Endocrine Disorders: Diabetes

Diabetes

◦Group of diseases characterized by hyperglycemia due to defects in insulin secretion, insulin action, or both

◦Prevalence is increasing

◦Has physical, social, and economic consequences

◦Minority populations are disproportionately affected

Type 1

(5-10% of all patients with diabetes; formerly juvenile diabetes, or insulin-dependent diabetes)

-pancreas does not make any insulin at all

Type 2

(90-95% of all diabetes: patients with obesity—80% of type 2, patients without obesity—20% of type 2; formerly adult-onset diabetes, or non-insulin-dependent diabetes)

-pancreas makes insuline but isnt adequate

Gestational

Onset during pregnancy, usually in the second or third trimester

-can be genetic as soon as the baby is born blood glucose goes back to normal

Patho of diabetes

-beta cells in islets of langerhans secretes insulin in response to glucose. Moves glucose to muscle liver and fat cells.

Insulin functions

◦Transports and metabolizes glucose for energy

◦Stimulates storage of glucose in the liver and muscle as glycogen

◦Signals the liver to stop the release of glucose

◦Enhances the storage of dietary fat in adipose tissue

◦Accelerates transport of amino acids into cells

◦Inhibits the breakdown of stored glucose, protein, and fat

Diabetes risk factors

◦Family history (parents, siblings)

◦Obesity (> 20% over desired body weight)

◦Race/ethnicity (African Americans, Hispanic Americans, Native Americans, Asian Americans, Pacific Islanders)

◦Age > 45 years

◦Previous impaired fasting glucose or glucose tolerance

◦HTN (> 140/90)

◦Decreased HDL < 35 mg/dL and/or triglycerides greater than 250

◦History of gestational diabetes or delivery of a baby over 9 lbs

T1 Diabetes

-Genetic, environmental, or immunological factors

-destroy pancreatic beta cells

-little to no insulin production

-glucose remain in bloodstream

hyperglycemia

-glycosuria

-osmotic diuresis

-ADDITIONALLY Glycogenolysis and glycogenesis is not inhibited

-further hyperglycemia

-fat breakdown occurs

-increased production of ketones

-diabetic ketoacidosis (DKA)

Diabetic ketoacidosis

When the body doesn’t have enough insulin to work on glucose to break down for energy, it starts to break down fat for fuel — producing acidic substances called ketones

T2 Diabetes

◦Affects approximately 95% of adults with diabetes

Decreased sensitivity to insulin (insulin resistance) and impaired beta cell function results in decreased insulin production

-hyperglycemia

- hyperglycemic hyperosmolar syndrome (HHS)

◦Prevention is possible with Type 2 diabetes with life style changes

hyperglycemic hyperosmolar syndrome (HHS)

-severe dehydration

-very very high sugar

-life threatening

CM of diabetes

◦hree Ps"

◦Polyuria

◦Polydypsia

◦Polyphagia

◦Fatigue

-weakness

-sudden vision changes

-tingling or numbness in hands or feet

-dry skin

-skin lesions or wounds that are slow to heal

recurrent infections

◦Type 1 may have sudden weight loss, nausea, vomiting, and/or abdominal pain if DKA has developed

type 2 diabetes FBS level is

>126

insulin is a _____ injection; so you must ________

-subcutaneous injection

-rotate the sites

T1/T2 SIMILARITIES

◦Delayed wound healing

◦Polyuria

◦Polydipsia

◦Increased Infections

◦Fatigue

◦Familial Tendence

T1/T2 differences

◦Type 1:

◦Risk of DKA

◦Weight loss

◦Peak incidence 10-15

◦Weight loss

-insulin dependent

Type 2:

Risk of HHS

Average age 50

FBG >126

Sedentary Lifestyle

Criteria for diagnosis

◦Random glucose exceeding 200 mg/dL and symptoms of diabetes

◦Fasting blood glucose 126 mg/dL or more

◦Two hour postload glucose of 200 mg/DL or more during oral glucose tolerance testing

◦A1C >= 6.5%

Assessment for diabetes

◦History

◦Physical Examination

◦Blood pressure

◦BMI

◦Fundoscopic-look inside eye at retina

◦Foot

◦Skin

◦Neurologic

◦Oral

Diabetes Laboratory Tests

◦Hgb A1c

◦Fasting lipid profile

◦Microalbuminuria

◦Urinalysis

◦EKG

◦Need for Referrals

medical management of diabetes

◦Goal: Normalize insulin activity and blood glucose levels to reduce development of complications

