Chapter 49 Diabetes Mellitus Assessment
Somogyi effect
Rebound effect in which an overdose of insulin causes hypoglycemia Release of counterregulatory hormones causes rebound hyperglycemia
Fiber Diabetic Nutritional Therapy
Recommendation: 25 to 30 g/day
Insulin preparations: Short-acting (bolus)
Regular with onset of action 30 to 60 minutes Injected 30 to 45 minutes before meal Onset of action 30 to 60 minutes
Other Specific Types of Diabetes
Results from damage to, injury to, interference with, or destruction of β-cell function in the pancreas From medical conditions and/or medications Resolves when underlying condition is treated or medication is discontinued
Hypoglycemia Treatment
Rule of 15 Consume 15 g of a simple carbohydrate Fruit juice or regular soft drink, 4 to 6 oz Recheck glucose level in 15 minutes Repeat if still less than 70 gm/dL Avoid foods with fat Decrease absorption of sugar Avoid overtreatment Give complex CHO after recovery
Carbohydrate counting
Serving size is 15 g of CHO Typically 45 to 60 g per meal Insulin dose based on number of CHOs consumed Patient teaching essential
Protein Diabetic Nutritional Therapy
Should make up 15% to 20% of total calories High-protein diets not recommended
Drug Therapy Glucagon-like Peptide Receptor Agonists
Simulate glucagon-like peptide-1 (GLP-1) : Increase insulin synthesis and release Inhibit glucagon secretion Decrease gastric emptying Increases satiety Must take oral meds 1 hour before injecting exenatide (Byetta) and liraglutide (Victoza)
Exchange lists
Starches, fruits, milk, meat, sweets, fats, free foods
Diabetes Exercise Rules
Start slowly after medical clearance Monitor blood glucose Glucose-lowering effect up to 48 hours after exercise Exercise 1 hour after a meal Snack to prevent hypoglycemia Do not exercise if blood glucose level exceeds 300 mg/dL and if ketones are present in urine
Nursing Assessment Diabetes
Subjective data: Past health history: Viral infections, trauma, infection, stress, pregnancy, chronic pancreatitis, Cushing syndrome, acromegaly, family history of diabetes Medications:Insulin, OAs, corticosteroids, diuretics, phenytoin Recent Surgery
α-Glucosidase Inhibitors
"Starch blockers" Slow down absorption of carbohydrate in small intestine Take with first bite of each meal Example: Acarbose (Precose) Miglitol (Glyset)
Lipodystrophy
(atrophy of subcutaneous tissue) may occur if the same injection sites are used frequently. 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
Chronic Skin Problems with diabetes
-Diabetic dermopathy: Most common Red-brown, round or oval patches -Acanthosis nigricans: Velvety light brown to black skin -Necrobiosis lipoidica diabeticorum Red-yellow lesions
Nursing Assessment Diabetes Objective data
Sunken eyeballs, vitreal hemorrhages, cataracts Dry, warm, inelastic skin Pigmented skin lesions, ulcers, loss of hair on toes, acanthosis nigricans Kussmaul respirations Hypotension Weak, rapid pulse Dry mouth Vomiting Fruity breath Altered reflexes, restlessness Confusion, stupor, coma Muscle wasting Serum electrolyte abnormalities Fasting blood glucose level of 126 mg/dL or higher Oral glucose tolerance test and/or random glucose level exceeding 200 mg/dL Leukocytosis ↑ Blood urea nitrogen, creatinine ↑ Triglycerides, cholesterol, LDL, VLDL ↓ HDL Hemoglobin A1C value higher than 6.0% Glycosuria Ketonuria Albuminuria Acidosis
Diagnostic Studies For Diabetes
1)Hemoglobin A1C level: 6.5% or higher 2)Fasting plasma glucose level: higher than 126 mg/dL 3)Two-hour plasma glucose level during OGTT: 200 mg/dL (with glucose load of 75 g) 4)Classic symptoms of hyperglycemia with random plasma glucose level of 200 mg/dL or higher(DKA Symptoms)
Four major metabolic abnormalities
1)Insulin resistance 2)Decreased insulin production by pancreas 3)Inappropriate hepatic glucose production 4)Altered production of hormones and cytokines by adipose tissue (adipokines
Glycemic index
Term used to describe rise in blood glucose levels after carbohydrate-containing food is consumed High glycemic index foods increase glucose levels faster
Diabetes Nutritional Therapy Goals
ADA healthy food choices for improved metabolic control: Maintain blood glucose levels to as near normal as safely possible Normal lipid profiles and blood pressure Prevent or slow complications Individual needs; personal, cultural preferences Maintain pleasure of eating
Chronic Complications of Diabetes
Angiopathy Macrovascular Angiopathy Diabetic Retinopathy Diabetic Nephropathy Diabetic Neuropathy Neurotrophic Ulceration Foot Complications
Hypoglycemia
