diabetes c2

Focus onDiabetes MellitusVoice over : 

Focus onDiabetes MellitusVoice over (Relates to Chapter 49,“Nursing Management: Diabetes Mellitus,”in the textbook)

Clinical ManifestationsType 1 Diabetes Mellitus : 

Clinical ManifestationsType 1 Diabetes Mellitus Classic symptoms Polyuria (frequent urination) Polydipsia (excessive thirst) Polyphagia (excessive hunger) Weight loss Weakness Fatigue

Clinical ManifestationsType 2 Diabetes Mellitus : 

Clinical ManifestationsType 2 Diabetes Mellitus Nonspecific symptoms May have classic symptoms of type 1 Fatigue Recurrent infections Recurrent vaginal yeast or monilia infections Prolonged wound healing Visual changes

Diabetes MellitusDiagnostic Studies : 

Diabetes MellitusDiagnostic Studies Three methods of diagnosis Fasting plasma glucose level >126 mg/dl Random or casual plasma glucose measurement ≥ 200 mg/dl plus symptoms Two-hour OGTT level ≥ 200 mg/dl using a glucose load of 75 g

Question : 

Question 4) The nurse has just reviewed instructions for an oral glucose tolerance test (OGTT) with a patient. Which of the following statements made by the patient indicate a need for more teaching? A. “ I can expect to have my blood drawn at 30 and 60 minute intervals during the test.” B. “ I will eat a light breakfast the morning of the test.” C. “I will expect to take 100mg of glucose at the start of the test.” D. “I will report any symptoms of dizziness, sweating, and/or weakness if they occur during the test.”

Hemoglobin A1C : 

Hemoglobin A1C Glucose attaches to the hemoglobin molecule in a one-way reaction through the 120 day life of the RBC. This blood test is performed on a random blood sample; the client does not have to fast. The result is not influenced by exercise or diabetic drugs. In a patient with diabetes, a value of 7% indicates good control of the disease, and greater than 8% is considered high.

Diabetes MellitusDiagnostic Studies : 

Diabetes MellitusDiagnostic Studies Hemoglobin A1C test Useful in determining glycemic levels over time Not diagnostic but monitors success of treatment Shows the amount of glucose attached to hemoglobin molecules over RBC life span 90 to 120 days

Diabetes MellitusDiagnostic Studies : 

Diabetes MellitusDiagnostic Studies Hemoglobin A1C (cont’d) Regular assessments required Ideal goal ADA ≤7.0% American College of Endocrinology <6.5% Normal A1C reduces risk of retinopathy, nephropathy, and neuropathy

Question : 

Question 5) Which of the following is the most significant controllable risk factor in the development of type 2 diabetes mellitus. A. Cigarette Smoking B. Family history of Diabetes C. Hypertension D. Obesity

What is the oral glucose tolerance test? : 

What is the oral glucose tolerance test? The patient fasts overnight (8 hrs but not more than 16 hrs) First blood is drawn Pt. Drinks 75 grams glucose Then blood is tested up to four times at intervals

Diabetes MellitusCollaborative Care : 

Diabetes MellitusCollaborative Care Goals of diabetes management Decrease symptoms Promote well-being Prevent acute complications Delay onset and progression of long-term complications

Diabetes MellitusCollaborative Care : 

Diabetes MellitusCollaborative Care Patient teaching Self-monitoring of blood glucose Nutritional therapy Drug therapy Exercise

Drug TherapyInsulin : 

Drug TherapyInsulin Exogenous insulin Insulin from an outside source Required for type 1 diabetes Prescribed for patient with type 2 diabetes who cannot control blood glucose by other means

Drug TherapyInsulin : 

Drug TherapyInsulin Types of insulin Human insulin Only type used today Prepared through genetic engineering Common bacteria (Escherichia coli) Yeast cells using recombinant DNA technology

Drug TherapyInsulin : 

Drug TherapyInsulin Types of insulin Insulins differ in regard to onset, peak action, and duration Characterized as rapid-acting, short-acting, intermediate-acting, long-acting Different types of insulin may be used for combination therapy

Drug TherapyInsulin : 

