Care of Patients With Diabetes and Hypoglycemia (Chapter 37)

Key Terms

• Basal insulin: Long-acting insulin that helps control blood glucose levels between meals and overnight.

• Bolus dose: A dose of insulin taken at mealtime to manage the rise in blood glucose from eating.

• Correction dose: An extra dose of insulin used to lower high blood glucose levels.

• Diabetic nephropathy: Kidney damage that results from long-term diabetes.

• Diabetic neuropathy: Nerve damage caused by high blood sugar levels, common in people with diabetes.

• Endogenous: Originating within the body.

• Exogenous: Originating from outside the body.

• Gastroparesis: A condition where the stomach takes too long to empty its contents, often seen in people with diabetes.

• Glucometer: A device used to measure blood glucose levels.

• Glycemic control: The management of blood glucose levels in people with diabetes.

• Glycosuria: The presence of glucose in the urine.

• Hyperglycemia: High blood glucose levels.

• Incretin mimetics: Medications that mimic hormones to help lower blood sugar by increasing insulin release.

• Insulin resistance: A condition where the body’s cells do not respond properly to insulin.

• Insulin-to-carbohydrate ratios: A calculation used to determine how much insulin is needed based on the amount of carbohydrates consumed.

• Ketoacidosis: A serious complication of diabetes where the body produces high levels of blood acids called ketones.

• Medical nutrition therapy (MNT): A dietary approach to treat medical conditions like diabetes, guided by a registered dietitian.

• Metabolic syndrome: A group of conditions, including high blood pressure and high blood sugar, that increase the risk of heart disease and diabetes.

• Neuroglycopenia: A shortage of glucose in the brain, leading to symptoms like confusion or unconsciousness.

• Polydipsia: Excessive thirst, often a symptom of diabetes.

• Polyphagia: Excessive hunger or eating, also a symptom of diabetes.

• Polyuria: Excessive urination, common in uncontrolled diabetes.

Diabetes Mellitus and Hypoglycemia

🔹 What is Diabetes Mellitus?

• A group of diseases with problems in glucose metabolism.

• Involves insulin problems, affecting carbs, fats, and proteins.

• Can lead to high blood sugar, ketone buildup, and acid-base imbalance.

• Nearly 30 million Americans have diagnosed diabetes.

• Around 9.4% of the U.S. population.

• Diabetes treatment costs: $327 billion/year (National Diabetes Association, 2018a)

Types of Diabetes Mellitus

Symptoms: Type 1 vs Type 2

Types of Diabetes Mellitus – Comparison Chart

Complications if Uncontrolled

• Kidney (renal) damage

• Heart (cardiovascular) issues

• Eye (retinal) damage

• Nerve (neurologic) damage

• Risk of coma or death from ketoacidosis or very high blood sugar

Nutrition and Prevention Tips

• To lower Type 2 diabetes risk, the ADA (2018) recommends:

  • Eating nuts, berries, yogurt

  • Drinking coffee and tea

  • Following a healthy, balanced diet

Important Terms

• Insulin: Hormone made by pancreas to help glucose enter cells

• Endogenous: From inside the body

• Exogenous: From outside the body (injected insulin)

• Ketones: By-products from fat breakdown; excess can cause ketoacidosis

• Ketoacidosis: Serious condition with high ketones, low pH (acidic blood)

• Insulin resistance: When cells do not respond well to insulin

Factors Associated With Development of Diabetes

Type 1 Diabetes

• 🔹 Family history – Genetic predisposition

• 🔹 Infectious diseases – Prior viral infections

• 🔹 Race – More common in:

  • Whites

  • American Indians/Alaska Natives
    Less common in:

  • African Americans

  • Asians

  • Hispanics

• 🔹 Islet cell antibodies – Found in blood; indicates autoimmune activity

Type 2 Diabetes

• 🔹 Older age

• 🔹 Obesity – Strongly linked (80% of type 2 patients are obese)

• 🔹 Family history

• 🔹 Gestational diabetes – History increases risk

• 🔹 Impaired glucose metabolism

• 🔹 Physical inactivity

• 🔹 Race/Ethnicity – More common in:

  • African Americans

  • Hispanic/Latino Americans

  • American Indians

  • Some Asian Americans

  • Native Hawaiian/Pacific Islanders

Cultural Considerations

• Type 2 diabetes is increasing in children and adolescents, especially among:

  • American Indians

  • African Americans

  • Hispanic/Latino Americans

Latent Autoimmune Diabetes in Adults (LADA)

• Also called type 1.5 or slow-onset type 1

• Usually not overweight, no signs of metabolic syndrome

• History of autoimmune diseases possible

• Diagnostic Criteria:

