dioxide and acid due to metabolic acidosis.
◯ Other manifestations can include acetone/fruity breath odor due to accumulation of ketones, headache, nausea, vomiting, abdominal pain, inability to concentrate, decreased level of consciousness, and seizures leading to coma.
Laboratory Tests
■ Diagnostic criteria for diabetes include two findings (on separate days) of one of the following:
☐ Manifestations of diabetes plus casual blood glucose concentration greater than 200 mg/dL (without regard to time since last meal)
☐ Fasting blood glucose greater than 126 mg/dL
☐ 2-hr glucose greater than 200 mg/dL with an oral glucose tolerance test

■ Fasting blood glucose
☐ Nursing Actions – Postpone administration of antidiabetic medication until after the level is drawn.
☐ Client Education – Instruct the client to fast (no food or drink other than water) for the 8 hr prior to the blood test.

■ Oral glucose tolerance test
☐ A fasting blood glucose level is drawn at the start of the test. The client is then instructed to consume a specified amount of glucose. Blood glucose levels are obtained every 30 min for 2 hr. The clients must be assessed for hypoglycemia throughout the procedure.
☐ Client Education – Instruct the client to consume a balanced diet for 3 days prior to the test. Then instruct the client to fast for 10 to 12 hr prior to the test.

■ Glycosylated hemoglobin (HbA1c)
☐ The expected reference range is 4% to 6%, but an acceptable target for clients who have diabetes may be 6.5% to 8%, with a target goal of less than 7%.
☐ HbA1c is the best indicator of the average blood glucose level for the past 120 days. It assists in evaluating treatment effectiveness and compliance.

◯ Client Education
■ Instruct the client that the test evaluates treatment effectiveness and compliance.
■ Recommended quarterly or twice yearly depending on the glycemic levels.

◯ Urine Ketones
■ High ketones in the urine associated with hyperglycemia (exceed 300 mg/dL) is a medical emergency.

Diagnostic Procedures: Self-monitored blood glucose (SMBG)
☐ Nursing Action – Ensure that the client follows the proper procedure for blood sample collection and use of a glucose meter. Supplemental short-acting insulin may be prescribed for elevated pre-meal glucose levels.

☐ Client Education
> Instruct the client to check the accuracy of the strips with the control solution provided.
> Instruct the client to use the correct code number in the meter to match the strip bottle number.
> Instruct the client to store strips in the closed container in a dry location.
> Instruct the client to obtain an adequate amount of blood sample when preforming the test.
> Encourage appropriate hand hygiene.
> Encourage use of fresh lancets, and avoid sharing glucose monitoring equipment to prevent infection.
> Advise the client to keep a record of the SMBG that includes time, date, serum glucose level, insulin dose, food intake, and other events that may alter glucose metabolism, such as activity level or illness.

Medications
Insulin regimens are established for clients who have type 1 diabetes mellitus and are as follows:
■ More than 1 type of insulin (rapid, short, intermediate, and long-acting).
■ Given one or more times a day based on blood glucose results.
■ Insulin may be required by some clients who have type 2 diabetes or women who have gestational diabetes if glycemic control is not obtained with diet, exercise, and oral hypoglycemic agents.
☐ Continuous infusion of insulin may be accomplished using a small pump that is worn externally. The pump is programmed to deliver insulin through a needle in subcutaneous tissue. The needle should be changed at least every 2 to 3 days to prevent infection.
☐ Complications of the insulin pump are accidental cessation of insulin administration, obstruction of the tubing/needle, pump failure, and infection.

◯ Insulin pens are prefilled cartridges of 150 to 300 units of insulin in a programmable device with disposable needles.
■ Used if only one insulin is given at a time
■ Convenient for travel

◯ Oral hypoglycemics are used by clients who have type 2 diabetes, along with diet and exercise, to regulate their blood glucose.