Drug TherapyInsulin Types of insulin (cont’d) Rapid-acting: Lispro (Humalog), Aspart (Novolog), and glulisine (Apidra), Exubera Short-acting: Regular Intermediate-acting: NPH Long-acting: Glargine (Lantus), detemir (Levemir)

Drug TherapyInsulin : 

Drug TherapyInsulin Regimen that closely mimics endogenous insulin production is basal-bolus Long-acting (basal) once a day Rapid/short-acting (bolus) before meals

Drug TherapyInsulin : 

Drug TherapyInsulin Insulin preparations Rapid-acting (bolus) Lispro, aspart, glulisine Injected 0 to 15 minutes before meal Onset of action 15 minutes Short-acting (bolus) Regular Injected 30 to 45 minutes before meal Onset of action 30 to 60 minutes

Drug TherapyInsulin : 

Drug TherapyInsulin Long-acting (basal) Injected once a day at bedtime or in the morning Released steadily and continuously No peak action Cannot be mixed with any other insulin or solution

Insulin Preparations : 

Insulin Preparations Fig. 49-4

Drug TherapyInsulin : 

Drug TherapyInsulin Storage of insulin Do not heat/freeze In-use vials may be left at room temperature up to 4 weeks Lantus only for 28 days Extra insulin should be refrigerated Avoid exposure to direct sunlight

Drug TherapyInsulin : 

Drug TherapyInsulin Administration of insulin Cannot be taken orally Subcutaneous injection for self-administration IV administration

Drug TherapyInsulin : 

Drug TherapyInsulin Administration of insulin (cont’d) Fastest absorption from abdomen, followed by arm, thigh, buttock Abdomen Preferred site Rotate injections within one particular site Do not inject in site to be exercised

Subcutaneous Injection Sites : 

Subcutaneous Injection Sites Fig. 49-6

Drug TherapyInsulin : 

Drug TherapyInsulin Administration of insulin (cont’d) Do not inject in site to be exercised Usually available as U100 1 ml contains 100 units of insulin No alcohol swab on site needed before injection

Drug TherapyInsulin : 

Drug TherapyInsulin Administration of insulin (cont’d) Hand washing with soap adequate Do not recap needle 45- to 90-degree angle depending on fat thickness of patient Insulin pens preloaded with insulin now available

Insulin Pen : 

Insulin Pen Fig. 49-7

Drug TherapyInsulin : 

Drug TherapyInsulin Inhaled insulin Exubera Rapid-acting, dry powder inhaled through mouth into lungs Not recommended for patients with asthma, bronchitis, or emphysema

Question : 

Question 6) During a home visit, the nurse finds a patient with type 1 diabetes who has been experiencing flu like symptoms for the last 14-16 hours. Which of the following statements made by the patient indicates a need for more teaching? A. “I am drinking liquids (water and broth) every hour.” B. “I am holding my insulin until my appetite returns.” C. “I am testing my blood sugar every 3-4 hours.” D. “I am testing my urine for ketones every 3-4 hours.”

DiabetesNutritional Therapy : 

DiabetesNutritional Therapy Cornerstone of care for person with diabetes Most challenging for many people Recommended that diabetes nurse educator and registered dietitian with diabetes experience be members of team

DiabetesNutritional Therapy : 

DiabetesNutritional Therapy American Diabetes Association (ADA) Guidelines indicate that within context of an overall healthy eating plan, person with diabetes can eat same foods as person who does not have diabetes

DiabetesNutritional Therapy : 

DiabetesNutritional Therapy American Diabetes Association (ADA) (cont’d) Overall goal Assist people in making changes in nutrition and exercise habits that will lead to improved metabolic control

DiabetesNutritional Therapy : 

DiabetesNutritional Therapy Type 1 diabetes mellitus Meal plan based on individual’s usual food intake and is balanced with insulin and exercise patterns Insulin regimen managed day to day

DiabetesNutritional Therapy : 

DiabetesNutritional Therapy Type 2 diabetes mellitus Emphasis based on achieving glucose, lipid, and blood pressure goals Calorie reduction

DiabetesNutritional Therapy : 

DiabetesNutritional Therapy Food composition Nutrient balance of diabetic diet is essential Nutritional energy intake should be balanced with energy output