  1. Onset after age 30

  2. Islet cell antibodies in blood

  3. No insulin needed for first 6 months

• May be misdiagnosed as type 2

• Treatment:

  • Metformin early

  • Insulin within 1 year

  • Avoid sulfonylureas – may destroy beta cells faster

🤰 Gestational Diabetes

• Caused by pregnancy stress

• Treated with diet, oral agents, or insulin

• After birth:

  • 35–60% of mothers develop type 2 diabetes later

  • Babies are at increased risk of type 2 later in life

Etiology & Pathophysiology

Four Contributing Factors

1. Genetic – Diabetes runs in families

2. Metabolic – Obesity, stress, sedentary lifestyle

3. Microbiological – Possible viral triggers (especially in type 1)

4. Immunologic – Autoimmune destruction of beta cells in type 1

• Obesity + inactivity → major role in type 2

• Aging → linked to decreased insulin production

Signs, Symptoms, and Diagnosis

🔬 Diagnostic Tests (ADA recommends):

• Hemoglobin A1c

• Fasting Plasma Glucose (FPG)

• Oral Glucose Tolerance Test (OGTT)

📌 Classic Symptoms (All Types)

• Polyuria – Frequent urination

• Polydipsia – Excessive thirst

• Polyphagia – Excessive hunger

• Fatigue – Glucose not used properly for energy

Weight loss (Type 1) – From fluid loss and fat/protein breakdown

Fatigue and Muscular Weakness in Type 1 Diabetes:

• Fatigue and weakness occur because the body cannot properly metabolize glucose for energy.

Weight Loss:

• Weight loss in Type 1 diabetes happens for two main reasons:

  1. Loss of body fluid.

  2. Due to insufficient insulin, the body begins to break down its own proteins and stored fat for energy.

  • This leads to incomplete oxidation of fats, converting fatty acids into ketone bodies and acetone.

  • When the kidneys cannot handle the accumulated ketones, ketosis occurs.

  • The accumulation of these strong organic acids lowers the blood pH, leading to severe acidosis, which can be fatal.

Elevated BUN Levels:

• The metabolism of proteins in the absence of insulin leads to an elevated blood urea nitrogen (BUN) level.

Infection and Delayed Healing:

• People with diabetes are more prone to infection, delayed healing, and vascular diseases.

  • This is partly due to decreased leukocyte function and abnormal phagocyte activity.

  • Hyperglycemia creates an environment that fosters infection.

Vascular Issues:

• Decreased blood supply to tissues can contribute to delayed healing and an increased risk of infection. This is due to atherosclerotic changes in blood vessels.

  • An impaired blood supply means fewer protective cells are delivered to areas of injury, which hinders healing.

💉 Other Concerns

• Ketosis & Acidosis – From fat breakdown in type 1

• Elevated BUN – From protein metabolism

• Infections & Slow Healing – Due to:

  • Poor blood supply (atherosclerosis)

  • Poor immune response

• Vaccination Alert – Recommend flu and pneumonia shots

Think Critically

How can you or your family decrease the risk of type 2 diabetes?

• Maintain a healthy weight

• Eat balanced meals

• Exercise regularly

• Monitor blood sugar if at risk

• Avoid sedentary lifestyle

Goal of Diabetes Management

• No cure for diabetes mellitus; the goal is to manage blood glucose and lipid levels to prevent complications.

• Tight Glycemic Control: Intensive therapy with frequent blood glucose testing and insulin injections or insulin pumps. However, tight control is not suitable for everyone due to the risk of hypoglycemia (insulin reaction).

• Glycemic control (control of glucose in the blood) for people with both type 1 and type 2 diabetes.

• A1c Levels: A1c of 6.5% is ideal for reducing microvascular complications (eye, kidney, nerve diseases), but older or frail individuals may benefit from an A1c of <8-8.5%.

• The management plan is individualized based on factors like the type of diabetes, age, health status, and patient's ability to follow the regimen.

Older Adult Care Considerations

• Hypoglycemia: Older adults are more prone to rapid hypoglycemia and may not show symptoms until blood glucose is dangerously low.

• Severe hypoglycemia can lead to cardiac events (e.g., MI, angina), stroke, or seizures.

• Tight control may not be appropriate for older adults due to these risks.

Diet and Medical Nutrition Therapy (MNT)

• Diet is crucial for diabetes management:

  • Weight gain in Type 2 diabetes may increase insulin resistance.

  • Caloric reduction and exercise may help control blood glucose, especially in Type 2 diabetes.

