Glucose Management Nursing Practice - Adult Health I

Unit 2: Glucose Management Nursing Practice - Adult Health I

List of Glucose Intolerance Disorders

  • Pre-diabetes
  • Diabetes
      - Type 1
      - Type 2
      - Gestational Diabetes
      - Metabolic Syndrome
  • Hypoglycemia
  • Hyperglycemia
  • Somogyi Effect
  • Dawn Phenomenon

General Diabetes Information

  • Definition: Metabolic disorder characterized by hyperglycemia.
  • Causes include:
      - Insufficient insulin secretion
      - Ineffective insulin action
  • Common and underdiagnosed; clients may move between categories (e.g., Gestational to Type 2).

Endogenous Insulin

  • Clears from circulating blood in 10 to 15 minutes.
  • Major metabolic functions:
      - Converts carbohydrates to glucose.
      - Converts fats to lipids.
      - Converts proteins to amino acids.
  • Functions:
      - Lowers blood glucose levels.
      - Instructs the liver to stop releasing glucose.
      - Promotes glucose storage in fat tissue.

Risk Factors for Glucose-Related Disorders

  • Family History
  • Obesity
  • Race/Ethnicity
  • Metabolic Syndrome
  • Age (older adults are more at risk)
  • Hypertension
  • Elevated triglycerides/cholesterol
  • History of gestational diabetes with an overweight baby
  • Consider the number and severity of risk factors.

Pre-Diabetes

  • Definition: Impaired insulin sensitivity or impaired insulin synthesis/release.
  • Symptoms: None; levels remain normal or mildly elevated, between normal and diabetic levels.
  • Diagnosis:
      - Fasting glucose: 100-125 mg/dL
      - A1C: 5.7-6.4%
  • Care Education (Prevention):
      - Diet
      - Exercise
      - Weight management

Diabetes Types

Type 1 Diabetes
  • Constitutes 5% of diabetic clients.
  • Common in youth; often presents with thinness and weight loss.
  • Cause: Genetic, immunologic, and environmental factors.
  • Insulin Dependency: Requires insulin for management, as there is little to no endogenous insulin.
  • Acute Complication: Diabetic Ketoacidosis (DKA).
Type 2 Diabetes
  • Constitutes 95% of diabetic clients; occurs in individuals of any age, generally adults.
  • Commonly associated with obesity, heredity, and lifestyle factors.
  • Insulin Presence: Endogenous insulin is present but decreased.
  • Management:
      - Weight loss
      - Diet
      - Oral antidiabetics
      - Insulin
  • Acute Complication: Hyperglycemic Hyperosmolar State (HHS).

Clinical Manifestations of Diabetes Mellitus (DM)

  • Common Symptoms: Hyperglycemia, the "3 P's" (polyuria, polydipsia, polyphagia), dehydration, fatigue, weakness, vision changes, paresthesia, dry skin, slow-healing wounds, and recurrent infections.
  • Symptoms may be subtle in Type 2 diabetes; testing for glucose levels is crucial as part of routine care.

Diagnosis of Diabetes Mellitus (DM)

  • Criteria:
      - A1C > 6.5%
      - Fasting glucose > 126 mg/dL (after an 8-hour fast)
      - Glucose tolerance test: > 200 mg/dL
      - Random glucose > 200 mg/dL (with symptoms).

Goals of Care for DM

  • Achieve euglycemia without hypoglycemia.
  • Complication prevention:
      - Diabetic retinopathy
      - Nephropathy
      - Neuropathy
  • Education: Planning, assessments, and educational methods should be culturally competent and involve patient preferences.
Nutritional Considerations
  • Caloric Requirements: Adequate to meet metabolic and activity levels.
      - Distribution: Carbohydrates > Fat > Protein
  • Alcohol: Consume in moderation to avoid risk of hypoglycemia.
  • Artificial Sweeteners: Use in moderation; maintain dietary adherence.
Nutrition Nursing Care for DM
  • Combining starchy foods with protein and fat can slow absorption and glycemic response.
  • Raw or whole foods typically result in lower glycemic response compared to cooked, chopped, or pureed foods.
  • Preference for whole fruits over juices can reduce glycemic response due to fiber content.

Nursing Care for DM: Exercise & Rest

  • Benefits: Lowers glucose levels and cardiovascular risk.
  • Exercise Recommendations:
      - Start with glucose levels between 100-250 mg/dL.
      - Exercise 3 times a week with consistency.
      - Plan exercises according to insulin peaks.
  • Precautions:
      - Monitor for severely elevated glucose and ketones in urine.
      - Have a snack before exercise, and consider snacks as backup.
Hygiene & Foot Care
  • 50% of diabetic amputations are avoidable.
  • Foot Care Recommendations:
      - Do not apply moisturizer to already 'moist' areas.
      - Trim nails straight across.
      - Wash feet daily with lukewarm water and gentle soap; dry thoroughly.
      - Inspect feet daily using a mirror.
      - Wear well-fitted shoes and do not walk barefoot.

Nursing Care for DM: Monitoring

  • Self Monitoring:
      - Regular blood glucose checks and awareness.
      - Monitoring glycosylated hemoglobin and ketone testing is essential.
  • Clinical checks for foot health to prevent neuropathic complications.