DiabetesNutritional Therapy : 

DiabetesNutritional Therapy Carbohydrates Carbohydrates and monounsaturated fats should provide 45% to 65% of total energy intake ↓ Carbohydrate diets are not recommended for diabetics

DiabetesNutritional Therapy : 

DiabetesNutritional Therapy Glycemic index (GI) Term used to describe rise in blood glucose levels after consuming carbohydrate-containing food Should be considered when formulating a meal plan

DiabetesNutritional Therapy : 

DiabetesNutritional Therapy Fats No more than 25% to 30% of meal plan’s total calories <7% from saturated fats

DiabetesNutritional Therapy : 

DiabetesNutritional Therapy Protein Contribute <10% of total energy consumed Intake should be significantly less than general population

DiabetesNutritional Therapy : 

DiabetesNutritional Therapy Alcohol High in calories No nutritive value Promotes hypertriglyceridemia Detrimental effects on liver Can cause severe hypoglycemia

DiabetesNutritional Therapy : 

DiabetesNutritional Therapy Diet teaching Dietitian initially provides instruction Should include patient’s family and significant others USDA MyPyramid guide An appropriate basic teaching tool Plate method Helps patient visualize the amount of vegetable, starch, and meat that should fill a 9-inch plate

Question : 

Question 7) The nurse administers a dose of six units of regular insulin to a patient at 0800. Knowing the action of Regular insulin, when would the nurse anticipate that a hypoglycemic reaction could occur? A. Between 0800-1000 B. Between 1000-1200 C. Between 1400-2200 D. Between 2200-0800

Diabetes Exercise : 

Diabetes Exercise Exercise Essential part of diabetes management ↑ Insulin receptor sites Lowers blood glucose levels Contributes to weight loss

Diabetes Exercise : 

Diabetes Exercise Exercise (cont’d) Several small carbohydrate snacks can be taken every 30 minutes during exercise to prevent hypoglycemia Best done after meals Exercise plans should be started After medical clearance Slowly with gradual progression

Diabetes Exercise : 

Diabetes Exercise Exercise (cont’d) Should be individualized Monitor blood glucose levels before, during, and after exercise

Question : 

Question 8) A second generation patient with type 2 diabetes mellitus is prescribed the oral hypoglycemia agent glyburide (Micronase, DiaBeta, Glynase). How does the nurse explain the basic mechanism of action of this medication in lowering blood glucose. A. It decreases the renal threshold of glucose. B. It increases the renal threshold of glucose. C. It potentates the action of insulin. D. It stimulates the pancreas to release insulin.

Monitoring Blood Glucose : 

Monitoring Blood Glucose Self-monitoring of blood glucose (SMBG) Enables patient to make self-management decisions regarding diet, exercise, and medication

Monitoring Blood Glucose : 

Monitoring Blood Glucose Self-monitoring of blood glucose (SMBG) (cont’d) Important for detecting episodic hyperglycemia and hypoglycemia Patient training is crucial Supplies immediate information about blood glucose levels

Nursing ManagementNursing Assessment : 

Nursing ManagementNursing Assessment Past health history Viral infections Medications Recent surgery Positive health history Obesity

Nursing ManagementNursing Assessment : 

Nursing ManagementNursing Assessment Weight loss Thirst Hunger Poor healing Kussmaul respirations

Nursing ManagementNursing Diagnoses : 

Nursing ManagementNursing Diagnoses Ineffective therapeutic regimen management Risk for injury Risk for infection Powerlessness Imbalanced nutrition: More than body requirements

Nursing ManagementPlanning : 

Nursing ManagementPlanning Overall goals Active patient participation Few or no episodes of acute hyperglycemic emergencies or hypoglycemia Maintain normal blood glucose levels

Nursing ManagementPlanning : 

Nursing ManagementPlanning Overall goals (cont’d) Prevent or delay chronic complications Lifestyle adjustments with minimal stress

Nursing ManagementNursing Implementation : 

Nursing ManagementNursing Implementation Health promotion Identify those at risk Routine screening for overweight adults over age 45 FPG is preferred method in clinical settings

Nursing ManagementNursing Implementation : 

