Nursing Care of Patients with Diabetes Mellitus

The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign, if exhibited in the client, would indicate hyperglycemia? 1. Polyuria 2. Diaphoresis 3. Hypertension 4. Increased pulse rate

1. Polyuria Hyperglycemia ● Teach the client manifestations of hyperglycemia (hot, dry skin, and fruity breath) and measures to take in response to hyperglycemia. ● Encourage oral fluid intake of sugar-free fluids to prevent dehydration. ● Administer insulin as prescribed. ● Test urine for ketones and report if outside of the expected reference range. ● Consult the provider if manifestations progress.

The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply. 1. Polyuria 2. Shakiness 3. Palpitations 4. Blurred vision 5. Lightheadedness 6. Fruity breath odor

2. Shakiness 3. Palpitations 5. Lightheadedness Hypoglycemia Insufficient glucocorticoid causes increased insulin sensitivity and decreased glycogen, which leads to hypoglycemia. NURSING ACTIONS ● Monitor glucose levels. ● Administer glucagon as needed. CLIENT EDUCATION ● Monitor for hypoglycemia. Manifestations can include diaphoresis, shaking, tachycardia, and headache. ● Have a 15 g carbohydrate snack readily available Hypoglycemia ----Teach the client measures to take in response to manifestations of hypoglycemia (mild shakiness, mental confusion, sweating, palpitations, headache, lack of coordination, blurred vision, seizures, and coma). Hyperglycemia ● Teach the client manifestations of hyperglycemia (hot, dry skin, and fruity breath) and measures to take in response to hyperglycemia. ● Encourage oral fluid intake of sugar-free fluids to prevent dehydration. ● Administer insulin as prescribed. ● Test urine for ketones and report if outside of the expected reference range. ● Consult the provider if manifestations progress. Diabetic ketoacidosis (DKA) is an acute, life-threatening condition characterized by uncontrolled hyperglycemia (greater than 300 mg/dL), metabolic acidosis, and an accumulation of ketones in the blood and urine. The onset is rapid, and the mortality rate is up to 10%. ● Lack of sufficient insulin related to undiagnosed or untreated type 1 diabetes mellitus or nonadherence to a diabetic regimen ● Reduced or missed dose of insulin (insufficient dosing of insulin or error in dosage) ● Any condition that increases carbohydrate metabolism (physical or emotional stress, illness) ● Infection is the most common cause ● Increased hormone production (cortisol, glucagon, epinephrine) that stimulates the liver to produce glucose and decreases the effect of insulin

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings would the nurse expect to note as confirming this diagnosis? Select all that apply. 1. Increase in pH 2. Comatose state 3. Deep, rapid breathing 4. Decreased urine output 5. Elevated blood glucose level 6. Low plasma bicarbonate level

3. Deep, rapid breathing 5. Elevated blood glucose level 6. Low plasma bicarbonate level Hyperglycemia The person with DM may experience relatively brief and transient episodes of hyperglycemia (the dawn phenomenon and the Somogyi phenomenon) as well as the acute complications of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). MANIFESTATIONS of DKA ● Dysrhythmias ● Vital signs: Bradycardia, weak peripheral pulses, hypotension, tachypnea ● Neurologic: Headache, drowsiness, confusion ● Respiratory: Rapid, deep respirations (Kussmaul respirations) ● Skin: Warm, dry, pink Metabolic acidosis RESULTS FROM ● Excess production of hydrogen ions ● Diabetic ketoacidosis (DKA) ● Starvation ● Lactic acidosis can result from: ◯ Heavy exercise ◯ Seizure activity ◯ Hypoxia ● Excessive intake of acids ◯ Ethyl alcohol ◯ Methyl alcohol ◯ Acetylsalicylic acid (aspirin) ● Inadequate elimination of hydrogen ions ◯ Kidney failure ◯ Severe lung problems ● Inadequate production of bicarbonate ◯ Kidney failure ◯ Pancreatitis ● Impaired liver or pancreatic function: Liver failure ● Excess elimination of bicarbonate: Diarrhea RESULTS IN ● Decreased HCO3 ‑ ● Increased H+ concentration MANIFESTATIONS ● Dysrhythmias ● Vital signs: Bradycardia, weak peripheral pulses, hypotension, tachypnea ● Neurologic: Headache, drowsiness, confusion ● Respiratory: Rapid, deep respirations (Kussmaul respirations) ● Skin: Warm, dry, pink NURSING CARE: Varies with causes. If DKA, administer insulin. If related to GI losses, administer antidiarrheals and provide rehydration. If blood bicarbonate is low, administer sodium bicarbonate 1 mEq/kg. Diabetic ketoacidosis (DKA) is an acute, life-threatening condition characterized by uncontrolled hyperglycemia (greater than 300 mg/dL), metabolic acidosis, and an accumulation of ketones in the blood and urine. The onset is rapid, and the mortality rate is up to 10%.

