Module 2

Insulin Needs - non diabetic

50% Basal 50 % Bolus / meal coverage the body makes the correct amount of insulin to maintain a normal blood glucose As the "need" increases, the production of insulin increases The production of insulin is variable over time but the result is stable, consistent normal blood glucose readings

Basal- Bolus Model Human body requires insulin for 2 reasons

Basal coverage - 24 hour need Insulin resistance (genetics and fat consumption from diet) Hepatic glucose production Cover food - 2 hour need / meal Direct proportion to carbohydrate intake (carb ratio)

Nursing Implementation Ambulatory and home care

Because diabetes is a complex chronic condition, a great deal of patient contact takes place in outpatient and home settings. The major goal of patient care in these settings is to enable the patient or caregiver to reach an optimal level of independence in self-care activities. Unfortunately, many patients with diabetes face challenges in reaching these goals. Diabetes increases the risk for other chronic conditions that can affect self-care activities. These include visual impairment, lower extremity problems that affect mobility, and other functional limitations related to stroke. Successful management of diabetes requires ongoing interaction among the patient, the caregiver, and the health care team. It is important that a certified diabetes educator (CDE) be involved in the care of the patient and the family. This person provides expertise in many areas of specialized care needs. Careful assessment of what it means to the patient to have diabetes should be the starting point of teaching. The goals of teaching should be mutually determined by you and the patient, based on individual needs, as well as therapeutic requirements. Identify the patient's support system and include them in planning, teaching, and counseling. When family members and other individuals close to the patient are included, they can support the patient's self-care behaviors. In addition, they can provide care if self-care is not possible. Encourage the family and caregivers to provide emotional support and encouragement as the patient deals with the reality of living with a chronic disease. Important nursing functions are to assess the ability of patients and caregivers in performing activities such as SMBG and insulin injection. Assistive devices for self-administration of insulin include syringe magnifiers, vial stabilizers, and dosing aids for the visually impaired. In some cases, referrals are made to help the patient achieve the self-care goal. These may include an occupational therapist, a social worker, a home health aide, or a dietitian. Assessment of the patient must include an evaluation of his or her ability to safely manage this therapy. This includes the ability to understand the interaction of medication, diet, and activity and to be able to recognize and treat the symptoms of hypoglycemia appropriately. If the patient does not have the cognitive skills to do these things, identify and teach another responsible person. Teach manifestations and how to treat hypoglycemia and hyperglycemia The potential for infection necessitates diligent skin and dental hygiene practices. Because of the susceptibility to periodontal disease, encourage daily brushing and flossing in addition to regular visits to the dentist. When dental work is done, the dentist should be informed that the patient has diabetes. Teach patients regarding the importance of informing dentists and other health care professionals of their diagnosis. Routine care should include regular bathing, with particular emphasis given to foot care. Advice patients to inspect their feet daily, avoid going barefoot, and wear shoes that are supportive and comfortable. If cuts, scrapes, or burns occur, they should be treated promptly and monitored carefully. Patients should wash the area, apply a nonabrasive or nonirritating antiseptic ointment, and cover the area with a dry, sterile pad. They should notify the health care provider immediately if the injury does not begin to heal within 24 hours or if signs of infection develop. Travel for a patient with diabetes requires advance planning. Being sedentary for long periods of time may raise the person's glucose level. Encourage the patient to get up and walk at least every 2 hours to prevent the risk for deep vein thrombosis and to prevent elevation of glucose levels. The patient should have a full set of diabetes care supplies in the carry-on luggage when traveling by plane, train, or bus. This includes blood glucose monitoring equipment, insulin and/or oral medications, and syringes or insulin pens. When equipment such as syringes, lancing devices, insulin vials or pens, and insulin pumps are taken onto a commercial airliner, the professional printed pharmaceutical labels should accompany them. A letter from the prescribing health care provider indicating medical necessity may prevent delays at security checkpoints. Notify screeners if an insulin pump is used so they can inspect it while it is on the patient's body, rather than removing it. For patients who use insulin, OAs, or noninsulin injectable agents that can cause hypoglycemia, snack items and a quick-acting carbohydrate source for treating hypoglycemia should be included in the carry-on luggage. Extra insulin should be available in case a bottle breaks or is lost. For longer trips, the patient should carry a full day's supply of food in the event of canceled flights, delayed meals, or closed restaurants. If the patient is planning a trip out of the country, it is wise to have a letter from the health care provider explaining that the patient has diabetes and requires all the materials, particularly syringes, for ongoing health care. When travel involves time changes such as traveling coast to coast or across the International Date Line, the patient should contact the health care provider to plan an appropriate insulin schedule. During travel, most patients find it helpful to keep watches set to the time of the city of origin until they reach their destination. The key to travel when taking insulin is to know the type of insulin being taken, its onset of action, the anticipated peak time, and mealtimes.

Neuropathy: Neurotrophic Ulceration

Foot injury and ulcerations can occur without the patient's ever having pain. Neuropathy can also cause atrophy of the small muscles of the hands and feet, causing deformity and limiting fine movement.

Order on MAR

For each 15 grams of carbohydrate consumed give 1 unit of Novolog subcutaneously immediately following each meal LUNCH MENU ¾ cup chicken and mushrooms (13 gm) ½ cup broccoli and cauliflower (4 gm) 1/3 cup mashed potato with gravy (20 gm) 1 diet chocolate pudding (13 gm) 6 oz. cranberry juice (14 gm) PATIENT CONSUMES ALL OF THE ABOVE FOOD/DRINK How many units of Novolog insulin will you administer?

Insulin Therapy

There are many different ways that insulin therapy can be given. Intensive insulin regimens attempt to mimic the body's normal pattern of insulin secretion and use the concepts of basal and bolus insulin coverage. In order for this to control blood sugars well, intensive therapy requires more injections and calculations. However it provides more freedom and flexibility such that insulin doses can be adjusted to fit daily changes in your lifestyle.

factors that put an individual at an increased risk for diabetes

These include age, ethnicity (being Native American, Hispanic, African American, Asian, Pacific Islander), obesity, having a baby that weighs more than 9 pounds, and a family history of diabetes. A diabetes risk test is available at http://www.diabetes.org/risk-test.jsp. The diabetes risk test determines if a person is at risk for prediabetes or diabetes on the basis of the number of risk factors present.

Microvascular: Diabetic Neuropathy Sensory neuropathy

This can lead to the loss of protective sensation in the lower extremities, and, coupled with other factors, this significantly increases the risk for complications that result in a lower limb amputation.

Oral Agents

Work on three defects of type 2 diabetes Insulin resistance Decreased insulin production Increased hepatic glucose production Can be used in combination with agents from other classes or with insulin to achieve blood glucose goals OAs and noninsulin injectable agents work to improve the mechanisms by which insulin and glucose are produced and used by the body

Hypoglycemic Unawareness what is it what is it related to what do you do to prevent it

a condition in which a person does not experience the warning signs and symptoms of hypoglycemia until the glucose levels reach a critical point. Then the person may become incoherent and combative or lose consciousness. This is often related to autonomic neuropathy of diabetes that interferes with the secretion of counterregulatory hormones that produce these symptoms. Using intensive treatment to get tight blood glucose control in patients who are at risk for hypoglycemic unawareness may not be an appropriate goal because a major drawback is hypoglycemia. These patients are usually managed with blood glucose goals that are somewhat higher than those of patients who are able to detect and manage the onset of hypoglycemia.

Glucagon

a hyperglycemic hormone secreted by the alpha cells of the islets of Langerhans in the pancreas. increases blood sugar by stimulating glycogenolysis (glycogen breakdown) in the liver. available for use (S.Q, I.M., and I.V.). It is used to treat insulin-induced hypoglycemia Blood glucose levels increase within 10 minutes after administration

