Diabetic Outline - from book

1. Differentiate between the types of diabetes, associated etiologic factors, and pathophysiologic alterations.

2. Identify the diagnostic and clinical significance of blood glucose test results.

3. Describe the relationships among diet and dietary modifications, exercise, and medication

(i.e., insulin or oral antidiabetic agents) for people with diabetes.

4. Use the nursing process as a framework for care of the patient who has hyperglycemia with

diabetic ketoacidosis or hyperglycemic hyperosmolar syndrome.

5. Describe management strategies for a person with diabetes to use during “sick days.”

6. Outline the major complications of diabetes and the self-care behaviors that are important in their prevention.

  1. Types of Diabetes, Etiologic Factors, and Pathophysiologic Alterations

• Type 1 Diabetes (T1D): Caused by autoimmune destruction of pancreatic beta cells, leading to absolute insulin deficiency. Pathophysiological, the lack of insulin prevents glucose uptake, causing hyperglycemia and reliance on fat for energy, potentially leading to ketoacidosis.

• Type 2 Diabetes (T2D): Associated with insulin resistance and a relative insulin deficiency, often linked to genetics, obesity, and physical inactivity. Cells become less responsive to insulin, leading to hyperglycemia.

• Gestational Diabetes: Develops during pregnancy due to insulin resistance caused by placental hormones. This type generally resolves post-pregnancy but may increase the risk of T2D later.

• Other Types (e.g., MODY, drug-induced): Can arise from specific genetic mutations, medications (e.g., corticosteroids), or conditions like pancreatic disease.

  1. Diagnostic and Clinical Significance of Blood Glucose Test Results

    • Normal Blood Glucose Levels: Fasting <100 mg/dL; Post-meal (2 hours after) <140 mg/dL.

    • Prediabetes: Fasting 100-125 mg/dL; A1C 5.7-6.4%.

    • Diabetes Diagnosis: Fasting >126 mg/dL; Random glucose >200 mg/dL with symptoms; A1C >6.5%.

    • Significance: High glucose levels indicate a failure in insulin function or production and signal the need for lifestyle changes, monitoring, or medication.

  1. Relationships Among Diet, Exercise, and Medication for People with Diabetes

    • Diet: Focuses on carbohydrate management to avoid glucose spikes, balancing protein, and healthy fats. Fiber and low glycemic index foods help stabilize blood sugar.

    • Exercise: Enhances insulin sensitivity and aids glucose utilization by muscles, helping maintain stable levels.

    • Medication: Insulin or oral antidiabetics regulate glucose uptake or reduce liver glucose production. Medications and insulin dosages may vary depending on dietary intake and physical activity.

  1. Nursing Process for Hyperglycemia, Diabetic Ketoacidosis (DKA), or Hyperglycemic Hyperosmolar Syndrome (HHS)

    • Assessment: Monitor glucose, ketone levels, hydration, and electrolyte status.

    • Diagnosis: Risk for fluid imbalance, electrolyte disturbance, and altered mental status.

    • Planning: Aim to reduce blood glucose, correct acidosis (for DKA), and rehydrate.

    • Interventions: Administer fluids, insulin (IV), electrolyte replacements, and continuous monitoring.

    • Evaluation: Check improvement in blood glucose, mental status, and resolution of acidosis.

  1. Management Strategies for Sick Days in People with Diabetes

    • Blood Glucose Monitoring: Increase frequency, as illness can cause unpredictable blood glucose changes.

    • Hydration: Drink fluids regularly to prevent dehydration.

    • Medication: Continue insulin or medication, adjusting doses if needed, as illness can raise glucose.

    • Ketone Monitoring: For T1D, check for ketones if glucose is high, as they may indicate DKA risk.

  1. Major Complications of Diabetes and Self-Care Behaviors

    • Complications: Include neuropathy, retinopathy, nephropathy, cardiovascular disease, and diabetic foot ulcers.

    • Self-Care Behaviors: Regular blood glucose monitoring, foot care, eye exams, proper diet, regular exercise, and adherence to medications help prevent or delay complications.

three major acute complications of diabetes related to short-term imbalances in blood glucose levels: hypoglycemia, DKA, and HHS

  • Hypoglycemia means low (hypo) sugar in the blood (glycemia) and occurs when the blood glucose falls to less than 70 mg/dL (3.9 mmol/L) (ADA, 2020). It can occur when there is too much insulin or oral hypoglycemic agents, too little food, or excessive physical activity. Hypoglycemia may occur at any time of the day or night. It often occurs before meals, especially if meals are delayed or snacks are omitted. For example, midmorning hypoglycemia may occur when the morning insulin is peaking, whereas hypoglycemia that occurs in the late afternoon coincides with the peak of the morning NPH insulin. Middle-of-the-night hypoglycemia may occur because of peaking evening or predinner NPH insulins, especially in patients who have not eaten a bedtime snack.