A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level was 950 mg/dL. A continuous intravenous infusion of short-acting insulin is initiated, along with intravenous rehydration with normal saline. The serum glucose level is now 240 mg/dL. The nurse would next prepare to administer which item? 1. Ampule of 50% dextrose (hypogly) 2. NPH insulin subcutaneously 3. Intravenous fluids containing dextrose 4. Phenytoin (Dilantin) for the prevention of seizures

3. Intravenous fluids containing dextrose In DKA, IV administration of insulin and dextrose must continue even when glucose is less than 200 mg/dL until the acidosis resolves and the client is able to take subcutaneous insulin. diabetic ketoacidosis (DKA). ● Check vital signs every 15 min until stable, then every 4 hr. ● Check for indications of dehydration (weight loss, decreased skin turgor, oliguria, rapid, weak pulse). ● Always treat the underlying cause (infectious process). ● Provide isotonic fluid replacement to maintain perfusion to vital organs. The client can require 6 to 10 L of IV fluid. ◯ Physiological changes in cardiac and pulmonary function can place older adult clients at greater risk for fluid overload (precipitate heart failure exacerbation) from fluid replacement therapy. ● Start with a rapid infusion of 0.9% sodium chloride for the first 1 to 3 hr. (Clients who have elevated blood sodium levels might require 0.45% sodium chloride.) ● Follow with a hypotonic fluid (0.45% sodium chloride) to continue replacing losses to total body fluid. ● When blood glucose levels decrease to 250 mg/dL, change the IV solution to one containing 5% dextrose to minimize the risk of cerebral edema associated with drastic changes in blood osmolarity and prevent hypoglycemia. ● Administer regular insulin 0.1 to 0.15 unit/kg as an IV bolus dose and then follow with a continuous IV infusion of regular insulin at 0.1 unit/kg/hr. ● Insulin is administered IV rather than subcutaneously to provide immediate treatment. The client who has DKA will absorb subcutaneous insulin slowly and erratically, making it difficult to adjust dosages of insulin appropriately. Monitor blood glucose hourly. Blood glucose of less than 200 mg/dL is the goal for resolution, with a pH greater than 7.3, blood bicarbonate level greater than 18 mEq/L, and calculated anion gap less than 12 mEq/L. In DKA, IV administration of insulin and dextrose must continue even when glucose is less than 200 mg/dL until the acidosis resolves and the client is able to take subcutaneous insulin. ● Monitor blood potassium levels. Potassium levels might initially be increased because potassium has been pulled out of the cells, but with insulin therapy potassium will shift into cells, and the client will need to be monitored for hypokalemia. ◯ Provide potassium replacement therapy in all replacement IV fluids, as indicated by laboratory values; potassium replacement usually begins when the level falls below 5 mEq/L. ◯ Monitor cardiac rhythm constantly. Monitor for weak pulse, shallow respirations, malaise, muscle weakness, and confusion. ◯ Make sure urinary output is adequate before administering potassium. ● Administer sodium bicarbonate by slow IV infusion for severe acidosis (pH less than 7.0). Infuse potassium along with bicarbonate because bicarbonate promotes hypokalemia, unless the client has hyperkalemia. ● Monitor for and report changes in neurologic status in clients who have HHS. ● Provide the client with education to prevent recurrence. Hypoglycemia ● Teach the client measures to take in response to manifestations of hypoglycemia (mild shakiness, mental confusion, sweating, palpitations, headache, lack of coordination, blurred vision, seizures, and coma). When glucose declines slowly, manifestations relate to the central nervous system (headache, confusion, fatigue, drowsiness). With rapid glucose decline, the sympathetic nervous system is affected (tachycardia, diaphoresis, nervousness). ● If the client is unconscious, place the client in a lateral position to prevent aspiration and administer glucagon subcutaneous or IM, and notify the provider. Repeat in 10 min if the client is still unconscious. ● Glucagon or IV 50% dextrose is appropriate for clients who cannot swallow. ● To avoid hypoglycemia, avoid excess insulin, exercise, and alcohol consumption on an empty stomach, and eat about the same amounts and at the same time periods daily. ● Measure blood glucose level if manifestations occur; if it confirms hypoglycemia (below 70 mg/dL), follow the steps below, or other protocol outlined by the provider ◯ Provide 15 to 20 g of a readily absorbable carbohydrate (4 to 6 oz of fruit juice or regular soft drink, glucose tablets or glucose gel per package instructions, 6 to 10 hard candies, or 1 tbsp of honey). 10 g of glucose will increase the blood glucose by 40 mg/dL over 30 min. ◯ Recheck the blood glucose 15 min following intervention, and retreat the client if manifestations continue or the glucose is not above 70 mg/dL