Nursing Interventions for DKA

a serious condition that proceeds rapidly and must be treated promptly. Ensure an patent airway and administer oxygen via nasal cannula or non-rebreather mask. Because fluid imbalance is potentially life-threatening, the initial goal of therapy is to establish IV access and begin fluid and electrolyte replacement. Typically, the initial fluid therapy regimen consists of an infusion of 0.45% or 0.9% NaCl at a rate to restore urine output to 30 to 60 mL/hr and to raise blood pressure. When blood glucose levels approach 250 mg/dL (13.9 mmol/L), 5% to 10% dextrose is added to the fluid regimen to prevent hypoglycemia, as well as a sudden drop in glucose that can be associated with cerebral edema. Overzealous rehydration, especially with hypotonic IV solutions, can result in cerebral edema. Monitor patients with renal or cardiac compromise for fluid overload. Measure serum potassium level before starting insulin. If the patient is hypokalemic, insulin administration will further decrease the potassium levels, making early potassium replacement is essential. Although initial serum potassium value may be normal or high, levels can decrease rapidly once therapy starts, as insulin drives potassium into the cells, leading to life-threatening hypokalemia. IV insulin administration is therapy directed toward correcting hyperglycemia and hyperketonemia. Insulin is immediately started at 0.1 U/kg/hr by a continuous infusion. It is important to prevent rapid drops in serum glucose to avoid cerebral edema. A blood glucose reduction of 36 to 54 mg/dL (2 to 3 mmol/L) per hour will avoid complications. Insulin allows water and potassium to enter the cell along with glucose and can lead to a depletion of vascular volume and hypokalemia; therefore, monitor the patient's fluid balance and potassium levels. a serious condition that proceeds rapidly and must be treated promptly. Ensure an patent airway and administer oxygen via nasal cannula or non-rebreather mask. Because fluid imbalance is potentially life-threatening, the initial goal of therapy is to establish IV access and begin fluid and electrolyte replacement. Typically, the initial fluid therapy regimen consists of an infusion of 0.45% or 0.9% NaCl at a rate to restore urine output to 30 to 60 mL/hr and to raise blood pressure. When blood glucose levels approach 250 mg/dL (13.9 mmol/L), 5% to 10% dextrose is added to the fluid regimen to prevent hypoglycemia, as well as a sudden drop in glucose that can be associated with cerebral edema. Overzealous rehydration, especially with hypotonic IV solutions, can result in cerebral edema. Monitor patients with renal or cardiac compromise for fluid overload. Measure serum potassium level before starting insulin. If the patient is hypokalemic, insulin administration will further decrease the potassium levels, making early potassium replacement is essential. Although initial serum potassium value may be normal or high, levels can decrease rapidly once therapy starts, as insulin drives potassium into the cells, leading to life-threatening hypokalemia. IV insulin administration is therapy directed toward correcting hyperglycemia and hyperketonemia. Insulin is immediately started at 0.1 U/kg/hr by a continuous infusion. It is important to prevent rapid drops in serum glucose to avoid cerebral edema. A blood glucose reduction of 36 to 54 mg/dL (2 to 3 mmol/L) per hour will avoid complications. Insulin allows water and potassium to enter the cell along with glucose and can lead to a depletion of vascular volume and hypokalemia; therefore, monitor the patient's fluid balance and potassium levels. Ensure patent airway; administer O2 Establish IV access; begin fluid resuscitation NaCl, 0.45% or 0.9% Add 5% to 10% dextrose when blood glucose level approaches 250 mg/dL Continuous regular insulin drip, 0.1 U/kg/hr. Potassium replacement as needed HEART AND MUSCLES AND BRAIN

Diabetes: Nutritional Therapy: Type 1

Meal plan is based on individual's usual food intake and is balanced with insulin and exercise patterns Day-to-day consistency in timing and amount of food eaten is important for patients using conventional, fixed insulin regimens More flexibility with rapid-acting insulin, multiple daily injections, and insulin pump Patients using rapid-acting insulin can make adjustments in dosage before the meal on the basis of the current blood glucose level and the carbohydrate content of the meal. Intensified insulin therapy, such as multiple daily injections or the use of an insulin pump, allows considerable flexibility in food selection and can be adjusted for alterations from usual eating and exercise habits. Dietitian initially provides instruction The insulin regimen should be developed with the patient's eating habits and activity pattern in mind

Diabetes: Nutritional Therapy fiber

Recommendation: 25 to 30 g/day Nutritive and nonnutritive sweeteners used in moderation within FDA daily intake levels Nonnutritive sweeteners include the sugar substitutes saccharine, aspartame, sucralose, neotame, and acesulfame-potassium With all individuals, should be included as part of a healthy meal plan. There is no evidence that a person with diabetes should consume more than an individual who does not have diabetes. The current recommendation for the general population is 25 to 30 g/day. .

Microvascular damage to retina is a result of

Result of chronic hyperglycemia Most common cause of new cases of blindness in people 20 to 74 years 15 years after dx = 100% of Type I 85% of type 2

Nursing Diagnoses

Risk for unstable blood glucose levels Risk for infection Risk for peripheral neurovascular dysfunction Ineffective self-health management Ineffective self-health management related to deficient knowledge of diabetes management and lack of adherence to diabetes management plan as evidenced by inaccurate statements regarding diabetes and its management and stated confusion regarding the pathophysiology of diabetes Risk for unstable blood glucose levels related to inadequate blood glucose monitoring and lack of adherence to diabetes management plan Risk for injury related to decreased tactile sensation, episodes of hypoglycemia Risk for peripheral neurovascular dysfunction related to vascular effects of diabetes

Desired Outcomes When Teaching Patient about a Pump

Teaching the patient about insulin pump therapy can allow the patient to: Gain a better understanding of the advantages and disadvantages of pump therapy Be willing and able to continuously wear the pump device, successfully perform carbohydrate counting, and perform BG testing at a minimum of 4 times daily Understand the importance of site rotation, how site rotation is achieved, and how frequently site changes should be made Record data using a log or diary and/or upload data stored in the pump and be able to use the data to make reasonable adjustments in insulin administration Be able to identify safety issues and prevent/manage complications

Diabetes: Nutritional Therapy Glycemic index

Term used to describe rise in blood glucose levels after carbohydrate-containing food is consumed The glycemic index of foods was developed to compare the postprandial responses of carbohydrate-containing foods High glycemic index foods increase glucose levels faster and higher than foods with a low glycemic index. Starch and sugar in foods will raise your blood sugar The use of glycemic index may provide a modest additional benefit over that found when total carbohydrates are considered alone. An online calculator for glycemic index is available at http://www.glycemicindex.com 1 serving of CHO = 15 grams

Microvascular: Diabetic Nephropathy

damage to the small blood vessels that supply the glomeruli of the kidney. It is the leading cause of end-stage kidney disease in the United States and is seen in 20% to 40% of people with diabetes. Risk factors for the development of diabetic nephropathy include hypertension, genetic predisposition, smoking, and chronic hyperglycemia. Results of the DCCT and UKPDS research have demonstrated that kidney disease can be significantly reduced when near-normal blood glucose control is achieved and maintained. Patients with diabetes are screened for nephropathy annually for albuminuria and a measurement of the albumin-to-creatinine ratio in a random spot urine collection. Serum creatinine is also measured. Serum creatinine measurements provide an estimation of the glomerular filtration rate and thus the degree of kidney function. Patients with diabetes who have microalbuminuria or macroalbuminuria should receive either angiotensin-converting enzyme (ACE) inhibitor drugs (e.g., lisinopril [Prinivil, Zestril]) or angiotensin II receptor antagonists (e.g., losartan [Cozaar]). Both classifications of these drugs are used to treat hypertension and have been found to delay the progression of nephropathy in patients with diabetes. Hypertension will significantly accelerate the progression of nephropathy. Therefore, aggressive blood pressure management is indicated for all patients with diabetes. Tight blood glucose control is also critical for the prevention and delay of diabetic nephropathy. Diabetic neuropathy is nerve damage that occurs because of the metabolic derangements associated with diabetes mellitus. Approximately 60% to 70% of patients with diabetes have some degree of neuropathy. Screening for neuropathy should begin in patients with type 2 diabetes at the time of diagnosis and 5 years after diagnosis in patients with type 1 diabetes. The pathophysiologic processes of diabetic neuropathy are not well understood. Several theories exist, including metabolic, vascular, and autoimmune factors. The prevailing theory is that persistent hyperglycemia leads to an accumulation of sorbitol and fructose in the nerves that causes damage by an unknown mechanism. The result is reduced nerve conduction and demyelinization. Ischemia in blood vessels damaged by chronic hyperglycemia that supply the peripheral nerves is also implicated in the development of diabetic neuropathy. Neuropathy can precede, accompany, or follow the diagnosis of diabetes. The two major categories of diabetic neuropathy are sensory neuropathy, which affects the peripheral nervous system, and autonomic neuropathy. Each of these types can take several forms.

Macrovascular Angiopathy

diseases of the large and medium-size blood vessels that occur with greater frequency and with an earlier onset in people with diabetes Cerebrovascular disease Cardiovascular disease Peripheral vascular disease

Hyperosmolar Hyperglycemic Syndrome (HHS)

life-threatening syndrome that can occur in the patient with diabetes who is able to produce enough insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion. HHS is less common than DKA. It often occurs in patients older than 60 years with type 2 diabetes. Common causes of HHS are urinary tract infections, pneumonia, sepsis, any acute illness, and newly diagnosed type 2 diabetes. HHS is often related to impaired thirst sensation and/or a functional inability to replace fluids. There is usually a history of inadequate fluid intake, increasing mental depression, and polyuria. The main difference between HHS and DKA is that the patient with HHS usually has enough circulating insulin so that ketoacidosis does not occur. Because HHS produces fewer symptoms in the earlier stages, blood glucose levels can climb quite high before the problem is recognized. Fewer symptoms lead to high glucose level (>600 mg/dL) The higher blood glucose levels increase serum osmolality and produce more severe neurologic manifestations, such as somnolence, coma, seizures, hemiparesis, and aphasia. Because these manifestations resemble a stroke, immediate determination of the glucose level is critical for correct diagnosis and treatment. Laboratory values in HHS include a blood glucose level greater than 600 mg/dL (33.33 mmol/L) and a marked increase in serum osmolality. Ketone bodies are absent or minimal in both blood and urine.

Hypoglycemia

low blood glucose level, occurs when there is too much insulin in proportion to available glucose in the blood. This causes the blood glucose level to drop to less than 70 mg/dL (3.9 mmol/L). When plasma glucose level drops below 70 mg/dL (3.9 mmol/L), neuroendocrine hormones are released, and the autonomic nervous system is activated.

factors that can cause falsely elevated values in a diagnostic study

recent severe restrictions of dietary carbohydrate, acute illness, medications (e.g., contraceptives, corticosteroids), and restricted activity such as bed rest. A patient with impaired GI absorption or who has recently taken acetaminophen may have false-negative test results.