◦Nutritional Therapy

◦Exercise

◦Monitoring Glucose Levels and Ketones

◦Pharmacologic Therapy

Nutritional therapy goals

◦Achieve and maintain:

◦Normal blood glucose and serum lipid ranges

◦Normal blood pressure

◦Prevent or slow the rate of development of chronic complications of diabetes

◦Address the individual nutritional needs by considering personal, cultural preferences

best carbs to eat

-plantains

-corns

-brown rice

help normalize BS

nutritional Therapy:Role of the Nurse

◦Be knowledgeable about dietary management

◦Communicate important information to the dietician or other management specialists

◦Reinforce patient understanding

◦Support dietary and lifestyle changes

carbs cal requirements for one day

50-60% carbohydrates, emphasize whole grains

fats requirements for one day

less than 30%, with >10% from saturated fat and < 300 mg cholesterol

Avoid which meats

-pork

-beef

proteins requirements for one day

10-20% lean animal proteins or no animal sources of protein, may be reduced in early signs of kidney disease

Fiber requirements for one day

least 25 g per day

Nutritional Therapy:Meal Planning and Education

◦Exchange Lists: **See Table 46-2

◦Nutrition Labels: Utilized in calorie, carbohydrate counting

◦Healthy Food Choices: One carbohydrate serving = 15 g of carbohydrates

◦MyPlate Food Guide: Incorporates 5 food groups

◦Glycemic Index: describes how foods increase blood glucose

concern-alcohol

◦Increases risk for DKA

◦Hypoglycemia in those on medications

◦Impaired ability to recognize & treat hypoglycemia

◦Lead to excessive weight gain and hyperlipidemia

Nutritive and nonnutritive sweeteners concern

◦Nutritive sweeteners: fructose, sorbitol, and xylitol

◦Nonnutritive sweeteners: saccharin, aspartame, and sucralose

◦Both cause little to no elevation in blood glucose when used

concern misleading food labels

◦"Sugarless or sugar-free or no sugar added"

◦"Dietetic"

◦"Health foods"

exercise recommendations

◦"Exercise lowers blood glucose levels by increasing the uptake of glucose by muscles and by improving insulin utilization (Hinkle & Cheever, 2018, p. 1465)

◦Encourage regular daily exercise

◦Gradual, slow increase in exercise period is encouraged

◦Modify exercise regimen to patient needs and presence of diabetic complications or potential cardiovascular problems

◦Exercise stress test for patients older than age 30 who have 2 or more risk factors is recommended

◦Gerontologic considerations

exercise precautions

◦Exercise with elevated blood sugar levels (above 250 mg/dL) and ketones in urine should be avoided

◦Insulin normally decreases with exercise; patients on exogenous insulin should eat a 15g carbohydrate snack before moderate exercise to prevent hypoglycemia

◦If exercising to control or reduce weight, insulin must be adjusted

◦Potential post-exercise hypoglycemia

◦Need to monitor blood glucose levels

Exercise: Patient Education Considerations

◦3 times/week

◦Resistance training twice a week (Type 2)

◦Exercise at the same time of the day

◦Utilize proper footwear

◦Avoid trauma

◦Avoid exercise during times of poor metabolic control

What Lifestyle Modifications are Recommended ?

◦Increased Exercise Same Time of the Day

◦Low Fat Diet

◦Increase Fiber intake slowly- Soluble Fiber

◦Proper Footwear and Care

◦What others can you think of ?

◦Self-monitoring (SMBG)

◦Nurse's role: providing initial education on times and techniques

◦Continuous glucose monitoring (CGMS)

◦Monitor attached to patient for 72 hours (similar to insulin pump)

◦Glycated hemoglobin (also referred to as glycosylated hemoglobin, HgbA1C, or A1C

◦Monitors glucose control over last 3 months

◦Normal range 4-6%

◦Target range for people with diabetes < 7%

ketones

Urine dipstick

lantus

NPH

What exclusive to REGULAR insulin?

fast acting and it’s the only type of insulin that can be given through IV

Pharmacological Therapy: Insulin Therapy

◦Grouped into categories based on onset, peak and duration

◦1-4 injections/day

◦Usually combination of short-acting insulin and longer-acting insulin

◦Conventional and Intensive regimen

◦Delivery: Pens, pumps,

Insulin Complications

◦Allergic reaction

◦Lipodystrophy

◦Resistance

◦Morning hyperglycemia (Chart 46-5)

• Insulin waning

• Dawn phenomenon

• Somogyi effect

insulin waning

gradual decrease in insulin over time

dawn phenomenom

natural increase in morning blood glucose and insulin requirements 2-8 am

somogyi effect

rise of sugar after a period of low

Oral Antidiabetic Agents

◦Used for patients with type 2 diabetes who cannot be treated with diet and exercise alone

