Diabetes

Management of Patients With Diabetes

Overview

  • Presenter: Diane Robillard, DNP RN

  • Course: N3805 2026

  • Reference Book: Medical Surgical Nursing, 12th Ed, 2023

  • Institution: Augusta University Nursing

  • Key Assessment Tool: Toe Brachial Index vs ABI

Learning Outcomes

  1. Understand the different types of diabetes and the at-risk populations.

  2. Describe the interprofessional care for diabetes patients.

  3. Describe the nursing role for newly diagnosed diabetes patients.

  4. Understand nursing management strategies for diabetic patients in hospital and clinic settings.

  5. Identify chronic complications of diabetes and their clinical manifestations.

  6. Explain nursing management and interprofessional care for diabetic complications.

Key Vocabulary

  • Dawn Phenomenon: Early morning rise in blood glucose.

  • Metabolic Syndrome: A cluster of conditions that increase the risk of heart disease and diabetes.

  • DKA: Diabetes-related ketoacidosis.

  • Pre-diabetes: Glucose levels higher than normal but not high enough for a diabetes diagnosis.

  • Diabetes-related Neuropathy: Nerve damage due to diabetes.

  • Somogyi Effect: Rebound hyperglycemia following hypoglycemia.

  • Diabetes-related Retinopathy: Damage to the retina due to diabetes.

  • Insulin Resistance: Reduced sensitivity to insulin.

  • HHS: Hyperosmolar Hyperglycemic Syndrome.

  • Lipodystrophy: Abnormal fat distribution, often due to insulin injections.

  • Types of Diabetes: Type 1 and Type 2 diabetes.

Diabetes Overview

  • Prevalence: 12% of the USA population has diabetes.

  • Causes of Diabetes:

    1. Absent or insufficient insulin supply.

    2. Poor body utilization of available insulin.

  • Leading Causes of:

    1. Adult blindness (after cataract, the second leading cause).

    2. End-stage renal disease.

    3. Non-trauma limb amputation.

    4. Contributing factor to heart disease and stroke.

Classifications of Diabetes

1. Type 1 Diabetes

  • Body produces insufficient insulin for survival.

  • Autoimmune destruction of insulin-producing beta cells in the pancreas.

  • Requires insulin therapy; no oral diabetic medications (e.g., metformin).

  • Onset is acute, typically before age 40.

  • Accounts for 5-10% of diabetes cases.

2. Type 2 Diabetes

  • Body does not produce enough insulin or is unresponsive to it.

  • Characterized by insulin resistance and impaired beta cell function.

  • 90-95% of diabetes cases, typically presents after age 30; increasing prevalence in children and obese populations.

  • Slow, progressive glucose intolerance; managed initially with diet and exercise; may need oral hypoglycemic agents and ultimately insulin or a combination of both.

3. Prediabetes

  • Impaired glucose tolerance and/or impaired fasting glucose.

  • Fasting blood glucose levels: 100-125 mg/dL.

  • Monitoring done with A1C and frequent blood sugar checks (A1C 5.7-6.4%).

  • A1C 6.5% or greater indicates diabetes.

  • Lifestyle changes are the foremost intervention (diet and exercise).

4. Gestational Diabetes

  • Diagnosed between weeks 24-28 of pregnancy.

  • 60% of women with this form develop type 2 diabetes within 16 years.

Nursing Diagnoses for Diabetes

  • Ineffective health management: Patients lack knowledge for optimal management.

  • Risk for unstable blood glucose levels: Potential for severe hypo or hyperglycemia.

  • Risk for injury: Due to neuropathy or low blood glucose.

  • Risk for peripheral neurovascular dysfunction: Potential for complications involving nerves and blood vessels.

Clinical Manifestations of Diabetes

  • Common Symptoms (Three Ps):

    • Polyuria: Excessive urination.

    • Polydipsia: Increased thirst.

    • Polyphagia: Increased hunger.

  • Additional symptoms:

    • Fatigue.

    • Weakness.

    • Vision changes (e.g., blurriness).

    • Tingling or numbness in extremities.

    • Dry skin and slow-healing wounds.

    • Recurrent infections.

    • Type 1 can experience sudden weight loss.

Diagnostic Studies and Findings

  1. Fasting blood glucose level ≥126 mg/dL after no caloric intake for at least 8 hours.

  2. Random blood glucose level ≥200 mg/dL accompanied by the classic symptoms of diabetes (Three Ps).

  3. 2-hour glucose challenge test >200 mg/dL post-consumption of a 75-100 g glucose solution.

