CHAPTER 49 Nursing Management Diabetes Mellitus (lewis)

Intermediate-acting insulin

NPH (Humulin N, Novolin N, ReliOn N)

Long-acting insulin

glargine (Lantus) detemir (Levemir)

Regardless of the type, the diagnosis of diabetes mellitus can be made through one of four methods

1.A1C ≥6.5%. 2.Fasting plasma glucose (FPG) level ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 hours. 3.Two-hour plasma glucose level ≥200 mg/dL (11.1 mmol/L) during an OGTT, using a glucose load of 75 g. 4.In a patient with classic symptoms of hyperglycemia (polyuria, polydipsia, unexplained weight loss) or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (11.1 mmol/L).

glycemic index

A measure of how the ingestion of a particular food affects blood glucose levels.

diabetes mellitus

Chronic metabolic disorder caused by insulin deficiency, which impairs carbohydrate usage and enhances usage of fats and proteins.

Dawn phenomenon

Early morning glucose elevation produced by the release of growth hormone, which decreases peripheral uptake of glucose resulting in elevated morning glucose levels. Admin of insulin at a later time in day will coordinate insulin peak with the hormone release.

impaired fasting glucose

Impaired fasting glucose (IFG) for a fasting plasma glucose between 110 & 126 mg/dl

prediabetes

Impaired fasting glucose (IFG) ≥ 100 but <126 mg.dl or impaired glucose tolerance ≥ 140mgdl but <200mgdl confirmed by at least 2 diff measurements

insulin resistance

Insulin becomes less effective at lowering blood sugars. The resulting increase in blood glucose may raise levels outside the normal range and cause adverse health effects.

Combination therapy (premixed)

NPH/regular 70/30* (Humulin 70/30, Novolin 70/30, ReliOn 70/30) NPH/regular 50/50* (Humulin 50/50) lispro protamine/lispro 75/25* (Humalog Mix 75/25) lispro protamine/lispro 50/50* (Humalog Mix 50/50) aspart protamine/aspart 70/30* (NovoLog Mix 70/30)

diabetic ketoacidosis

One of the most serious complications of hyperglycemia. Caused by drawing fluid out of the cell into circulation, excreted by kidneys. Results in Polyuria, dehydration & electrolyte imbalance. This increases fat metabolism and ketones, resulting in metabolic acidosis.

impaired glucose tolerance

What Does not meet the criteria for diagnosis of DM however they have abnormalities noted on the glucose tolerance test

hyperosmolar hyperglycemic syndrome

What acute high blood glucose complication can occur as a result of uncontrolled type 2 DM?

GLUCOSE-LOWERING EFFECT

acetaminophen (Tylenol) alcohol allopurinol (Zyloprim) α-glucosidase inhibitors anabolic steroids β-adrenergic blockers biguanides chloramphenicol clofibrate (Atromid-S) DPP-4 inhibitors exenatide (Byetta) insulin meglitinides monoamine oxidase inhibitors NSAIDs phenylbutazone potassium salts pramlintide (Symlin) probenecid salicylates in large doses sulfonylureas thiazolidinediones tricyclic antidepressants urinary acidifiers

GLUCOSE-RAISING EFFECT

acetazolamide (Diamox) arginine asparaginase (Elspar) caffeine in large doses barbiturates calcitonin calcium channel blockers cholestyramine (Questran) corticosteroids cyclosporine ethacrynic acid (Edecrin) morphine epinephrine furosemide (Lasix) glucagon glucose glycerin glycerol levodopa lithium niacin marijuana nicotine oral contraceptives phenobarbital phenothiazines phenytoin (Dilantin) rifampin tacrolimus (Prograf) thiazide diuretics urinary alkalizing agents

intensive insulin therapy

insulin therapy that requires multiple daily injections of insulin and frequent self monitoring of blood glucose levels (4-6 times per day)

Rapid-acting insulin

lispro (Humalog) aspart (NovoLog) glulisine (Apidra)

Somogyi effect

manifests as high blood sugar upon wakening

Short-acting insulin

regular (Humulin R, Novolin R, ReliOn R)

Protein

• 15%-20% of total calories. • High-protein diets are not recommended for weight loss.

Diagnostic Studies

• A diagnosis of diabetes is based on one of three methods: fasting plasma glucose level, random plasma glucose measurement, or 2-hour oral glucose tolerance test. • The glycosated hemoglobin test (HbA1c) is useful in evaluating long-term glycemic levels. The American Diabetes Association (ADA) recommends keeping the A1C level below 7%.