• MNT involves:

  • Carbohydrate counting and meal plans.

  • Reducing fat intake and improving food choices.

  • Insulin-to-carbohydrate ratios to match insulin doses with food intake.

  • Adjusting calories to maintain normal body weight and cholesterol levels.

• Meal Distribution:

  • Breakfast: 20% of daily calories.

  • Lunch: 35% of daily calories.

  • Dinner: 30% of daily calories.

  • Evening Snack: 15% of daily calories.

  • Proteins should make up 15% to 20%; for patients with diabetic nephropathy (kidney disease secondary to high blood glucose level)

• Fiber: Aim for 14g of fiber per 1000 kcal.

• Saturated fats, trans fats, and cholesterol should be reduced to improve cardiovascular health.

• Cultural Preferences: It's important to consider cultural preferences when devising meal plans.

• Older Adult Care: Weight loss is not typically a goal unless obesity is present. Older adults may be at risk of nutritional deficiencies due to issues like teeth problems or illness.

Exercise

• Exercise improves glucose use and circulation:

  • It helps lower blood glucose levels by utilizing glucose for energy and makes insulin receptors more sensitive.

  • Exercise contributes to lowering triglycerides and increasing HDL levels.

  • People with Type 1 diabetes benefit from cardiovascular risk reduction, even if exercise doesn't directly control blood glucose.

• Exercise Plan:

  • Should be individualized based on age, physical condition, and diabetes control.

  • Blood glucose should be checked before exercise to avoid hypoglycemia.

  • Exercise should be consistent and can start with lighter exercises, gradually increasing in intensity.

Critical Considerations

• Hypoglycemia Risk:

  • Exercise can lower blood glucose rapidly, leading to hypoglycemia. Patients should check their blood glucose before exercise and carry snacks if needed.

  • Medical alert bracelets are recommended, especially if exercise leads to low blood glucose levels.

• Meal Scheduling: It's best to exercise after meals when blood glucose is higher to reduce hypoglycemia risk.

Think Critically

• How would you obtain accurate data about your patient's daily eating habits?

  • Food diaries or daily logs can be useful.

  • Frequent patient education and working with a registered dietitian (RD) or certified diabetes educator (CDE) can ensure an accurate dietary assessment.

Conclusion

Diabetes management is highly individualized, focusing on:

• Blood glucose control through medication, diet, exercise, and monitoring.

• Lifestyle factors like diet and exercise have a significant impact on managing the disease.

• Older adults and special populations may require adjusted goals to ensure safety while controlling diabetes.

Home Treatment for Hypoglycemia:

When signs of hypoglycemia are present and the patient is able to swallow:

• Provide 15 to 20 g of glucose or simple carbohydrates. Here are some options:

  • ½ cup (4 oz) of juice or regular soda (not diet)

  • 1 cup (8 oz) of nonfat or 1% milk

  • 6 or 7 hard candies, such as Life Savers (not sugar-free)

  • 1 small box (2 tablespoons) of raisins

  • 3 glucose tablets

  • 1 tablespoon of honey, sugar, or corn syrup

  • 1 small tube (2 oz) of cake icing or glucose gel

Follow-up with a longer-acting source of carbohydrates (such as crackers and cheese or a meat sandwich) to maintain blood glucose levels.

If the patient is unable to swallow (groggy or unconscious):

1. Turn the patient onto the side to prevent aspiration.

2. Administer 1 mg of glucagon by injection after mixing the solution in the bottle until it is clear.

3. Call 911 if unable to administer the injection or if the patient does not awaken within 15 minutes.

4. If the patient doesn't respond to the glucagon after 15 minutes, administer another dose of glucagon and immediately contact a health care provider.

5. If a health care provider is unavailable, call 911 or your local emergency service.

Clinical Cues:

• Advise patients to check with their health care provider before starting an exercise program, especially if they have complications like neuropathy, retinopathy, or renal insufficiency. Certain activities might not be recommended depending on their condition.

Older Adult Care Points:

• Physical limitations may prevent older adults with diabetes from exercising.

• Older patients are at higher risk of hypoglycemia up to 24 hours after exercising, especially if the activity is strenuous.

• Safe exercises for older adults include walking, swimming, or stationary bicycle riding. Start slowly and increase to 30 to 45 minutes, three to four times a week. This gradual increase helps prevent hypoglycemia, stress fractures, and cardiovascular complications.

General Guidelines for Exercise:

• Foot care is crucial, especially for those with peripheral neuropathy, as it can result in decreased sensation in the feet. Proper shoes and socks should be worn to prevent injury.