Microvascular: Diabetic Retinopathy

refers to the process of microvascular damage to the retina as a result of chronic hyperglycemia, presence of nephropathy, and hypertension in patients with diabetes estimated to be the most common cause of new cases of adult blindness Retinopathy can be classified as nonproliferative or proliferative

Microvascular Angiopathy

result from thickening of the vessel membranes in the capillaries and arterioles in response to conditions of chronic hyperglycemia. They differ from the macrovascular complications in that they are specific to diabetes can be found throughout the body, the areas most noticeably affected are the eyes (retinopathy), the kidneys (nephropathy), and the skin (dermopathy). present in some patients with type 2 diabetes at the time of diagnosis. However, clinical manifestations usually do not appear until 10 to 20 years later

Continuous glucose monitoring (CGM)

systems provide another route for monitoring glucose. Using a sensor inserted subcutaneously under the skin, the systems display glucose values continuously, updating values every 1 to 5 minutes. The patient inserts the sensor by using an automatic insertion device. Data are sent from the sensor to a transmitter, which displays the glucose value on either an insulin pump or a pager-like receiver. The glucose monitor can be used without an insulin pump. assist the patient and health care provider to identify trends and patterns in glucose levels and are useful for the management of insulin therapy or when continuous blood glucose readings are clinically important. The patient is alerted to episodes of hypoglycemia and hyperglycemia, thus allowing corrective action to be quickly taken. Both systems still require finger-stick measurements and the use of a blood glucose monitor to calibrate the sensor and to make treatment decisions. The MiniMed Paradigm insulin pump (A) delivers insulin into a cannula (B) that sits under the skin. Continuous glucose monitoring occurs through a tiny sensor (C) inserted under the skin. Sensor data are sent continuously to the insulin pump transmitter (D). The transmitter sends data to the insulin pump through wireless technology.

Microvascular: Diabetic Retinopathy Non-proliferative

the most common form, partial occlusion of the small blood vessels in the retina causes microaneurysms to develop in the capillary walls. The walls of these microaneurysms are so weak that capillary fluid leaks out, causing retinal edema and eventually hard exudates or intraretinal hemorrhages. Vision may be affected if the macula is involved

HHS usual history of

Inadequate fluid intake Increasing mental depression Polyuria

Diabetic Ketoacidosis (DKA)

Caused by profound deficiency of insulin Characterized by Hyperglycemia Ketosis Acidosis Dehydration Most likely to occur in type 1 diabetesbut may be seen in people with type 2 diabetes in conditions of severe illness or stress when the pancreas cannot meet the extra demand for insulin

Examples of 1 serving of carbohydrate

1 serving of CHO = 15 grams ½ cup juice 1 cup milk 1 slice of bread ½ cup mashed potatoes

Components for a Treatment Model for Diabetes

1) Patient centered - Establish the cause of hyperglycemia or hypoglycemia and initiate therapy which corrects the defect in glucose homeostasis 2) The effects from treatment need to be reproducible day after day - interpret blood glucose patterns and the actions of insulin and oral medications to understand how to get a predictable and reproducible response 3) Must have a mechanism for the patient to adjust therapy to compensate for results outside of the desired range of blood glucoses (Diabetes Self-Management Education)

Diagnostic Studies diabetes

1. Glycosylated hemoglobin (A1C) level: 6.5% or greater. Reflects glucose levels over the last 2-3 months 2. Fasting plasma glucose level: higher than 126 mg/dL. Fasting is defined as no caloric intake for at least 8 hours 3. Two-hour plasma glucose level during OGTT: 200 mg/dL (11.1 mmol/L) r higher during an OGTT, with a glucose load of 75 g.(with glucose load of 75 g) 4. Classic symptoms of hyperglycemia (polyuria, polydipsia, unexplained weight loss)with random plasma glucose level of 200 mg/dL or higher or hyperglycemic crisis, a random plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher. repeat testing is not warranted. Criteria 1 -3 should be confirmed by repeat testing to rule out laboratory error It is preferable for the repeat test to be the same test used initially. For example, if a random blood glucose test showed elevated blood glucose levels, the same test should be used again when the person is retested The accuracy of test results depends on adequate patient preparation and attention to the many factors that may influence the test results.

Patient and Caregiver Teaching Guide: Insulin Therapy

1. Wash hands thoroughly. 2. Always inspect insulin bottle before using it. Make sure that it is the proper type and concentration, expiration date has not passed, and top of bottle is in perfect condition. The insulin (except for NPH) should look clear and colorless. Discard if it appears discolored or if you see particles in the solution. 3. If insulin solutions are cloudy (see Table 49-3), gently roll the insulin bottle between the palms of hands to mix the insulin. 4. Select proper injection site (see Fig. 49-5). 5. Cleanse the skin with soap and water or alcohol. 6. Pinch up the skin, and push the needle straight into the pinched-up area (90-degree angle). If you are very thin or using a 516-in needle, you may need to use a 45-degree angle. 7. Push the plunger all the way down, let go of pinched skin, leave needle in place for 5 sec to ensure that all insulin has been injected, and then remove needle. 8. Destroy and dispose of single-use syringe safely. Table 49-5 p. 1161 in text.

What Not To Recommend!

Applebee's -Sizzling Apple Pie -1085 cal, 56 grams fat, 146 grams CHO Auntie Anne's Pretzel -Original Pretzel (with butter) 370 cal, 4 grams fat, 72 grams CHO Starbuck's -Double Chocolate Chip Frappuccino 16 oz 365 cal, 7.5 gm fat, 69 grams CHO

Insulin Storage: Heating and Freezing Alter the Insulin Molecule

As a protein, insulin requires special storage considerations In-use vials and insulin pens may be left at room temperature up to 4 weeks unless the room temperature is higher than 86º F (30º C) or below freezing (less than 32º F [0º C]). Heat and freezing alter the insulin molecule. Extra insulin should be refrigerated Unopened insulin vials and insulin pens should be stored in the refrigerator Avoid exposure to direct sunlight, extreme heat or cold A patient who is traveling in hot climates may store insulin in a thermos or cooler to keep it cool (not frozen) Store prefilled syringes upright for 1 week if two insulin types when stored in the refrigerator ; 30 days for one Patients who are traveling or caregivers of patients who are sight impaired or who lack the manual dexterity to fill their own syringes may prefill insulin syringes. Syringes should be stored in a vertical position with the needle pointed up to avoid clumping of suspended insulin in the needle. Before injection, gently roll prefilled syringes between the palms 10 to 20 times to warm the insulin and resuspend the particles. Some insulin combinations are not appropriate for prefilling and storage because the mixture can alter the onset, action, and/or peak times of either of the types. Consult a pharmacy reference as needed when mixing and prefilling different types of insulin.

Retinopathy Vitrectomy

Aspiration of blood, membrane, fibers from inside eye through small incision Used when Vitreal hemorrhage does not clear in 6 months Threatened or actual retinal detachment

Laboratory findings

Blood glucose > 300 mg/dl Arterial blood pH below 7.30 Serum bicarbonate level <15 mEq/L Ketones in blood and urine Airway management Oxygen administration

HHS Laboratory values

Blood glucose >400 mg/dl Increase in serum osmolality Absent/minimal ketone bodies

Combination Insulin Therapy

Can mix short- or rapid-acting insulin with intermediate-acting insulin in same syringe Provides mealtime and basal coverage in one injection Commercially premixed or self-mix For patients who want to use only one or two injections per day, a short- or rapid-acting insulin is mixed with intermediate-acting insulin in the same syringe. Although this may be more appealing to the patient, most patients achieve better control with basal-bolus therapy. Premixed formulas offer convenience to patients, who do not have to draw up and mix insulin from two different vials. This is especially helpful to those who lack the visual, manual, or cognitive skills to mix insulin themselves. However, the convenience of these formulas sacrifices the potential for optimal blood glucose control because there is less opportunity for flexible dosing based on need.

Somogyi Effect and Dawn Phenomenon Treatment

Careful assessment is required to document the Somogyi effect or Dawn phenomenon because the treatment for each differs The treatment for Somogyi effect is less insulin. The treatment for Dawn phenomenon is an increase in insulin or an adjustment in administration time. Ask the patient to measure and document bedtime, nighttime (between 2:00 and 4:00 AM), and morning fasting blood glucose levels on several occasions. If the predawn levels are less than 60 mg/dL (3.3 mmol/L) and signs and symptoms of hypoglycemia are present, the insulin dosage should be reduced. If the 2:00 to 4:00 AM blood glucose level is high, the insulin dosage should be increased. In addition, counsel the patient on appropriate bedtime snacks

Chronic Complications: Angiopathy

Chronic complications of diabetes are primarily those of end-organ disease from damage to blood vessels (angiopathy) secondary to chronic hyperglycemia leading causes of diabetes-related deaths; approximately 68% of deaths are due to cardiovascular disease and 16% to strokes in patients aged 65 and older. These chronic blood vessel dysfunctions are divided into two categories: macrovascular complications and microvascular complications. The Diabetes Control and Complications Trial (DCCT), a landmark study in diabetes management, demonstrated that in patients with type 1 diabetes, the risk for microvascular complications could be significantly reduced by keeping blood glucose levels as near to normal as possible for as much of the time as possible (tight glucose control). Subjects who maintained tight glucose control reduced their risk for the development of retinopathy and nephropathy, some of the most common microvascular complications. On the basis of these findings, the ADA issued recommendations for the management of diabetes that included treatment goals to maintain blood glucose levels as near to normal as possible. Specific targets for individual patients must take into account the risk for severe or undetected hypoglycemia as a side effect of tight glucose control. The United Kingdom Prospective Diabetes Study (UKPDS) demonstrated that intensive treatment of type 2 diabetes significantly lowered the risk for developing diabetes-related eye, kidney, and neurologic problems. The findings from this study included a 25% reduction of microvascular disease and a 16% reduction in the risk for myocardial infarction in subjects who maintained long-term glycemic control

Insulin to Carbohydrate Ratio

Collect patients menu and keep at bedside to complete carb counting after patient eats meal. Follow insulin: carb ratio to administer proper amount of insulin to the patient.