Too much insulin in proportion to glucose in the blood Blood glucose level less than 70 mg/dL Neuroendocrine hormones released Autonomic nervous system activated Common manifestations: -Shakiness -Palpitations -Nervousness -Diaphoresis -Anxiety -Hunger -Pallor -Altered mental functioning: `Difficulty speaking `Visual disturbances `Stupor `Confusion `Coma Untreated hypoglycemia can progress to loss of consciousness, seizures, coma, and death
Hypoglycemia Causes
Too much insulin or oral hypoglycemic agents Too little food Delaying time of eating Too much exercise Symptoms can also occur when high glucose level falls too rapidly
Diabetes Exercise
Type/amount: Minimum 150 minutes/week aerobic Resistance training three times/week Benefits: ↓ Insulin resistance and blood glucose Weight loss ↓ Triglycerides and LDL , ↑ HDL Improve BP and circulation
Administration of insulin
Typically given by subcutaneous injection Regular insulin may be given IV Cannot be taken orally Usually available as U100 insulin (1 mL contains 100 U of insulin) Syringes marked for units: various sizes Only user recaps syringe No alcohol swab for self-injection; wash with soap and water Inject at 45- to 90-degree angle
(Basal) Background Insulin
Used to control glucose levels in between meals and overnight
Oral Agents
Work on three defects of type 2 diabetes Insulin resistance Decreased insulin production Increased hepatic glucose production Can be used in combination
Type 1 Diabetes Mellitus Onset of Disease
Autoantibodies are present for months to years before symptoms occur Manifestations develop when pancreas can no longer produce insulin—then rapid onset with ketoacidosis Necessitates insulin Patient may have temporary remission after initial treatment
Type 1 Diabetes Mellitus Etiology and Pathophysiology
Autoimmune destruction of β-cells Total absence of insulin Genetic predisposition and viral exposure HLA-DR3 and HLA-DR4 Idiopathic diabetes Latent autoimmune diabetes in adults (LADA)
Self-Monitoring of Blood Glucose (SMBG) When to test
Before meals Two hours after meals When hypoglycemia is suspected During illness Before, during, and after exercise
Dipeptidyl Peptidase-4 (DDP-4) Inhibitor
Blocks inactivation of incretin hormones ↑ Insulin release ↓ Glucagon secretion ↓ Hepatic glucose production Examples (gliptins): Sitagliptin (Januvia) Saxagliptin (Onglyza) Linagliptin (Tradjenta)
Dopamine Receptor Agonist
Bromocriptine (Cycloset) Mechanism of action unknown Thought that patients with type 2 diabetes have low levels of dopamine Increases dopamine receptor activity Alone or in combination
Fructosamine
can also be used to assess glucose control. Fructosamine is formed by a chemical reaction of glucose with plasma protein. It reflects glucose control in the previous 1 to 3 weeks. Fructosamine levels may show a change in glucose control before hemoglobin A1C does
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
Diabetic Ketoacidosis (DKA)
Caused by profound deficiency of insulin Characterized by: Hyperglycemia Ketosis Acidosis Dehydration Most likely to occur in type 1 diabetes Precipitating factors: Illness Infection Inadequate insulin dosage Undiagnosed type 1 diabetes Poor self-management Neglect Clinical manifestations: Dehydration -Poor skin turgor -Dry mucous membranes Tachycardia Orthostatic hypotension Lethargy and weakness early Skin dry and loose; eyes soft and sunken Abdominal pain, anorexia, nausea/vomiting Kussmaul respirations Sweet, fruity breath odor Blood glucose level of 250 mg/dL or higher Blood pH lower than 7.30 Serum bicarbonate level lower than 16 mEq/L Moderate to high ketone levels in urine or serum 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 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
Clinical Manifestations Type 1 Diabetes Mellitus
Classic symptoms: Polyuria (frequent urination) Polydipsia (excessive thirst) Polyphagia (excessive hunger) Weight loss Weakness Fatigue
Etiology and Pathophysiology of DM
Combination of causative factors: Genetic Autoimmune Environmental Absent/insufficient insulin and/or poor utilization of insulin Regardless of its cause, diabetes is primarily a disorder of glucose metabolism related to absent or insufficient insulin supply and/or poor utilization of the insulin that is available
Insulin pump
Continuous subcutaneous infusion Battery-operated device Connected to a catheter inserted into subcutaneous tissue in abdominal wall Program basal and bolus doses that can vary throughout the day Potential for tight glucose control
Diabetes Nutritional Therapy
Counseling Education Ongoing monitoring Interdisciplinary team with registered dietitian as lead