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar state (HHS) is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription? 1. Endotracheal intubation 2. 100 units of NPH insulin 3. Intravenous infusion of normal saline 4. Intravenous infusion of sodium bicarbonate

3. Intravenous infusion of normal saline ● Start with a rapid infusion of 0.9% sodium chloride for the first 1 to 3 hr. (Clients who have elevated blood sodium levels might require 0.45% sodium chloride.) ● Follow with a hypotonic fluid (0.45% sodium chloride) to continue replacing losses to total body fluid. ● When blood glucose levels decrease to 250 mg/dL, change the IV solution to one containing 5% dextrose to minimize the risk of cerebral edema associated with drastic changes in blood osmolarity and prevent hypoglycemia. ● Administer regular insulin 0.1 to 0.15 unit/kg as an IV bolus dose and then follow with a continuous IV infusion of regular insulin at 0.1 unit/kg/hr. ● Insulin is administered IV rather than subcutaneously to provide immediate treatment. The client who has DKA will absorb subcutaneous insulin slowly and erratically, making it difficult to adjust dosages of insulin appropriately. Monitor blood glucose hourly. Blood glucose of less than 200 mg/dL is the goal for resolution, with a pH greater than 7.3, blood bicarbonate level greater than 18 mEq/L, and calculated anion gap less than 12 mEq/L. In DKA, IV administration of insulin and dextrose must continue even when glucose is less than 200 mg/dL until the acidosis resolves and the client is able to take subcutaneous insulin. ● Monitor blood potassium levels. Potassium levels might initially be increased because potassium has been pulled out of the cells, but with insulin therapy potassium will shift into cells, and the client will need to be monitored for hypokalemia. ◯ Provide potassium replacement therapy in all replacement IV fluids, as indicated by laboratory values; potassium replacement usually begins when the level falls below 5 mEq/L. ◯ Monitor cardiac rhythm constantly. Monitor for weak pulse, shallow respirations, malaise, muscle weakness, and confusion. ◯ Make sure urinary output is adequate before administering potassium. ● Administer sodium bicarbonate by slow IV infusion for severe acidosis (pH less than 7.0). Infuse potassium along with bicarbonate because bicarbonate promotes hypokalemia, unless the client has hyperkalemia.

The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention? 1. Correct the acidosis. 2. Administer 5% dextrose intravenously. 3. Apply a monitor for an electrocardiogram. 4. Administer short-duration insulin intravenously.

4. Administer short-duration insulin intravenously. Rapid‑acting insulin: Insulin lispro, insulin aspart, insulin glulisine, inhaled human insulin ● Administer before meals to control postprandial rise in blood glucose. ● Onset is rapid (10 to 30 min), depending on which insulin is administered. ● Administer in conjunction with intermediate- or long-acting insulin to provide glycemic control between meals and at night.