• Some exercises can increase blood glucose due to the release of epinephrine, while most exercises decrease blood glucose levels.

• Exercise management varies depending on whether the patient has type 1 or type 2 diabetes, and the exercise program should be individualized.

• A gradual increase in activity is recommended, and patients should consult with their healthcare provider before starting an exercise program.

Key Guidelines for Safe Exercise:

• Check blood glucose before exercise to ensure it's within a safe range. If blood sugar is low, consume a carbohydrate snack (20 to 40 g based on body weight) before starting exercise.

• Snacks during exercise may be needed to prevent hypoglycemia. The amount and frequency will depend on the type and duration of exercise. A liquid or readily absorbed carbohydrate source is recommended for quick absorption.

• Avoid exercise at peak insulin action times as it can trigger an acute hypoglycemic reaction.

• Type 1 diabetes: If exercising between meals, eating a piece of fruit can help prevent hypoglycemia.

• Once a regular exercise program is established, insulin dosages and dietary needs may need to be adjusted. Patients may need less insulin and increased caloric intake.

• Keeping a daily record of exercise, along with weight, insulin dosage, and blood glucose levels, can help track progress and motivate continued exercise.

Oral Hypoglycemic Agents (OHAs)

• Purpose: Prescribed for patients with type 2 diabetes to help manage blood glucose levels.

• Only for type 2 diabetes

• Important Note: These medications are not oral insulin. They belong to different pharmacologic classes and work differently in the body.

• How They Work: OHAs fall into several major categories, each with a unique mechanism to assist with blood glucose control.

• Medication Combinations: Many OHAs are combined into single tablets and sold under various brand names.

Hypoglycemic Agents

Safety Alert – Sulfa Drug Allergy

• Sulfonylureas (a type of oral diabetes medicine) are related to sulfa antibiotics.

• If someone has a sulfa allergy, they might have a bad reaction to sulfonylureas, so these must be used carefully in such patients.

Important Reminders for Patients on Oral Hypoglycemic Agents (OHAs):

• OHAs don’t replace healthy eating and exercise.
  ➤ Patients still need to follow their meal plan and stay active.

• It’s wrong to think they can eat anything and just take more pills.

• Side effects may include:

  • Stomach issues like nausea, vomiting, or diarrhea.

  • Liver problems (can cause yellow skin or eyes).

  • Bone marrow problems (low blood cells).

  • Allergic skin rashes.

• During illness or hospital stays, patients may temporarily need insulin instead.

• After recovery, they can usually go back to pills.

Before Giving Rapid-Acting Insulin:

• Always make sure the patient’s food tray is in front of them.

  • Why? Because rapid-acting insulin starts working within 15 minutes, and giving it without food can cause hypoglycemia. type 1 and type 2 diabetes.

• Goal: Mimic natural insulin levels:

  • Basal insulin: steady level throughout the day.

  • Postprandial insulin: extra insulin after meals

Types of Insulin

Insulins vary by how fast and how long they work:

• Rapid-acting (for meals)

• Short-acting

• Intermediate-acting

• Long-acting (for all-day control)

🟢 Rapid-Acting Insulins

🔵 Short-Acting Insulins

🟡 Intermediate-Acting Insulins

🔴 Long-Acting Insulins

🟠 Combination Insulins

Before Giving Rapid-Acting Insulin:

• Always make sure the patient’s food tray is in front of them.

  • Why? Because rapid-acting insulin starts working within 15 minutes, and giving it without food can cause hypoglycemia.

Mixing Insulins (Clear to Cloudy):

• When mixing regular (clear) and long-acting (cloudy) insulin in one syringe:

  1. Draw up regular insulin first (clear).

  2. Then draw up NPH or long-acting insulin (cloudy).

  • Use the phrase: “Clear to cloudy” to remember the order.

  • Why? Prevents contaminating the regular insulin vial with long-acting insulin.

Double-Check Requirement:

• Always have another nurse verify the insulin dose before administration.

  • This is required every time you prepare an insulin dose.

  • Helps meet the National Patient Safety Goal for safe medication practices.

Insulin Delivery Methods:

1. Oral or Feeding Tube Administration:

   • Insulin cannot be taken orally or via a feeding tube because it is destroyed by gastric juices.

2. Inhaled Insulin:

   • While inhaled insulin was discontinued after trials in the 2000s, a new inhaled rapid-acting insulin is now available. It’s dispensed in a device similar to inhalers for lung disease.

3. Insulin Pens:

   • Insulin pens are an alternative to the syringe-and-needle method.

   • How it works: The patient sets the correct dose on a dial and injects insulin through a small needle at the end of the pen.

