NUR 205 Ch 30 Nursing Management: Diabetes Mellitus

Teaching Patients to Self-Administer Insulin: Selecting & Rotating the Injection Site (Figure 30-4)

- 4 Main Areas for Injection: abdomen, posterior surface of upper arms, anterior surface of thighs, & hips-->Rate of absorption is greatest in the abdomen & decreases progressively in the arm, thigh, & hip, respectively - Systemic rotation of injection sites within an anatomic area is recommended to prevent localized changes in fatty tissue (lipodystrophy) - to promote consistency in insulin absorption, pt should be encouraged to use all available injection sites within 1 area rather then randomly rotating sites from area to area (ex: exclusively use abdomen, administering each injection 0.5-1 inch away from previous site) - Another approach to site oration is always to use the same area at the same time of day (ex: morning doses into abdomen & evening doses into arms/legs) - if pt plans to exercise, insulin shouldn't be injected into limb that will be exercised b/c it will cause faster absorption & may result in hypoglycemia

Monitoring Glucose Levels & Ketones: Continuous Glucose Monitoring System (Figure 30-2)

- A continuous glucose monitoring sys (CGMS) uses new technology capable of continuously monitoring blood glucose - A sensor inserted subcutaneously & attached to an infusion set is capable of detecting high or low glucose lvls; Info from the CGMS is esp useful for pts using insulin pumps & can also be used to identify patterns of diabetes control over a 24-72 hr period

Nursing Process: Interventions (Providing Continuing Care)

- A pt who is hospitalized for another health problem may require referral for home care for that problem or if gaps in knowledge about self-care are found - Home care nurse reinforces teaching provided during hospitalization & assesses home care environment to determine its adequacy for self-care & safety

Diabetes: Nursing Management

- A solid educational foundation is necessary for competent self-care & is an essential component of nursing care - DM is a chronic illness that requires a lifetime of special self-management behaviors; B/c diet, physical activity, & physical & emotional stress affect diabetic control, pts must learn to balance a multitude of factors-->They must learn daily self-care skills to prevent acute fluctuations in blood glucose, & they must also incorporate into their lifestyle many preventive behaviors for avoidance of LT diabetic complications - Pts must become knowledgeable about nutrition, med effects & side effects, exercise, disease progression, prevention strategies, blood glucose monitoring techniques, & medication adjustment - They must learn the skills a/w monitoring & managing diabetes & must incorporate many new activities into daily routines - An understanding of the knowledge & skills that pts w/ diabetes must acquire helps nurses provide effective pt education & counseling

Diabetic Ketoacidosis: Medical & Nursing Management: Reversing Acidosis

- Accumulation of ketone (acetone) bodies occurs as a result of fat breakdown; The acidosis that occurs in DKA is reversed w/ insulin, which inhibits fat breakdown - Regular insulin is added to a saline soln & infused intravenously at a slow, continuous rate - Hourly blood glucose values must be measured to avoid precipitous drops in glucose or an inadequate decline; The goal is to decrease serum glucose lvl by 50- 100 mg/dL/hr to prevent complications like cerebral edema - When serum osmolality is decreased too rapidly, fluid shifts into the CNS causing cerebral edema; Pts may complain of HA & exhibit changes in LOC & cranial nerve function - To avoid a rapid drop in the blood glucose lvl during tx, NS solns w/ higher concentrations of glucose (e.g. D5NS, D5∙45NS) are administered when blood glucose lvls reach 250- 300 mg/dL - Although other rapid acting insulin may be suitable for IV admin, regular insulin is the most commonly used; Nurse must convert hourly rates of insulin infusion to IV drip rates (ex: if 100 units of regular insulin are mixed in 500 mL of 0.9% NS, then 1 unit of insulin equals 5 mL; therefore, an initial insulin infusion rate of 5 U/hr would equal 25 mL/hr)-- The insulin soln is infused separately from rehydration solns to allow for frequent changes in the rate & concentration of the latter - Insulin is infused continuously until subQ admin of insulin can be resumed; Even if blood glucose lvls are decreasing & returning to normal, the insulin drip must not be stopped until subQ insulin therapy has been started; Instead, the rate or concentration of the dextrose infusion can be increased - Blood glucose lvls are usually corrected before acidosis is corrected-->Therefore, IV insulin may be continued for 12-24 hrs, until the serum bicarbonate lvl improves (to at least 15- 18 mEq/L) & until pt can eat

Diabetes: Nursing Management: Providing Continuing Care

- Age, socioeconomic lvl, existing complications, types of diabetes, & other health problems all may influence frequency of follow-up visits -Many pts w/ diabetes are seen by home health nurses for diabetes education, wound care, insulin prep, or assistance w/ glucose monitoring - Even pts who achieve excellent glucose control & have no complications should see their PCP at least twice a year for ongoing eval - Nurse should remind pt about the importance of participating in other health promotion activities like immunizations & recommended age-appropriate health screenings - Participation in support groups is encouraged for pts who have had diabetes for many yrs, as well as for those who are newly dx'd--> Those who participate in support groups often have an opportunity to share valuable info & experiences & to learn from others

Teaching Patients to Self-Administer Insulin: Storing Insulin

- All insulin should be refrigerated; extremes of temp should be avoided; insulin shouldn't be allowed to freeze & shouldn't be kept in direct sunlight or high temps - Insulin via that is in use should be kept at room temp to reduce local irritation at injection site (which could occur if cold insulin is injected) - Vials that will be used within 1 month may be kept at room temp; Pt should be instructed to always have a spare vial of the type(s) of insulin used - Vials of intermediate-acting insulin should be inspected for flocculation (frosted, whitish coating inside bottle) & if present should not be used b/c some of the insulin is bound - Vials that have been opened for several wks, or those that have passed expiration date should be discarded

LT Complications of Diabetes: Complications of the Feet & Legs (Figure 30-9)

- Amputation & foot ulcers, consequences of diabetic neuropathy &/or PAD, are common & major causes of death & disability in people w/ diabetes; Early recognition & management of risk factors can prevent or delay these complications of diabetes - The typical sequence of events in the development of a diabetic foot ulcer begins w/ a soft tissue injury of the foot, formation of a fissure b/w the toes or in an area of dry skin, or formation of a callus - Pts w/ an insensitive foot don't feel injuries, which may be thermal (e.g. from using heating pads, walking barefoot on hot concrete, testing bath water w/ foot), chemical (e.g. burning the foot while using caustic agents on calluses, corns, or bunions), or traumatic (e.g. injuring skin while cutting nails, walking w/ an undetected foreign object in the shoe, or wearing ill-fitting shoes & socks) - If pt is not in the habit of thoroughly inspecting both feet on a daily basis, the injury or fissure may go unnoticed until a serious infection has developed - Drainage, swelling, redness of the leg, or gangrene may be the 1st sign of foot problems that the pt notices - Tx of foot ulcers involves antibiotics & debridement; Controlling glucose lvls, which tend to increase when infections occur, is important for promoting wound healing, as is smoking cessation - In pts w/ peripheral vascular disease, foot ulcers may not heal b/c of the decreased ability of oxygen, nutrients, & antibiotics to reach the injured tissue-->Amputation may be necessary to prevent the spread of infection - The risk of amputation & other problems involving the lower extremities is esp high for pts who have had diabetes for more than 10 yrs, those w/ poor blood glucose control, & those w/ peripheral vascular disease & peripheral neuropathy - Foot assessment & foot care instructions are vitally important for pts who are at high risk for foot infections

Diabetes: Nursing Management: Developing A Diabetic Teaching Plan Cont'd

- Assessing Readiness to Learn: before starting diabetes education, nurse assesses pt's readiness to learn; Once pt's questions have been answered & possible misconceptions are corrected, nurse focuses on concrete surveil skills; B/c of the immediate need for multiple new skills, teaching is initiated ASAP after dx; Nurses whose pts are in the hospital rarely have the luxury of waiting until pt feels ready to learn; short hospital stays necessitate initiation of survival skill education as early as possible; This gives pt the opportunity to practice skills w/ supervision by nurse before discharge; Follow-up by home health nurses is often necessary for reinforcement of survival skills - Determining Teaching Methods: Pt teaching must be flexible & planned to meet individual pts needs; Teaching skills & providing info in a logical sequence is not always the most helpful approach for pts (Ex: many pts fear self-injection; Before they learn how to prepare insulin, pts should be taught to insert the needle & inject insulin; Once they have actually performed injections, most pts are better prepared to hear & to comprehend other info necessary for insulin admin); Ample opportunity should be provided for pts & families to practice skills under supervision

Pathophysiology: Diabetes Type 1

- Autoimmune disease; Characterized by an acute onset & most commonly affects children & young adults; Characterized by destruction of pancreatic beta cells - Combined genetic, immunologic, & environmental factors are thought to contribute to beta cell destruction; Although the events that lead to beta cell destruction are not fully understood, it is generally accepted that genetic susceptibility is a common underlying factor in the development of type 1 diabetes--> People don't inherit type 1 diabetes itself, but rather a genetic predisposition, or tendency, toward development of the disease - Immune destruction of the beta cells, caused by autoantibodies against islet cells & insulin, is a/w certain human leukocyte antigen (HLA) types; It is thought that immune system destruction of the beta cells is initiated by environmental factors, like viruses or toxins - Beta cell destruction results in decreased insulin production, unchecked glucose production by the liver, & fasting hyperglycemia; Glucose derived from food can't be stored in the liver but instead remains in the blood & contributes to postprandial (after meals) hyperglycemia - If the concentration of glucose in the blood exceeds the renal threshold for glucose (about 180- 200 mg/dL), the kidneys can't reabsorb all of the filtered glucose; glucose then appears in the urine (glycosuria)--> Glucose is an osmotic agent; water follows it; As the glucose is excreted in the urine, it is accompanied by excessive loss of fluids & electrolytes (This is called osmotic diuresis) - B/c insulin normally inhibits glycogenolysis & gluconeogenesis, these processes occur unrestrained in people w/ insulin deficiency & contribute further to hyperglycemia; Fat breakdown also occurs, resulting in an increased production of ketones, which are organic acids; If excessive amounts of ketones are present in the blood, ketoacidosis develops