Angiopathy
Damage to blood vessels secondary to chronic hyperglycemia Leading cause of diabetes-related death Macrovascular and microvascular Tight glucose control can prevent or minimize complications
Diabetic Nephropathy
Damage to small blood vessels that supply the glomeruli of the kidney Leading cause of end-stage kidney disease Risk factors: -Hypertension -Genetics -Smoking -Chronic hyperglycemia Annual screening If albuminuria present, drugs to delay progression: -ACE inhibitors -Angiotensin II receptor antagonists Control of hypertension and tight blood glucose control: imperative
Chronic Complications Infection
Defect in mobilization of inflammatory cells and impaired phagocytosis Recurring or persistent infections Treat promptly and vigorously Patient teaching for prevention ~Hand hygiene ~Flu and pneumonia vaccine
Gestational Diabetes
Develops during pregnancy Increases risk of need for cesarean delivery and of perinatal complications Screen high-risk patients first visit; others at 24 to 28 weeks of gestation Usually glucose levels normal 6 weeks post partum
Diabetes Mellitus
Diabetes mellitus (DM) is a chronic multisystem disease related to abnormal insulin production, impaired insulin utilization, or both. Diabetes mellitus is a serious health problem throughout the world, and its prevalence is rapidly increasing. Currently in the United States, an estimated 25.8 million people, or 8.3% of the population, have diabetes mellitus, and 79 million more people have prediabetes. In approximately 7.0 million people with diabetes mellitus, the disease has not been diagnosed, and they are unaware that they have the disease. Diabetes mellitus is the seventh leading cause of death in the United States, but it is likely to be underreported. The annual cost of diabetes exceeds $174 billion, with $116 billion in direct medical costs. related to abnormal insulin production, impaired insulin utilization, or both Affects 25.8 million people 7th leading cause of death Leading cause of: Adult blindness End-stage kidney disease Nontraumatic lower limb amputations Major contributing factor: Heart disease Stroke Hypertension Adults with diabetes have heart disease death rates two to four times higher than adults without diabetes. The risk for stroke is also two to four times higher among people with diabetes. In addition, it is estimated that 67% of adults with diabetes have hypertension.
Acute Complications of Diabetes
Diabetic ketoacidosis (DKA) Hyperosmolar hyperglycemic syndrome (HHS) Hypoglycemia
Diet teaching
Dietitian initially provides instruction
Macrovascular Angiopathy
Diseases of large and medium-sized blood vessels Greater frequency and earlier onset in patients with diabetes Cerebrovascular disease Cardiovascular disease Peripheral vascular disease Decrease risk factors (yearly screening): -Obesity -Smoking -Hypertension -High fat intake -Sedentary lifestyle Screen for and treat hyperlipidemia Thickening of vessel membranes in capillaries and arterioles Specific to diabetes and includes: -Retinopathy -Nephropathy -Dermopathy Usually appear 10 to 20 years after diagnosis
Storage of insulin
Do not heat/freeze In-use vials may be left at room temperature up to 4 weeks Extra insulin should be refrigerated Avoid exposure to direct sunlight, extreme heat or cold Store prefilled syringes upright for 1 week if two insulin types; 30 days for one
Metabolic syndrome increases risk for type 2 diabetes
Elevated glucose levels Abdominal obesity Elevated blood pressure High levels of triglycerides Decreased levels of HDLs
Diabetes Nutritional Therapy: Type 2 DM
Emphasis on achieving glucose, lipid, and blood pressure goals Weight loss: Nutritionally adequate meal plan with ↓ fat and CHO Spacing meals Regular exercise
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 Frequency of testing varies 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
Nursing Evaluation Diabetes
Expected outcomes: Knowledge Self-care measures Balanced diet and activity Stable, normal blood glucose levels No injuries
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
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
Type 2 Diabetes Mellitus
Formerly known as adult-onset diabetes (AODM) or non-insulin-dependent diabetes (IDDM) Most prevalent type (90% to 95%) Risk factors: overweight, obesity, advancing age, family history Increasing prevalence in children Greater prevalence in ethnic groups Pancreas continues to produce some endogenous insulin Insulin insufficient or poorly utilized Multiple etiologic factors Obesity is greatest risk factor Genetic component increases insulin resistance and obesity
