ENDOCRINE - Diabetes (Acute & Chronic Conditions)

1. Nutritional considerations

2. Pharmacologic interventions

3. Monitoring blood glucose

4. Activity

5. Education

5 parts of DM therapeutic management

1 - prescribed meal plan

2 - individualized

Nutritional considerations principle

Eat according to (1) that is (2) to the dietary needs of a specific client

1 - desirable body weight

2 - occupation

3 - age

4 - activities

5 - type of diabetes

Determinants of individualized meal plan

FALSE - never skip meals

TRUE OR FALSE

you should skip meals when you have DM

Dietary adherence

The key to be therapeutic nutritionally for DM

Insulin or oral hypoglycemic agents (OHA)

Pharmacologic interventions in DM include

Sulfonyureas

Biguanides

Two kinds of OHA

1. Proper administration

2. Assesment of use and response

3. Education of client and family

Principles of pharmacologic interventions.

Sulfonyureas

Stimulates beta cell production of insulin

Biguanides

Potentiates action of insulin; inhibits glucose absorption in the GIT

Compliance

Key to effective management (pharmacologic intervention)

Monitoring blood glucose

This is where you see the response to the pharmacologic intervention

SMBG

- Glucometer

- test strips/testape/reagent strip

- lancet/needle prick

Ways to monitor blood glucos

RECORDING

Key consideration when monitoring blood glucose

E/A should be enjoyable,does not have to be vigorous

Principles of exercse

30 mins to 1 hour

Walking has to be how long to be therapeutic

Walking

Stationary biking

Dancing

Swimming

Other means of exercise include

After a meal

Exercise is best done when?

Weight reduction, control cholesterol, triglycerides

What does exercise contribute to

Both type 1 & type 2 + improves circulation

Increased muscle tone benefits what kind of DM

CONSISTENCY

KEY TO BE THERAPEUTIC OF EA

Achieve a level of self management

(The more in control the client, the more they will accept and adhere to the management program)

Major goal of DM education

Endocrinologist

DM nurse specialist

Dietitian

Podiatrist

Counselor

Medical Social worker

Family & SO

Team approach to management includes

OPEN TO LEARNING AND KNOWLEDGE

KEY TO EDUCATION

1. Diabetic Ketoacidosis (DKA), Diabetic Acidosis, Diabetic Coma

2. Hypoglycemia

Acute complications of DM

DKA

Caused by too little insulin accompanied by increased caloric intake & physical or emotional stress

Diabetic acidosis/ Diabetic Coma

Other names for DKA

Cause - too little insulin

Accompanied by - increased caloric intake & physical or emotional stress

What is the cause of DKA and what would it be accompanied by

Undiagnosed DM (Type 1)

DKA is RT what

Glucose cannot be used for cellular energy for the body

When insulin is insufficient,

Body releases and breaks down stored fats and proteins to provide needed energy

In response to cellular starvation

KETONE BODIES

Free fatty acids are released and metabolized forming

1. Too little insulin

2. Glucose not used for cellular energy

3. Body use stored fat and CHON (broken down and metabolized)

4. End products become ketone bodies (acetylacetic acid)

5. DKA, DA, DC

Process of DKA

Dehydration

Clinical picture of DKA

Increased urine output

Why does dehyration in DKA happen?

Neurologic - lower level of conscious -> COMA

Respiratory - deep, rapid breathing (Kussmaul sign), sweet fruit odor of breath (acetone breath)

Systematic effects of DKA

Kussmaul sign

Deep rapid breathing

Acetone breath

Sweet fruity odor of breath

Labs

IVF

Medication

Monitoring

TESTS TO BE DONE

Stat blood glucose

ABG

LABS TO BE DONE

0.9% NS

Start on IVF, what do you give?

Administer insulin, monitor RBS Q15

What do you administer and monitor in DKA?

V/S

IO

LOC

Labs

Patient response (do they wake up or not)

What else do you monitor for DKA?