Safety Alert - Insulin Pen Use:

1. Check the Dialing of Dose Carefully:

   • Be careful when dialing the insulin dose. Transposing numbers (e.g., 52 units instead of 25 units) can lead to serious errors.

   • Misdialing can happen if the pen is held incorrectly (e.g., in the left hand or upside down).

Injection Site Rotation & Absorption:

1. Absorption Rate Differences:

   • Abdomen: Quickest absorption rate.

   • Upper arms: Moderate absorption rate.

   • Thighs and buttocks: Slowest absorption rate, unless injected before exercise (blood flow increases to these areas).

2. Rotate Injection Sites:

   • Regularly rotating injection sites within one body area helps enhance insulin absorption.

   • Charts and Records: Patients should keep a daily record of injection sites to avoid erratic absorption.

Changing Insulin Requirements:

1. Factors Influencing Insulin Needs:

   • Diet, exercise, age, and seasonal changes can alter insulin requirements.

   • Stress or illness also affects insulin needs.

   • For example, increased outdoor activity in summer might require more insulin.

Insulin-to-Carbohydrate Ratio Method:

1. Carbohydrate Counting:

   • Some patients use the insulin-to-carbohydrate ratio method for more precise control of blood glucose.

   • One unit of insulin usually covers 15g of carbohydrate (individual factors like weight and insulin sensitivity matter).

   • Diabetic educators can help patients learn to calculate bolus doses based on carbohydrate intake.

Insulin Pump Therapy:

• Insulin Pumps provide an alternative to daily insulin injections. They use a continuous infusion system with a battery-driven electronic "brain" and a syringe attached to plastic tubing and a subcutaneous needle.

• Basal and Bolus Insulin: The pump delivers basal insulin continuously to maintain blood glucose levels between meals and can provide bolus doses for meals or elevated blood sugar levels.

• Continuous Glucose Monitoring (CGM): Some pumps can be combined with CGM, which monitors glucose levels via a sensor under the skin and can adjust insulin delivery based on glucose changes.

• Suitability: Insulin pumps are best for patients willing to monitor their blood glucose frequently and who understand the principles of basal and bolus insulin and carbohydrate counting.

• Increasing Popularity: As technology becomes more sophisticated and user-friendly, insulin pumps are becoming more widely used for better glucose control.

Clinical Cues:

1. Disconnection for Diagnostic Tests:

   • Disconnect the pump for tests like MRI. Blood glucose should be checked before disconnecting and after reconnecting. Most patients can go without the pump for up to 1 hour.

Other Injectable Agents:

1. Incretin Mimetics:

   • These injectable agents mimic incretins (hormones from the intestines) to lower postprandial blood glucose levels in type 2 diabetes.

   • Caution: Do not mix these with insulin in the same syringe. Carefully monitor for hypoglycemia.

2. Pramlintide (Symlin):

   • A synthetic hormone for type 1 and type 2 diabetes.

   • Safety Alert: Pramlintide has a black box warning for severe hypoglycemia within 3 hours of administration. Monitor patients closely.

Preoperative and Postoperative Insulin Management:

• Surgical Stress: Surgery increases stress, which can elevate blood glucose levels and change insulin requirements.

• Type 2 Diabetes Management:

  • Oral hypoglycemic agents (OHAs) may be stopped 48 hours before surgery, and insulin is used for glycemic control.

  • Insulin doses (bolus or correction) are adjusted during surgery, and IV fluids are given.

  • Blood Glucose Monitoring: Blood glucose levels are checked frequently during surgery and postoperatively.

Clinical Cues for Postoperative Monitoring:

• Hypoglycemia Risk: Be vigilant for hypoglycemia in patients receiving an insulin infusion. Blood glucose should be checked hourly, and the infusion rate adjusted as per protocol.

Islet Cell and Pancreas Transplantation:

1. Islet Cell Transplantation:

   • Clinical trials are underway to transplant insulin-producing islet cells to treat type 1 diabetes. Donor pancreas cells are injected into the recipient's liver to produce insulin.

   • Immunosuppressive medications are required for life to prevent rejection.

2. Pancreas and Kidney Transplantation:

   • Combined pancreas and kidney transplants can be performed for patients with type 1 diabetes and kidney issues. This dual transplant improves outcomes related to renal function.

Complications of Diabetes:

People with diabetes are at risk for both short-term (acute) and long-term complications. Below, the focus is on acute complications, which result from either hyperglycemia (high blood glucose) or hypoglycemia (low blood glucose).