Pharmacological Therapy for DM: Insulin

  • Types of Insulin:
      - Rapid
      - Short
      - Intermediate
      - Long
  • Delivery Methods:
      - Insulin Pump: Mimics pancreatic function, change catheter every 3 days.
      - Insulin Pen: Multidose administration, typically used at home.
      - Subcutaneous Injection:
        - Check glucose levels before administering.
        - Injection site options: abdomen, upper arm, thigh, hip; rotate sites.
Complications of Insulin Therapy
  • Potential for local and systemic allergic reactions, insulin lipodystrophy, and resistance to injected insulin.
  • Morning hyperglycemia may occur in patients.

Oral Anti-Diabetic Agents

  • For clients with Type 2 diabetes who need more than just diet and exercise.
  • Major side effect: hypoglycemia.
  • Types of Oral Anti-diabetics:
      - Sulfonylureas (e.g., glipizide, glyburide)
      - Alpha Glucosidase Inhibitors (e.g., acarbose)
      - Biguanides (e.g., metformin)
      - Incretin memetics (e.g., exenatide)
      - Thiazolidinediones (e.g., rosiglitazone)
      - Dipeptidyl peptidase-4 Inhibitor (e.g., sitagliptin)
      - Meglitinides (e.g., repaglinide)

Gestational Diabetes

  • Pregnancy-related glucose intolerance.
  • Diagnosed through glucose tolerance tests (GTT).
  • Risk factors include obesity, a history of gestational diabetes, and race/ethnicity.
  • Complications:
      - Perinatal complications
      - Macrosomia (large baby)
      - Increased risk for Type 2 diabetes later in life.

Latent Autoimmune Disease of Adults (LADA)

  • Represents a slower progression of autoimmune beta-cell destruction and presents with symptoms similar to diabetes.
  • Delayed need for insulin therapy.

Metabolic Syndrome

  • Defined as a cluster of metabolic abnormalities, including insulin resistance, increased fasting glucose, dyslipidemia, abdominal obesity, and hypertension, increasing cardiovascular disease risk.

Prevention of DM

  • Lifestyle Modifications:
      - Diet
      - Exercise
      - Adequate rest

Hyperglycemia Emergencies

  • Characterized by blood glucose levels > 300 mg/dL leading to diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS).
  • Symptoms: Change in level of consciousness, severe dehydration, hypotension, and specific symptoms like Kussmaul’s breathing in DKA.
  • Monitor and Educate:
      - Focus on lifestyle, insulin therapy, and the importance of maintaining balanced glucose levels.

Client Education for DM / Hyperglycemia

  • Assess readiness to learn; understand fears, literacy levels, and family support.
  • Ask about hypoglycemia and its causes, such as:
      - Excess medication
      - Inadequate food intake
      - Excessive exercise
Diagnosis of Hypoglycemia
  • Defined as glucose < 70 mg/dL.
  • Symptoms: include sweating, tremors, tachycardia, nervousness, confusion, and slurred speech.
  • Treatment:
      - Quickly administer simple carbohydrates or sugars.
      - For severe cases, administer glucagon.

Dawn Phenomenon

  • Definition: Morning hyperglycemia due to a nocturnal surge in growth hormone secretion requiring greater insulin in the morning.
  • Diagnosis:
      - Measure glucose levels at bedtime, 0300, and upon waking.
Somogyi Effect
  • Characterized by “HYPO overnight” followed by hyperglycemia in the morning.
  • Pathophysiology: Hypoglycemia at 2-3 AM causes counter-regulatory hormone production, resulting in morning hyperglycemia.
  • Diagnosis: Confirm glucose levels at bedtime, 0200-0300, and upon waking.

Gerontology and Diabetes

  • Symptoms of diabetes may be less pronounced or absent in older adults.
  • Blood testing is more reliable than urine testing.
  • Exercise Considerations: Adapting physical capacity and involving physical therapy may be necessary.
SICK DAY RULES for DM Patients
  • S: Check blood sugar every 4 hours.
  • I: Continue insulin and DM medications.
  • C: Eat meals at regular times and drink 8-12 oz of fluid hourly.
      - If blood sugar is high, choose sugar-free options.
      - If blood sugar is low, choose sugary options.
  • K: Check urine ketones when blood sugar > 240 mg/dL and call your doctor if positive.

Long-Term Complications of Diabetes

  1. Macrovascular Complications:
       - Accelerated atherosclerotic changes
       - Coronary artery disease
       - Cerebrovascular disease
       - Peripheral vascular disease
  2. Microvascular Complications:
       - Diabetic retinopathy
       - Nephropathy
  3. Neuropathic Complications:
       - Peripheral neuropathy
       - Autonomic neuropathies
       - Neuropathic issues related to sexual function and hypoglycemic unawareness.
Nursing Diagnoses for Diabetic Clients
  • Risk for injury
  • Self-care deficit
  • Knowledge deficit about diabetes management and care.

Class Summary

  • Engaged learning through probing questions regarding lecture material, encouraging self-assessment of knowledge.
  • Reference: Hinkle, J. L., Cheever, K. H., & Overbaugh, K. (2026). Brunner & Suddarth’s textbook of medical-surgical nursing (16th ed.). Wolters Kluwer.