INFECTION

• A patient with diabetes is more susceptible to infections because of a defect in the mobilization of inflammatory cells and an impairment of phagocytosis by neutrophils and monocytes.

CHRONIC COMPLICATIONS OF DIABETES MELLITUS

• Chronic complications of diabetes are primarily those of end-organ disease from damage to blood vessels as a result of chronic hyperglycemia. These chronic blood vessel dysfunctions are divided into two categories: macrovascular complications and microvascular complications. o Macrovascular complications are diseases of the large and medium-sized blood vessels that occur with greater frequency and with an earlier onset in people with diabetes. o Microvascular complications result from thickening of the vessel membranes in the capillaries and arterioles in response to conditions of chronic hyperglycemia. • Diabetic retinopathy refers to the process of microvascular damage to the retina as a result of chronic hyperglycemia in patients with diabetes. There are two types: proliferative and nonproliferative. Because the earliest and most treatable stages produce no vision changes, persons with diabetes should have an annual dilated eye examination. • Diabetic nephropathy is a microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidney. Patients should be screened annually with a measurement of albumin-creatinine ratio from a urine specimen. • Diabetic neuropathy is nerve damage that occurs because of the metabolic derangements associated with diabetes mellitus. The two major categories of diabetic neuropathy are sensory neuropathy, which affects the peripheral nervous system, and autonomic neuropathy. • The most common form of sensory neuropathy is distal symmetric neuropathy, which affects the hands and/or feet bilaterally. This is sometimes referred to as "stocking-glove neuropathy." • Autonomic neuropathy can affect nearly all body systems and lead to hypoglycemic unawareness, bowel incontinence and diarrhea, and urinary retention.

INTEGUMENTARY COMPLICATIONS

• Common skin complications in diabetes include Acanthosis nigricans, diabetic dermatopathy, Necrobiosis lipoidica diabeticorum, and Granuloma annulare. • Because the thin skin is prone to injury, special care must be taken to protect affected areas from injury and ulceration.

Etiology and Pathophysiology

• Diabetes mellitus is a chronic multisystem disorder of glucose metabolism related to absent or insufficient insulin supplies, impaired utilization of insulin, or both. • Current theories link the causes of diabetes to genetic, autoimmune, and environmental factors.

ACUTE COMPLICATIONS OF DIABETES MELLITUS

• Diabetic ketoacidosis (DKA), also referred to as "diabetic acidosis" and "diabetic coma," is a life-threatening condition caused by a profound deficiency of insulin and is characterized by hyperglycemia, ketosis, acidosis, and dehydration. It is most likely to occur in people with type 1 diabetes. • Hyperosmolar hyperglycemic syndrome (HHS) is a 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. • Hypoglycemia, or low blood glucose, occurs when there is too much insulin in proportion to available glucose in the blood. o Causes of hypoglycemia are 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. o A critical role of the nurse is the prompt recognition of hypoglycemia and initiating the appropriate treatment dependent on the patient's status.

Drug Therapy: Insulin

• Exogenous (injected) insulin is needed when a patient has inadequate insulin to meet specific metabolic needs. • Insulin is divided into two main categories: short-acting (bolus) and long-acting (basal) insulin. Basal insulin is used to maintain a background level of insulin throughout the day; bolus insulin is used at mealtime to combat postprandial hyperglycemia and at bedtime. • A variety of insulin regimens are recommended for patients depending on the needs of the patient and their preference. • Routine administration of insulin is most commonly done by means of subcutaneous injection, intravenous administration of regular insulin can be done when immediate onset of action is desired. • The technique for insulin injections should be taught to new insulin users and reviewed periodically with long-term users. • The speed with which peak serum concentrations are reached varies with the anatomic site for injection. The fastest absorption is from the abdomen. • Continuous subcutaneous insulin infusion can be administered using an insulin pump, a small battery-operated device that resembles a standard paging device in size and appearance. It is programmed to deliver a continuous infusion of short-acting insulin 24 hours a day with boluses at mealtime.