  • hypoglycemia may be grouped into two categories: adrenergic symptoms and central nervous system (CNS) symptoms.

Mild Hypoglycemia

  • • Cause: Blood glucose drop triggers sympathetic nervous system, releasing epinephrine and norepinephrine.

  • • Symptoms: Sweating, tremor, rapid heartbeat (tachycardia), palpitations, nervousness, and hunger.

Moderate Hypoglycemia

  • • Cause: Further drop in blood glucose deprives the brain of glucose, affecting CNS function.

  • • Symptoms:

    • • Cognitive Impairment: Inability to concentrate, confusion, memory lapses.

    • • Physical Signs: Headache, lightheadedness, numbness of lips/tongue, slurred speech, poor coordination.

    • • Behavioral Changes: Emotional instability, irrational or combative behavior.

    • • Vision and Drowsiness: Double vision, drowsiness.

    • • Note: Moderate hypoglycemia may include symptoms from mild hypoglycemia (e.g., sweating, hunger).

Severe Hypoglycemia

  • • Cause: Severe lack of glucose impairs CNS function significantly, requiring external help for treatment.

  • • Symptoms:

    • • Behavioral Changes: Disorientation, confusion.

    • • Serious Symptoms: Seizures, difficulty waking up, or loss of consciousness.

Assessment and Diagnostic Findings of Hypoglycemia

• Symptom Variation: Symptoms can appear suddenly and vary by individual.

• Reduced Symptoms: Some patients with long-term diabetes may not feel early hypoglycemia symptoms due to decreased adrenaline response, often linked to autonomic neuropathy (a chronic diabetic complication).

• Delayed Detection: In these patients, typical symptoms like sweating and shakiness might not appear until moderate or severe CNS symptoms (like confusion or drowsiness) occur.

• Self-Monitoring: Patients at risk for low-symptom hypoglycemia must check their blood glucose regularly, especially before activities like driving.

Management of Hypoglycemia

Treating with Carbohydrates

• Immediate Treatment: Give 15-20 grams of fast-acting carbohydrate, such as juice (no need to add sugar to juice; natural sugar is enough).

• Avoid Excess Sugar: Adding sugar to juice can cause a sharp spike, potentially leading to hyperglycemia.

Emergency Measures for Severe Hypoglycemia

• For Blood Glucose Below 54 mg/dL or Unconsciousness:

• Glucagon Injection: Administer 1 mg of glucagon subcutaneously or intramuscularly. This hormone helps release stored glucose from the liver.

• Timing and Side Effects: It may take up to 20 minutes for the patient to regain consciousness. After waking, give a snack to stabilize blood glucose and replenish liver stores. Turn the patient on their side if they feel nauseous to prevent aspiration.

• Glucagon Availability: Requires a prescription and should be included in the emergency kit of all insulin-dependent patients. Family and caregivers should be trained to administer it.

• In Hospital Settings:

• IV Dextrose (D50W): For unconscious patients, 25-50 mL of 50% dextrose in water can be given intravenously, usually working within minutes. IV site patency is essential, as D50W is harsh on veins.

Patient Education for Hypoglycemia Prevention and Recognition

• Consistent Routine: Prevent hypoglycemia with regular eating, insulin administration, and exercise patterns.

• Snacking: Additional snacks may be needed for insulin peaks or extra physical activity.

• Blood Glucose Testing: Routine checks help adjust insulin based on changes.

• Emergency Identification: Patients on insulin should wear a medical ID indicating diabetes.

• Education for Family and Caregivers:

• Recognize Symptoms: Family members should be aware of subtle changes, which could indicate hypoglycemia. Encourage testing if symptoms appear.

• Dealing with Resistance: Patients may resist testing or eating due to low blood glucose’s effects on behavior. Teach family members to persist calmly.

• Medications Masking Symptoms:

• Beta-Blockers: Medications like propranolol can hide typical hypoglycemia symptoms.