  4. A1C levels >6.5% indicate diabetes.

Oral Glucose Tolerance Test (OGTT)

  • Purpose: Assesses the body’s ability to metabolize glucose.

  • Procedure: After an overnight fast (8-12 hours), a baseline blood sample is taken, then the patient drinks a glucose solution (75g-100g). Blood is drawn at set intervals (1, 2, or 3 hours) to monitor glucose metabolism.

  • In pregnancy, typically a 50g glucose solution is used for tests.

Treatment Goals for Diabetes

  1. Maintain blood glucose levels within normal range.

  2. Target A1C < 7% (optimal <6.5%).

Insulin Therapy

i. Intensive Control: Basal-bolus method for closest mimicking of physiological insulin release—combination of rapid/short-acting and long-acting insulin.
ii. Insulin Pump Therapy: Continuous subcutaneous insulin delivery.
iii. Frequent monitoring of blood glucose and regular contact with educators can significantly reduce complication risks (e.g., retinopathy, nephropathy, neuropathy).

Essential Insulin Information

  • Types of Glucose-lowering Agents:

    1. Insulin.

    2. Oral agents.

    3. Non-insulin injectables.

    4. Glucagon-Like Peptide-1 (GLP-1).

  • Storage of Insulin: Room temperature for up to 4 weeks; cooler storage needed in heat.

Complications of Insulin Therapy

  1. Hypoglycemia: Low blood sugar levels due to excess insulin or inadequate food intake.

  2. Allergic Reactions: Localized inflammation, usually resolves within 1-3 months.

  3. Lipodystrophy: Tissue atrophy from repeated injections at the same site.

  4. Somogyi Effect: Morning hyperglycemia due to overnight hypoglycemia followed by glucose rebound; treatment usually requires less insulin.

  5. Pre-Dawn Effect: Morning hyperglycemia due to hormone release during sleep; treatment requires more insulin.

Sick-Day Rules for Diabetic Patients

  • Continue insulin as usual and maintain a “Sick Day” journal for monitoring.

  • Test blood glucose every 3-4 hours.

  • Adjust insulin doses as needed.

  • Consume small meals every 6-8 hours; if vomiting/diarrhea occurs, focus on hydration with liquids every 30-60 minutes—options include soda or Gatorade.

  • Report severe vomiting/diarrhea to healthcare provider.

  • If unable to retain fluids, hospitalization may be needed.

Hospital Management of Diabetes

Common Hospital Problems

  1. Hyperglycemia: May result from medications (e.g., steroids), IV fluids containing glucose, or illness.

  2. Hypoglycemia: Can arise from delayed meals post-insulin administration or sliding-scale insulin overuse.

  3. NPO (Nothing by Mouth) Status: Special caution of DKA risk in Type 1 diabetes; basal insulin usually continued. Type 2 may require monitoring and adjust insulin per physician orders.

Hospital Guidelines

  • Clear Liquid Diet: Ensure caloric intake to prevent hypoglycemia; sugar-free alternatives not effective.

  • Tube Feedings: High carbohydrate content can elevate blood glucose levels; need careful monitoring.

  • IV Nutrition: Monitor glucose levels frequently; excess dextrose in IV can cause spikes.

  • Patient Hygiene: Emphasize oral and dermatologic care to prevent infections and ensure wound healing.

  • Stress Management: Recognize that stress can lead to both hyper and hypoglycemia.

Role of the Nurse

  • Understand and guide dietary management.

  • Work with dieticians for proper meal planning.

  • Support lifestyle changes including adequate dietary and exercise practices.

  • Educate patients on their glucose monitoring equipment and procedures.

  • Monitor for complications and risks, ensuring supplies are adequate.

Meal Planning for Healthy Eating

  • Consider individual preferences, dietary histories, and goals (weight loss/gain).

  • Carbohydrates: Focus on whole grains, fruits, and vegetables; limit sugars and starches.

  • Fats: Healthy fats are derived from plants and nuts (e.g., avocados).

  • Proteins: Adequate intake relative to renal function status.

Self-Monitoring of Blood Glucose (SMBG)

  • Patient Education: Instruct on the proper use and calibration of blood glucose monitors.

  • When to Test:

    • Before meals.

    • Two hours post meals.

    • Whenever hypoglycemia is suspected.

    • During illness or before/during/after exercise.

Acute Complications of Diabetes

Major Complications:

  1. Hypoglycemia: Both types of diabetes can experience this.

  2. DKA: More commonly associated with Type 1 diabetes.

  3. HHS: More commonly seen in Type 2 diabetes.

Hypoglycemia

  • Definition: Blood glucose levels ≤ 70 mg/dL.