Hypoglycemia

Occurs when there is too much insulin for available glucose

Too much insulin

What happens during hypoglycemia

50 mg/dL

Hypoglycemia means glucose less than

1. Too much insulin

2. Ingestion of too little food

3. Unusual amounts of exercise

4. Delayed exercise

Causes of hypoglycemia

SNS

What part of the nervous system is involved with hypoglycemia

Cold sweats

Weakness

Trembling

Nervousness

Pallor

Brain supply is inadequate - confusion, fatigue, abnormal behavior, LOC

SNS response includes

STAT BLOOD GLUCOSE

LABS for hypoglycemia

Give fast acting of CHO

Management of hypoglycemia

One glass of OJ w/ sugar

Regular soft drinks

4-5 pcs of hard candy

2 Tbsp of sugar in water

Buko juice

Fast acting CHO includes

Give IV push D50W

If hypoglycemic patient is unconscious

Angiopathy (Macropathy & Micropathy)

CHRONIC COMPLICATIONS

CVD

HPN

PVD

Kinds of macropathy

Retinopathy

Nephropathy

Neuropathy

Desmopathy

Kinds of micropathy

Peripheral vascular disease (PVD)

Combination of macro/micro angiopathy & clotting abnormality

macro/micro angiopathy & clotting abnormality

PVD is a combination of

Legs and feet

In PVD, what part is usually affected

PVD

This accounts for a number of diabetic hospitalizations

Infection

Gangrene (can be necrotic).

Possible amputation

TRIAD for PVD

Intermittent claudication (muscle pain @ calves, comes and goes during ambulation)

Pain @ rest

Cold feet

Delayed capillary refill

Dependent rubor

Classic S/S of PVD

Impaired oxygenation

Inadequate tissue perfusion

Poor peripheral circulation

Possible nsg diagnosis for PVD

Doppler study; peripheral angiography

Diagnostic tests for PVD

Control or reduction of risk factors (smoking, increased cholesterol, HPN)

Proper care of feet

Antibiotic therapy (IV ABX)

Treatment for PVD

Diabetic retinopathy

Minute miscroscopis BV of the eye; disease of the retina DT damaged capillaries, capillary drop out abnormal BV growth on the surface of the retina

Damaged capillaries

Capillary drop out

Abnormal BV growth on the surface of the retina

Causes of diabetic retinopathy

Glaucoma

Cataracts

Clinical blindness

Diabetic retinopathy is usually seen in

Diabetic nepropathy

Microangiopathy causes diffuse (large) nodular glomerulosclerosis

Glomerulus thickens

Leaking of proteins into the urine (proteinuria)

Glomerulosclerosis essentially means

Renal failure

2 - ESRD

Diabetic nephropathy can progress to (1) and is usually ass. with

Kidney transplant

Because of RF and ESRD, pt with diabetic nephropathy can be a candidate for

Diabetic neuropathy

Results from reduced nerve conduction and demyelinization

reduced nerve conduction and demyelinization

Diabetic neuropathy results from

Destroyed myelin sheath -> decreased blood supply to the area -> diminished nerve conduction

demyelinization means

Because myelin sheath is where nerve transmission happens

Why is there decreased nerve conduction?

Symmterical

Peripheral

Polyneuropathy

When demyelinization happens, it is usually

Symmetrical - affecting both sides

Peripheral - affects upper extremities (arms & hands) and lower extremities

Polyneuropathy - many BV

What do you mean by: symmetrical, peripheral, and polyneuropathy?

A disease involving MANY BV affecting UPPER AND LOWER EXTREMITIES of BOTH SIDES

Therefore, diabetic neuropathy means

Pain even at rest

Paresthesias

Partial loss of sensations to touch and temp

3 Ps of diabetic neuropathy

Provide socks or blankets or lower the thermostat

Since a patient with diab neuropathy has Partial loss of sensations to touch and temp, what do you give if they get cold?