• Sulfonylureas: Type 2 diabetes patients on sulfonylureas risk prolonged hypoglycemia, particularly older adults.

• Carbohydrate Access: Patients should always carry simple sugars, such as glucose tablets or gels, for emergencies. Avoid high-fat foods (like ice cream or doughnuts) as they slow glucose absorption and may cause blood sugar spikes or weight gain.

• Incorporating Treats: Patients who feel restricted may be taught to occasionally include desserts in their meal plan to prevent overindulging during hypoglycemic episodes.

• Reporting Episodes: Patients should report all severe hypoglycemic episodes and any increase in their frequency or severity to their healthcare provider.

Diabetic Ketoacidosis (DKA) Overview

DKA is caused by a significant lack of insulin, leading to disrupted metabolism of carbohydrates, proteins, and fats. The three primary clinical features are:

1. Hyperglycemia

2. Dehydration and Electrolyte Loss

3. Acidosis

Prevention: Sick Day Rules for Managing Diabetes During Illness

When ill, it’s essential for patients with diabetes to:

• Never skip insulin due to nausea or vomiting. Take the usual dose or prescribed “sick day” dose.

• Consume frequent carbs (even foods usually avoided like juice, soda, or gelatin).

• Hydrate: Drink fluids every hour to avoid dehydration.

• Monitor glucose and ketones: Check blood glucose and urine ketones every 3-4 hours.

• Contact provider: If unable to take fluids or if glucose/ketones remain high, contact the healthcare provider.

Patients should have a “sick day” kit, including food, urine test strips, blood glucose strips, and 24-hour provider contact information.

Sick Day Guidelines for Patients (Chart 46-9)

• Take insulin or antidiabetic medication as usual.

• Check blood glucose and urine ketones every 3-4 hours.

• Report high glucose or ketones to your provider.

• Take extra insulin every 3-4 hours if needed.

• Substitute soft foods (like gelatin, cream soup, custard, graham crackers) if a regular meal plan isn’t possible.

• Drink liquids (e.g., juice, cola, broth, sports drink) every 30-60 minutes if nausea, vomiting, or fever occurs to prevent dehydration.

• Notify provider if experiencing nausea, vomiting, or diarrhea.

• Seek hospitalization if unable to retain fluids to avoid severe DKA or coma.

Clinical Manifestations of DKA

1. Hyperglycemia: Causes excessive urination, thirst, and fatigue. Patients may have blurred vision, weakness, and headache. Severe dehydration can lead to orthostatic hypotension or hypotension with a rapid pulse.

2. Ketosis and Acidosis: GI symptoms like nausea, vomiting, abdominal pain, and acetone (fruity) breath. Deep, unlabored Kussmaul respirations may occur to offset acidosis. Mental state varies from alert to comatose.

Assessment and Diagnostic Findings

• Blood Glucose: Ranges from 250–800 mg/dL; may vary depending on dehydration.

• Ketoacidosis: Low bicarbonate (0-15 mEq/L), low pH (6.8-7.3), and low PaCO2 (10-30 mm Hg) reflecting respiratory compensation (Kussmaul respirations).

• Ketone Accumulation: Seen in blood and urine tests.

• Electrolytes: Sodium and potassium levels vary, but overall body depletion is significant, requiring replacement.

• Dehydration Indicators: Elevated creatinine, BUN, and hematocrit levels; persistent high levels after rehydration may indicate kidney issues.

Management of DKA

Treatment goals focus on:

1. Hydration: Address dehydration.

2. Electrolyte Balance: Correct electrolyte loss.

3. Acidosis Correction: Stabilize pH levels.

4. Insulin Administration: Once hydration and electrolyte imbalances are addressed, treat hyperglycemia with insulin.

This approach helps stabilize DKA and reduces the risk of complications, promoting safe and effective recovery.

Hyperglycemic Hyperosmolar Syndrome (HHS) Overview

HHS is a severe complication of type 2 diabetes triggered by an insulin deficiency often caused by an illness that increases insulin needs. HHS primarily affects older adults and involves extreme hyperglycemia and hyperosmolality, often without ketosis. Key features include:

• High blood glucose leads to osmotic diuresis, causing dehydration and electrolyte loss.

• Lack of Ketosis: Unlike DKA, HHS typically does not involve ketone buildup due to minimal fat breakdown.

Causes and Risk Factors

• HHS usually affects people aged 50–70, often without a known history of diabetes.