COMPLICATIONS OF FOOT AND LOWER EXTREMITIES

• Foot complications are the most common cause of hospitalization in the person with diabetes. Sensory neuropathy is a major risk factor for lower extremity amputation in the person with diabetes. • Proper care of a diabetic foot ulcer is critical to prevent infections. • Loss of protective sensation often prevents the patient from becoming aware that a foot injury has occurred

Gestational Diabetes

• Gestational diabetes develops during pregnancy and is detected at 24 to 28 weeks of gestation, usually following an oral glucose tolerance test. • Although most women with gestational diabetes will have normal glucose levels within 6 weeks postpartum, their risk for developing type 2 diabetes in 5 to 10 years is increased.

Fat

• Limit saturated fat to <7% of total calories. • Trans fat should be minimized. • Dietary cholesterol <200 mg/day. • ≥2 servings of fish per week to provide polyunsaturated fatty acids.

Alcohol

• Limit to moderate amount (≤1 drink per day for women and ≤2 drinks per day for men). • Alcohol should be consumed with food to reduce risk of nocturnal hypoglycemia in those using insulin or insulin secretagogues. • Moderate alcohol consumption has no acute effect on glucose and insulin concentrations, but carbohydrate taken with the alcohol (mixed drink) may raise blood glucose.

Total carbohydrate

• Minimum of 130 g/day. • Include carbohydrate from fruits, vegetables, whole grains, legumes, and low-fat milk. • Monitor by carbohydrate counting, exchanges, or experienced-based estimation. • Glycemic index may provide additional benefit. • Sucrose-containing food can be substituted for other carbohydrates in the meal plan. • Fiber intake at 14 g/1000 kcal (same as general population). • Sugar alcohols and nonnutritive sweeteners are safe when consumed within FDA daily intake levels.

NURSING MANAGEMENT: DIABETES MELLITUS

• Nursing responsibilities for the patient receiving insulin include proper administration, assessment of the patient's response to insulin therapy, and education of the patient regarding administration of, adjustment to, and side effects of insulin. • Proper administration, assessment of the patient's use of, and response to the OA, as well as education of the patient and the family about OAs, are all part of the nurse's function. • The goals of diabetes self-management education are to enable the patient to become the most active participant in his or her care, while matching the level of self-management to the ability of the individual patient.

Prediabetes (keypoints)

• Prediabetes is a condition in which blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes. Those with prediabetes will usually develop type 2 diabetes within 10 years if no preventive measures are taken. • Long-term damage to the body, especially the heart and blood vessels, may already be occurring in patients with prediabetes

Monitoring Blood Glucose

• Self-monitoring of blood glucose (SMBG) is a cornerstone of diabetes management. By providing a current blood glucose reading, SMBG enables the patient to make self-management decisions regarding diet, exercise, and medication. • The frequency of monitoring depends on several factors, including the patient's glycemic goals, the type of diabetes that the patient has, the patient's ability to perform the test independently, and the patient's willingness to test.

Collaborative Care

• The goals of diabetes management are to reduce symptoms, promote well-being, prevent acute complications of hyperglycemia, and prevent or delay the onset and progression of long-term complications. These goals are most likely to be met when the patient is able to maintain blood glucose levels as near to normal as possible.

Type 1 Diabetes Mellitus

• Type 1 diabetes mellitus most often occurs in people who are under 30 years of age, with a peak onset between ages 11 and 13, but can occur at any age. • Type 1 diabetes is the end result of a long-standing process where the body's own T cells attack and destroy pancreatic cells, which are the source of the body's insulin. • Because the onset of type 1 diabetes is rapid, the initial manifestations are usually acute. • The classic symptoms—polyuria, polydipsia, and polyphagia—are caused by hyperglycemia and the accompanying spillover of excess glucose in the urine. • The individual with type 1 diabetes requires a supply of insulin from an outside source, such as an injection, in order to sustain life. Without insulin, the patient will develop diabetic ketoacidosis (DKA), a life-threatening condition resulting in metabolic acidosis.

Type 2 Diabetes Mellitus

• Type 2 diabetes mellitus accounts for over 90% of patients with diabetes. • In type 2 diabetes, the pancreas usually continues to produce some endogenous (self-made) insulin. However, the insulin that is produced is either insufficient for the needs of the body and/or is poorly used by the tissues. • The most important risk factor for developing type 2 diabetes is believed to be obesity, specifically abdominal and visceral adiposity. • The manifestations of type 2 diabetes are more nonspecific, and include fatigue, recurrent infections, recurrent vaginal yeast or monilia infections, prolonged wound healing, and visual changes.