Short-Term Problems:

1. Hypoglycemia (Low Blood Sugar)

Etiology (Causes):

• Overdose of insulin

• Skipping or delaying meals

• Unplanned strenuous exercise

• Failure to take insulin

• Illness or infection

• Overeating or consuming too many carbohydrates

• Severe stress (e.g., surgery, trauma, emotional upset)

Symptoms:

• Headache

• Weakness

• Hunger (polyphagia)

• Pallor

• Irritability

• Lack of muscle coordination

• Apprehension

• Shakiness

• Diaphoresis (sweating) with cool, clammy skin

• Blurred vision

• Rapid heartbeat

• Confusion

• Coma (late stage)

Treatment:

• If the patient is able to swallow:

  • 3 glucose tablets or equivalent glucose gel

  • 6 oz of juice, regular cola, or 8 oz of milk

  • 6–8 Life Savers candies

• If the patient cannot swallow:

  • Administer glucagon IM (intramuscularly)

• If in the hospital:

  • Give D50W (dextrose 50% in water) solution IV.

Prevention:

• Eat meals every 4–5 hours with prescribed snacks.

• Take the correct dose of insulin.

• Test blood glucose levels regularly, and more often during illness.

• Eat extra food if exercising more than usual.

• Consult a health care provider when ill.

2. Ketoacidosis (Diabetic Ketoacidosis or DKA)

Etiology (Causes):

• Failure to take insulin

• Illness or infection

• Severe stress (surgery, trauma, emotional upset)

• Infection is the most common cause of DKA; however, other causes include poor compliance with the prescribed regimen of diet and insulin therapy and insulin pump failure

Symptoms:

• Increased thirst (polydipsia)

• Increased urination (polyuria)

• Acetone breath odor (fruity smell)

• Dry mucous membranes and sunken eyeballs (dehydration)

• Nausea and vomiting

• Kussmaul respirations (deep, labored breathing)

• Abdominal pain and rigidity

• Paresthesias (tingling), weakness, paralysis

• Hypotension (low blood pressure)

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

• Stupor or coma (late stage)

Treatment:

• IV fluids and insulin to correct electrolyte imbalances.

• Severe cases may require hospitalization for stabilization.

Prevention:

• Take the correct dose of insulin.

• Consult your healthcare provider when ill, even for minor illnesses.

• Follow the prescribed diet, avoid overeating, and limit carbohydrate intake

Comparison Summary:

Immediate Care Safety Alert

• When in doubt between hyperglycemia or hypoglycemia, treat for hypoglycemia first to avoid brain damage from low glucose.

• Rapid blood glucose testing is critical.

• Hypoglycemia comes on fast and can cause changes in consciousness quickly.

• Hyperglycemia develops slowly and usually doesn’t affect consciousness early on.

Diabetic Ketoacidosis (DKA) – Type 1 DM

• Caused by lack of insulin → body burns fat → ketones form → acidosis.

• Symptoms: Kussmaul breathing, fruity breath, dehydration, electrolyte imbalance.

• Key treatment steps:

  • IV fluids first

  • Then correct electrolytes (especially potassium)

  • Start insulin drip

• Monitor for hyperkalemia initially and hypokalemia after insulin starts.

• Infection is the most common trigger.

Hyperglycemic Hyperosmolar State (HHS) – Type 2 DM

• Very high blood glucose (>600 mg/dL), often >1000 mg/dL.

• No ketones or acidosis (due to some insulin still being present).

• Triggered by infection, illness, dehydration, or medications.

• Symptoms: Severe dehydration, altered mental status, possible seizures.

• Older adults are at greater risk.

• Treatment: Rapid fluids, electrolyte correction, small doses of insulin, treat underlying cause.

Rebound Hyperglycemia (Somogyi Effect)

• Happens after nighttime hypoglycemia → body overcompensates → morning high glucose.

• May involve nightmares or sweating.

• Treatment: Reduce insulin dose or change timing, possibly add bedtime snack.

Dawn Phenomenon

• Natural hormone release overnight raises glucose levels by morning.

• Common in diabetes due to poor AM carb tolerance.

• Treatment: Intermediate-acting insulin at night.

Hypoglycemia

• Glucose < 70 mg/dL; severe = <40 mg/dL.

• Causes: Too much insulin, too little food, too much exercise.

• Symptoms: Tremors, sweating, hunger, blurred vision, confusion.

• Treatment:

  • If awake: Juice, crackers, milk, or sugar.

  • If unconscious: IV glucose or IM glucagon.

Important Notes

• Diabetes is a leading cause of death and the #1 cause of blindness, renal failure, and nontraumatic amputations.

• Cardiovascular disease is the most common cause of death in people with diabetes.