Insulin Pumps

Continuous subcutaneous infusion Battery-operated device Connected to a catheter inserted into subcutaneous tissue in abdominal wall Most insulin pumps are worn on the belt or under clothing and loaded with rapid-acting insulin, which is connected via plastic tubing to a catheter inserted into the subcutaneous tissue in the abdominal wall Program basal and bolus doses that can vary throughout the day Potential for tight glucose control All insulin pumps are programmed to deliver a continuous infusion of rapid-acting insulin 24 hours a day, known as the "basal rate." Basal insulin can be temporarily increased or decreased on the basis of carbohydrate intake, activity changes, or illness. Some individuals require different basal rates at different times of the day. At mealtime, the user programs the pump to deliver a bolus infusion of insulin appropriate to the amount of carbohydrate ingested and an additional amount, if needed to bring down high premeal blood glucose levels. Insulin pump users must check their blood glucose level at least four times per day. Testing eight times or more per day is common. A major advantage of the insulin pump is the potential for tight glucose control. This is possible because insulin delivery becomes very similar to the normal physiologic pattern.

Microvascular: Diabetic Neuropathy Treatment for sensory neuropathy

Control of blood glucose is the only treatment for diabetic neuropathy. It is effective in many, but not all, cases. Drug therapy may be used to treat neuropathic symptoms, particularly pain. Medications commonly used include topical creams (e.g., capsaicin [Zostrix]), tricyclic antidepressants (e.g., amitriptyline [Elavil]), selective serotonin and norepinephrine reuptake inhibitors (e.g., duloxetine [Cymbalta]), and antiseizure medications (e.g., gabapentin [Neurontin], pregabalin [Lyrica]). Capsaicin is a moderately effective topical cream made from chili peppers. It depletes the accumulation of pain-mediating chemicals in the peripheral sensory neurons. The cream is applied three to four times a day. There is usually an increase in symptoms at the start of therapy, which is followed by relief of pain in 2 to 3 weeks. Tricyclic antidepressants are moderately effective in treating the symptoms of diabetic neuropathy. They work by inhibiting the reuptake of norepinephrine and serotonin, which are neurotransmitters believed to play a role in the transmission of pain through the spinal cord. Duloxetine is thought to relieve pain by increasing the levels of serotonin and norepinephrine, which improves the body's ability to regulate pain. Antiseizure medications decrease the release of neurotransmitters that transmit pain.

Diabetes: Nutritional Therapy: Overall

Counseling Education: Formal Inpatient Diabetes Education (IDE) IDE is recommended and studies show that this will lead to fewer readmissions Ongoing monitoring Interdisciplinary team with registered dietitian as lead Individualized medical nutrition therapy (MNT), consisting of counseling, education, and ongoing monitoring, is a cornerstone of care for person with diabetes and prediabetes Although MNT has many positive outcomes, adherence to a dietary regimen is often challenging for many people. Achieving nutritional goals requires a coordinated team effort that takes into account the behavioral, cognitive, socioeconomic, cultural, and religious aspects of the patient. Because of these complexities, it is recommended that a registered dietitian with expertise in diabetes management takes the lead in MNT. The dietitian should conduct a dietary assessment and develop an individualized food plan. Additional team members involved in MNT may include nurses, certified diabetes educators, clinical nurse specialists, health care providers, and social workers.

Acute Complications

Diabetic ketoacidosis (DKA) Hyperosmolar hyperglycemic syndrome (HHS) Hypoglycemia

Macrovascular Angiopathy risk factors teaching on the risk factors

Decrease risk factors (yearly screening) Nursing Assessment and Teaching on: Obesity Smoking Hypertension High fat intake Sedentary lifestyle Hyperlipidemia Patients with diabetes can decrease several risk factors associated with macrovascular complications, such as obesity, smoking, hypertension, high fat intake, and sedentary lifestyle. Smoking, which is detrimental to health in general, is especially injurious to people with diabetes and significantly increases their risk for blood vessel and cardiovascular disease (CVD), stroke, and lower extremity amputation. The ADA recommends yearly screening of diabetic patients for CVD risk factors. Optimizing blood pressure (BP) control in patients with diabetes is significant for the prevention of cardiovascular and renal disease. Treating hypertension in diabetic patients results in a decrease in macrovascular and microvascular complications. Hypertension causes an increase in mortality rate among people with diabetes in comparison with those with hypertension without diabetes. A target BP of less than 130/80 mm Hg is recommended for all patients with diabetes. Patients with diabetes have an increase in lipid abnormalities. This contributes to the increase in cardiovascular disease seen in this population. The American Diabetes Association recommends the LDL cholesterol goal of less than 100 mg/dL (2.6 mmol/L), triglyceride levels of less than 150 mg/dL (1.7 mmol/L), and HDL cholesterol levels greater than 40 mg/dL (1.0 mmol/L) in men and greater than 50 mg/dL (1.3 mmol/L) in women as target values. The ADA advocates lifestyle interventions including MNT, exercise, and weight loss and smoking cessation to treat hyperlipidemia. Medications (primarily statins) are recommended for patients who do not reach lipid goals with lifestyle modifications and for people older than 40 years with other CVD risk factors, regardless of their baseline lipid levels.

Collaborative Care: Goals of Management

Decrease symptoms Promote well-being Prevent acute complications such as hyperglycemia Prevent or Delay onset and progression of long-term complications Maintain blood glucose levels as near to normal as possible

Clinical manifestations DKA

Dehydration occurs with manifestations of poor skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension. Early symptoms may include lethargy and weakness. As the patient becomes severely dehydrated, the skin becomes dry and loose, and the eyes become soft and sunken. Abdominal pain may be present and accompanied by anorexia, nausea, and vomiting. Kussmaul respirations (rapid, deep breathing associated with dyspnea) are the body's attempt to reverse metabolic acidosis through the exhalation of excess carbon dioxide. Acetone is noted on the breath as a sweet, fruity odor. Laboratory findings include a blood glucose level of 250 mg/dL (13.9 mmol/L) or higher, arterial blood pH less than 7.30, serum bicarbonate level less than 16 mEq/L (16 mmol/L), and moderate to high ketone levels in the urine or serum

Hypoglycemia Altered mental functioning

Difficulty speaking Visual disturbances Stupor Confusion Coma

Reading Labels

Do look at serving size in the package Do look at calories Look at total fat 1 teaspoon of butter = 5 grams Look at total CHO 1 CHO serving = 15 grams Look at fiber > than 5 grams is great

Nursing Care Related to Insulin Therapy

Does the patient understand the interaction of insulin, diet, and activity? Does the patient recognize and know how to treat the symptoms of hypoglycemia? Is the patient, or caregiver, able to prepare and inject the insulin?

Collaborative Care: Tools

Drug Therapy A. Insulin B. Oral and Noninsulin Injectable Agents Nutritional therapy Exercise Self-monitoring of blood glucose (SMBG)

Self-Monitoring of Blood Glucose (SMBG)

Enables decisions regarding diet, exercise, and medication Accurate record of glucose fluctuations Helps identify hyperglycemia and hypoglycemia Helps maintain glycemic goals A must for insulin users. The frequency of testing varies Self-monitoring of blood glucose (SMBG) is a critical part of diabetes management. By providing a current blood glucose reading, the primary advantage of SMBG is that it enables the patient to make decisions regarding food intake, activity patterns, and medication dosages. other patients with diabetes use SMBG to help achieve and maintain glycemic goals, and monitor for acute fluctuations in blood glucose level. The frequency of monitoring depends on several factors, including the patient's glycemic goals, the type of diabetes that the patient has, the medication regimen, the patient's ability to perform the test independently, and the patient's willingness to test. Patients who use multiple insulin injections or insulin pumps should monitor their blood glucose four or more times a day. Patients using less frequent insulin injections, noninsulin therapy, or medical nutrition therapy alone will monitor as often as needed to achieve their glycemic goals Alternative blood sampling sites Data uploaded to computer Continuous glucose monitoring Displays glucose values with updating every 1 to 5 minutes Helps identify trends and track patterns Alerts to hypoglycemia or hyperglycemia Newer systems allow the user to collect blood from alternative sites such as the forearm or palm. Alternate site testing is not recommended when blood glucose readings change rapidly, during pregnancy, or when symptoms of low blood glucose levels are present. Patient teaching How to use, calibrate, control solution; Control solution should be used when a glucometer is first used, when a new bottle of strips are used, or if there is a reason to believe that the readings are not correct When to test Before meals Two hours after meals When hypoglycemia is suspected During illness, the person should test blood glucose levels at 4-hour intervals to determine the effects of the illness on glucose levels Before, during, and after exercise

Nursing Responsibilities Related to Insulin Therapy

Ensure proper administration of insulin Assess patient's response to insulin therapy Teach the patient about administration, side effects of insulin

"Sick Day" Rules

Especially for type 1 diabetic and type 2 diabetic requiring insulin Monitor blood glucose every 2-4 hours Monitor urine for presence of ketones During critical illness there is evidence that maintaining normoglycemia is associated with improved outcomes including decreased sepsis, and improved wound healing

Insulin to Carbohydrate Ratio example

Example #1, assume: Patient eats 60 grams of carbohydrate for lunch Your Insulin: CHO ratio is 1:10 To get the CHO insulin dose, plug the numbers into the formula: CHO insulin dose = Total grams of CHO in the meal (60 g) ÷ grams of CHO disposed by 1 unit of insulin (10) = 6 units You will need 6 units of rapid acting insulin to cover the carbohydrate.