Type 1 Diabetes Mellitus
Formerly known as juvenile-onset or insulin-dependent diabetes Accounts for 5% of all cases of diabetes Onset in people younger than 40 years Incidence increasing More frequently in younger children
Human insulin
Genetically engineered in laboratories Categorized according to onset, peak action, and duration: Rapid-acting Short-acting Intermediate-acting Long-acting
Counterregulatory hormones
Glucagon, epinephrine, growth hormone, cortisol Oppose effects of insulin Stimulate glucose production by liver Decrease movement of glucose into cell Help maintain normal blood glucose levels
Hemoglobin A1C test
Glycosylated hemoglobin: reflects glucose levels over past 2 to 3 months Used to diagnose, monitor response to therapy, and screen patients with prediabetes Goal: less than 6.5% to 7%
Collaborative Care of Diabetes
Goals of diabetes management: Decrease symptoms Promote well-being Prevent acute complications Delay onset and progression of long-term complications Need to maintain blood glucose levels as near to normal as possible Patient teaching: Nutritional therapy Drug therapy Exercise Self-monitoring of blood glucose Diet, exercise, and weight loss may be sufficient for patients with type 2 diabetes All patients with type 1 require insulin
Type 2 Diabetes Mellitus Onset of Disease
Gradual onset Hyperglycemia may go many years without being detected Many times discovered with routine laboratory testing
Sulfonylureas
↑ Insulin production from pancreas Major side effect: hypoglycemia Examples: Glipizide (Glucotrol) Glyburide (Micronase, DiaBeta, Glynase) Glimepiride (Amaryl)
Meglitinides
↑ Insulin production from pancreas Rapid onset: ↓ hypoglycemia Taken 30 minutes to just before each meal Should not be taken if meal skipped Examples: Repaglinide (Prandin) Nateglinide (Starlix)
Nursing Implementation Diabetes
Health promotion: Identify, monitor, and teach patients at risk Obesity: primary risk factor Routine screening for all overweight adults and those older than 45 Diabetes risk test Acute intervention: Hypoglycemia Diabetic ketoacidosis Hyperosmolar hyperglycemic nonketotic syndrome Acute illness, injury, and surgery ↑ Blood glucose level secondary to counterregulatory hormones Frequent monitoring of blood glucose Ketone testing if glucose level exceeds 240 mg/dL Report glucose levels exceeding 300 mg/dL for two tests or moderate to high ketone levels Increase insulin for type 1 diabetes Type 2 diabetes may necessitate insulin therapy
USDA MyPlate method
Helps patient visualize the amounts of nonstarchy vegetable (1/2), starch (1/4), and protein (1/4) that should fill a 9-inch plate Consistent CHO diet
Self-Monitoring of Blood Glucose (SMBG) Education
How to use, calibrate
Problems with insulin therapy
Hypoglycemia Allergic reaction Lipodystrophy
Nursing Implementation Diabetes: Intraoperative period
IV fluids and insulin Frequent monitoring of blood glucose
Hypoglycemia Blood glucose level
If less than 70 mg/dL, begin treatment If more than 70 mg/dL, investigate further for cause of signs/symptoms If monitoring equipment not available, treatment should be initiated
Nutritive and nonnutritive sweeteners Diabetic Therapy
In moderation
Gerontologic Considerations
Increased prevalence and mortality Glycemic control challenging: -Increased hypoglycemic unawareness -Functional limitations -Renal insufficiency Diet and exercise: main treatment Patient teaching must be adapted to needs
Prediabetes
Individuals at risk for type 2 diabetes Impaired glucose intolerance (IGT) Two-hour oral glucose tolerance test (OGTT): 140 to 199 mg/dL Impaired fasting glucose (IFG) Fasting glucose level: 100 to 125 mg/dL Asymptomatic but long-term damage already occurring Patient teaching important: Undergo screening Manage risk factors Monitor for symptoms of diabetes Maintain healthy weight, exercise, healthy diet
Nursing Diagnoses Diabetes
Ineffective self-health management Risk for unstable blood glucose levels Risk for infection Risk for peripheral neurovascular dysfunction
Exogenous insulin
Insulin from an outside source Required for type 1 diabetes Prescribed for patients with type 2 diabetes who cannot control blood glucose by other means
Long-acting (basal)
Insulin glargine (Lantus) and detemir (Levemir) Released steadily and continuously with no peak action Administered once or twice a day Do not mix with any other insulin or solution
Autoantibodies Test
Islet cell autoantibody testing is ordered primarily to help distinguish between autoimmune type 1 diabetes and diabetes due to other causes.