• Always watch for foot ulcers, infection, and delayed healing in patients.

Foot Care Tips

• Check your feet every day. Look for cuts, blisters, or changes in color. Use a mirror or ask someone to help if needed. Don’t forget to look between your toes.

• Wash your feet daily with warm (not hot) water and mild soap. Do not soak them.

• Dry your feet well, especially between the toes. If your skin is dry, use lotion—but not between the toes.

• Trim your toenails straight across and file the edges. See a foot doctor for corns, calluses, or ingrown nails.

• Wear clean cotton socks every day.

• Choose shoes that fit well, with firm soles. Never wear tight shoes or go barefoot.

• Break in new shoes slowly.

• Avoid sandals that expose your toes or have straps between them.

• Keep your feet warm with socks and blankets. Do not use heating pads or hot water bottles.

• Check bath water temperature with your wrist or forearm first.

• Raise your feet when you sit or lie down to help blood flow.

Long-Term Complications

• Macrovascular: Coronary artery disease, stroke, peripheral arterial disease.

• Microvascular: Kidney failure (nephropathy), nerve damage (neuropathy), blindness (retinopathy).

• Tight blood glucose control helps prevent these.

Diabetes-Related Complications

1. Cardiovascular Disease

• Big Risk: 2 out of 3 people with diabetes die early from a heart attack or stroke.

• Prevention: Keep blood sugar tightly controlled. This helps stop damage to blood vessels.

• What Helps: Follow treatment plans that reduce stroke risk (per The Joint Commission’s Core Measures).

2. Peripheral Vascular Disease (PVD)

• High Risk of Amputation: Over 60% of nontraumatic amputations happen in people with diabetes.

• Cause: Poor circulation in the legs and feet, plus slow wound healing and infection.

• Prevention:

  • Control blood sugar.

  • Practice daily foot care.

  • Get help early if problems are noticed.

3. Nephropathy (Kidney Disease)

• Cause: High blood sugar damages the kidneys over time, leading to protein in the urine.

• Warning Sign: Small amounts of protein in the urine (albuminuria).

• Without Control: Leads to kidney failure and the need for dialysis or transplant.

• Prevention:

  • Tight blood sugar and blood pressure control.

  • ACE inhibitors help protect kidneys in early stages.

4. Retinopathy (Eye Damage)

• Common Issues: Diabetic retinopathy, cataracts, and glaucoma.

• Cause: High blood sugar damages blood vessels in the retina, leading to vision loss.

• Prevention and Treatment:

  • Keep blood sugar in range.

  • Get regular eye exams.

  • Laser treatment + medication (like ranibizumab) can reduce vision loss.

5. Neuropathy (Nerve Damage)

• Common: Affects 60–70% of people with diabetes.

• Symptoms:

  • Numbness, tingling, pain, or no feeling (especially in feet).

  • Problems with digestion, bladder, sexual function, and blood pressure.

• Why It's Serious: Patients may not feel injuries on their feet, which can lead to infection and amputation.

• Prevention:

  • Blood sugar control.

  • Daily foot checks.

  • Careful management of symptoms (no cure yet for the nerve pain).

Assessment (Data Collection)

• Monitor for classic signs of diabetes: weight changes, increased hunger/thirst, frequent urination, fatigue.

• Inspect skin and feet for poor healing or infection.

• Ask about numbness, tingling, constipation, and sexual difficulties.

• Evaluate patient's ability to use a glucometer (manual dexterity, vision, memory).

• Review blood glucose records, dietary habits, medication compliance, and regular healthcare visits.

Nursing Diagnoses Examples

• Altered nutrition (r/t insulin issues)

• Insufficient knowledge (r/t new diagnosis)

• Risk for infection (r/t high glucose)

• Impaired coping (r/t lifestyle changes)

• Altered sensory perception (r/t nerve damage)

• Risk for injury (r/t decreased sensation in feet)

• Pain (r/t neuropathy)

Planning and Interventions

• Time glucose checks: 30 min before meals.

• Insulin timing: Rapid-acting insulin after food tray arrives.

• If patient is NPO, adjust insulin, but do not withhold without a provider’s order.

• Be ready for hypoglycemia: Know onset/peak times for each insulin.

• Watch for signs of ketoacidosis: polyuria, fruity breath, dehydration, fatigue.