Types of Insulin
■ Rapid-acting insulin
☐ Lispro insulin (Humalog), aspart insulin (Novolog), glulisine insulin (Apidra).
☐ Administer before meals to control postprandial rise in blood glucose.
☐ Onset is rapid, 10 to 30 min depending on which insulin is administered.
☐ Administer in conjunction with intermediate- or long-acting insulin to provide glycemic control between meals and at night.

■ Short-acting insulin
☐ Regular insulin (Humulin R, Novolin R).
☐ Administer 30 to 60 min before meals to control postprandial hyperglycemia.
☐ Available in two concentrations.
> U-500 is reserved for the client who has insulin resistance and is never administered IV.
> U-100 is prescribed for most clients and may be administered IV.

■ Intermediate-acting insulin
☐ NPH insulin (Humulin N), detemir insulin (Levemir).
☐ Administered for glycemic control between meals and at night.
☐ Not administered before meals to control postprandial rise in blood glucose.
☐ Contains protamine (a protein), which causes a delay in the insulin absorption or onset and extends the duration of action of the insulin.
☐ Administer NPH insulin subcutaneous only and as the only insulin to mix with short-acting insulin.
☐ Administer detemir insulin subcutaneous only and is never mixed with other insulin.

■ Long-acting insulin
☐ Glargine insulin (Lantus)
☐ Administered once daily, anytime during the day but always at the same time each day.
☐ Glargine insulin forms microprecipitates that dissolves slowly over 24 hr and maintains a steady blood sugar level with no peaks or troughs.
☐ Administer glargine insulin subcutaneous only and never administer IV.
■ Nursing Considerations – Observe the client perform self-administration of insulin and offer additional instruction as indicated.

■ Client Education
☐ Provide information regarding self-administration of insulin.
> Rotate injection sites (prevent lipohypertrophy) within one anatomic site (prevent day-to-day changes in absorption rates).
> Inject at a 90° angle (45° angle if thin). Aspiration for blood is not necessary.
> When mixing a rapid- or short-acting insulin with a longer-acting insulin, draw up the shorter-acting insulin into the syringe first and then the longer-acting insulin (this reduces the risk of introducing the longer-acting insulin into the shorter-acting insulin vial).
◯ Advise the client to eat at regular intervals, avoid alcohol intake, and adjust insulin to exercise and diet to avoid hypoglycemia.

Hypoglycemia Manifestations and Management
■ Teach the client measures to take in response to manifestations of hypoglycemia (mild shakiness, mental confusion, sweating, palpitations, headache, lack of coordination, blurred vision, seizures, and coma).
■ Hypoglycemia preventive measures are to avoid excess insulin, exercise, and alcohol consumption
■ A decrease in food intake or delay in food absorption can also cause hypoglycemia.
■ Check blood glucose level.
■ Follow guidelines outlined by the provider/diabetes educator. Guidelines may include:
☐ Instruct the client who has hypoglycemia (glucose of 70 mg/dL or less) to take 15 to 20 g of a readily absorbable carbohydrate (4 to 6 oz of fruit juice or regular soft drink, 3 to 4 glucose tablets, 8 to 10 hard candies, or 1 tbsp of honey) and recheck blood glucose in 15 min.
☐ Repeat the administration of carbohydrates if not within normal limits, and recheck blood glucose in 15 min.
☐ If blood glucose is within normal limits, have a snack containing a carbohydrate and protein (if the next meal is more than 1 hr away).
> Blood glucose increases approximately 40 mg/dL over 30 min following ingestion of 10 g of absorbable carbohydrate.
■ If the client is unconscious or unable to swallow, administer glucagon subcutaneous or IM (repeat in 10 min if still unconscious) and notify the provider.
■ In acute care, the nurse should administer 50% dextrose if IV access is available. Consciousness should occur within 20 min.
■ Once consciousness occurs and the client is able to swallow, have the client ingest oral carbohydrates.
Hyperglycemia Manifestations and Management
■ Teach the client manifestations of hyperglycemia (hot, dry skin and fruity breath) and measures to take in response to hyperglycemia.
■ Encourage oral fluid intake of sugar-free fluids to prevent dehydration.
■ Administer insulin as prescribed.
■ Restrict exercise when blood glucose levels are greater than 250 mg/dL.
■ Test urine for ketones and report if outside of expected reference range.
■ Consult the provider if manifestations progress.
Oral hypoglycemics: Biguanides: Metformin HCI (Glucophage)
Action
› Reduces the production of glucose by the liver (gluconeogenesis).
› Increases tissue sensitivity to insulin.