Diabetes: Nursing Management: Developing A Diabetic Teaching Plan

- B/c many pts w/ diabetes are admitted to the hospital for reasons other than diabetes or its complications, all nurses play a vital role in identifying pts w/ diabetes, assessing self-care skills, providing basic education, reinforcing teaching, & referring pts for follow-up care after discharge; Regardless of the setting, all encounters w/ pts w/ diabetes are opportunities for reinforcement of self-management skills - Pts w/ newly dx'd diabetes & those who have had diabetes for several yrs should be assessed for self-care needs; The American Diabetes Association recommends that teaching include 3 lvls of care; The 1st, survival skills, provides pt w/ basic knowledge & skills for diabetes management; An outline of survival info includes the following: (1) Simple pathophysiology: Basic definition of diabetes; Normal blood glucose ranges & target blood glucose lvls; Effect of insulin & exercise; Effect of food & stress, including illness & infections; Basic tx approaches (2) Tx modalities: Admin of insulin & oral meds; Meal planning; Monitoring of blood glucose & urine ketones (3) Recognition, tx, & prevention of acute complications: Hypoglycemia; Hyperglycemia (4) Practical info: Where to buy & store insulin, syringes, & glucose monitoring supplies; When & how to contact the PCP - When pts have mastered basic skills & info, they are ready for home management, the 2nd lvl of teaching-->This lvl involves providing pt w/ detailed info, beyond basic survival skills, to foster self-reliance & independence for diabetes management at home - More advanced pt education includes skills & info to improve lifestyle & individualization of diabetes self-management - The degree of advanced diabetes education provided depends on the pt's interest & ability

Monitoring Glucose Levels & Ketones: Urine Glucose Testing

- Before SMBG was available, urine glucose testing was the only way to monitor diabetes on a daily basis - Its advantages are that it is less expensive than SMBG, noninvasive, & painless; But, urine glucose testing is no longer recommended b/c the results don't accurately reflect blood glucose lvl at the time of the test & b/c they are unpredictable - Also, the renal threshold for glucose, 180-200 mg/dL, is far above target blood glucose lvls

Monitoring Glucose Levels & Ketones: Self- Monitoring Blood Glucose

- Blood glucose monitoring is a cornerstone of diabetes management - Self-monitoring of blood glucose (SMBG) lvls by pts has dramatically altered diabetes care - Using frequent SMBG & learning how to respond to the results enable people w/ diabetes to adjust their tx regimen to obtain optimal blood glucose control--> This allows for detection & prevention of hypoglycemia & hyperglycemia & plays a crucial role in normalizing blood glucose lvls, which in turn may reduce risk of LT diabetic complications - SMBG is a key component of tx for any intensive insulin therapy regimen & for diabetes management during pregnancy; It is also recommended for pts w/ unstable diabetes, those w/ a tendency to develop severe ketosis or hypoglycemia, & for pts who experience hypoglycemia w/o warning ax's - For pts not taking insulin, SMBG is helpful for monitoring the effectiveness of exercise, diet, & oral anti diabetic agents; It can also help motivate pts to continue w/ tx - For pts w/ type 2 diabetes, SMBG is recommended during periods of suspected hyperglycemia (e.g. illness) or hypoglycemia (e.g. unusual increased activity lvls) & when the med or dosage of med is modified - Various methods for SMBG are available; Most involve applying a drop of blood to a special reagent strip & allowing the blood to stay on the strip for the amount of time specified by the manufacturer; Blood glucose meters give a digital readout of the blood glucose value

Diabetes: Medical Management: Nutrition (Caloric Requirements & Distribution)

- Calorie- Controlled diets are planned by 1st calculating a person's energy needs & caloric requirements based on gender, age, height, & weight; Then activity element is factored in to give the actual # of calories needed for weight maintenance - For 1-2lb weight oss per week, 500-1000 calories are subtracted from daily total-->The calories are distributed into carbs, proteins, & fats, & a meal plan is developed - Recommended: 50-60% of calories should be from carbs, 20-30% from fat, & 10-20% from protein - Carbs: important energy source; have greatest effects on blood glucose lvls b/c they are more quickly digested than other foods & are rapidly converted to glucose; Sources: grains, fruits, veggies, & milk-->majority in diabetic diet should come from whole grains; Foods containing sucrose (sugar) should be limited; Carbs should be rate in moderation to avoid high postprandial blood glucose lvls - Fats: recommended to reduce total %age of calories from fat to <30% of total calories & limit the amount of sat fats to <7% or total calories; Also recommended to limit total intake of dietary cholesterol to <200mg/day -->This approach may help reduce risk factors like increased serum cholesterol lvls that are a/w coronary artery disease, the leading cause of death amount people w/ diabetes - Protein: to help reduce sat fat & cholesterol intake, the meal plan for diabetes should include use of some non animal sources of protein (legumes, whole grains); Amount of protein may be reduced in pts w/ early signs of renal disease - Fiber: helps lower total cholesterol & LDLs in the blood; may also improve blood glucose lvls & decrease need for exogenous insulin; 2 types: soluble (in foods like legumes, oats, & some fruits; appears to lower blood glucose & lipid lvls more than insoluble) & insoluble found in whole grain breads & cereals, & in some veggies; important for increasing stool bulk & preventing constipation); Both types are helpful for weight loss; Risk in suddenly increasing fiber intake is that it may require adjusting dosage of insulin or oral agents to prevent hypoglycemia; Addition of fiber to the diet should be done gradually & in consultation w/ dietician

Diabetes: Clinical Manifestations (Box 30-2 & Box 30-3)

- Classic clinical manifestations of all types of diabetes include the "3 Ps": polyuria, polydipsia, & polyphagia - Polyuria (increased urination) & polydipsia (increased thirst) occur as a result of the excess loss of fluid a/w osmotic diuresis; Polyphagia (increased appetite) results from the catabolic state induced by insulin deficiency & the breakdown of proteins & fats - Other sx's: dehydration, weight loss, fatigue & weakness, vision changes, tingling or numbness in hands or feet, dry skin, skin lesions or wounds that are slow to heal, & recurrent infections ***Hyperglycemia impairs immune function (decreases WBC function), promotes inflammation, increases blood viscosity, favors growth of yeast organisms, & is a/w blood vessel wall changes resulting in increased risk for infection, microvascular, macrovascular complications & foot ulcers - An abnormally high blood glucose lvl is the basic criterion for the dx of diabetes; Fasting plasma glucose (FPG) lvls of 126 mg/dL or higher (no caloric intake for at least 8 hrs) or random plasma glucose lvls exceeding 200 mg/dL on more than one occasion (any time of day w/o regard to meals) are diagnostic for diabetes (Normal fasting glucose for a nondiabetic is 80- 90 mg/dL w/ a range of 70- 120mg/dL) - Prediabetes is dx'd 2/ fasting plasma glucose of 100- 125 mg/dL - The oral glucose tolerance test (OGTT) is no longer recommended for routine clinical use in non pregnant adults - Ongoing specialized assessment of pts w/ known diabetes & evaluation for complications in pts w/ newly dx'd diabetes are important components of care

Diabetic Ketoacidosis

- DKA is caused by an absence or markedly inadequate amount of insulin; This deficiency of insulin results in disorders in metabolism of carbs, proteins, & fats - Primary clinical features of DKA are hyperglycemia, ketosis, dehydration, electrolyte loss, & acidosis - W/o insulin, the amount of glucose entering the cells is reduced, & production & release of glucose by the liver is increased-->Both factors lead to hyperglycemia; In an attempt to rid the body of the excess glucose, the kidneys excrete excess glucose causing an osmotic diuresis, leading to dehydration & marked electrolyte loss - The hyperosmolality of the extracellular fluid leads to the stimulation of thirst w/ resulting polydipsia, & fluid shifting from intracellular to extracellular space; This fluid shifting results in low or normal serum sodium lvls despite water losses w/ polyuria; This low serum sodium lvl is referred to as pseudohyponatremia - Another effect of insulin deficiency is the breakdown of fat (lipolysis) into free fatty acids & glycerol;The free fatty acids are converted into ketone bodies by the liver - In DKA, the excessive production of ketoacids leads to the development of metabolic acidosis; A characteristic response to this acidemia is for the respiratory center to blow off its respiratory acid, leading to rapid deep respirations (Kussmaul respirations) ***Since ketones are a volatile acid, as they are exhaled, an acetone breath may be noted that has a fruity odor similar to overripe apples - Causes of DKA include insufficient or missed doses of insulin, physical or emotional stress, & illness or infection; An insulin deficit may result from an insufficient dosage of insulin prescribed or from insufficient insulin being administered by pt - Physical & emotional stress increases the lvl of the counterregulatory ("stress") hormones—glucagon, epinephrine, norepinephrine, & cortisol—all of which cause an increase in blood glucose - Finally, illness & infection are a/w insulin resistance, which puts pt at risk for hyperglycemia; If insulin is not increased during times of stress, illness, & infection, hyperglycemia may progress to DKA; For some patients with undiagnosed or untreated type 1 diabetes, DKA is the initial manifestation of diabetes