An external insulin pump is prescribed for a client with diabetes mellitus and the client asks the nurse about the functioning of the pump. The nurse bases the response on which information about the pump? 1. Is timed to release programmed doses of short-duration or NPH insulin into the bloodstream at specific intervals 2. Continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels 3. Is surgically attached to the pancreas and infuses regular insulin into the pancreas, which in turn releases the insulin into the bloodstream 4. Gives a small continuous dose of short-duration insulin subcutaneously, and the client can self-administer a bolus with an additional dose from the pump before each meal

4. Gives a small continuous dose of short-duration insulin subcutaneously, and the client can self-administer a bolus with an additional dose from the pump before each meal Short- or rapid-acting insulins are used in insulin pumps so that if pump therapy is stopped the effect of the insulin rapidly declines. The onset, peak, and duration of action of insulin can be changed by changing the insulin molecule or by adding protamine, a protein that slows insulin absorption. NPH insulin contains protamine to prolong its action, and it is classified as an intermediate-acting insulin. NPH insulin preparations appear cloudy when properly mixed prior to injection. Protamine is a foreign substance and may cause hypersensitivity reactions. Fixed-dose combinations of NPH insulin with a short-acting insulin are available to simplify administration. Insulin detemir (Levemir) and insulin glargine (Lantus) are long-acting insulins, with a duration of action up to 24 hours. While these insulins are clear preparations, they must not be mixed with other insulins and cannot be used in insulin pumps The onset, peak, and duration of action of insulin can be changed by changing the insulin molecule or by adding protamine, a protein that slows insulin absorption. NPH insulin contains protamine to prolong its action, and it is classified as an intermediate-acting insulin. NPH insulin preparations appear cloudy when properly mixed prior to injection. Protamine is a foreign substance and may cause hypersensitivity reactions. Fixed-dose combinations of NPH insulin with a short-acting insulin are available to simplify administration Insulin glargine and insulin detemir are clear, unlike NPH insulins. Do not mistake these for regular insulin. Do not mix with any other insulins. Do not inject IV, only subcutaneously. The vial of insulin currently being used may be kept at room temperature for up to 30 days. Stored vials should be kept in the refrigerator and brought to room temperature prior to administration. Regular insulin does not require mixing. If the solution is cloudy or discolored, the vial should be discarded. Modified insulin such as NPH insulin must be mixed to disperse the particles evenly throughout the solution. Mix the vial by gently rolling it between the hands. 1. Wash hands. 2. Inspect regular insulin for clarity. 3. Gently rotate NPH insulin to mix well. 4. Wipe off the top of both vials with an alcohol pad. 5. Draw 20 units of air into the syringe, and inject air into the NPH vial (Figure A). Withdraw needle. The vial should remain upright (not inverted) when adding air to the vial. 6. Draw 10 units of air into the syringe, and inject air into the regular vial (Figure B). 7. Invert the vial, and withdraw 10 units of regular insulin (Figure C). Withdraw the needle. 8. Insert the needle into the NPH vial, and carefully withdraw 20 units of NPH insulin (Figure D). 9. Don disposable gloves. 10. Administer the insulin. 11. Discard gloves, wash hands, and properly dispose of the syringe. 12. Document insulin administration.

A patient recently diagnosed with diabetes wants to check the urine for glucose instead of using capillary blood because of the cost. Which response should the nurse make to the patient? 1. "Urine testing is best when combined with serum testing." 2. "Urine testing is as reliable as finger stick testing." 3. "Yes, urine testing is cheaper than glucose test strips." 4. "Would you like to switch to this method of monitoring?"

Answer: 1 Explanation: 1. Urine testing may be used for glucose, ketones, and albumin. Urine analysis for increased glucose and ketones indicates hyperglycemia and ketosis. Urine tests for albumin are used to detect the early onset of kidney damage. 2. Advising the patient the method of testing is not reliable is not entirely correct and does not provide needed information to the patient. 3. Urine testing is not necessarily less expensive than glucose test strips. 4. It is inappropriate for the nurse to make such a suggestion about the method of testing to be utilized by the patient.

The nurse notes that a patient who has not been diagnosed with diabetes has a hemoglobin A1C level of 6%. What should the nurse suspect is occurring with the patient? 1. Severe hyperglycemia 2. Consistent with diabetes 3. Normal results 4. High risk for developing diabetes

Answer: 4 Explanation: 1. This is not severe hyperglycemia. If it were, the nurse would immediately notify the healthcare provider. 2. Diabetes is fasting blood glucose level of 126 mg/dL or greater. 3. A normal fasting blood glucose level is less than or equal to 100 mg/dL. 4. A hemoglobin A1C level of 5.7% to 6.4% indicates a high risk for developing diabetes.