Nursing Considerations
› Monitor significance of gastrointestinal (GI) effects (flatulence, anorexia, nausea, vomiting).
› Monitor for lactic acidosis, especially in clients who have renal insufficiency or liver dysfunction.
› Stop medication for 48 hr before any type of radiographic test with iodinated contrast dye- may cause lactic acidosis.

Client Education
› Take with food to decrease adverse GI effects.
› Instruct the client to take vitamin B12 and folic acid supplements.
› Contact the provider if manifestations of lactic acidosis develop (myalgia, sluggishness, somnolence, and hyperventilation).
› May take during pregnancy for gestational diabetes.
› Never crush or chew the medication.

Oral hypoglycemics: Second-Generation Sulfonylureas: Glipizide (Glucotrol), glimepiride (Amaryl), glyburide (DiaBeta, Glynase PresTab)
Action
› Stimulates insulin release from the pancreas causing a decrease in blood sugar levels.
› Increases tissue sensitivity to insulin.

Nursing Considerations
› Monitor for hypoglycemia.
› Beta-blockers can mask tachycardia typically seen during hypoglycemia.

Client Education
› Administer 30 min before meals.
› Monitor for hypoglycemia and report frequent episodes to the provider.
› Instruct the client to avoid alcohol due to disulfiram effect.

Oral hypoglycemics: Meglitinides: Repaglinide (Prandin), nateglinide (Starlix)
Action
› Stimulates insulin release from pancreas.
› Administered for postmeal hyperglycemia.

Nursing Considerations
› Monitor for hypoglycemia.
› Monitor HbA1c every 3 months to determine effectiveness.

Client Education
› Administer 15 to 30 min before a meal.
› Omit the dose if skipped a meal to prevent hypoglycemic crisis.

Oral hypoglycemics: Thiazolidinediones: Pioglitazone (Actos)
Action
› Reduces the production of glucose by the liver (gluconeogenesis).
› Increases tissue sensitivity to insulin.

Nursing Considerations
› Monitor for fluid retention, especially in clients who have a history of heart failure.
› Monitor for elevation of the client’s LDL and triglycerides levels.

Client Education
› Report rapid weight gain, shortness of breath, decreased exercise tolerance.
› Use additional contraception methods because the medication reduces the blood levels of oral contraceptives and stimulate ovulation.
› Have liver function tests every 2 months the first year.

Oral hypoglycemics: Alpha-Glucosidase Inhibitors: Acarbose (Precose), miglitol (Glyset)
Action
› Slow carbohydrate absorption from the intestinal tract.
› Reduces postmeal hyperglycemia.

Nursing Considerations
› Alert the client that GI discomfort (abdominal distention, cramps, excessive gas, diarrhea) is common with these medications.
› Monitor liver function every 3 months.
› Treat hypoglycemia with dextrose, not table sugar (prevents table sugar from breaking down).

Client Education

› Instruct the client to have liver function tests performed every 3 months or as prescribed.
› Take the medication with the first bite of each meal in order for the medication to be effective.
› Have available dextrose paste to treat hypoglycemia.

Oral hypoglycemics: Dipeptidyl Peptidase-4 (DPP-4) Inhibitors: Sitagliptin (Januvia), saxagliptin (Onglyza)
Action
› Augments naturally occurring intestinal incretin hormones, which promote release of insulin and decrease secretion of glucagon
› Lowers fasting and postprandial glucose levels

Nursing Considerations
› Few side effects, but upper respiratory symptoms (nasal and throat inflammation) may be present.
› Alert the client of GI discomforts (nausea, vomiting, and diarrhea).