Patient Education Topics

• Pathophysiology of diabetes

• Diet and meal planning

• Home glucose monitoring and glucometer use

• Foot care (daily inspection)

• Sick day management

• Identifying and treating hypoglycemia

• Using ID bracelets or medical alert systems

• Available community support/resources

• Insulin device aids (for arthritis or visual issues)

Red Flags to Report

• Wounds or sores on the feet

• Rapid respirations or excessive urination

• Hypoglycemia symptoms (shaking, confusion, sweating)

• Symptoms of ketoacidosis: fruity breath, abdominal pain, dry mucous membranes

• Electrolyte changes, especially potassium

What to Do on Sick Days

When sick (with a cold, flu, or stomach upset), diabetes can become harder to manage. Here’s what to do:

Medication

• Keep taking insulin or pills unless told otherwise by your doctor.

• Don’t take extra medicine unless the doctor says to.

• If vomiting and can’t take pills, you might need insulin for a short time.

Diet

• Eat your regular meals if possible.

• If you’re too sick to eat, sip sugary drinks like juice or regular soda.

• Drink at least 1 cup of water or non-caffeinated fluid every hour. Take small sips if nauseated.

Monitoring

• Check your blood sugar every 4 hours (every 2 hours if very sick).

• Test your urine for ketones if your sugar is over 300 mg/dL.

Call Your Doctor If:

• You vomit, have belly pain, or a fever over 100.2°F (38.8°C).

• Your sugar stays over 200 mg/dL.

• Ketones show in your urine.

• Extra insulin doesn’t lower your blood sugar.

• You can’t reach your doctor—go to the ER

Instructions for Traveling

Travel can affect blood sugar. Plan ahead:

• Pack twice as much medicine and copies of prescriptions.

• Wear a medical alert ID.

• Carry quick sugar (like candy) and longer-lasting snacks (like crackers with peanut butter).

• Bring healthy snacks (nuts, seeds, dried fruit), measured out ahead of time.

• Check your sugar often—time zones, food, and activity affect it.

• Seek help if you get sick.

• Try to follow your meal plan, substituting when needed.

• Rest and avoid stress to prevent high sugar.

• Travel with someone who knows about your diabetes if possible.

• Let travel staff know you have diabetes.

• Keep exercising or adjust food/medicine.

• Drink water every 2 hours.

• Protect insulin from hot or cold temperatures.

• Eat something at least every 4 hours.

• Call ahead to request diabetic meals or bring your own.

• Learn about local food ahead of time for better meal planning.

• If going west, your day is longer—might need more insulin. Going east shortens the day—may need less insulin.

Working With an Older Adult Who Has Diabetes

Older adults may need extra support for learning:

• Check hearing and vision—use aids and good lighting.

• Pick a good time for the session.

• Use a quiet space with few distractions.

• Make sure they are comfortable.

• Keep sessions short—15 to 20 minutes.

• Teach just a few important points each time.

• Go slow and check for understanding.

• Let them write things down.

• Repeat often and rephrase if needed.

• Use bold print on yellow or white paper.

• Give handouts with simple drawings and less text.

• Handouts should be written simply (5th–10th grade level).

• If frustrated, pause and try again later.

• At the end, go over what was taught and learned.

Hypoglycemia (Nondiabetic) Overview

Causes:

• Conditions affecting the intestines, liver, or pancreas (e.g., after surgery like gastric bypass).

• Insulin-secreting tumors (insulinomas).

• Liver disease or hormone disorders (adrenal or pituitary problems).

• Alcohol or drug abuse.

Symptoms:

• Fast heartbeat, shaking, weakness, nervousness, and hunger.

• Sudden symptoms, often 4 hours after meals.

• Behavior changes: irritability, mood swings, or confusion (can mimic mental illness).

Diagnosis:

• Blood glucose test.

• Insulin and C-peptide levels.

• Glucose tolerance test or monitored fasting.

• CT scan or ultrasound if a tumor is suspected.

Treatment:

• Eat small, frequent meals.

• Avoid sugar and white flour.

• Eat more protein and complex carbs (like fruits, vegetables, whole grains).

• If due to surgery, medicines may help slow digestion for better absorption.

Complications:

• If untreated, it can lead to brain damage (neuroglycopenia) or death.

Nursing Responsibilities

Assessment:

• Ask about eating habits, how often the patient eats, and what they eat.

• Ask if they crave sweets or have had symptoms like weakness, sweating, blurry vision, confusion, etc.

• Determine if symptoms happen after eating or when fasting.

Interventions:

• Educate patients on their condition and why tests are needed.

• Watch and report symptoms.

• Reinforce proper diet instructions and limits.

Community and Long-Term Care:

• Healthy People 2030 aims to increase formal diabetes education.

• Nurses are key in home care, long-term care, and public education.

• Early detection and consistent teaching can help reduce complications and lower healthcare costs.