Diabetes Care

Diabetes Classifications

type 1 and 2

gestational

LADA and MODY

diabetes associated with other conditions

except for type 1 people may move from one category to another

Symptoms

fatigue

thirst and hunger

increased urinary output

vision changes

Diagnostics

random blood glucose over 200 or

fasting glucose over 126 or

two hour post prandial glucose over 200 or

HgA1c levels over 6.5 - 7

Patient Education

self monitoring and management of blood glucose (SMBG)

foot care especially in older adults

s Fs → food, fitness, and fixes (in illness)

disease processes

consequences and complications → cardiovascular, nephropathy, neuropathy, retinopathy

Self Monitoring at Home

useful tool as part of diabetes management

helps to detect and prevent hypoglycemia

helps to adjust insulin dosing

Insulin at Home

needle or syringe

insulin pens

jet injectors

insulin pumps and pods

Freestyle Libre

one continuous glucose monitoring system (another dexcom G7)

uses a thin filament to measure glucose every minute

sensor is on the back of the arm

handheld scanner reads results

requires a fingerstick for confirmation of problems

Insulin Pump

omnipod insulin management system

provides up to 3 days of non stop insulin management without multiple daily injections

Sick Day Care

teach not to eliminate insulin doses even with nausea and vomiting

person should attempt small frequent portions of carbs

drink fluids every hour

assess blood glucose every 3-4 hours

Foot Care

daily inspection and bathing of feet

properly fitting shoes/podiatry (no bare feet)

toenail management

Consequences

type 1 → blindness, kidney disease (50% of newly diagnosed ESRD are diabetic), and peripheral neuropathies

type 2 → heart disease, hypertension, and stroke

Complications

hypoglycemia or hyperglycemia

diabetic ketoacidosis (DKA)

hyperglycemia hyperosmolar nonketotic syndrome (HHS or HHNKS)

Hypoglycemia Medical

first 15g oral carbs

emergency → 1 amp of D50W given IV

25 gm dextrose

1 gm will increase blood glucose 4mg approx

metabolized in ½ hours

maintain IV solution

Hypoglycemia Nursing

monitor IV site

I&O

monitor labs → glucose and electrolytes

monitor IV fluid, rate, and site

education on signs and symptoms and prevention

Hyperglycemia Medical

IV regular insulin infusion

frequent glucose checks

IV fluids

Hyperglycemia Nursing

monitor IV concentration and rate

I&O

monitor labs → glucose and electrolytes

educations on signs and symptoms and prevention

Insulin Drip

regular insulin may be given IV

dilute in normal saline

nursing alert → specific flushing and priming procedure

in patient treatment ONLY and ALWAYS with an IV pump (computer guided)

DKA Causes

sepsis

skipped insulin dose

stress

sugar

surgery

substance abuse

DKA Symptoms

thirst or very dry mouth

frequent urination

fatigue

dry or flushed skin

nausea, vomiting, or abdominal pain

shortness of breath

difficulty concentrating

DKA Diagnosis

blood glucose levels over 250

ketones in the urine

blood gases → pH less than 7.3 and bicarb less than 18

high creatinine

sodium, potassium, phosphate are normal or elevated

DKA

D → diuresis, dehydration, delirium, dizziness

K → kussmaul breathing and ketotic breath

A → abdominal pain

DKA HHS Rehydration

monitor vital signs, I&O, and IV (solution, rate, and site)

monitor lungs and extremities for edema

monitor mental status

DKA HHS Restore Electrolytes

monitor labs → glucose, potassium, bicarb, and CO2

maintain telemetry

replace electrolytes as ordered

monitor neuro status

DKA Reverse Acidosis

administer IV insulin and bicarb as ordered

monitor ABGs

HHS

causes → inadequate insulin, not enough to prevent hyperglycemia but enough to prevent lipolysis

due to acute illness, meds that exacerbate hyperglycemia (contraceptives, thiazides, steroids) and dialysis

HHS Symptoms

persistant osmotic diuresis due to hyperglycemia

profound dehydration → dry mucous membranes, poor skin turgor, tachycardia, variable neuro signs (altered mental status, seizures, hemiparesis)

hypotension

HHS Diagnostics

extremely high blood glucose → 600 to 1200

electrolytes

CBC

increased BUN

increased serum osmolality to exceed 350

ABGs → bicarb is normal

HHS Rehydration

vital signs and mental status

monitor I&O

monitor IV → solution, rate, and site

monitor lungs and extremities for edema

HHS IV Insulin

administer insulin as ordered

monitor ABGs

Hospitalization

often not the primary diagnosis

glucose control needs to change

self care issues → conflict with hospital routine and monitor for educational opportunities

Hospital Nursing Interventions

assess patient home routine and communicate to appropriate departments

assess patient reaction to any previous hypoglycemic episodes

know insulin actions and peaks

arrange for snacks if meals delayed

Preop

monitor for symptoms of hypo and hyperglycemia

stress will elevate blood glucose

prolonged NPO status may lower glucose

monitor labs

Postop

routine postop care and monitoring for symptoms of hypo and hyperglycemia

monitor labs

monitor for cardiovascular complications

monitor for skin breakdown

maintain adequate nutrition and hydration

Inpatient Insulin

insulin is a high risk medication

verify order and insulin vial with another nurse

check patients blood glucose before administering

know how to mix insulin in one syringe → ensure they can be mixed (most cannot)