Pancreas Transplantation

For type 1 diabetes with kidney transplant Eliminates need for exogenous insulin, SMBG, dietary restrictions Can also eliminate acute complications Long-term complications may persist Lifelong immunosuppression Islet cell transplantation experimental Usually it is done for patients who have end-stage kidney disease and who have had or plan to undergo kidney transplantation. Kidney and pancreas transplantations are often performed together, or a pancreas may be transplanted after kidney transplantation. Pancreas transplantation alone is rare. If renal failure is not present, the ADA recommends that pancreas transplantation be considered only for patients who exhibit the following three criteria: (1) a history of frequent, acute, and severe metabolic complications (e.g., hypoglycemia, hyperglycemia, ketoacidosis) necessitating medical attention; (2) clinical and emotional problems with exogenous insulin therapy that are so severe as to be incapacitating; and (3) consistent failure of insulin-based management to prevent acute complications. Successful pancreas transplantation can improve the quality of life of people with diabetes, primarily by eliminating the need for exogenous insulin, frequent blood glucose measurements, and many of the dietary restrictions imposed by the disorder. Transplantation can also eliminate the acute complications commonly experienced by patients with type 1 diabetes (e.g., hypoglycemia, hyperglycemia). However, pancreas transplantation is only partially successful in reversing the long-term renal and neurologic complications of diabetes. The patient will also require lifelong immunosuppression to prevent rejection of the graft. Complications can result from immunosuppressive therapy. Pancreatic islet cell transplantation is another potential treatment measure. During this procedure, the islet cells are harvested from the pancreas of a deceased organ donor. Most recipients require the use of two or more pancreases. The islet cells are infused via a catheter through the upper abdomen into the portal vein of the liver. With only the islet cells transplanted, pain and recovery time are diminished in comparison with whole pancreas transplantation. Currently, this procedure is experimental in the United States. Research is continuing to determine the best ways to implant the islet cells and to prevent their rejection.

When supply of insulin insufficient Must be treated promptly

Glucose cannot be properly used for energy Body breaks down fats stores Ketones are by-products of fat metabolism Alters pH balance, causing metabolic acidosis Ketone bodies excreted in urine Electrolytes become depleted- potassium imbalances Depending on signs/symptoms May or may not need hospitalized

Diabetes: Nutritional Therapy Goals Type 2

Guidelines from the ADA indicate that within the context of an overall healthy eating plan, a person with diabetes can eat the same foods as a person who does not have diabetes. This means that the same principles of good nutrition that apply to the general population also apply to the person with diabetes. According to the ADA, the overall goal of MNT is to assist people with diabetes in making healthy nutritional choices that will lead to improved metabolic control. Additional specific goals include the following: Maintain blood glucose levels to as near normal as safely possible to prevent or reduce the risk for complications of diabetes Normal lipid profiles and blood pressure that reduce the risk for cardiovascular disease Prevent or slow the rate of development of chronic complications of diabetes by modifying nutrient intake and lifestyle Address individual nutritional needs while taking into account personal and cultural preferences and respecting the individual's willingness to change. Maintain the pleasure of eating by allowing as many food choices as appropriate Emphasis on achieving glucose, lipid, and blood pressure goals Weight loss Nutritionally adequate meal plan, with appropriate serving sizes, ↓ sat and trans fat and low CHO (carbohydrates) can bring about decreased calorie consumption Spacing meals-spreads nutrient intake throughout the day Regular exercise and learning new behaviors and attitudes can help facilitate long-term lifestyle changes. Modest weight loss has been associated with improved insulin resistance. Therefore, weight loss is recommended for all individuals with diabetes who are overweight or obese. There is no one proven strategy or method that can be uniformly recommended. A weight loss of 5% to 7% of body weight often improves glycemic control, even if desirable body weight is not achieved. Weight loss is best attempted by a moderate decrease in calories and an increase in caloric expenditure. Monitoring of blood glucose levels, hemoglobin A1C, lipids, and blood pressure provide feedback on how well the goals of nutritional therapy are being met.

HHS management

HHS constitutes a medical emergency and has a high mortality rate. The management of DKA and that of HHS are similar and includes immediate IV administration insulin and either 0.9% or 0.45% NaCl. HHS usually necessitates greater volumes of fluid replacement. This should be accomplished slowly and carefully. Patients with HHS are commonly older and may have cardiac or renal compromise, necessitating hemodynamic monitoring to avoid fluid overload during fluid replacement. When blood glucose levels fall to approximately 250 mg/dL (13.9 mmol/L), IV fluids containing glucose are administered to prevent hypoglycemia. Electrolytes are monitored and replaced as needed. Hypokalemia is not as significant in HHS as it is in DKA, although fluid losses may result in milder potassium deficits that necessitate replacement. Assess vital signs, intake and output, tissue turgor, laboratory values, and cardiac monitoring to check the efficacy of fluid and electrolyte replacement. This includes monitoring of serum osmolality and frequent assessment of cardiac, renal, and mental status. Once the patient is stabilized, attempts to detect and correct the underlying precipitating cause should be initiated.

Nursing Implementation

Health promotion Identify, monitor, and teach patients at risk Obesity: primary risk factor The Diabetes Prevention Program found that a modest weight loss of 5% to 7% of body weight and regular exercise of 30 minutes five times a week lowered the risk of developing type 2 diabetes up to 58%. Routine screening for all overweight adults and those older than 45 for type 2 diabetes for all adults who are overweight or obese (BMI of 25 kg/m2 or higher) or have one or more risk factors Diabetes risk testscreening should begin at age 45. If values are normal, repeat testing at 3-year intervals

Diabetes: Nutritional Therapy USDA MyPlate Method

Helps patient visualize the amounts of non-starchy vegetable (1/2), starch (1/4), and protein (1/4) that should fill a 9-inch plate

Herbs That May Affect Blood Glucose

Herbs that may LOWER blood glucose: cinnamon, garlic, ginseng

HHS Medical emergency because

High mortality rate Therapy similar to DKA Except HHS requires greater fluid replacement

Somogyi Effect

Hyperglycemia in the morning A high dose of insulin produces a decline in blood glucose levels during the night. As a result, counter-regulatory hormones (e.g. Growth Hormone, Cortisol) are released, which in turn produce rebound hyperglycemia. The danger of this effect is that when blood glucose levels are measured in the morning, hyperglycemia is apparent and the patient (or the health care professional), stimulating lipolysis, gluconeogenesis, and glycogenolysis, may increase the insulin dose. If a patient is experiencing morning hyperglycemia, checking blood glucose levels between 2:00 AM and 4:00 AM for hypoglycemia will help determine if the cause is the Somogyi effect. The patient may report headaches on awakening and may recall having night sweats or nightmares. A bedtime snack, a reduction in the dose of insulin, or both can help to prevent the Somogyi effect.

Insulin Therapy Problems

Hypoglycemia (See October 12th PowerPoint Presentation). Allergic reaction (local inflammatory reactions such as itching, erythema, and burning around the injection site) Local reactions may be self-limiting within 1 to 3 months or may improve with a low dose of antihistamine. A true insulin allergy is rare. It is manifested by a systemic response with urticaria and possibly anaphylactic shock. Zinc or protamine, used as preservatives in the insulin, and the latex or rubber stoppers on the vials have been implicated in allergic reactions. Lipodystrophy (atrophy of subcutaneous tissue) The use of human insulin has significantly reduced the risk for lipodystrophy. Hypertrophy, a thickening of the subcutaneous tissue, eventually regresses if the patient does not use the site for at least 6 months. The use of hypertrophied sites may result in erratic insulin absorption. Somogyi Effect Dawn Phenomenon

Example of Nursing Policy to Treat Hypoglycemia

If patient exhibits signs and symptoms of low blood glucose, check by fingerstick. If there is uncertainty about whether the blood glucose is low, assume the blood sugar is in fact low and treat accordingly. If blood glucose is < 80mg/dl TREAT THE PATIENT. Eat or drink 15 grams of carbohydrate immediately. Examples: 4 ounces of fruit juice (Apple juice) 6 ounces of regular soda pop 1 cup skim milk Repeat blood glucose in 15 minutes. If not over 90 mg/dl, repeat treatment. For patients with renal insufficiency, use apple juice to reduce the risk of hyperkalemia. If the patient requests orange juice document this in the nurse's notes. Please refer to page 9 in the Clinical Instructor and Student Nurse Policy Handbook --- Geisinger Health System Fall 2015 in NSG 710 BlackBoard course. In cases where the patient is unresponsive, the following protocol may be seen in the PRN section on the Medication Administration Record: Dextrose 50% inj. Frequency: PRN (Hypoglycemic with CNS changes). Route: IV PUSH ADMINISTRATION INSTRUCTIONS: Glucose less than 80 give D50W by the following formula: (100 - blood glucose) x 0.3 to equal the total mL of D50W to be given. Recheck the blood glucose in 15 minutes. How many mL will the nurse give of D50W for a blood glucose of 40?