Client Education
› Instruct the client to report persistent upper respiratory symptoms.
› Medication only works when blood sugar is rising.

Oral hypoglycemics: Incretin Mimetic: Exenatide (Byetta)
Action
› Mimics the function of intestinal incretin hormone by decreasing glucagon secretion and gastric emptying.
› Decrease insulin demand by reducing fasting and postprandial hyperglycemia.

Nursing Considerations
› Administer subcutaneously 60 min before morning and evening meal.
› Monitor for gastrointestinal distress.

Client Education
› Do not administer after a meal.
› Oral antibiotic, oral contraceptive, or acetaminophen (Tylenol) should never be given within 1 hr of oral exenatide or 2 hr after an injection of exenatide.
› May have decreased appetite and weight loss.
› Wait for next scheduled dose if the scheduled medication is missed.

Oral hypoglycemics: Amylin Mimetic: Pramlintide (Symlin)
Action
› A synthetic amylin hormone found in the beta cells of the pancreas, it suppresses glucagon secretion and controls postprandial blood glucose levels.

Nursing Considerations
› Administer subcutaneously immediately before each major meal.
› Do not administer if HbA1c is greater than 9%.
› May administered with insulin therapy or oral hypoglycemic agent.

Client Education
› Monitor and report frequent periods of hypoglycemia.
› Monitor for injection site reactions.

Nursing Care
◯ Monitor
■ Blood glucose levels and factors affecting levels (other medications)
■ I&O and weight
■ Skin integrity and healing status of any wounds for presence of recurrent infections
☐ Feet and folds of the skin should be monitored.
■ Sensory alterations (tingling, numbness)
■ Visual alterations
■ Dietary practices
■ Exercise patterns
■ The client’s SMBG skill proficiency
■ The client’s self-medication administration proficiency
Client Education
■ Teach the client appropriate techniques for SMBG, including obtaining blood samples, recording and responding to results, and correctly handling supplies and equipment.

■ Provide information regarding self-administration of insulin.

■ Rotate injection sites to prevent lipohypertrophy (increased swelling of fat) or lipoatrophy (loss of fat tissue) within one anatomic site (prevents day-to-day changes in absorption rates).