◦Combinations of oral drugs may be used

◦Major side effect: hypoglycemia

◦Nursing interventions: monitor blood glucose, and for hypoglycemia and other potential side effects

◦Patient teaching

Pharmacological Therapy: Nursing Management

◦Hospital

◦Targeted BG levels

◦SC or IV preferred to oral agents

◦Insulin protocols and emergent treatments

◦Appropriate timing of glucose checks, meals, and insulin dose

patient education

◦Developing a plan

◦Survival skills (Chart 51-5)

◦Assessing readiness to learn

◦Includes social factors

◦Educational methods

◦Educate self-administration of medications

◦Oral

◦Injectable (non-insulin)

◦Insulin (Chart 46-7 & 46-8)

Acute Complications of Diabetes: Hypoglycemia

◦Abnormally low blood glucose level (<70 mg/dL)

Causes include too much insulin or oral hypoglycemic agents, too little food, and excessive physical activity

CM hypoglycemia

◦Adrenergic symptoms: sweating, tremors, tachycardia, palpitations, nervousness, hunger

◦Central nervous system symptoms: inability to concentrate, headache, confusion, memory lapses, slurred speech, numbness of lips and tongue, irrational or combative behavior, double vision, drowsiness

◦Severe hypoglycemia: CNS function impaired, may cause disorientation, seizures, and loss of consciousness

Hypoglycemia: Assessment

◦Symptoms vary from person to person

◦Symptoms also vary related to the rapid decrease in blood glucose and usual blood glucose range

◦Chronic diabetics with long-term complications (e.g. autonomic neuropathy and certain medications) may not respond with adrenergic response to hypoglycemia

Hypoglycemia: Management

◦Treatment must be immediate

◦Give 15 g of fast-acting, concentrated carbohydrate

◦2 or 3 glucose tablets

◦1 tube glucose gel

◦0.5 cup juice

◦After initial treatment, follow with snack including starch and protein, such as cheese and crackers, milk and crackers, half sandwich

◦Provide information on how to prevent hypoglycemia

◦Keep record of blood glucose, insulin dose, hypoglycemic reactions, variations in diet

Hypoglycemia: Emergency Measures

◦If the patient cannot swallow or is unconscious:

◦Subcutaneous or intramuscular glucagon 1 mg

◦25-50 mL 50% dextrose solution IV (once the patient comes to you dont need anymore)

Acute Complications of Diabetes: Diabetic Ketoacidosis (DKA)

◦Clinical Features:

◦Hyperglycemia

◦Dehydration

◦Acidosis

DKA CM

◦Polyuria, polydipsia

◦Blurred vision, headache

◦Weakness

◦Anorexia, abdominal pain

◦Nausea/vomiting

◦Acetone breath smell

◦Hyperventilation/Kussmaul respirations

◦Mental status changes

Assessment & Diagnostic Findings

◦Blood glucose levels vary from 300-800 mg/dL

◦Severity of DKA is not related to blood glucose level

◦Ketoacidosis is reflected in low serum bicarbonate and low pH; low PCO2 reflects respiratory compensation

◦Ketone bodies in blood and urine

◦Electrolytes vary according to water loss and level of hydration

DKA: Management

◦Rehydration

◦May need 6 to 10 L of IV fluids

◦Watch fluid volume status (deficits, overload)

◦Restoring Electrolytes

◦Potassium

◦Reversing Acidosis

◦IV regular insulin continuous infusion

◦

Potassium drops with rehydration and insulin treatment à May require potassium replacement

IV fluids

Initially, 0.9% sodium chloride (normal saline [NS]) solution is given at a rapid rate, usually 0.5 to 1 L per hour for the first 2 to 4 hours (Fayfman et al., 2017). Half-strength NS (0.45%) solution (also known as hypotonic saline solution) may be used for patients with hypertension or hypernatremia and those at risk for heart failure. After the first few hours, half-strength NS solution is the fluid of choice for continued rehydration, provided the blood pressure is stable and the sodium level is not low

DKA: Clinical Manifestations

Kussmaul's respirations deep unlabored respirations.

Evidence of ketoacidosis is reflected in low serum bicarbonate (0 to 15 mEq/L) and low pH (6.8 to 7.3) values. A low partial pressure of carbon dioxide (PaCO2 10 to 30 mm Hg) reflects respiratory compensation (Kussmaul respirations) for the metabolic acidosis. Accumulation of ketone bodies (which precipitates the acidosis) is reflected in blood and urine ketone measurements (Down, 2018).