Precipitating factors Diabetic Ketoacidosis (DKA)

Illness Infection Inadequate insulin dosage Undiagnosed type 1 diabetes Poor self-management Neglect

Diabetes exchange lists are another tool for meal planning.

Instead of counting carbohydrates, the individual is given a meal plan with specific numbers of helpings from a list of exchanges for each meal and snack. The exchanges are starches, fruits, milk, meat, sweets, fats, and free foods. The patient will choose foods from the various exchanges on the basis of the prescribed meal plan. For some patients, this method may be easier than carbohydrate counting. The other advantage to this approach is that it helps the patient limit portion sizes and overall food intake, an important component of weight management. MyPlate was developed by the United States Department of Agriculture (USDA) to represent national nutritional guidelines. This simple method helps the patient visualize the amount of vegetables, starch, and meat that should fill a 9-inch plate. For a diabetic person, each meal has one half of the plate filled with nonstarchy vegetables, one fourth is filled with a starch, and one fourth is filled with a protein (see eFig. 49-1, available on the website). A glass of nonfat milk and a small piece of fresh fruit complete the meal. It is important to include family members and caregivers in nutrition education and counseling whenever possible, particularly the person who cooks for the household. However, the responsibility for maintaining a diabetic diet should not fall to someone other than the person with diabetes. Reliance on another person to make health decisions interferes with the patient's ability to develop self-care skills, which is essential in the management of diabetes. Independence should be fostered, except in special situations in which there is a barrier to self-care such as visual or cognitive impairment. It is also important to discuss traditional foods with the patient. To improve adherence, the diet needs to be individualized to take into account the patient's preferences and foods that are culturally appropriate. In an acute health care facility, the nutritional needs of the diabetic patient vary slightly from the normal meal plans. Previously, standardized calorie-level meal patterns were used, but new systems are now being used, such as the consistent carbohydrate diabetes meal plan. Under this system, meal plans are created with consistent carbohydrate content. For example, breakfast contains the same amount of carbohydrates every day.

Maintaining tight glucose control is the key! How???

Insulin:: Carb ratio at meal time Sliding scale Insulin sensitivity calculation

Microvascular: Diabetic Retinopathy treatment

Laser photocoagulation therapy is indicated to reduce the risk of vision loss in patients with proliferative retinopathy or macular edema and in some cases of nonproliferative retinopathy. Laser photocoagulation destroys the ischemic areas of the retina that produce growth factors that encourage neovascularization. A patient who develops vitreous hemorrhage and retinal detachment of the macula may need to undergo vitrectomy. Vitrectomy is the aspiration of blood, membrane, and fibers from the inside of the eye through a small incision just behind the cornea. Research has identified the importance of vascular endothelial growth factor (VEFG) in the development of diabetic retinopathy. Drugs injected into the eye that block the action of VEGF and reduce inflammation are currently being studied for their effectiveness in treating retinopathy.

DKA AND HOSPITALIZATION

Less severe form may be treated on outpatient basis Hospitalize for severe fluid and electrolyte imbalance, fever, nausea/vomiting, diarrhea, altered mental state Also if communication with health care provider is lacking; nature of the cause of the ketoacidosis Patients with DKA who have an illness such as pneumonia or a urinary tract infection are usually admitted to the hospita

Nutritional Therapy: Alcohol Intake

Limit intake to moderate amount Consume with food to reduce risk of nocturnal hypoglycemia if using insulin or insulin secretagogues Consume with CHO to reduce hypoglycemia, but then watch for hyperglycemia from CHOs Alcohol inhibits gluconeogenesis (breakdown of glycogen to glucose) by the liver. This can cause severe hypoglycemia in patients taking insulin or oral hypoglycemic medications that increase insulin secretion. Encourage patients to discuss their use of alcohol honestly with their health care providers because its use can make blood glucose more difficult to control. Moderate alcohol consumption can sometimes be safely incorporated into the meal plan if blood glucose levels are well controlled and if the patient is not taking medications that will cause adverse effects. Moderate consumption is defined as one drink per day for women and two drinks per day for men. A patient can reduce the risk for alcohol-induced hypoglycemia by eating carbohydrates when drinking alcohol. To decrease the carbohydrate content, recommend the use of sugar-free mixes and drinking dry, light wines.

Diabetes: Nutritional Therapy Fats

Limit saturated fats; Fat is bad Has 9 calories per gram Should have less than 30% of our calories from fat Limit cholesterol to less than 200 mg/day Minimize trans fat Two or more servings of fish per week to provide polyunsaturated fatty acids Dietary fat provides energy, carries fat-soluble vitamins, and provides essential fatty acids. The ADA recommends limiting saturated fat to less than 7% of total calories. Less than 200 mg/day of cholesterol and limited trans fats are also recommended as part of a healthy meal plan. Decreasing fat and cholesterol intake assists in reducing the risk for cardiovascular disease.

Nursing Implementation Acute illness Situations Acute illness, injury, and surgery

Maintain normal diet if able- body requires extra energy to deal with the stress of the illness If patients are able to eat normally, they should continue with their regular meal plan while increasing the intake of noncaloric fluids, such as water, diet gelatin, and other decaffeinated beverages, and continue taking oral agents, nonisulin injectable agents, and insulin as prescribed. Continue taking antidiabetic medications (oral agents, noninsulin injectable agents, and insulin) as prescribed while supplementing food intake with carbohydrate-containing fluids such as low sodium soups, juices and regular decaffeinated soft drinks Contact the HCP if unable to keep down food or fluid ↑ Blood glucose level secondary to counterregulatory hormones resulting in hyperglycemia. Even common illnesses such as a viral upper respiratory infection or the flu can cause this response. When patients with diabetes are ill, they should check blood glucose at least every 4 hours Frequent monitoring of blood glucose Ketone testing if glucose level exceeds 240 mg/dL every 3 to 4 hours Report glucose levels exceeding 300 mg/dL for two tests or moderate to high ketone levels Increase insulin for type 1 diabetes to prevent DKA Type 2 diabetes may necessitate insulin therapy to prevent or treat hyperglycemic symptoms and avoid an acute hyperglycemic emergency. In critically ill patients, insulin therapy may be started if the blood glucose level is persistently greater than 180 mg/dL. These patients have a higher targeted blood glucose goal, which is usually 140 to 180 mg/dL. Both emotional and physical stress can increase the blood glucose level and result in hyperglycemia. Because stress is unavoidable, certain situations may require more intense management, such as extra insulin, to maintain glycemic goals and avoid hyperglycemia

Diabetes: Nutritional Therapy Carbohydrates

Minimum of 130 g/day 45-60 grams of CHO per meal 15-30 grams of CHO per snack Fruits, vegetables, whole grains, legumes, low-fat milk should be included as part of a healthy meal plan Monitor with CHO counting, exchanges, or experienced-based estimation Use glycemic index sugars, starches, and fiber provide important sources of energy, fiber, vitamins, and minerals and are therefore important to all people, as well as those with diabetes Sucrose-containing food can be substituted for other carbohydrates in the meal plan

DKA/HHS Nursing Management

Monitor IV fluids Insulin therapy Electrolytes Assess Renal status Cardiopulmonary status Level of consciousness Closely monitor blood glucose and urine for output and ketones, as well laboratory data to determine appropriate patient care. Monitor the administration of (1) IV fluids to correct dehydration, (2) insulin therapy to reduce blood glucose and serum acetone levels, and (3) electrolytes given to correct electrolyte imbalance. Assess renal status and the cardiopulmonary status related to hydration and electrolyte levels. Monitor the level of consciousness. Assess for signs of potassium imbalance resulting from hypoinsulinemia and osmotic diuresis. When treatment with insulin begins, serum potassium levels may decrease rapidly as potassium moves into the cells once insulin becomes available. This movement of potassium into and out of extracellular fluid influences cardiac functioning. Cardiac monitoring is a useful aid in detecting hyperkalemia and hypokalemia because characteristic changes indicating potassium excess or deficit are observable on electrocardiographic tracings. Assess vital signs often to determine the presence of fever, hypovolemic shock, tachycardia, and Kussmaul respirations.

Dawn Phenomenon

Morning hyperglycemia present on awakening The Dawn phenomenon affects a majority of people with diabetes and tends to be most severe when growth hormone is at its peak in adolescence and young adulthood. Due to release of counterregulatory hormones in predawn hours growth hormone and cortisol, excreted in increased amounts in the early morning hours are responsible. The treatment for Dawn Phenomenon is an increase in insulin or an adjustment in administration time.