Hyperosmolar Hyperglycemic Syndrome (HHS)
Life-threatening syndrome Occurs with type 2 diabetes Precipitating factors UTIs, pneumonia, sepsis Acute illness Newly diagnosed type 2 diabetes Impaired thirst sensation and/or inability to replace fluids Enough circulating insulin to prevent ketoacidosis Fewer symptoms lead to higher glucose levels (>600 mg/dL) More severe neurologic manifestations because of ↑ serum osmolality Ketones absent or minimal in blood and urine Medical emergency High mortality rate Therapy similar to that for DKA IV insulin and NaCl infusions More fluid replacement needed Monitor serum potassium and replace as needed Correct underlying precipitating cause Monitor: -IV fluids -Insulin therapy -Electrolytes Assess: -Renal status -Cardiopulmonary status -Level of consciousness
Fats Diabetic Nutritional Therapy
Limit saturated fats to less than 7% of total calories Limit cholesterol to less than 200 mg/day Minimize trans fat Two or more servings of fish per week to provide polyunsaturated fatty acids
Alcohol Diabetic Nutritional Therapy
Limit 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
Insulin preparations: Rapid-acting (bolus)
Lispro, aspart, glulisine Onset of action 15 minutes Injected within 15 minutes of mealtime
Nursing Implementation Diabetes: Acute Illness
Maintain normal diet if able Increase noncaloric fluids Continue taking antidiabetic medications If normal diet not possible, supplement with CHO-containing fluids while continuing medications
Nursing Assessment Diabetes Subjective Data
Malaise Obesity, weight loss or gain Thirst, hunger, nausea/vomiting Poor healing Dietary compliance Constipation/diarrhea Frequent urination, bladder infections Nocturia, urinary incontinence Muscle weakness, fatigue Abdominal pain, headache, blurred vision Numbness/tingling, pruritus Impotence, frequent vaginal infections Decreased libido Depression, irritability, apathy Commitment to lifestyle changes
Diabetes Nutritional Therapy: Type 1 DM
Meal plan is based on individual's usual food intake and is balanced with insulin and exercise patterns Day-to-day consistency important for patients using conventional, fixed insulin regimens More flexibility with rapid-acting insulin, multiple daily injections, and insulin pump
Biguanides
Metformin (Glucophage) Reduce glucose production by liver Enhance insulin sensitivity Improve glucose transport May cause weight loss Used in prevention of type 2 diabetes Withhold if contrast medium is used Withhold if patient is undergoing surgery or radiologic procedure with contrast medium Day or two before and at least 48 hours after Monitor serum creatinine Contraindications: Renal, liver, cardiac disease Excessive alcohol intake
Foot Complications
Microvascular and macrovascular diseases increases risk for injury and infection Sensory neuropathy and PAD are major risk factors for amputation Also clotting abnormalities, impaired immune function, autonomic neuropathy Smoking increases risk Sensory neuropathy → loss of protective sensation → unawareness of injury Monofilament screening Peripheral artery disease ↓ Blood flow, ↓ wound healing, ↑ risk for infection Patient teaching to prevent foot ulcers: -Proper footwear(white cotton socks) -Avoidance of foot injury -Skin and nail care -Daily inspection of feet -Prompt treatment of small problems -Diligent wound care for foot ulcers -Neuropathic arthropathy (Charcot's foot)
Diabetic Retinopathy
Microvascular damage to retina Most common cause of new cases of adult blindness -Nonproliferative: more common ~Proliferative: more severe Nonproliferative: -Partial occlusion of small blood vessels in retina causes microaneurysms Proliferative: ~Involves retina and vitreous humor ~New blood vessels formed (neovascularization): very fragile and bleed easily ~Can cause retinal detachment Initially no changes in vision Annual eye examinations with dilation to monitor Maintain glycemic control and manage hypertension Treatment: -Laser photocoagulation Most common Laser destroys ischemic areas of retina -Vitrectomy Aspiration of blood, membrane, and fibers inside the eye -Drugs to block action of vascular endothelial growth factor (VEFG)