Foot Care
■ Inspect feet daily. Wash feet daily with mild soap and warm water. Test water temperature with hands before washing feet.
■ Pat feet dry gently, especially between the toes, and avoid lotions between toes to decrease excess moisture and prevent infection.
■ Use mild foot powder (powder with cornstarch) on sweaty feet.
■ Do not use commercial remedies for the removal of calluses or corns, which may increase the risk for tissue injury and infection.
■ Consult a podiatrist.
■ The best time to perform nail care is after a bath/shower, when toenails are soft and easier to trim.
■ Separate overlapping toes with cotton or lamb’s wool.
■ Avoid open-toe, open-heel shoes. Leather shoes are preferred to plastic. Wear shoes that fit correctly. Wear slippers with soles. Do not go barefoot.
■ Wear clean, absorbent socks or stockings that are made of cotton or wool and have not been mended.
■ Do not use hot water bottles or heating pads to warm feet. Wear socks for warmth.
■ Avoid prolonged sitting, standing, and crossing of legs.
■ Teach the client to follow facility policies or recommendations of a podiatrist for nail care. Some protocols allow for trimming toenails straight across with clippers and filing edges with an emery board or nail file to prevent soft tissue injury. If clippers or scissors are contraindicated, the client should file the nails straight across.
■ Teach the client to cleanse cuts with warm water and mild soap, gently dry, and apply a dry dressing. Instruct the clients to monitor healing and to seek intervention promptly.
Nutritional Guidelines
■ Consult dietician for collaborative education with the client and family on meal planning to include food intake, weight management, and lipid and glucose management.
■ Plan meals to achieve appropriate timing of food intake, activity, onset, and peak of insulin. Calories and food composition should be similar each day.
■ Eat at regular intervals, and do not skip meals.
■ Count grams of carbohydrates consumed for glycemic control.
■ Recognize that 15 g of carbohydrates are equal to 1 carbohydrate exchange.
■ Restrict calories and increase physical activity as appropriate to facilitate weight loss (for clients who are obese) or to prevent obesity.
■ Include fiber in the diet to increase carbohydrate metabolism and to help control cholesterol levels.
■ Use artificial sweeteners.
■ Read and interpret fat content information on food labels to keep saturated fats within 7% of the recommendations of the daily total caloric intake.
Teach the client guidelines to follow when sick.
■ Monitor blood glucose every 3 to 4 hr.
■ Continue to take insulin or oral hypoglycemic agents.
■ Consume 4 oz of sugar-free, noncaffeinated liquid every 30 min to prevent dehydration.
■ Meet carbohydrate needs through soft food (custard, cream soup, gelatin, graham crackers) six to eight times per day, if possible. If not, consume liquids equal to usual carbohydrate content.
■ Test urine for ketones and report to provider if they are outside the expected reference range. (The level should be negative to small.)
■ Rest.
■ Call the provider if:
☐ Blood glucose is greater than 240 mg/dL. Test urine for ketones, if prescribed.
☐ Fever is greater than 38.6° C (101.5° F), does not respond to acetaminophen, or lasts more than 24 hr.
☐ Feeling disoriented or confused.
☐ Experiencing rapid breathing.
☐ Vomiting occurs more than once.
☐ Diarrhea occurs more than five times or for longer than 24 hr.
☐ Unable to tolerate liquids.
☐ Illness lasts longer than 2 days.
Complications: Cardiovascular and cerebrovascular disease
● Consistent maintenance of blood glucose within the expected reference range is the best protection against the complications of diabetes mellitus. Expected reference ranges may vary.

◯ Hypertension, myocardial infarction, and stroke

◯ Nursing Actions – Monitor blood pressure.

◯ Client Education
■ Encourage checks of cholesterol (HDL, LDL, and triglycerides) yearly and monitoring of blood pressure (below 130/80 mm Hg), and HbA1c every 3 months.
■ Encourage participation in regular activity for weight loss and control.
■ Encourage a diet of low-fat meals that are high in fruits, vegetables, and whole-grain foods.
■ Teach the client to report shortness of breath, headaches (persistent and transient), numbness in distal extremities, swelling of feet, infrequent urination, and changes in vision.
■ Encourage a dietary consult.

Complications: Diabetic retinopathy
◯ Impaired vision and blindness

◯ Client Education
■ Encourage yearly eye exams to ensure the health of the eyes and to protect vision.
■ Encourage management of blood glucose levels.

Complications: Diabetic neuropathy
◯ Caused from damage to sensory nerve fibers resulting in numbness and pain.
◯ Is progressive, may affect every aspect of the body, and can lead to ischemia and infection.

◯ Nursing Actions
■ Monitor blood glucose levels to keep within an acceptable range to slow progression.
■ Provide foot care.

◯ Client Education
■ Encourage annual exams by a podiatrist.
■ Encourage regular follow-up with provider to assess and treat neuropathy.

Complications: Diabetic nephropathy
◯ Damage to the kidneys from prolonged elevated blood glucose levels and dehydration

◯ Nursing Actions
■ Monitor hydration and kidney function (I&O, serum creatinine).
■ Report an hourly output of less than 30 mL/hr.
■ Monitor blood pressure.

◯ Client Education
■ Encourage yearly urine analysis, BUN, and serum creatinine.
■ Encourage the client to avoid soda, alcohol, and toxic levels of acetaminophen or NSAIDS.
■ Teach the client to consume 2 to 3 L of fluid per day from food and beverage sources, and to drink an adequate amount of water.
■ Tell the client to report decrease in output to the provider.