LT Complications of Diabetes: Macrovascular Complications

- Diabetic macrovascular (macroangiopathy) complications result from changes in medium to large blood vessels--> Blood vessel walls thicken, sclerose, & become occluded by plaque that adheres to the vessel walls; Eventually, blood flow is blocked - These atherosclerotic changes tend to occur more often & at an earlier age in pts w/ poorly controlled diabetes - Coronary artery disease, cerebrovascular disease, & peripheral vascular disease are the 3 main types of macrovascular complications that occur frequently in the diabetic population - CV disease is the major cause of illness & death for people w/ diabetes - One unique feature of CAD in pts w/ diabetes is that typical ischemic sx's may be absent; Therefore, pt may not experience early warning signs of decreased coronary blood flow & may have a "silent" MI--> This lack of ischemic sx's may be secondary to autonomic neuropathy - Cerebral blood vessels are similarly affected by accelerated atherosclerosis; Occlusive changes or an embolus elsewhere in the vasculature that lodges in a cerebral blood vessel can lead to TIAs & strokes; People w/ diabetes have twice the risk of developing cerebrovascular disease & a greater likelihood of death--> Recovery from a stroke is likely to be more difficult for pts w/ elevated blood glucose lvls at the time of, & immediately after, a stroke - B/c sx's of cerebrovascular disease may be similar to sx's of acute diabetic complications (HHNS or hypoglycemia), it is very important to assess the blood glucose lvl & treat abnormal lvls rapidly, so that testing & tx of cerebrovascular disease can be initiated promptly, if indicated - Atherosclerotic changes in the large blood vessels of the lower extremities are responsible for a 2-3X higher incidence of occlusive peripheral arterial disease in people w/ diabetes; S/s of peripheral vascular disease include diminished peripheral pulses & intermittent claudication (pain in the buttock, thigh, or calf during walking); Severe arterial occlusive disease in the lower extremities is largely responsible for the increased incidence of gangrene & subsequent amputation in pts w/ diabetes

LT Complications of Diabetes: Microvascular Complications

- Diabetic microvascular disease (microangiopathy) is characterized by capillary basement membrane thickening - The basement membrane surrounds the endothelial cells of the capillary--> Increased blood glucose lvls react through a series of biochemical responses to thicken the basement membrane to several times its normal thickness - 2 areas affected by these changes are the retina & kidneys

Microvascular Complications: Diabetic Nephropathy

- Diabetic nephropathy, or renal disease secondary to microvasular changes in the kidney is the leading cause of ESRD - It's characterized by albuminuria, HTN, & progressive renal insufficiency-->Many pts require dialysis or renal transplantation - Pts w/ type 1 diabetes frequently show initial signs of renal disease after 10-15 yrs, while pts w/ type 2 diabetes may develop renal disease within 10 yrs after dx--> However, b/c many pts w/ type 2 diabetes have had diabetes for many yrs before dx, there can be evidence of nephropathy at the time of dx - If blood glucose lvls are elevated consistently for a significant period of time, the kidney's filtration mechanism is stressed, allowing blood proteins to leak into the urine-->As a result, the pressure in the blood vessels of the kidney increases; It is thought that this elevated pressure serves as the stimulus for the development of nephropathy

Patients with Diabetes Who are Undergoing Surgery

- During periods of stress (like surgery), blood glucose lvls tend to increase, b/c lvls of stress hormones increase; If hyperglycemia is not controlled during surgery, the resulting osmotic diuresis may lead to excessive loss of fluids & electrolytes (Pts w/ type 1 diabetes also risk developing ketoacidosis during periods of stress) - Hypoglycemia also is a concern in pts w/ diabetes who are undergoing surgery (Ex: this is a special concern during the preop period if surgery is delayed beyond the morning when the pts received a morning injection of intermediate-acting insulin) - There are various approaches to managing glucose control during the perioperative period; Frequent blood glucose monitoring is essential throughout the preop & postop periods, regardless of the method used for glucose control - During the postop period, pts w/ diabetes also must be closely monitored for CV complications b/c of the increased prevalence of atherosclerosis, wound infection, & skin breakdown

Diabetes: Medical Management: Exercise (Benefits)

- Exercise is extremely important in diabetes management b/c of its effects on lowering blood glucose & reducing CV risk factors - Exercise lowers blood glucose lvls by increasing the uptake of glucose by body muscles & by improving insulin utilization - Moderate to vigorous aerobic activities help w/ weight control & improve CV health; Resistance exercises like weight lifting, increase lean muscle mass, thereby increasing the resting metabolic rate - These effects are useful in diabetes in relation to losing weight, easing stress, & maintaining a feeling of well-being - Exercise also alters blood lipid concentrations, increasing lvls of HDLs & decreasing total cholesterol & triglyceride lvls - This is esp important for people w/ diabetes b/c of their increased risk of CV disease

Diabetes: Risk Factors (Box 30-1)

- Family hx of diabetes (parents or siblings w/ diabetes) - Obesity (BMI ≥25 kg/m2) - Ethnicity (Afr. Amer., Latino, Native Amer., Asian Amer., Pacific Islanders) - Age ≥45 - Previously identified impaired glucose tolerance or impaired fasting glucose - HTN (≥140/90 mm Hg) - HDL cholesterol lvl ≤35 mg/dL (0.90 mmol/L) &/or triglyceride lvl ≥250 mg/dL (2.82 mmol/L) - Hx of gestational diabetes or delivery of babies over 9 lbs

Macrovascular Complications: Medical & Nursing Management

- Focus of management is aggressive modification & reduction of risk factors - Diet & exercise are important in managing obesity, HTN, & hyperlipidemia; Smoking cessation is essential - If BP goals are not met within 3 months of lifestyle changes, ACE inhibitors or ARBs are recommended for BP control; Antilipidemic meds (e.g. statins) may be added - It is also recommended that 81 mg of enteric coated aspirin be taken daily to reduce possibility of atherosclerosis - When macrovascular complications do occur, pts may require increased amounts of insulin or may need to change from oral antidiabetic agents to insulin

Monitoring Glucose Levels & Ketones: Frequency

- For most pts who require insulin, SMBG is recommended 2-4x/day, usually before meals & at bedtime - For pts w/ type 1 & pregnant women taking insulin, SMBG is recommended 3+ times daily - Pts not receiving insulin may be instructed to assess their blood glucose levels at least 2-3x/wk, including a 2-hr postprandial test - For all pts, testing is recommended whenever hypoglycemia or hyperglycemia is suspected - Pts should increase frequency of SMBG w/ changes in meds, activity, or diet & w/ stress or illness - Pts are asked to keep a record or logbook of blood glucose lvls so that patterns can be detected; SMBG instruction should include parameters for contacting the PCP

Monitoring Glucose Levels & Ketones: Measuring Glycated Hemoglobin

- Glycated hemoglobin (aka glycosylated hemoglobin, HgbA1C, or A1C) is a blood test that reflects avg blood glucose lvls over a period of approx 2-3 months - When blod glucose lvls are elevated, glucose molecules attach to hemoglobin in RBCs--> The longer the amount of glucose in the blood remains above normal, the more glucose binds to hemoglobin & the higher the glycated hgb lvl becomes; The glucose remains attached to the hemoglobin for the life of the individual RBC, approx 120 day - If near-normal blood glucose lvls are maintained, w/ only occasional increases, the overall value will not be greatly elevated; But, if the blood glucose values are consistently high, then the test result also is elevated - If pt reports mostly normal SMBG results but the glycated hemoglobin is high, there may be errors in the methods used for glucose monitoring, errors in recording results, or frequent elevations in glucose lvls at times during the day when pt is not usually monitoring blood sugar lvls - Normal values differ slightly from test to test & from lab to lab, but typically range from 4- 6%; Values within the normal range indicate consistently near-normal blood glucose concentrations, a goal made easier by SMBG

Hyperglycemia Hyperosmolar Nonketonic Syndrome (Table 30-7:Comparison of HHNS & DKA)

- HHNS is a serious life-threatening condition characterized by hyperosmolality (≥340 mOsm/L) & hyperglycemia (≥600 mg/dL) w/ alterations in LOC; Ketosis is minimal or absent - Persistent hyperglycemia causes osmotic diuresis, which results in losses of water & electrolytes - HHNS occurs most often in older people b/w the ages of 50- 70 who have no known hx of diabetes or who have type 2 diabetes - HHNS often can be traced to a precipitating event like infection, acute or chronic illness (e.g. pneumonia, stroke), meds that exacerbate hyperglycemia, or therapeutic procedures like surgery or dialysis - The hx may include days- weeks of polyuria & polydipsia - What distinguishes HHNS from DKA is that ketosis & acidosis generally don't occur in HHNS, partly b/c of differences in insulin lvls--> In DKA, no insulin is present, & this promotes the breakdown of stored glucose, protein, & fat, which leads to the production of ketone bodies & ketoacidosis; In HHNS, the insulin lvl is too low to prevent hyperglycemia & subsequent osmotic diuresis, but it is high enough to prevent fat breakdown

Nursing Process: Interventions (Addressing Knowledge Deficits)