• Common Triggers: Infection, acute illness (e.g., stroke), or medications that increase blood glucose.

• Patients may experience days to weeks of frequent urination and dehydration.

Clinical Manifestations

1. Dehydration Symptoms: Dry mucous membranes, poor skin turgor, low blood pressure, and rapid pulse.

2. Neurologic Symptoms: Confusion, seizures, or even one-sided weakness due to severe dehydration affecting the brain.

Diagnostic Findings

• Blood Glucose: Above 600 mg/dL.

• Osmolality: Over 320 mOsm/kg.

• Electrolyte Imbalance: Reflects severe dehydration.

• Neurologic Changes: Can include altered consciousness and hallucinations due to brain dehydration.

• Vital Signs: Low blood pressure, rapid pulse, and signs of fluid deficit.

Management of HHS

Treatment priorities focus on:

1. Fluid Replacement: Start with 0.9% or 0.45% normal saline, based on sodium levels and severity.

2. Electrolyte Monitoring: Regular potassium checks with ECG monitoring.

3. Insulin Therapy: Low-dose insulin is given to manage hyperglycemia, although it plays a lesser role than in DKA.

4. Monitoring for Complications: Particularly important in older adults to avoid fluid overload, heart failure, and kidney failure.

5. Underlying Illness Management: Treatment depends on the initial cause (e.g., infection).

Recovery and Long-term Management

• Neurologic symptoms may take 3–5 days to fully resolve.

• After stabilization, many patients manage diabetes with medical nutrition therapy (MNT) and/or oral medications.

Nursing Considerations for DKA and HHS

Assessment

• DKA: Monitor ECG, vitals, mental status, and blood glucose hourly, watching for cerebral edema.

• HHS: Monitor vitals, fluid status, and labs closely, particularly for cardiovascular and kidney function due to risks from dehydration.

Nursing Diagnoses

1. Risk for Hypovolemia due to dehydration and polyuria.

2. Fluid Imbalance from excessive fluid loss.

3. Knowledge Deficit about diabetes management.

4. Anxiety due to fear of complications or lack of diabetes knowledge.

Collaborative Problems and Complications

• Fluid Overload or heart failure from excessive fluid replacement.

• Hypokalemia due to electrolyte shifts.

• Hyperglycemia and Ketoacidosis (especially in DKA).

• Hypoglycemia following insulin treatment.

• Cerebral Edema due to rapid fluid shifts.

Goals and Outcomes

• Fluid and Electrolyte Balance: Achieve stability through careful monitoring and treatment.

• Diabetes Education: Increase patient knowledge about self-care and diabetes management.

• Anxiety Reduction: Help patients feel more in control of their condition.

• Complication Prevention: Avoid severe outcomes like fluid overload and cerebral edema.

Nursing Interventions for Managing HHS and DKA

1. Maintaining Fluid and Electrolyte Balance

• Intake & Output Monitoring: Measure all intake and output accurately.

• IV Fluids: Administer fluids as prescribed, usually 0.9% or 0.45% normal saline based on fluid status.

• Electrolyte Monitoring: Regular checks on serum sodium and potassium levels; watch for hypokalemia due to insulin therapy.

• Vital Signs: Hourly monitoring for dehydration signs like tachycardia and orthostatic hypotension.

• Breath Sounds & Cardiac Status: Continuous assessment of breath sounds, cardiac rhythm (ECG), and signs of edema to detect fluid overload early.

2. Increasing Knowledge About Diabetes Management

• Diabetes Plan Assessment: Evaluate the patient’s understanding of their diabetes management plan, including medication adherence, diet, and blood glucose monitoring.

• Education on Complications: Explain how missed medication, illness, or stress can trigger HHS or DKA, and discuss strategies to prevent future episodes.

• Self-Care Skills: Reinforce skills like insulin administration, glucose monitoring, and recognizing early symptoms of complications.

• Undiagnosed Diabetes: For newly diagnosed patients, provide comprehensive education on managing blood glucose and preventing complications.

3. Decreasing Anxiety

• Cognitive Techniques: Teach anxiety-relieving methods such as imagery, distraction, optimistic self-recitation, and listening to soothing music to help the patient relax and reduce stress about their condition.

4. Monitoring and Managing Potential Complications

• Fluid Overload: Closely monitor older patients or those with cardiac issues for fluid overload. Use central venous pressure or hemodynamic monitoring when needed.