Insulin Regimens: Basal-Bolus Model what does it closes mimic what two types of insulin do you take and when

Most closely mimics endogenous insulin production Rapid- or short-acting (bolus) insulin before meals Intermediate- or long-acting (basal) background insulin once or twice a day Less intense regimens can also be used

Retinopathy Photocoagulation

Most common Laser destroys ischemic areas of retina Prevents further visual loss

Retinopathy path from photo

Nonproliferative Most common form Partial occlusion of small blood vessels in retina Causes development of micro aneurysms Capillary fluid leaks out Retinal edema and eventually hard exudates or intraretinal hemorrhages occur Proliferative Most severe form When retinal capillaries become occluded Body forms new blood vessels Vessels are extremely fragile and hemorrhage easily Produces vitreous contraction Retinal detachment can occur Involves retina and vitreous

Diabetes: Nutritional Therapy Food composition

Nutrient balance of diabetic diet is essential to maintain blood glucose levels Nutritional energy intake should be balanced with energy output taking into account exercise and metabolic bodywork Each patient's individual meal plan should be constructed with her or his lifestyle and health goals in mind.

Planning

Overall goals Active patient participation Few or no episodes of acute hyperglycemic emergencies or hypoglycemia Maintain normal blood glucose levels Prevent or minimize chronic complications Adjust lifestyle to accommodate diabetes regimen

Nursing Assessment Subjective data

Past health history: mumps, rubella, coxsackievirus or other viral infections; recent trauma, infection, or stress; pregnancy, delivering infant weighing more than 9 lb; chronic pancreatitis; Cushing syndrome; acromegaly; family history of type 1 or type 2 diabetes mellitus Medications: use of and compliance with insulin or OA regimen; use of corticosteroids, diuretics, phenytoin (Dilantin) Surgery or other treatments: any recent surgery Health perception-health management: positive family history; malaise; date of last eye and dental examination Nutritional-metabolic: obesity; weight loss (type 1), weight gain (type 2); thirst, hunger; nausea and vomiting; poor healing (especially involving the feet), compliance with diet in patients with previously diagnosed diabetes Elimination: constipation or diarrhea; frequent urination, frequent bladder infections, nocturia, urinary incontinence Activity-exercise: muscle weakness, fatigue Cognitive-perceptual: abdominal pain; headache; blurred vision; numbness or tingling of extremities; pruritus Sexuality-reproductive: impotence; frequent vaginal infections; decreased libido Coping-stress tolerance: depression, irritability, apathy Value-belief: commitment to lifestyle changes involving diet, medication, and activity patterns

Nursing Assessment Objective Data

Possible focused assessment findings: Soft, sunken eyeballs*; vitreal hemorrhages; cataracts Dry, warm, inelastic skin; pigmented lesions (on legs); ulcers (especially on feet); loss of hair on toes; acanthosis nigricans Rapid, deep respirations (Kussmaul respirations)* Hypotension*; weak, rapid pulse* Dry mouth; vomiting*; fruity breath* Altered reflexes; restlessness; confusion; stupor; coma Muscle wasting * Indicates manifestations of diabetic ketoacidosis Serum electrolyte abnormalities; fasting blood glucose level of126 mg/dL or higher; oral glucose tolerance test result exceeding 200 mg/dL; random glucose test result of 200 mg/dL or higher; leukocytosis; ↑ blood urea nitrogen, creatinine levels ↑ Triglycerides, cholesterol, LDL, VLDL levels; ↓ HDL level; hemoglobin A1C level exceeding 6.0%; glycosuria; ketonuria; albuminuria; acidosis

HHS Patient has enough circulating insulin so ketoacidosis does not occur

Produces fewer symptoms in earlier stages Neurologic manifestations occur due to ↑ serum osmolality

Nursing Care Related to Oral and Noninsulin Injectable Agents

Proper administration Assessment of the patient's use and response to these drugs Teaching the patient and family Nursing assessment is valuable in determining the most appropriate drug for a patient (mental status, eating habits, home environment, attitude toward diabetes, and medication history).

Hypoglycemia Common manifestations

Shakiness Palpitations Nervousness Diaphoresis Anxiety Hunger Pallor Epinephrine release causes manifestations that include shakiness, palpitations, nervousness, diaphoresis, anxiety, hunger, and pallor.

Diabetes: Nutritional Therapy Protein

Should make up 15% to 20% of total calories 1 oz. of meat = 7 grams of protein High-protein diets not recommended for weight loss The amount of daily protein in the diet for people with diabetes and normal renal function is the same as for the general population.

Causes of Hypoglycemia

Symptoms can also occur when high glucose level falls too rapidly often related to a mismatch in the timing of food intake and the peak action of insulin or oral hypoglycemic agents that increase endogenous insulin secretion. The balance between blood glucose and insulin can be disrupted by administering too much insulin or medication, ingesting too little food, delaying the time of eating, and performing unusual amounts of exercise. can occur at any time, but most episodes occur when the OA or insulin is at its peak of action or when the patient's daily routine is disrupted without adequate adjustments in diet, medications, and activity. Although more common with insulin therapy, it can occur with OAs, and it may be severe and persist for an extended time because of the longer duration of action. Symptoms may occur when a very high blood glucose level falls too rapidly (e.g., a blood glucose level of 300 mg/dL [16.7 mmol/L] falling quickly to 180 mg/dL [10 mmol/L]). Although the blood glucose level is above normal by definition and measurement, the sudden metabolic shift can evoke hypoglycemic symptoms. Overly vigorous management of hyperglycemia with insulin can cause this type of situation.

Microvascular: Diabetic Retinopathy signs

The earliest and most treatable stages of diabetic retinopathy often produce no changes in the vision. Therefore, patients with type 2 diabetes should have an eye examination with pupil dilation by an ophthalmologist or a specially trained optometrist at the time of diagnosis and annually thereafter for early detection and treatment. A person with type 1 diabetes should have the eye examined with dilation within 5 years after the onset of diabetes and then repeat this examination annually. The best approach to the management of diabetic eye disease is to prevent it by maintaining good glycemic control and managing hypertension.

Microvascular: Diabetic Neuropathy Distal symmetric polyneuropathy

The most common form of sensory neuropathy which affects the hands and/or feet bilaterally. This is sometimes referred to as stocking-glove neuropathy. Characteristics of distal symmetric polyneuropathy include loss of sensation, abnormal sensations, pain, and paresthesias. The pain, which is often described as burning, cramping, crushing, or tearing, is usually worse at night and may occur only at that time. The paresthesias may be associated with tingling, burning, and itching sensations. The patient may report a feeling of walking on pillows or numb feet. At times the skin becomes so sensitive (hyperesthesia) that even light pressure from bed sheets cannot be tolerated. Complete or partial loss of sensitivity to touch and temperature is common.

Mealtime Insulin (Bolus) Insulin Preparations

To control postmeal blood glucose levels, the timing of administration of rapid- and short-acting insulin in relation to meals is crucial Rapid-acting (bolus) Lispro: (Humalog) Aspart: (Novolog) Onset of action 15 minutes Injected within 15 minutes of mealtime Most closely mimic natural insulin secretion in response to a meal Short-acting (bolus) Regular with onset of action 30 to 60 minutes to ensure that the onset of action coincides with meal absorption Injected 30 to 45 minutes before meal Onset of action 30 to 60 minutes Because timing an injection 30 to 45 minutes before a meal is difficult for people to incorporate into their lifestyles, the flexibility that rapid-acting insulins offer is preferred by those taking insulin with their meals. Short-acting insulin is also more likely to cause hypoglycemia because of a longer duration of action

Diabetes: Exercise

Type/amount Minimum 150 minutes/week aerobic Resistance training three times/week The ADA also encourages people with type 2 diabetes to perform resistance training three times a week, in the absence of contraindications. Benefits ↓ Insulin resistance and blood glucose Weight loss ↓ Triglycerides and LDL , ↑ HDL Improve BP and circulation The therapeutic benefits of regular physical activity may result in a decreased need for diabetes medications in order to reach target blood glucose goals. Start slowly after medical clearance, gradual progression toward the desired goal Monitor blood glucose it is possible for hypoglycemia to occur for that long after the activity Glucose-lowering effect up to 48 hours after exercise Exercise 1 hour after a meal Snack to prevent hypoglycemia It is recommended that patients who use medications that can cause hypoglycemia schedule exercise about 1 hour after a meal or that they have a 10- to 15-g carbohydrate snack and check their blood glucose level before exercising. Small carbohydrate snacks can be taken every 30 minutes during exercise to prevent hypoglycemia. Patients using medications that place them at risk for hypoglycemia should always carry a fast-acting source of carbohydrate, such as glucose tablets or hard candies, when exercising Do not exercise if blood glucose level exceeds 300 mg/dL and if ketones are present in urine Patients who use insulin, sulfonylureas, or meglitinides are at increased risk for hypoglycemia when there is an increase in physical activity, especially if the patient exercises at the time of peak drug action or if food intake has not been sufficient to maintain adequate blood glucose levels. This can also occur if a normally sedentary patient with diabetes has an unusually active day. Although exercise is generally beneficial to blood glucose levels, strenuous activity can be perceived by the body as a stress, causing a release of counterregulatory hormones that result in a temporary elevation of blood glucose. In a person with type 1 diabetes who is hyperglycemic and ketotic, exercise can worsen hyperglycemia and ketosis. Therefore, vigorous activity should be avoided if the blood glucose level exceeds 300 mg/dL and if ketones are present in the urine. If hyperglycemia is present without ketosis, it is not necessary to postpone exercise.