- Hospital admission of the pt w/ diabetes provides an ideal opportunity for nurse to assess pt's lvl of knowledge about diabetes & its management - Nurse uses this opportunity to assess pt's understanding of diabetes management, including blood glucose monitoring, admin of meds, meal planning, exercise, & strategies to prevent LT & ST complications of diabetes - Nurse also assesses adjustment of pt & family to diabetes & its management & identifies any misconceptions they may have

Patients with Diabetes who are Hospitalized Cont'd

- Hypoglycemia During Hospitalization: usually the result of too much insulin or delays in eating; Causes of hypoglycemia in hospitalized pts include: (1) Overuse of "sliding scale" regular insulin (2) Lack of change in insulin dosage when dietary intake is changed (3) Overly vigorous tx of hyperglycemia (4) Delayed meal after insulin admin-->Nurse must assess pattern of glucose values & avoid giving doses of insulin that repeatedly lead to hypoglycemia; Successive doses of subQ regular insulin should be administered no more frequently than every 3-4hrs; For pts receiving NPH insulin before breakfast & dinner, nurse must use caution in giving supplemental doses of regular insulin at lunch & bedtime since hypoglycemia may occur when 2 insulins peak at similar times; To avoid hypoglycemic reactions caused by delayed food intake, nurse should arrange for snacks to be given to pt if meals are postponed b/c of procedures, PT, or other activities - Assisting With Hygiene: Nurses caring for hospitalized pts w/ diabetes must focus attn on oral hygiene & skin care; B/c these pts are at increased risk for periodontal disease, it is important for nurse to assist pt w/ daily dental care; Pt may also require assistance in keeping skin clean & dry, esp in the groin & axillary areas & under breasts, where chafing & fungal infections tend to occur; For pts who are confined to bed, nursing care must emphasize prevention of skin breakdown at pressure points. Heels are particularly susceptible to breakdown b/c of loss of sensation of pain & pressure a/w sensory neuropathy; Feet should be cleaned, dried, lubricated w/ lotion, & inspected frequently; If pt is in the supine position, pressure on the heels can be alleviated by elevating the lower legs on a pillow, w/ heels positioned over the edge of the pillow; When pt is seated in a chair, feet should be positioned so that pressure is not placed on the heels; If pt has an ulcer on one foot, it is important to provide preventive care to the unaffected foot, as well as to give special care to the affected foot; As always, every opportunity should be taken to teach pt about diabetes self-management, including daily oral, skin, & foot care

Nursing Process: Nursing Diagnoses

- Imbalanced nutrition R/T increase in stress hormones secondary to the primary medical problem & imbalances in insulin, food, & physical activity - Risk for impaired skin integrity R/T immobility & decreased sensation - Deficient knowledge about diabetes self-care skills R/T new dx, lack of basic diabetes education or lack of continuing in-depth diabetes education - Potential complications from inadequate control of blood glucose may include: Hyperglycemia, hypoglycemia DKA or HHNS

Microvascular Complications: Diabetic Nephropathy (Medical Management)

- In addition to achieving & maintaining near-normal blood glucose lvls, management for all pts w/ diabetes should include careful attn to control of HTN to decrease/ delay onset of early albuminuria - Other concerns include prevention/ vigorous tx of UTIs & avoidance of nephrotoxic meds - As renal function changes, adjustment of meds & introduction of a low-sodium, low-protein diet will be necessary - For pts who have developed microalbuminuria, an ACE inhibitor should be prescribed; ACE inhibitors lower BP & reduce microalbuminuria, thereby protecting the kidney-->Alternatively, ARB agents may be prescribed; This preventive strategy should be part of the standard of care for all people w/ diabetes - In chronic or end-stage renal failure, 2 types of tx are available: dialysis (hemodialysis or peritoneal dialysis) & kidney transplantation

Diabetic Ketoacidosis: Medical & Nursing Management: Rehydration

- In dehydrated pts, rehydration is important for maintaining tissue perfusion; Fluid replacement enhances excretion of excessive glucose by kidneys - Pt may need as much as 6- 10 L of IV fluid to replace fluid losses caused by polyuria, hyperventilation, diarrhea, & vomiting - Initially, 0.9% NaCL (NS) soln is administered at a rapid rate, usually 0.5- 1 L/hr for 2 -3 hrs; Subsequent fluid replacement will depend on the sodium lvl & lvl of dehydration & typically will be either NS or half-strength normal saline soln - Moderate to high rates of infusion (200- 500 mL/hr) may continue for several more hrs depending on pt's vital signs, physical assessment findings, & urinary output - Too rapid admin of IV fluid increases risk of cerebral edema, & while pt clinically may present w/ hypovolemic shock it is essential to monitor pt closely to avoid cerebral edema while correcting the fluid volume deficit - When blood glucose lvl reaches 250 mg/dL or less, change to IV solns containing glucose (D5NS, D5.45NS) to prevent a precipitous decline in the blood glucose lvl w/ insulin admin of fluid volume status involves frequent measurements of vital signs; resp., cardiac, & neuro assessment; & eval of I&O - Monitoring for signs of fluid overload is esp important for pts who are older, have renal impairment, or who are at risk for HF--> Signs include crackles, distended neck veins, edema, weight gain, SOB, orthopnea, PND, HTN, moist mucous membranes, & a full & bounding pulse

Pharmacologic Therapy: Inulin Therapy

- In type 1 diabetes, exogenous insulin must be administered daily for life b/c the body has lost its ability to produce insulin - In type 2 diabetes, insulin may be necessary on a LT basis to control glucose lvls if meal planning & oral agents are ineffective; Some pts w/ type 2 who usually are controlled by meal planning alone, or by meal planning & an oral antidiabetic agent, may require insulin temporarily during illness, infection, pregnancy, surgery, or other stressful events - Sources of Insulin: In the past, all insulins were obtained from pork & beef pancreas; Now, recombinant DNA technology or genetic engineering is used to create "human" insulin; Modification of the amino acid sequence of the human insulin molecule has produced new, rapid-acting insulin analogues; Human source insulin, which is designed to act more like insulin from the human pancreas, is now standard therapy

Nursing Process: Interventions (Monitoring & Managing Potential Complications)

- Inadequate control of blood glucose lvls may hinder recovery from the primary health problem - Blood glucose lvls are monitored & insulin is administered as prescribed; It is important for nurse to ensure that prescribed insulin dosage is modified as needed to compensate for changes in pt's schedule or eating pattern - Tx is given for hypoglycemia or hyperglycemia; Blood glucose records are assessed for patterns of hypoglycemia & hyperglycemia at the same time of day, & findings are reported to PCP - In pt w/ prolonged elevations in blood glucose, lab values & pt's physical condition are monitored for s/s of DKA or HHNS - Development of acute complications of diabetes secondary to inadequate control of blood glucose lvls may be a/w other health care problems b/c of changes in activity lvl & diet, & physiologic alterations r/t the primary health problem itself-->Therefore, pt must be monitored for hyperglycemia & hypoglycemia, & measures must be implemented for their prevention and early tx

Teaching Patients to Self-Administer Insulin: Insulin Injection (Box 30-5 & Box 30-6)

- Injection site cleansed prior to insertion of needle - To inject insulin, skin is gently pinched & needle inserted at 90 degree angle (for small pts, 45 degree angle is used) - injection sites should be about 1 inch apart - Injection that is too deep or too shallow may affect rate of absorption - B/c insulin is injected into subQ tissue, routine aspiration to assess for blood being drawn into the syringe is not necessary - Following injection, gentle pressure is applied; the injection site shouldn't be massaged b/c massaging can interfere w/ insulin absorption

Teaching Patients to Self-Administer Insulin: Alternative Methods of Insulin Delivery (Pens & Jet Injectors)

- Insulin Pens: se small, prefilled insulin cartridges that are loaded into a pen-like holder; Disposable needle is attached to a device for insulin injection & insulin is delivered by dialing in a dose or by pushing a button for every 1 to 2 unit increment administered--Those using these devices still need to insert the needle for each injection, but they don't ned to carry insulin vials or draw up insulin before each injection; most useful for pots ewho need to inject only one type of insulin at a time or who use premixed insulins; They are convenient for those who administer insulin before dinner when eating out or traveling; useful for pts w/ impaired manual dexterity, vision, or cognitive function that makes the use of traditional syringes difficult - Jet Injectors: deliver insulin through the skin under pressure in an extremely fine stream; more expensive than other methods of insulin admin & require thorough training & supervision when 1st used; Pts should be cautioned that absorption rates, peak insulin activity , & insulin lvls may be different when using this method

Pathophysiology: Diabetes (Table 30-1)

- Insulin is a hormone produced by the pancreas that controls blood glucose lvls by regulating the production, use, & storage of glucose; It is secreted by beta cells, in the islets of Langerhans of the pancreas-->In diabetes, cells may stop responding to insulin or the pancreas may decrease insulin secretion or stop insulin production completely - When a person eats a meal, insulin secretion increases & moves glucose from the blood into muscle, liver, & fat cells-->Once inside the cells, insulin functions in the following ways: (1) Transports & metabolizes glucose for energy (2) Stimulates storage of glucose as glycogen in the liver & muscle cells (3) Signals liver cells to stop the release of glucose (4) Enhances storage of dietary fat in adipose tissue (5) Accelerates transport of amino acids into cells (6) Facilitates the transport of K+ into the cells (7) Inhibits breakdown of stored glucose, protein, & fat - During fasting periods b/w meals & overnight, the pancreas continuously releases a small amount of "basal" insulin; If the blood sugar becomes too low, another pancreatic hormone, glucagon, is secreted by the alpha cells of the islets of Langerhans - Glucagon stimulates the liver to release stored glucose, thereby increasing the blood sugar--> In short, insulin promotes hypoglycemia; glucagon promotes hyperglycemia; They work together to maintain a constant lvl of glucose in the blood - The liver assists w/ glucose control by storing glucose in the form of glycogen; When the blood sugar becomes too low, the liver produces glucose through the breakdown of glycogen (glycogenolysis); After 8- 12 hrs w/o food, the liver forms glucose from the breakdown of noncarbohydrate substances, including amino acids (gluconeogenesis)