Carbohydrates Diabetic Nutritional therapy
Minimum of 130 g/day Fruits, vegetables, whole grains, legumes, low-fat milk Monitor with CHO counting, exchanges, or experienced-based estimation Use glycemic index Sucrose-containing food substituted for other CHOs
Dawn phenomenon
Morning hyperglycemia present on awakening Due to release of counterregulatory hormones in predawn hours
Basal-bolus regimen
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
Thiazolidinediones
Most effective in those with insulin resistance Improve insulin sensitivity, transport, and utilization at target tissues Examples: Pioglitazone (Actos) Rosiglitazone (Avandia) Rarely used because of adverse effects
Intermediate-acting insulin((Basal) Background 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
Diabetic Neuropathy
Nerve damage due to metabolic derangements of diabetes Of patients with diabetes, 60% to 70% have some degree of neuropathy Reduced nerve conduction and demyelinization Sensory or autonomic Sensory neuropathy: ~Loss of protective sensation in lower extremities ~Major risk for amputation Distal symmetric polyneuropathy: ~Most common form ~Affects hands and/or feet bilaterally ~Loss of sensation, abnormal sensations, pain, and paresthesias Treatment for sensory neuropathy: -Tight blood glucose control -Drug therapy: -Topical creams -Tricyclic antidepressants -Selective serotonin and norepinephrine reuptake inhibitors -Antiseizure medications Autonomic neuropathy: Can affect nearly all body systems Gastroparesis: Delayed gastric emptying Cardiovascular abnormalities: Postural hypotension, resting tachycardia, painless myocardial infarction Sexual function: Erectile dysfunction Decreased libido Vaginal infections Neurogenic bladder → urinary retention Empty frequently, use Credé's maneuver Medications Self-catheterization
Hypoglycemic unawareness
No warning signs/symptoms until glucose level critically low Related to autonomic neuropathy and lack of counterregulatory hormones Patients at risk should keep blood glucose levels somewhat higher
Clinical Manifestations Type 2 Diabetes Mellitus
Nonspecific symptoms Classic symptoms of type 1 may manifest Fatigue Recurrent infection Recurrent vaginal yeast or candidal infection Prolonged wound healing Visual changes
Food composition
Nutrient balance of diabetic diet is essential Nutritional energy intake should be balanced with energy output Individualized
Nursing Implementation Diabetes: Ambulatory and home care
Overall goal is to enable patient or caregiver to reach an optimal level of independence Use services of certified diabetes educator (CDE) Establish individualized goals for teaching Include family and caregivers Assess patient's ability to perform SMBG and insulin injection Utilize assistive devices as needed Assess patient/caregiver knowledge and ability to manage diet, medication, and exercise therapy Teach manifestations and how to treat hypoglycemia and hyperglycemia Frequent oral care Foot care: Inspect daily Avoid going barefoot Proper footwear How to treat cuts Travel needs Medication, supplies, food, activity
Nursing Planning Diabetes
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
Drug Therapy Amylin Analog
Pramlintide (Symlin): Slows gastric emptying, reduces postprandial glucagon secretion, increases satiety Used concurrently with insulin Subcutaneously in thigh or abdomen before meals Watch for hypoglycemia
Normal insulin metabolism
Produced by Beta-cells in islets of Langerhans Released continuously into bloodstream in small increments with larger amounts released after food Stabilizes glucose level in range of 70 to 120 mg/dL Under normal conditions, insulin is continuously released into the bloodstream in small pulsatile increments, with increased release when food is ingested The average amount of insulin secreted daily by an adult is approximately 40 to 50 U, or 0.6 U/kg of body weight.
Insulin
Promotes glucose transport in skeletal muscle and adipose tissue Storage of glucose as glycogen Inhibits gluconeogenesis Enhances fat deposition Increases protein synthesis Not necessary for glucose transport in brain, liver, blood cells