Nursing ManagementNursing Implementation Acute intervention (cont’d) Stress of illness and surgery ↑ Blood glucose level Continue regular meal plan ↑ Intake of noncaloric fluids Continue taking oral agents and insulin Frequent monitoring of blood glucose Ketone testing if glucose > 240 mg/dl

Nursing ManagementNursing Implementation : 

Nursing ManagementNursing Implementation Acute intervention (cont’d) Stress of illness and surgery Patients undergoing surgery or radiologic procedures requiring contrast medium should hold their metformin day of surgery and 48 hours Begun after serum creatinine has been checked and is normal

Nursing ManagementNursing Implementation : 

Nursing ManagementNursing Implementation Ambulatory and home care Overall goal is to enable patient or caregiver to reach an optimal level of independence Insulin therapy and oral agents Personal hygiene

Nursing ManagementNursing Implementation : 

Nursing ManagementNursing Implementation Ambulatory and home care (cont’d) Insulin therapy and oral agent Education on proper administration, adjustment and side effects Assessment of patient’s response to therapy Personal hygiene Regular bathing with emphasis on foot care Daily brushing/flossing Dentist should be informed about diabetes diagnosis

Nursing ManagementNursing Implementation : 

Nursing ManagementNursing Implementation Ambulatory and home care (cont’d) Medical identification and travel card Must carry identification indicating diagnosis of diabetes Patient and family teaching Educate on disease process, physical activity, medications, monitoring blood glucose, diet, resources Enable patient to become most active participant in his/her care

Nursing ManagementEvaluation : 

Nursing ManagementEvaluation Knowledge Balance of nutrition Immune status Health benefits No injuries

DiabetesAcute Complications : 

DiabetesAcute Complications Hypoglycemia Low blood glucose Occurs when Too much insulin in proportion to glucose in the blood Blood glucose level less than 70 mg/dl

DiabetesAcute Complications : 

DiabetesAcute Complications Hypoglycemia (cont’d) Common manifestations Confusion Irritability Diaphoresis Tremors Hunger

DiabetesAcute Complications : 

DiabetesAcute Complications Hypoglycemia (cont’d) Common manifestations Weakness Visual disturbances Can mimic alcohol intoxication Untreated can progress to loss of consciousness, seizures, coma, and death

DiabetesAcute Complications : 

DiabetesAcute Complications Hypoglycemia (cont’d) Hypoglycemic unawareness Person does not experience warning signs/symptoms, increasing risk for decreased blood glucose levels Related to autonomic neuropathy

DiabetesAcute Complications : 

DiabetesAcute Complications Hypoglycemia (cont’d) Causes Mismatch in timing Food intake and peak action of insulin or oral hypoglycemic agents

DiabetesAcute Complications : 

DiabetesAcute Complications Hypoglycemia (cont’d) At the first sign Check blood glucose If <70 mg/dl, begin treatment If >70 mg/dl, investigate further for cause of signs/symptoms If monitoring equipment not available, treatment should be initiated

DiabetesAcute Complications : 

DiabetesAcute Complications Hypoglycemia (cont’d) Treatment If alert enough to swallow 15 to 20 g of a simple carbohydrate 4 to 6 oz fruit juice Regular soft drink Avoid foods with fat Decrease absorption of sugar

DiabetesAcute Complications : 

DiabetesAcute Complications Hypoglycemia (cont’d) Treatment If alert enough to swallow Do not overtreat Recheck blood sugar 15 minutes after treatment Repeat until blood sugar >70 mg/dl Patient should eat regularly scheduled meal/snack to prevent rebound hypoglycemia Check blood sugar again 45 minutes after treatment

DiabetesAcute Complications : 

DiabetesAcute Complications Hypoglycemia (cont’d) Treatment If no improvement after 2 or 3 doses of simple carbohydrate OR Patient not alert enough to swallow

DiabetesAcute Complications : 

DiabetesAcute Complications Hypoglycemia (cont’d) Treatment Administer 1 mg of glucagon IM or subcutaneously Side effect: Rebound hypoglycemia Have patient ingest a complex carbohydrate after recovery In acute care settings 20 to 50 ml of 50% dextrose IV push