Pharmacologic Therapy: Inulin Therapy (Insulin Preparations)

- Insulin is available in the following preps: rapid-acting, short-acting, intermediate-acting, & long-acting - In general, the rapid- & short-acting insulins are expected to cover the increase in glucose lvls after meals soon after injection; the intermediate-acting insulins are expected to cover subsequent meals; & the long-acting insulins provide a relatively constant (or basal) lvl of insulin - Rapid-acting insulins (insulin lispro (Humalog), insulin aspart (NovoLog), & insulin glulisine (Apidra)): produce a more rapid effect that is of shorter duration than regular insulin; B/c of their rapid onset, pt should be instructed to eat no more than 15 mins after injection; Short duration of action of these insulins usually requires pts w/ type 1 diabetes & some pts w/ type 2 or gestational diabetes receive additional longer-acting insulin to maintain glucose control - Short-acting insulin (aka regular insulin & marked "R" on the vial): an unmodified clear soln that usually is administered 20- 30 mins before a meal; Regular insulin is the only insulin that can be given IV; It can be given either alone or in combo w/ modified longer-acting insulins; Used to treat DKA & may also be used on a supplemental basis, sometimes called a "sliding scale"; Humulin R & Novolin R are ex of regular insulin - Intermediate-acting insulin (NPH insulin, marked "N" on the vial): is cloudy & white in appearance & frequently used in combo w/ a shorter-acting insulin; To avoid hypoglycemia, it is important that pts eat around the time of the onset & peak of intermediate-acting insulin; Humulin N & Novolin N are ex of NPH insulins - Insulin glargine (Lantus) & insulin detemir (Levemir) are long-acting "basal" insulins that are absorbed very slowly over 24 hrs; They are given subQ, once a day, & don't have a peak time of effect; Although both glargine & determir are clear, mixing them w/ other insulins may cause a dangerous precipitation or diminish the effect of the insulin; Lantus was originally approved to be given once a day at bedtime; but, it is now approved to be given once a day at any time of the day but must be given at the same time each day to prevent overlap of action - Exubera: an inhaled insulin; used as a pre-meal dose & is delivered through an inhaler device; It is the 1st insulin not given parenterally; was successfully used in combo w/ other insulin for type 1 diabetes & as monotherapy for type 2 diabetes; No adverse effects on the lungs were noted during ST use; further study on LT effects is needed; Use of inhaled insulin is contraindicated for pts who smoke & those with lung disease

Pharmacologic Therapy: Inulin Therapy (Insulin Regimens) (Table 30-4)

- Insulin regimens vary from1-4 injections a day; Usually there is a combo of short-acting insulin & longer-acting insulin - The normally functioning pancreas continuously secretes small amounts of insulin during the day & night; Whenever blood glucose increases after ingestion of food, there is a rapid burst of insulin secretion in proportion to the glucose-raising effect of the food - The goal of all but the simplest, 1-injection insulin regimens is to mimic this normal pattern of insulin secretion in response to food intake & activity patterns - Some pts can learn to use SMBG results & carb counting to vary insulin doses; This allows pt more flexibility in timing & content of meals & exercise periods - Complex insulin regimens require a strong lvl of commitment, intensive education, & close follow-up by the health care team; Pts aiming for normal blood glucose lvls run risk of more hypoglycemic reactions; There are 2 general approaches to insulin therapy: conventional & intensive - Conventional Insulin Therapy: One approach is to simplify insulin regimen as much as possible, w/ the goal of avoiding acute complications of diabetes; involves 1+ injections a day of a mixture of short- & intermediate-acting insulins; Pt using the conventional regimen shouldn't vary meal patterns or activity lvls - Intensive Insulin Therapy: A second approach is to use a more complex insulin regimen to achieve as much control of blood glucose lvls as is safe & practical; An intensive insulin therapy regime involves 3-4 injections of insulin a day; Although intensive tx is beneficial in reducing risk of complications, not all people w/ diabetes are candidates for this approach to diabetes management

Teaching Patients to Self-Administer Insulin: Disposing of Syringes & Needles

- Insulin syringes & pens, needles, & lancets should be disposed of according to local regulations - Some areas have special needle disposal programs to prevent sharps from being discarded in the main waste disposal system - If community disposal programs are unavailable, used sharps should be placed in a puncture-resistant container; Pt should contact local authorities for instructions about proper disposal of filled containers; they should never be mixed w/ containers to be recycled

Teaching Patients to Self-Administer Insulin: Alternative Methods of Insulin Delivery (Continuous Subcutaneous Insulin Infusion (CCSI): Insulin Pumps)

- Involve use of small, externally worn devices that closely mimic the functioning of normal pancreas - Pumps contain a 3-mL syringe connceted to a subQ needle by a thin, narrow-lumen tube w/ a needle or Teflon catheter attached to the end-->Pt inserts needle or cath into subQ tissue, usually on abdomen, & secures it w/ tape or a transparent dressing-->needle or cath is changed at least every 2-3 days - Pump is programmed to deliver rapid-or short-acting insulin by subQ infusion at a constant (basal) rate over 24-hr period; This allows flexibility for meal times & food choices - Pump can be easily disconnected for limited periods for showering, exercise, or sexual activity - Disadvantages: (1) unexpected disruptions in flow of insulin from the pump may happen if the tubing or needle becomes occluded, if the supply of insulin runs out, or if the battery is depleted (this increases risk of DKA) (2) Potential for infection at needle insertion sites (Effective pt teaching minimized both of these risks - Hypoglycemia also may occur w/ insulin pump therapy; but, this usually is r/t lowered blood glucose lvls many pts achieve, rather than to a specific problem w/ pump itself - Candidates for insulin pump must be willing to assess blood glucose lvl several times daily; They must be psychologically stable & open about having diabetes b /c the insulin pump is a visible sign to others & a constant reminder to pts that they have diabetes - Pts using insulin pumps must have extensive education in the use of the pump & in self-management of blood glucose & insulin doses - Medicare now covers insulin pumps for pts w/ type 1 diabetes

Monitoring Glucose Levels & Ketones: Testing for Ketones

- Ketones (or ketone bodies) are by-products of fat breakdown that accumulate in the blood & urine -Ketones in the urine signal that control of type 1 diabetes is deteriorating & that risk of DKA is high - When there is little or no effective insulin available, the body starts to break down stored fat for energy - Urine testing is the most common method used for self-testing of ketone bodies by pts; A urine dipstick (Ketostix or Chemstrip uK) is used to detect ketonuria; The reagent pad on the strip turns purplish when ketones are present. Other strips are available for measuring both urine glucose & ketones (Keto-Diastix or Chemstrip uGK) - Urine ketone testing should be performed whenever pts w/ type 1 diabetes have glycosuria or persistently elevated blood glucose lvls, as well as during illness & pregnancy

Microvascular Complications: Diabetic Retinopathy (Table 30-8 & Figure 30-8)

- Leading cause of blindness in the US; Occurs both in type 1 & 2 diabetes - Glaucoma, cataracts, & other eye disorders occur earlier & more frequently in people w/ diabetes - Diabetic Retinopathy is caused by changes in small blood vessels in the retina (area of the eye that receives images & sends info about the images to the brain) - The retina is richly supplied w/ blood vessels of all kinds: small arteries & veins, arterioles, venules, & capillaries - Risk for retinopathy increases w/ length of time a person has had diabetes; Chronic hyperglycemia & HTN also increase risk for retinopathy - Changes in microvasculature include microaneurysms, intracranial hemorrhage, hard excavates, & focal capillary closure - Retinopathy has 3 stages: nonproliferative, preproliferative, & proliferative - Stage I: Nonproliferative retinopathy is characterized by macular edema; It may lead to visual distortion & loss of central vision Stage II: Preproliferative retinopathy involves more widespread vascular changes & loss of nerve fibers; Approx 10%- 50% of pts w/ preproliferative retinopathy develop proliferative retinopathy in a short time, some within a yr Stage III: Proliferative retinopathy is characterized by production of new blood vessels & formation of scar tissue; The new vessels are prone to bleeding; Fibrous scar tissue places traction on the retina that may cause hemorrhage or retinal detachment, w/ subsequent loss of vision

Teaching Patients to Self-Administer Insulin: Complications of Insulin Therapy

- Local Allergic Reactions: redness, swelling, tenderness, induration may appear at injection site 1-2 hrs after insulin admin; These reactions are becoming rare b/c of increased used of human insulins - Systemic Allergic Reactions: these a also rare; When they occur, there is an immediate local skin reaction that gradually spreads into generalized urticaria (hives); Tx is desensitization w/ small doses of purified pork or human insulin administered in gradually increasing amounts; These reactions are occasionally a/w generalized edema or anaphylaxis - Insulin Lipodystrophy: localized reaction at insulin injection site, in form of either lipoatrophy (loss of subQ fat, appears as slight dimpling/ pitting if subQ fat) or lipohypertrophy (development of fibrofatty mass; appears as raised, hardened tissue; B/c injection into a damaged its may delay insulin absorption, use of these areas should be delayed until lipodystophy is resolved; Use of human insulin, site rotation, & admin of insulin at room temp decreases risk of lipodystrophy - Resistance to Injected Insulin: Many pts have some degree of insulin resistance at 1 time or another for various reasons, most common being obesity, which can be overcome by weight loss; Clinical insulin resistance has been defined as a daily insulin requirement of 200 units or more; Tx consists of administering a more concentrated insulin prep, like U-500, which is available by special order