Insulin Administration

Typically given by subcutaneous injection ONLY Regular insulin may be given IV when immediate onset of action is desired Cannot be taken orally - inactivated by gastric juices The speed with which peak serum concentrations are reached varies with the anatomic site for injection. Absorption is fastest from abdomen, followed by arm, thigh, and buttock Abdomen is preferred site; other sites are appropriate for insulin injections Do not inject in site to be exercised example, the patient should not inject insulin into the thigh and then go jogging Exercise of the area containing the injection site, together with the increased body heat and circulation generated by the exercise, may increase the rate of absorption and speed the onset of insulin action Rotate injections within one particular site. Teach patient to rotate the injection site within one anatomic site, such as the abdomen, for at least 1 week before using a different site This allows for better insulin absorption example, it may be helpful to think of the abdomen as a checkerboard, with each half-inch square representing an injection site. Injections are rotated systematically across the board, with each injection site at least ½ to 1 inch away from the previous injection site. Usually available as U100 insulin (1 mL contains 100 U of insulin) U100 insulin must be used with a U100-marked syringe Syringes marked for units: various sizes including 1.0, 0.5, and 0.3 mL The 0.5-mL size may be used for doses of 50 U or less, and the 0.3-mL syringe can be used for doses of 30 U or less. The 0.5- and 0.3-mL syringes are in 1-U increments. This provides more accurate delivery when the dose is an odd number. The 1.0-mL syringe is necessary for patients who require more than 50 U of insulin. The 1.0-mL syringe is in 2-U increments. When patients change from a 0.3- or a 0.5-mL to a 1.0-mL syringe, make them aware of the dose increment difference Only user recaps syringe. Never recap a needle used by a patient No alcohol swab for self-injection; wash with soap and water This applies primarily to patient self-injection technique. When injection occurs in a health care facility, policy may dictate site preparation with alcohol to prevent health care-associated infection (HAI). Inject at 45- to 90-degree angle, depending on the thickness of the patient's fat pad

Nursing Implications: for Herbs That May Affect Blood Glucose

Use supplements with caution Consult health care provider before using nutritional supplements Monitor blood glucose more closely

Background Insulin (Basal)

Used to control glucose levels in between meals and overnight Without 24-hour background insulin, people with type 1 diabetes are more prone to developing diabetic ketoacidosis. Many people with type 2 diabetes who use mealtime insulin injections or oral medications also require basal insulin to adequately control blood glucose levels. Long-acting (basal) Insulin glargine (Lantus) Detemir (Levemir) Released steadily and continuously with no peak action Administered once or twice a day subcutaneous administration, detemir can be given twice daily. Because they lack peak action time, the risk for hypoglycemia from this type of insulin is greatly reduced Do not mix with any other insulin or solution Intermediate-acting insulin (NPH) is also used as a basal insulin The disadvantage of NPH is that its peak of action ranges from 4 to 12 hours, which can result in hypoglycemia. NPH is the only basal insulin that can be mixed with short- and rapid-acting insulins Intermediate-acting insulin NPH Duration 12 to 18 hours Peak 4 to 12 hours Can mix with short- and rapid-acting insulins Cloudy; must agitate to mix

Retinopathy Cryotherapy

Used to treat peripheral areas of retina Probe creates frozen area until reaches specific point on retina

Nursing Implementation During the Intraoperative period

adjustments in the diabetes regimen can be planned to ensure glycemic control. The patient is given IV fluids and insulin (if needed) immediately before, during, and after surgery when there is no oral intake. The patient with type 2 diabetes who has been taking oral agents should understand that this is a temporary measure and it should not be interpreted as a worsening of diabetes. When caring for an unconscious surgical patient receiving insulin, be alert for hypoglycemic signs such as sweating, tachycardia, and tremors. Frequent monitoring of blood glucose will prevent episodes of severe hypoglycemia

Microvascular: Diabetic Neuropathy Autonomic neuropathy

can affect nearly all body systems and lead to hypoglycemic unawareness, bowel incontinence and diarrhea, and urinary retention. Gastroparesis (delayed gastric emptying) is a complication that can produce anorexia, nausea, vomiting, gastroesophageal reflux, and persistent feelings of fullness. Gastroparesis can trigger hypoglycemia by delaying food absorption. Cardiovascular abnormalities associated with autonomic neuropathy are postural hypotension, resting tachycardia, and painless myocardial infarction. Assess patients with diabetes for postural hypotension to determine if they are at risk for falls. Instruct the patient with postural hypotension to change from a lying or sitting position slowly. Diabetes can affect sexual function in men and women. Erectile dysfunction (ED) in diabetic men is well recognized and common, often being the first manifestation of autonomic neuropathy. ED in diabetes is also associated with other factors, including vascular disease, metabolic control, nutrition, endocrine disorders, psychogenic factors, and medications. Decreased libido is a problem for some women with diabetes. Candidal and nonspecific vaginitis are also common. ED or sexual dysfunction necessitates sensitive therapeutic counseling for both the patient and the patient's partner. A neurogenic bladder may develop as the sensation in the inner bladder wall decreases, causing urinary retention. A patient with retention has infrequent voiding, difficulty in voiding, and a weak stream of urine. Emptying the bladder every 3 hours in a sitting position helps prevent stasis and subsequent infection. Tightening the abdominal muscles during voiding and using Credé's maneuver (mild massage downward over the lower abdomen and bladder) may also help with complete bladder emptying. Cholinergic agonist drugs such as bethanechol (Urecholine) may be used. The patient may also need to learn self-catheterization.

Basal- Bolus Model less intense regimens what happens when not giving optimal control

can also achieve good glucose control for some people. Ideally, the patient and the health care provider should mutually select regimens. The criteria for selection are based on the desired and feasible levels of glycemic control and the patient's lifestyle, diet, and activity patterns. If not giving the patient optimal control, a more intense approach should be encouraged by the health care provider.

Foot Complications

can be the result of a combination of microvascular and macrovascular diseases that place the patient at risk for injury and serious infection. Sensory neuropathy and peripheral artery disease (PAD) are risk factors for foot complications. In addition clotting abnormalities, impaired immune function, and autonomic neuropathy also have a role. Smoking is deleterious to the health of lower extremity blood vessels and increases the risk for amputation. Sensory neuropathy is a major risk factor for lower extremity amputation in the person with diabetes. Loss of protective sensation (LOPS) often prevents the patient from being aware that a foot injury has occurred. Improper footwear and injury from stepping barefoot on foreign objects are common causes of undetected foot injury in patients with LOPS. Because the primary risk factor for lower extremity amputation is LOPS, annual screening with a monofilament is important. This is done by applying a thin, flexible filament to several spots on the plantar surface of the foot and asking the patient to report if it is felt. Insensitivity to a monofilament has been shown to greatly increase the risk for diabetic foot ulcers that can lead to amputation. PAD increases the risk for amputation by causing a reduction in blood flow to the lower extremities. When blood flow is decreased, oxygen, white blood cells, and vital nutrients are not available to the tissues. Wounds take longer to heal, and the risk for infection increases. Signs of PAD include intermittent claudication, pain at rest, cold feet, loss of hair, delayed capillary filling, and dependent rubor (redness of the skin that occurs when the extremity is in a dependent position). Management includes control or reduction of risk factors, particularly smoking, high cholesterol intake, and hypertension. Bypass or graft surgery is indicated in some patients.

hypoglycemia untreated

can progress to loss of consciousness, seizures, coma, and death Because the brain requires a constant supply of glucose in sufficient quantities to function properly, hypoglycemia can affect mental functioning. The manifestations are speaking difficulties, visual disturbances, stupor, confusion, and coma. Manifestations of hypoglycemia can mimic those of alcohol intoxication. Untreated hypoglycemia can progress to loss of consciousness, seizures, coma, and death.

Basal - Bolus Model Intensive insulin therapy,

consisting of multiple daily insulin injections together with frequent self-monitoring of blood glucose Goal: to achieve a near-normal glucose level of 70 to 130 mg/dL before meals

Microvascular: Diabetic Retinopathy Proliferative

the most severe form, involves the retina and the vitreous humor. When retinal capillaries become occluded, the body compensates by forming new blood vessels to supply the retina with blood, a pathologic process known as neovascularization. These new vessels are extremely fragile and hemorrhage easily, producing vitreous contraction. Eventually light is prevented from reaching the retina as the vessels become torn and bleed into the vitreous cavity. The patient sees black or red spots or lines. If these new blood vessels pull the retina while the vitreous contracts, causing a tear, partial or complete, retinal detachment will occur. If the macula is involved, vision is lost. Without treatment, more than half of patients with proliferative diabetic retinopathy will be blind. Persons with diabetes are also prone to other visual problems. Glaucoma occurs as a result of the occlusion of the outflow channels secondary to neovascularization. This type of glaucoma is difficult to treat and often results in blindness. Cataracts develop at an earlier age and progress more rapidly in people with diabetes.

Patients at risk for hypoglycemic unawareness include

those who have had repeated episodes of hypoglycemia, older patients, and patients who use β-adrenergic blockers.

Patient teaching to prevent foot ulcers

wash feet daily dry feet well keep the skin supple check feet with mirror use emery board to gently shape nail daily change sock keep feet dry and warm never walk barefoot examine your shoes everyday