  • Causes:

    • Excess insulin or oral agents.

    • Increased physical activity without adequate food intake.

  • Symptoms:

    • Adrenergic: Cold, clammy skin; tremors; tachycardia; hunger.

    • CNS: Inability to concentrate; headache; confusion; slurred speech; drowsiness.

    • Severe Cases: Disorientation, seizures, unconsciousness, potential death.

Management of Hypoglycemia

  • Rule of 15: Administer 15 g of fast-acting carbohydrate (e.g., 3-4 glucose tablets or 4-6 oz of juice).

  • Recheck blood glucose level in 15 minutes; retreat with 15-20 g of carbs if below 70 mg/dL; repeat as necessary.

  • Follow up with a snack that contains both protein and carbohydrate.

Emergency Measures

  • If oral sugar intake is unfeasible: administer 1 mg of glucagon subcutaneously or intramuscularly or 25-50 mL of 50% dextrose solution IV.

Diabetic Ketoacidosis (DKA)

  • Criteria: Blood glucose levels >250 mg/dL, indicating severe deficiency of insulin.

  • Signs of DKA:

    • Marked dehydration (up to 6.5L in 24 hours).

    • Low serum bicarbonate levels and low pH.

    • Kussmaul respirations and sweet/fruity odor on breath (due to ketone bodies).

Hyperglycemic Hyperosmolar Syndrome (HHS)

  • Here, hyperglycemia occurs without sufficient insulin (commonly due to an illness). Blood glucose levels often exceed 600 mg/dL.

  • Symptoms: Include hypotension, profound dehydration, altered consciousness, and seizures from cerebral dehydration.

  • Management: Includes rehydration, insulin administration, and electrolyte monitoring.

Differences Between DKA and HHS

  • DKA presents with ketosis and acidosis; no insulin is present leading to fat breakdown and ketone formation.

  • In HHS, some insulin is present, preventing fat breakdown hence no ketosis or acidosis.

  • Mortality Rates: DKA (1-5%) diagnosed earlier; HHS (10-20%) often diagnosed too late, usually in older patients with comorbidities.

Long-Term Complications of Diabetes

Assessment Findings:

  1. Macrovascular: Increased risk for atherosclerosis, coronary artery disease, cerebrovascular disease.

  2. Skin Changes: Approximately 2/3 of patients experience dermopathy (reddish/brown patches).

  3. Microvascular: Includes diabetic retinopathy, nephropathy.

  4. Infection: Compromised healing processes.

  5. Neuropathic: Includes peripheral neuropathy, sexual dysfunction (e.g. erectile dysfunction in males).

Diabetic Foot Care

  • Daily washing and inspection of feet; use of lanolin or diabetic cream to prevent cracking.

  • Careful trimming of toenails; avoidance of sandals/high heels.

  • Guard against frostbite and exercise feet regularly.

Other Issues Associated with Diabetes

Mental Health

  • Effects: High rates of depression, anxiety, and eating disorders; diabetes-related distress—managing diabetes perpetually can impact mental well-being.

Considerations for Older Adults

  • Over age 65: More than 25% have diabetes.

  • Aging can impact beta-cell function and cognitive health; treatment is essential to improve quality of life.

Case Study Example

  • Scenario: Unresponsive patient with a blood glucose level of 811 mg/dL presenting with fruity breath and rapid deep breathing.

  • Possible Diagnoses:
    A. Hypoglycemia
    B. Diabetic Ketoacidosis
    C. Hyperglycemic Syndrome
    D. Diabetic Neuropathy

Comparison of Type 1 vs Type 2 Diabetes

Factor

Type 1

Type 2

Age of Onset

Any age, but more common in youth

Typically adults

Incidence

Increasing in children

90% of diabetes cases

Type of Onset

Abrupt

Gradual / progressive

Primary Defect

Little or no insulin production

Insulin resistance and decreased production

Symptoms

Three Ps + weight loss

Fatigue, recurrent infections

Nutrition

Essential

Essential

Insulin Requirement

Required for all

Required for some; may need more

Emergency Management for Acute Coronary Syndrome

  1. Assess and monitor vital signs.

  2. Maintain appropriate positioning for comfort.

  3. Administer medications per physician orders.

  4. Auscultate lung sounds for abnormalities.

  5. Prepare for CPR if necessary.

Summary

  • Understanding the classifications, treatment goals, and management of diabetes is crucial for effective patient care. Nurses must be informed advocates for their patients, ensuring optimal diabetes control and complication prevention strategies are implemented.