Diabetic Ketoacidosis: Medical & Nursing Management: Restoring Electrolytes

- Major electrolyte of concern during tx of DKA is potassium; The initial plasma concentration of potassium may be low b/c of renal loss due to osmotic diuresis; Conversely, it may be normal or high b/c of the shifting of potassium out of the cell w/ hydrogen movement into the cells b/c of academia - If high, nurse is aware that potassium replacement is withheld until serum K+ lvls decline to normal; this prevents the possibility of cardiac arrest from hyperkalemial; K+ lvl will decrease w/ insulin admin as insulin facilitates the movement of K+ intracellularly - Rehydration leads to increased plasma volume & subsequent decreases in the concentration of serum K+, as well as to increased urinary excretion of K+ - It is critical that serum K+ lvls be carefully monitored during tx for DKA; Cautious but timely K+ replacement is vital to avoid arrhythmias that may occur w/ hypokalemia; An ECG must be done on admission, & continuous cardiac monitoring is anticipated until the crisis is resolved - To prevent hyperkalemia, urine output is monitored to ensure adequate renal function before K+ is administered; Frequent lab measurements of K+ are expected every 2-4 hrs during the 1st 8 hrs of tx

Diabetic Neuropathy (Autonomic Neuropathies): Medical & Nursing Management

- Management strategies depend on sx's & focus on modification & management of risk factors; Early recognition & appropriate management of neuropathy is important - Effective tx options for symptomatic diabetic neuropathy are available & may relieve ax's - Ex: tx of delayed gastric emptying includes a low-fat diet, frequent small meals, close blood glucose monitoring, & use of agents that increase gastric motility (e.g. metoclopramide and bethanechol); Tx of diabetic diarrhea may include bulk-forming laxatives or antidiarrheal agents; Constipation is treated w/ a high-fiber diet & adequate hydration; meds, laxatives, & enemas may be necessary if constipation is severe; Tx of erectile dysfunction may include meds (e.g. sildenafil citrate) & mechanical devices

Patients with Diabetes who are Hospitalized Cont'd

- Managing Stress: Physiologic stress, like infections & surgery, contributes to hyperglycemia & may precipitate DKA or HHNS; Emotional stress can have a negative impact on diabetes control as well; An increase in stress hormones leads to an increase in glucose lvls, esp if intake of food & insulin remains unchanged; During periods of emotional stress, people w/ diabetes may alter their usual pattern of meals, exercise, & meds--> This can contribute to hyperglycemia or hypoglycemia; People w/ diabetes must be made aware of the potential deterioration in diabetic control that can accompany emotional stress; They must be encouraged to follow the diabetes tx plan as much as possible during times of stress; In addition, learning strategies for minimizing stress & coping w/ stress are important aspects of diabetes education

Microvascular Complications: Diabetic Retinopathy (Medical & Nursing Management)

- Medical Management: primary focus of management is prevention through blood glucose control; Other strategies that may slow progression of diabetic retinopathy include control of HTN & smoking cessation; An important reason for screening for diabetic retinopathy is the effectiveness of laser photocoagulation surgery in preventing vision loss - Nursing Management: focuses on pt education about importance of prevention through regular ophthalmologic exams & blood glucose control; The effectiveness of early dx & prompt tx is emphasized; If vision loss occurs, nursing care must also address pt's adjustment to impaired vision & use of adaptive devices for diabetes self-care as well as ADLs

Monitoring Glucose Levels & Ketones: Advantages & Disadvantages of SMBG Systems

- Methods for SMBG must match the skill lvl of pts - Factors affecting SMBG performance include: visual acuity, fine motor coordination, cognitive ability, comfort w/ technology & willingness to use it, & cost - The use of meters to monitor blood glucose is recommended b/c meters have become much less expensive & less dependent on technique, making the results more accurate - Referral to a social worker may be needed to assist a pt who is w/o financial means to purchase a meter (Most insurance companies cover some or all of the costs of meters & strips) - Nurses play an important role in providing initial teaching about SMBG techniques; Equally important is evaluating the techniques of pts who are experienced in self-monitoring - Pts should be discouraged from purchasing SMBG products from stores or catalogs that don't provide direct education; Every 6- 12 months, pts should conduct a comparison of their meter result w/ a simultaneous lab-measured blood glucose lvls in their PCPs office - The accuracy of the meter & strips should also be assessed w/ control solns specific to that meter whenever a new vial of strips is used & whenever the validity of the reading is in doubt

Teaching Patients to Self-Administer Insulin: Complications of Insulin Therapy Cont'd (Table 30-5)

- Morning Hyperglycemia: An elevated blood glucose lvl on arising in the morning is caused by an insufficient lvl of insulin, which may be caused by several factors: (1) the dawn phenomenon (2) the Somogyi effect or (3) Insulin waning; Dawn phenomenon is characterized by a relatively normal blood glucose lvl until approx 3 a.m., when blood glucose lvls begin to rise; This phenomenon is thought to result from nocturnal surges in growth hormone secretions, which create a greater need for insulin in the early morning hrs in pts w/ type 1 diabetes; must be distinguished from insulin waning (the progressive increase in blood glucose from bedtime to morning) & from the Somogyi effect (nocturnal hypoglycemia followed by rebound hyperglycemia); It may be difficult to tell from a pts hx which of the causes is responsible for morning hyperglycemia-->To determine the cause, pt must be awakened once or twice during the night to test blood glucose lvls; Testing at bedtime, at 3 a.m., & on awakening provides info that can be used to make adjustments in insulin to avoid morning hyperglycemia

Nursing Process: Interventions (Improving Nutritional Status)

- Pt's food intake is planned w/ primary goal of glucose control - The dietary prescription must also consider the primary health problem in addition to lifestyle, cultural background, activity lvl, & food preferences--Alterations may be required b/x of pt's primary health problem -DPt may be NPO in preparation for diagnostic or surgical procedures - Other common alterations for the hospitalized pt include: special diets, tube feedings, & parenteral fluids-->All of these tx's require special consideration for pt w/ diabetes - Pt's nutritional intake is monitored carefully along w/ blood glucose & daily weight

Microvascular Complications: Diabetic Nephropathy (Clinical Manifestations & Assessment)

- Most of the s/s of renal dysfunction in pts w/ diabetes are similar to those seen in pts w/o diabetes - For pts w/ diabetes, as renal failure progresses, the catabolism (breakdown) of both exogenous & endogenous insulin decreases, causing frequent hypoglycemic episodes; Insulin needs change as a result of changes in the catabolism of insulin, changes in diet r/t the tx of nephropathy, & changes in insulin clearance that occur w/ decreased renal function - As renal function decreases, pts commonly have multiple-system failure - Nephropathy is characterized by the presence of albumin in the urine; Although small amounts of albumin may leak undetected for yrs, its presence in the urine is an early sign of nephropathy-->People w/ diabetes should have their urine checked annually for the presence of microalbumin - HTN often develops in pts who are in the early stages of renal disease; However, b/c essential HTN occurs in many people w/ diabetes, this sx may or may not be due to renal disease

Diabetic Neuropathy (Autonomic Neuropathies)

- Neuropathy of the ANS can result in a broad range of dysfunctions affecting many organ systems - 3 manifestations of autonomic neuropathy are r/t the cardiac, GI, & renal systems - CV sx's may range from resting tachycardia, exercise intolerance, & orthostatic hypotension to silent, or painless, MI & ischemia - GI sx's of early satiety, bloating, N/V, & constipation or diarrhea may occur as a result of delayed gastric emptying; Decreased gastric motility may result in poor blood glucose control caused by delayed absorption of glucose from ingested foods - Urinary retention, a decreased sensation of bladder fullness, & other urinary sx's of neurogenic bladder may result from autonomic neuropathy; The pt w/ a neurogenic bladder is predisposed to development of UTIs b/c of the inability to empty the bladder completely; This is esp true of pts w/ poorly controlled diabetes, b/c hyperglycemia impairs resistance to infection - Sexual dysfunction, esp erectile dysfunction & ejaculatory changes in men, is a complication of diabetes; Impotence occurs w/ greater frequency in men w/ diabetes; Some men w/ autonomic neuropathy have normal erectile function & can experience orgasm but don't ejaculate normally--The effects of autonomic neuropathy on female sexual functioning include reduced vaginal lubrication, decreased libido, & lack of orgasm; Vaginal infection, which is more common in women w/ diabetes, may be a/w decreased lubrication, itching, & tenderness

Hyperglycemia Hyperosmolar Nonketonic Syndrome: Nursing Management

- Nursing care of pts w/ HHNS includes close monitoring of vital signs, fluid status, & lab values; Strategies are implemented to maintain safety & prevent injury r/t changes in the sensorium secondary to HHNS - Fluid status & urine output are closely monitored b/c of high risk of renal failure secondary to severe dehydration - Nurse must direct care to the condition that may have precipitated the onset of HHNS; B/c HHNS tends to occur in older pts, the physiologic changes that occur w/ aging should be noted - Careful assessment of CV, pulmonary, & renal function throughout the acute & recovery phases of HHNS is important