DKA: Prevention

"Sick day rules"

• check glucose every 3-4 hours

• take supplemental insulin every 3-4 hours if you do take insulin

• report NVD to HCP, if applicable

• prevent dehydration

Assess for underlying causes

Diagnosis and proper management of diabetes

Acute Complications of Diabetes: Hyperglycemic Hyperosmolar Syndrome

◦Serious life-threatening medical emergency

◦High mortality rate - because metabolic changes are serious and these individuals are older with comorbidities

◦Pathophysiology: Infection or illness à causes hyperosmolarity and hyperglycemia à causes osmotic diuresis with loss of water and electrolytes à hypernatremia and increased osmolarity à profound dehydration

◦Insulin level too low to prevent hyperglycemia (and osmotic diuresis), but high enough to prevent fat breakdown

◦People with HHS lack ketosis-related symptoms

Tolerate polyuria & polydipsia until neurological changes or underlying illness prompts them or family members to seek treatment

HHS CM

◦Hypotension & Postural Hypotension

◦Profound Dehydration (dry mucous membranes, poor skin turgor)

◦Tachycardia

◦Neurological Signs (alteration in consciousness, seizures, hemiparesis)

Assessment & Diagnostic Findings HHS

Assessment & Diagnostic Findings

HHS: Management

◦Rehydration

◦Insulin administration

◦Monitor fluid volume and electrolyte status

◦Prevention

◦BGSM

◦Diagnosis and management of diabetes

◦Assess and promote self-care management skills

For the patient with HHS, the nurse assesses vital signs, fluid status, and laboratory values. Fluid status and urine output are closely monitored because of the high risk of kidney failure secondary to severe dehydration. Because HHS tends to occur in older patients, the physiologic changes that occur with aging should be considered. Careful assessment of cardiovascular, pulmonary, and kidney function throughout the acute and recovery phases of HHS is important

Diabetes Long-Term Complications:Macrovascular Complications

Accelerated atherosclerotic changes occur earlier in diabetics

• Coronary artery disease (MI)

• Cerebrovascular disease (TIAs, CVA)

• Peripheral vascular disease (PAD, PVD, neuropathy)

Management: Aggressive modification and reduction of risk factors

• Diet and exercise to manage obesity, HTN, and hyperlipidemia

• Smoking cessation

• Good blood glucose control

Diabetes Long-Term Complications:Microvascular Complications

Diabetic retinopathy

• Leading cause of blindness for individuals 20-74 years of age with diabetes mellitus

• Visual Complications (Table 46-8)

• Manifestations: Painless, blurry vision, asymptomatic

• Diagnostics: Retinal visualization

• Management: Primary & secondary prevention

• Patient Education: Frequent eye exams

Nephropathy

• 50% of new cases of ESRD are from individuals with diabetes mellitus

• Diagnostics: Microalbuminuria, BUN, creatinine, development of HTN

• Management: Control HTN, avoid nephrotoxic medications, low-sodium, low-protein diet

Diabetes Long-Term Complications:

Diabetic Neuropathies

• Neuropathic changes

• Peripheral neuropathy

• Autonomic neuropathies

• Hypoglycemic Unawareness

• Sudomotor Neuropathy

• Sexual Dysfunction

Foot and Leg Problems

• Neuropathy

• Peripheral vascular disease

• Immunocompromise

Diabetes Care Special Issues

Patients Undergoing Surgery

• Hyperglycemia due to physiologic stress

• Hypoglycemia concern -> if surgery delayed and received morning dose of insulin

• Frequent blood glucose monitoring

• IV insulin & Dextrose

Hospitalized Patients

• Self-care Issues

• Hyperglycemia during hospitalization

• Hypoglycemia during Hospitalizations

• Alterations in diet

• NPO, Clear liquid diet, enteral tube feedings, parenteral nutrition

• Hygiene

• Stress

Nursing Process: The Care of the Patient with Diabetes—Assessment

◦Assess the primary presenting problem

◦In addition, assess needs related to diabetes

◦Patient knowledge of diabetes and diabetes care skills

◦Blood glucose levels

◦Skin assessment

◦Preventative health measures

Teaching Patients Self-Care

◦Assess knowledge and adherence to plan of care.

◦Provide basic information about diabetes, its cause and symptoms, and acute and chronic complications and their treatment.

◦Teach self-care activities to prevent long-term complications including foot care, eye care, and risk-factor management.

◦Include family in plan of care.

◦Provide information, encourage health promotion activities, and recommended health screenings.