Chapter 37

Chapter 37. Care of Patients with Diabetes and Hypoglycemia

Diabetes Mellitus

• Type 1 Diabetes Mellitus:

  • Requires insulin; the body does not produce any.

  • Caused by autoimmune response leading to the malfunction of beta cells.

  • Beta cells in the pancreas are responsible for making insulin.

• Type 2 Diabetes Mellitus:

  • Caused by insulin resistance.

  • Insulin interaction with its receptors is less efficient, resulting in abnormal glucose metabolism.

DM Etiology and Pathophysiology

• Genetic Factors:

  • Tends to run in families.

• Metabolic Factors:

  • Emotional and physical stress.

  • Obesity.

• Microbiologic Factors:

  • Some forms of type 1 diabetes may relate to viral destruction of beta cells.

• Immunologic Factors:

  • The immune system destroys insulin-secreting beta cells of the pancreas.

Symptoms of Type 1 Diabetes

• Polydipsia (very thirsty).

• Polyuria (frequent urination).

• Polyphagia (extremely hungry).

• Rapid weight loss.

• Irritability.

• Weakness and fatigue.

• Nausea and vomiting.

Symptoms of Type 2 Diabetes

• Possibly polydipsia, polyuria, and polyphagia.

• More commonly associated with excessive weight gain.

• Family history of diabetes mellitus.

• Poor healing of scratches, abrasions, and wounds.

• Blurred vision.

• Itching.

• Drowsiness.

• Increased fatigue.

• Tingling or numbness in the feet.

DM Diagnosis

• Screening Methods:

  • Hemoglobin A1c (HbA1c) lab value target: 4.5-5.5% is good.

  • Fasting plasma glucose (FPG).

  • 2-hour 75g oral glucose tolerance test (OGTT).

Self-Management of DM

• Benefits of tight glycemic control.

• Monitor for hypoglycemia or insulin reaction.

• Overall goal of diabetes management.

• Older adult considerations include dietary management as the cornerstone treatment.

• Importance of focusing on allowed foods rather than forbidden ones for weight management.

• Exercise:

  • Increasing food intake when exercising.

  • Older adult care considerations.

  • Use of oral hypoglycemic agents, including metformin.

  • Insulin therapy.

Insulin Therapy

• Goals:

  • Closely mimic the body’s natural insulin.

  • Multiple daily insulin injection regimen.

• Insulin-to-carbohydrate ratio and the use of an insulin pump.

• Patient teaching and compliance are key.

• Incretin mimetics and preoperative/ postoperative insulin management.

• Rotation Sites for Insulin Injection:

  • Only regular (clear) insulin can be given through IV.

  • Mixing insulins: clear to cloudy.

Islet Cell Transplantation

• Requires two to four donor pancreases.

DM Nursing Management

• Monitor blood glucose trends, hemoglobin A1c, and fructosamine assay (best for older adults, unaffected by age).

• Monitor for hypoglycemia after insulin injections.

• Watch for signs of ketoacidosis (fruity breath).

Hyperglycemia or Hypoglycemia

• When in doubt, begin treatment for hypoglycemia until blood glucose is determined due to difficulty in raising blood sugar levels.

• Rapid blood glucose determination is crucial.

• Hyperglycemia:

  • Develops slowly, does not cause immediate changes in consciousness.

• Hypoglycemia:

  • Can occur quickly; patient may fall into a coma.

Diabetic Ketoacidosis (DKA)

• Serious condition from incomplete fat metabolism due to insufficient insulin supply.

• The body breaks down protein and fat for energy, leading to excess ketone production.

• Body compensates for acidosis by increasing respiratory rate (Kussmaul respirations).

• Signs and Symptoms of DKA:

  • Increased thirst (polydipsia).

  • Increased urination (polyuria).

  • Acetone breath odor (fruity).

  • Hot and dry skin, indicating high sugar.

  • Dry mucous membranes and sunken eyeballs (dehydration).

  • Nausea and vomiting.

  • Kussmaul respirations.

  • Abdominal pain and rigidity.

  • Paresthesias, weakness, paralysis.

  • Hypotension.

  • Minimal urine output (oliguria) or none (anuria; late sign).

  • Stupor or coma (late sign).

DKA Treatment

• Restore normal pH.

• Correct fluid and electrolyte imbalance.

• Gradually lower blood glucose levels (usually via insulin drip).

• Provide life support measures as necessary.

Patient Teaching

• Pathophysiology of diabetes mellitus, including pancreatic function and contributing factors.

• Dietary management and blood glucose monitoring at home.

• Foot care and blood testing methods.

• Importance of medical identification tags/cards.

• Guidelines for "sick days."

• Community resources for diabetic patients and families.

• Travel tips and tools for easier insulin administration.

Complications of Diabetes

• Short-Term Complications:

  • Hyperglycemia.

  • Hypoglycemia.

  • Diabetic ketoacidosis.

  • Rebound hyperglycemia (Somogyi effect).

  • Dawn phenomenon.

• Long-Term Complications:

  • Cardiovascular disease (atherosclerosis).

  • Metabolic syndrome.

  • Nephropathy (kidney issues).

  • Peripheral vascular disease.

  • Retinopathy (vision problems).

  • Diabetic neuropathy.

Hypoglycemia (Non-Diabetic)

• Etiology and Pathophysiology:

  • Conditions affecting intestines, liver, pancreas can lead to hypoglycemia (e.g., gastrectomy, insulinomas, liver disease).

  • Substance abuse (e.g., alcohol) can contribute.

• Signs and Symptoms:

  • Rapid heartbeat, tremulousness, weakness, anxiety, nervousness, hunger.

• Diagnosis:

  • Blood glucose values, insulin and C-peptide levels.

  • Imaging if insulinoma is suspected.

• Treatment:

  • Modify eating patterns; smaller and more frequent meals.

  • Emphasize protein high, low carbohydrates, and omit refined sugars and white flour.

Key Treatment Focus for Diabetes

• Weight loss is critical for effective diabetes management.