Oral Antidiabetic Agents (Table 30-6 & Figure 30-6)

- Oral antidiabetic agents may be effective for pts w/ type 2 diabetes who can't be treated effectively w/ diet & exercise alone - Oral antidiabetic agents include sulfonylureas, biguanides, alpha-glucosidase inhibitors, nonsulfonylurea insulin secretagogues (meglitinides & phenylalanine derivatives), & thiazolidinediones (glitazones) - Sulfonylureas & meglitinides are known as insulin secretagogues b/c their action increases the secretion of insulin by the pancreatic beta cells - Pts must understand that oral agents are prescribed as an addition to, not as a substitute for, diet & exercise - Use of oral antidiabetic meds may need to be temporarily stopped & insulin prescribed during illness, pregnancy, or hospitalization. - In time, as beta cells continue to decline, oral antidiabetic agents may no longer be effective in controlling type 2 diabetes; In such cases, pt is treated w/ insulin - Approx. half of all pts who initially use oral antidiabetic agents eventually require insulin; B/c mechanisms of action vary, use of multiple oral meds w/ different actions is common - For some pts w/ type 2 diabetes, the use of oral agents in combo w/ insulin is indicated

Diabetic Neuropathy (Peripheral Neuropathy): Medical & Nursing Management

- Pain, particularly of the lower extremities, is a disturbing sx for many people w/ neuropathy secondary to diabetes - The 1st step in pain management is to achieve optimal blood glucose control - Pharmacologic tx of pain may include nonopioid analgesics, antidepressants, & antiseizure meds, as well as use of transcutaneous electrical nerve stimulation (TENS)

Microvascular Complications: Diabetic Retinopathy (Clinical Manifestations & Assessment)

- Painless process - nonproliferative & Preproliferative: blurry vision secondary to macular edema occurs in some, although many are asymptomatic (even pts w/ significant degree of proliferative retinopathy & hemorrhaging may not experience major visual changes) - Sx's indicative of hemorrhaging: floaters/cobwebs in visual field, sudden visual changes (including spotty/hazy vision), or complete loss of vision - Dx made by direct visualization of the retina through dilated pupils w/ an opthalmoscope by an ophthalmologist/optometrist

Diabetic Neuropathy (Peripheral Neuropathy): Clinical Manifestations & Assessment

- Paresthesia (numbness/tingling), aching or burning sensations (esp at night), decrease in proprioception, decrease sensation of light touch (may lead to unsteady gait), Decreased sensations of pain & temp (place pt at risk for injury & undetectable foot infections), Joint deformities (may result in abnormal weight distribution on joints resulting from lack of proprioception) - Physical Exam: decrease in deep tendon reflexes & vibratory sensation are found; For pts who have few or no sx's of neuropathy, these physical findings may be the only indication of neuropathic changes

Diabetes: Medical Management: Exercise (Exercise Precautions)

- Pts w/ blood glucose lvls exceeding 250 mg/dL & ketones in the urine shouldn't begin exercising until urine test results are negative for ketones & the blood glucose lvl is closer to normal-->Exercising w/ elevated blood glucose lvls increases the secretion of glucagon, growth hormone, & catecholamines; The liver then releases more glucose, resulting in a further increase in the blood glucose lvl - Since exercising facilitates glucose uptake intracellularly, pts should also be instructed to avoid unexpected hypoglycemia-- Pts who require insulin should be taught to eat a 15 g carb snack or a snack of complex carbs w/ a protein before engaging in moderate exercise (amount varies per person based on glucose monitoring) - Another potential problem for pts who take insulin is hypoglycemia that occurs many hrs after exercise; To avoid post exercise hypoglycemia, esp after strenuous/ prolonged exercise, pt may need to eat a snack at the end of the exercise session & at bedtime, & to monitor the blood glucose lvl more frequently - Other participants or observers should be aware that the person exercising has diabetes, & they should know how to assist if hypoglycemia occurs - Regular daily exercise (at same time), rather than sporadic exercise, should be encouraged; Exercise recommendations must be altered as necessary for pts w/ diabetic complications (retinopathy, autonomic neuropathy, sensorimotor neuropathy, & CV disease) - Increased BP a/w exercise may aggravate diabetic retinopathy & increase risk of a hemorrhage into the vitreous or retina; Pts w/ ischemic heart disease risk triggering angina or MI; Avoiding trauma to lower extremities is esp important in pts w/ numbness r/t neuropathy - In general, a slow, gradual increase in the exercise period is encouraged - For many pts, walking is a safe & beneficial form of exercise that, other than proper shoes, requires no special equipment & can be performed anywhere - People w/ diabetes should discuss exercise w/ their HCPs & undergo medical eval before starting an exercise program

Diabetes: Medical Management: Nutrition (Other Dietary Concerns--Alcohol)

- Pts w/ diabetes don't need to give up alcoholic beverages entirely, but must be aware of the potential adverse effects of alcohol specific to diabetes; Alcohol is absorbed before other nutrients & doesn't require insulin for absorption; Large amounts can be converted to fats, increasing risk for diabetic ketoacidosis--> In general, the same precautions regarding use of alcohol by people w/o diabetes should be applied to those w/ diabetes - A major danger of alcohol consumption by pt w/ diabetes is hypoglycemia, esp for pts who take insulin; Alcohol may decrease the normal physiologic reactions in the body that produce glucose; Therefore, if a pts w/ diabetes consumes alcohol on an empty stomach, there is an increased likelihood of hypoglycemia - Excessive alcohol intake may impair pt's ability to recognize & treat hypoglycemia or to follow a prescribed meal plan to prevent hypoglycemia; To reduce risk of hypoglycemia, pt should be cautioned to consume food w/ alcohol - Alcohol consumption can lead to excessive weight gain from the high caloric content of alcohol, as well as to hyperlipidemia & elevated glucose lvls -Pt teaching about alcohol intake must emphasize moderation in the amount of alcohol consumed; Moderate intake is considered to be 1 alcoholic beverage per day for women & 2 per day for men; Lower-calorie or less sweet drinks ( light beer, dry wine) & food intake w/ alcohol consumption are advised - It is esp important that pts w/ type 2 diabetes who wish to control their weight include calories from alcohol in the overall meal plan

Nursing Process: The Patient with Diabetes as a Secondary Diagnosis

- Pts w/ diabetes frequently seek medical attn for problems not directly r/t blood glucose control - However, during the course of tx for primary medical dx, blood glucose control may worsen-->Therefore, it is important for nurses caring for pts w/ diabetes to focus attn on the diabetes, as well as on the primary health issue

Microvascular Complications: Diabetic Neuropathy

- Refers to a group of diseases that affect all types of nerves, including peripheral (sensorimotor) & autonomic nerves-->May be focal or diffuse - Etiology appears to be r/t elevated blood glucose lvls over a period of yrs - Pathogenesis of neuropathy may be attributed to either vascular or metabolic mechanisms, or both-->Capillary basement membrane thickening & capillary closure disrupt blood supply to nerves; Also, demyelination of nerves, thought to be r/t hyperglycemia, & accumulation of sorbitol in nerve cells slow nerve conduction - 2 types: sensorimotor polyneuropathy (aka peripheral neuropathy, mostly affects distal portions of the nerves, esp in lower extremities) & autonomic neuropathy (cause variety of clinical manifestations, depending on area involved)

Patients with Diabetes who are Hospitalized

- Self-Care Issues: all people in the hospital must relinquish some aspects of their daily care to the staff; For pts w/ diabetes who are involved in diabetes self-management, relinquishing control over meal timing, insulin timing, & insulin dosing can be difficult; It's important for nurse to acknowledge pt's concerns & involve pt in plan of care as much as possible; If pt diagrees w/ certain aspects of care r/t diabetes, nurse must communicate this to other members of health care team to make changes in the plan to meet pt's needs - Hyperglycemia During Hospitalization: hyperglycemia during hospitalization may be result of the original illness that led to the hospitalization; Other factors that may contribute to hyperglycemia during hospitalization include: (1) Changes in usual tx regimen (2) Use of meds & IV fluids,like partial parenteral nutrition (PPN) & total parenteral nutrition (TPN), that increase blood sugar (3) Inappropriate withholding of insulin or inappropriate use of "sliding scales" (4) Mismatched timing of meals & insulin-->Nursing actions to correct or manage these factors are important for avoiding hyperglycemia

Nursing Process: Interventions (Maintaining Skin Care)

- Skin is assessed daily for dryness or breaks - Feet are cleaned w/ warm water & soap;.Excessive soaking of the feet is avoided; Feet are dried thoroughly, esp b/w toes, & lotion is applied to the entire foot, except b/w toes - For pts who are confined to bed, heels are elevated off the bed w/ a pillow placed under the lower legs & the heels resting over the edge of the pillow - Dermal ulcers are treated as indicated & prescribed - Nurse promotes optimal blood glucose control in pt w/ skin breakdown

Complications of Legs & feet: Medical & Nursing Management (Box 30-8 & Figure 30-10)