• Hypokalemia: Replace potassium carefully while checking kidney function, since hypokalemia can affect cardiac function. Monitor ECG for arrhythmias.

• Cerebral Edema: Prevent rapid glucose shifts that can cause fluid shifts leading to cerebral edema. Track mental status, blood glucose, electrolyte levels, and other signs on an hourly flow sheet.

5. Educating Patients About Self-Care

• Long-Term Self-Management: Educate on diet, insulin use, and blood glucose monitoring. Stress the importance of hydration and recognizing signs of dehydration.

• Follow-up Support: Arrange follow-up with a home health nurse or diabetes education center, emphasizing self-monitoring and maintaining appointments to avoid recurrence of HHS or DKA.

Expected Outcomes

1. Achieves Fluid and Electrolyte Balance

• Balanced intake/output.

• Normalized electrolyte levels and vital signs.

• Resolution of dehydration symptoms.

2. Increased Knowledge of DKA and HHS

• Identifies triggers and signs of complications.

• Understands prevention strategies.

• Knows when to seek medical help for early symptoms.

3. Decreased Anxiety

• Identifies effective anxiety-reduction techniques.

4. Absence of Complications

• Stable cardiac rhythm and respiratory status

Medication Class Generic Names Action / Indications Side Effects Nursing Implications

Alpha-Glucosidase Inhibitors acarbose, miglitol Delays carb absorption, slows glucose entry; does not increase insulin; can be used alone or with other agents GI side effects (diarrhea, flatulence), hypoglycemia if combined with other agents Take with first bite of food; monitor GI side effects, blood glucose; monitor liver function (every 3 months for 1 year, then periodically); contraindicated in GI/kidney dysfunction, cirrhosis

Biguanides metformin, metformin with glyburide Inhibits liver glucose production, increases tissue insulin sensitivity; reduces hepatic cholesterol synthesis GI disturbances, lactic acidosis, hypoglycemia (if combined with other agents) Monitor for lactic acidosis, hypoglycemia; monitor kidney function; hold 48 hrs before and after iodinated contrast tests; contraindicated in kidney/liver dysfunction, severe infections, alcohol abuse

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors alogliptin, linagliptin, saxagliptin, sitagliptin, vildagliptin Increases incretin action to boost insulin and reduce glucagon for improved glucose control Upper respiratory infection, stuffy nose, sore throat, GI discomfort, headache Usually given once daily; monitor for hypoglycemia, especially with sulfonylureas; monitor kidney function; educate on hypoglycemia signs

Glucagon-like Peptide-1 (GLP-1) Agonists dulaglutide, liraglutide Enhances insulin secretion after eating, with other antihyperglycemic effects Pancreatitis, weight loss, GI side effects, injection site reactions Administered subcutaneously once a day; monitor for GI symptoms, pancreatitis

Non-Sulfonylurea Insulin Secretagogues nateglinide, repaglinide Stimulates insulin release from pancreas; used alone or with other agents to improve glucose control Hypoglycemia, weight gain (less likely than sulfonylureas), drug interactions Monitor blood glucose; rapid action/short half-life (take before meals); educate on hypoglycemia signs; monitor liver/renal function; avoid if unable to eat a meal

Second-Generation Sulfonylureas glimepiride, glipizide, glyburide Stimulates pancreatic beta cells to release insulin; may improve insulin binding or receptor count Hypoglycemia, weight gain, mild GI symptoms, drug interactions (NSAIDs, warfarin, sulfonamides) Monitor for hypoglycemia (high-risk in elderly/renal insufficiency); avoid alcohol; contraindicated with sulfa allergy; beta-blockers may mask hypoglycemia signs

Sodium-Glucose Co-Transporter 2 (SGL-2) Inhibitors anagliflozin, dapagliflozin, empagliflozin Prevents kidney reabsorption of glucose, releasing it in urine Urinary tract infections, increased LDL/HDL cholesterol Take once daily before first meal; monitor for genital/urinary infections

Thiazolidinediones (Glitazones) pioglitazone, rosiglitazone Sensitizes body tissue to insulin; used alone or with other agents; improves insulin action Hypoglycemia, weight gain, edema, anemia, liver dysfunction, hyperlipidemia, decreased oral contraceptive effectiveness Monitor glucose and liver function; arrange dietary education for weight control; counsel on potential pregnancy risk with oral contraceptives