Health alterations class 13: Glucose regulation 2

Classic symptoms of diabetes mellitus

1. Polydipsia

2. Polyuria

3. Polyphagia

Acute complications of DM

1. Diabetic ketoacidosis (DKA)

2. Hyperosmolar hyperglycemic state (HHS)

3. Hypoglycemia

DKA

Seen in Type 1 and sometimes type 2 (if severe illness or stress). Fats are metabolized in the absence of insulin. Progresses quickly, needs quick intervention

Some causes of DKA

Illness/infection, missed or forgotten insulin, undiagnosed DM, unable to maintain stable blood glucose

Signs and symptoms of DKA

1. Polyuria and Polydipsia

2. Dehydration

3. Lethargy and weakness

4. N/V and abdominal pain

5. Kussmauls respirations (to blow off excess CO2) and hyperventilation

6. Acetone or fruity breath

What can DKA cause

1. Hyperglycemia

2. Dehydration and electrolyte loss

3. Acidosis

Important history and physical for DKA

Cardiovascular, respiratory and mental status

Priorities for DKA treatment

1. Fluid imbalance-IV access and fluid and electrolyte replacement (life threatening)

2. IV insulin

How to give IV insulin with DKA

1. Bolus of regular insulin

2. Then sliding scale (check q1)

3. Dextrose after infusion to prevent rebound hypoglycemia

4. Also give potassium to prevent hypokalemia

Urinalysis and blood work for DKA

Blood/urine glucose, CBC, ketones in blood/urine, electrolytes, BUN, blood gases

Early stages of DKA

May have no electrolyte imbalance

HHS

Usually in type 2, enough insulin produced to prevent DKA but not enough to prevent hyperglycaemia, diuresis and fluid depletion

HHS symptoms

Few symptoms initially (blood glucose increases before symptoms appear)

Somnolence (sleepy), coma, seizures, hemiparesis, aphasia

Why are older adults with T2DM at an increased risk of HHS

Impaired thirst sensation, decreased functional ability to replace fluids or decreased dexterity

Dehydration is main priority!

Interprofessional care of HHS

1. Medical emergency and high mortality rates

2. Immediate IV access and fluids (rehydration)

3. IV insulin (bolus and sliding scale)

Nursing management of DKA and HHS

1. Moniter glucose, electrolytes and ketones (urine test strip)

2. IV fluids (dehydration is a priority)

3. Insulin therapy (bolus, SSI)

4. Renal status (dehydration, GFR, BUN, creatinine, output-want 30mls/hour)

5. Cardiopulmonary status (signs of fluid overload, hypokalemia-palpatations/arrythmia, numb, tingling and muscle spasms)

6. Level of consciousness (should go back to baseline once tx starts)

Hypoglycemia

Glucose <4 mmol/l. May be from too much insulin/med, not enough food or excessive exercise. Sudden onset

Signs and symptoms of hypoglycemia

1. Diaphoresis

2. Tremors

3. Hunger

4. Nervousness

5. Anxiety

6. Pallor

7. Palpitations

How to treat hypoglycemia

1. 15-20g of fast acting carb

2. Recheck q15 and repeat if still <4 mmol/l

3. If glucose >4mmol/l, eat snack with carbs and protein if meal is more than 1 hour away

4. Recheck blood glucose in 45 minutes

5. If no improvement after 2-3 doses of carbs or if pt not alert give 1 mg glucagon IM/SQ or 3mg intransanal or 20-30 ml 50%dextrose IV push (acute care)

Examples of fast acting carbs to treat hypoglycemia

3-4 glucose tabs, 175 ml fruit juice or regular pop, 6 life savers candies

Snacks with carbs and proteins, give 15 minutes after fast acting carb if glucose is over 4 and meal is more than an hour away

Peanut butter and crackers, cheese sandwich, cereal and milk

Most effective way to prevent chronic complications of diabetes mellitus

Maintain a stable blood glucose

Chronic complications of diabetes mellitus

Damage to large and small vessels secondary to chronic hyperglycemia

Macro vascular chronic complications of diabetes

1. Cerebrovascular (stroke)

2. Cardiovascular (MI)

3. Peripheral vascular (PAD)

Micro vascular complications of diabetes

1. Retinopathy

2. Nephropathy

3. Neuropathy

4. Dermopathy

Most common cause if blindness in working class age people

Diabetic retinopathy

Diabetic retinopathy

Micro vascular damage to vessels in retina. Patient may see spots or have reduced vision

Early intervention for diabetic retinopathy

Regular exams to monitor for changes

Treatment of diabetic retinopathy

1. Laser photocoagulation therapy (stops unwanted vessels from forming)

2. Virectomy (removes vitreous humorous from eye)

3. Intraocular injection of medications (to decrease edema in eyes)

Nephropathy

Damage to vessels that supply glomeruli

Why might patients who have nephropathy be prescribed ACE inhibitors and ARBs even if they don’t have HTN

Prevents complications (HTN accelerates progression)

Regular screening for Nephropathy

1. Microalbuminuria (detects early kidney damage)

2. Creatinine

3. GFR

Neuropathy

Nerve damage

Sensory neuropathy

1. Hands and feet

2. Paresthesias, abnormal sensations, pain, loss of sensation

Autonomic neuropathy

1. All body systems can be affected

2. Hypoglycemic unawareness

3. Bowel incontinence, urinary retention

4. Delayed gastric emptying (nausea, vomiting and acid reflux)

5. Sexual dysfunction

Neuropathy treatment

Control of blood glucose and medications to relieve pain (topical creams, antidepressants, anti seizure meds)

Complications of foot and lower extremities

1. From combo of micro vascular and macrovascular diseases

2. Sensory neuropathy and peripheral vascular disease (loss of sensation and injury)

How to prevent complications of foot and lower extremity

1. Regulate blood glucose

2. Proper footwear

3. Diligent foot (skin and nail) care

Integumentary complications and infection

Painless, discoloured spots on the skin. Increased susceptibility to infection

Diabetes age related considerations

1. Prevalence increased with age

2. Decreased beta cell function

3. Decreased insulin sensitivity

4. Altered carbohydrate metabolism

5. Progressive increased in A1C

6. Meds to treat other conditions may impair insulin action

7. Cognitive impairment