- Teaching pts proper foot care is a nursing intervention that can prevent costly & painful complications that result in disability - Preventive foot care begins w/ careful daily assessment of the feet; The feet must be inspected for redness, blisters, fissures, calluses, ulcerations, changes in skin temp, or development of foot deformities - For pts w/ visual impairment or decreased joint mobility, use of a mirror to inspect the bottoms of both feet or the help of a family member for foot inspection may be necessary - The interior surfaces of shoes should also be inspected for any rough spots or foreign objects - In addition to daily visual & manual inspection of the feet, the feet should be examined during every health care visit or at least once a yr - Pts w/ neuropathy also should undergo eval of neuro status by an experienced examiner using a monofilament device - Pts w/ pressure areas, like calluses, or thick toenails should be treated by a podiatrist - Blood glucose control is important for avoiding decreased resistance to infections & for preventing diabetic neuropathy; Pt may be referred by the health provider to a wound care center for management of persistent wounds of the feet or legs

Pathophysiology: Diabetes Type 2 (Figure 30-1)

- Slow, progressive glucose intolerance--May go undetected for yrs - Commonly a/w older age & obesity - 2 main issues r/t insulin in this type are insulin resistance & Impaired insulin secretion - Insulin Resistance: decreased tissue sensitivity to insulin - Normally insulin binds to special receptors on cell surfaces & initiates a series of reactions involved in glucose metabolism-->W/ type 2 diabetes, these intracellular reactions are diminished, making insulin less effective in stimulating glucose uptake by the cells & at regulating glucose released by liver - To overcome insulin resistance & prevent the buildup of glucose in the blood, increased amounts of insulin must be secreted to maintain glucose lvls; However, if the beta cells can't keep up w/ the increased demand for insulin, the glucose lvl rises, & type 2 diabetes develops - Despite the impaired insulin secretion that is characteristic of type 2 diabetes, there is enough insulin present to prevent the breakdown of fat & the accompanying production of ketone acids; Therefore, diabetic ketoacidosis (DKA) doesn't typically occur in type 2 diabetes; But uncontrolled type 2 diabetes may lead to hyperglycemic hyperosmolar nonketotic syndrome, another acute complication of diabetes - If pt has sx's, they are mild & may include fatigue, irritability, increased urination, increased thirst, poor wound healing, frequent infections, or changes in vision - One consequence of undetected diabetes is that LT microvascular (diabetic retinopathy, neuropathy, & nephropathy) & macrovascular complications (peripheral vascular, coronary disease, & stroke) may have developed before the actual dx of diabetes is made

Diabetes: Medical Management: Nutrition (Other Dietary Concerns--Sweeteners & Misleading Food Labels)

- Sweeteners: use of sweeteners is acceptable for pts w/ diabetes; Moderation in the amount of sweetener used is encouraged, to avoid potential adverse effects; 2 main types: nutritive (contains calories) & non-nutritive (have few or no calories) - Misleading Food Labels: foods labeled "sugarless" or "sugar-free" may still provide calories equal to those of the equivalent sugar-containing products if they are made w/ nutritive sweeteners-->For weight loss, these products may not always for useful & pts must not consider them "free" foods to be eaten in unlimited quantity, b/c they can elevate blood glucose lvls; Foods labeled "dietetic" are no necessarily reduced-calorie foods; They may be lower in sodium or have other special dietary uses--?Pts are advised that foods w/ this label may still contain significant amounts of sugar or fat; Pts are also taught to read labels of "health foods" (esp snacks) b/x they often contain carbs like honey, brown sugar, & corn syrup & they may contain sat vegetable fats (coconut & palm oils), hydrogenated veg. fats, or animal fats, which may be contraindicated in people w/ elevated blood lipid lvls

Teaching Patients to Self-Administer Insulin: Selecting Syringes

- Syringes must be matched w/ insulin concentration; 3 sizes available (1) 1mL syringes hold 100 units (2) 0.5mL syringes hold 50 units (3) 0.3mL syringes hold 30 units - Most commonly used is U-100 (there are 100 units of insulin per mL) - Small syringes allow pts who require small amounts of insulin to measure & draw up amount accurately; Pts who require large amounts of insulin use larger syringes - a U-500 (500U/mL) concentration of insulin is available by special order for pts who have severe insulin resistance & require massive doses of insulin - Most insulin syringes are disposable 27-to 29-gauge needle that is approx 0.5 inches long - The smaller syringes are marked in 1-unit increments & may be easier for pts w/ visual deficits & those taking very small doses; The 1-mL syringes are marked in 1-& 2-unti increments

Guidelines to Follow During Periods of illness ("Sick Day Rules")

- Take insulin or oral antidiabetic agents as usual - Test blood glucose & test urine ketones every 3- 4 hrs - Report elevated glucose lvls (>300 mg/dL [16.6 mmol/L] or as otherwise specified) or urine ketones to your HCP - If you take insulin, you may need supplemental doses of regular insulin every 3 -4 hrs - If you can't follow your usual meal plan, substitute soft foods (e.g. ⅓ cup regular gelatin, 1 cup cream soup, ½ cup custard, 3 squares graham crackers) 6-8X/day - If vomiting, diarrhea, or fever persists, take liquids (e.g. ½ cup regular cola or orange juice, ½ cup broth, 1 cup Gatorade) every ½- 1 hr to prevent dehydration & to provide calories - Report N/V, & diarrhea to your HCP, b/c extreme fluid loss may be dangerous - If you are unable to retain oral fluids, you may require hospitalization to avoid diabetic ketoacidosis & possibly coma

Diabetes: Nursing Management: Implementing The Plan

- Teaching Experienced Patients: Nurses should continue to assess skills & self-care behaviors of pts who have had diabetes for many yrs; Assessment of experienced pts must include direct observation of skills, not just pt's self-report of self-care behaviors; These pts must be fully aware of preventive measures r/t foot care, eye care, & risk factor management - Teaching Patients Self- Care: Pt teaching & support for diabetes self-management is an important nursing responsibility; Pts who are having difficulty following the diabetes tx plan must be approached w/ care & understanding; If problems w/ glucose control or w/ the development of preventable complications exist, nurse should assess pt to determine possible reasons; Often problems can be corrected simply by providing complete info & ensuring that pt understands the info; The focus of diabetes education is on pt empowerment, highlighting the knowledge, skills, & attitudes needed to maintain & improve one's health-->If knowledge deficit is not the problem, certain physical or emotional factors may be impairing pt's ability to perform self-care skills (Ex:decreased visual acuity may interfere w/ pt's ability to administer insulin accurately, measure blood glucose lvl, or inspect skin & feet; decreased joint mobility or other disability also may impair pt's ability to inspect the bottom of the feet); Emotional factors, like denial of the dx or depression, may impair pt's ability to carry out multiple daily self-care measures; Sometimes family, personal, or work problems are given priority over diabetes management; It is also important to assess pt for infection or emotional stress, which can lead to elevated blood glucose lvls despite adherence to tx regimen **When stressed the "fight-or-flight" response elevates catecholamine release, which stimulates glucose production & inhibits release, elevating serum glucose lvls

Hyperglycemia Hyperosmolar Nonketonic Syndrome: Clinical Manifestations & Assessment

- The clinical picture of HHNS is one of hypotension, profound dehydration (dry mucous membranes, poor skin turgor), tachycardia, & variable neurologic signs (e.g. alteration of sensorium, seizures, hemiparesis) - As HHNS tends to occur in the elderly, many who have coexisting cardiac & renal disease, the mortality rate ranges from 10%- 40%, usually r/t an underlying illness, the vulnerability of the elderly pt, & the severity of HHNS - Diagnostic assessment reveals very high blood glucose, usually 600-1,200 mg/dL, & high serum osmolality, often exceeding 350 mOsm/kg; Electrolyte & BUN lvls are consistent w/ the clinical picture of profound dehydration; Mental status changes & neuro deficits are common secondary to cerebral dehydration that results from extreme hyperosmolality; Postural hypotension results from the dehydration

Diabetic Ketoacidosis: Clinical Manifestations & Assessment (Figure 30-7)

- The hyperglycemia of DKA leads to polyuria & polydipsia, weakness, & malaise; Pt may experience blurred vision due to osmotic changes on the lens r/t hyperglycemia - Pts w/ marked intravascular volume depletion may present w/ orthostatic hypotension, warm, dry skin, decreased skin turgor, flat neck veins, & dry mucous membranes; Volume depletion may also lead to frank hypotension & a weak, rapid pulse - The ketosis & acidosis of DKA lead to GI sx's like anorexia, N/V, & abdominal pain - Pt may have acetone breath (a fruity odor), & Kussmaul respirations representing the body's attempt to decrease the acidosis, counteracting the effect of ketone accumulation - Mental status changes in DKA vary widely; pt may be alert, lethargic, or comatose, depending on plasma osmolality ***Ketone bodies are acids that disturb acid-base balance of the body when they accumulate in excessive amounts; The resulting DKA may cause s/s such as abdominal pain, N/V, hyperventilation, a fruity breath odor, &, if left untreated, altered lvl of consciousness, coma, & death--Initiation of insulin tx, along w/ fluid & electrolytes as needed, is essential to treat hyperglycemia & DKA & rapidly improves metabolic abnormalities - Diagnostic findings include: (1) Blood glucose lvls >250 mg/dL (2)Low serum pH (6.8 - 7.3) (3) Low serum bicarbonate (0- 15 mEq/L) (4) Accumulation of serum & urine ketones (5) Presence of glucose in the urine (6) Abnormal serum electrolyte lvls (sodium, potassium, & chloride)

Diabetes: Medical Management: Nutrition (Meal Planning)

- The meal plan must consider the pt's food preferences, lifestyle, usual eating times, & ethnic & cultural background; Recent advances in diabetic management & insulin therapy allows greater flexibility in the timing & content of meals - Initial education addresses the importance of consistent eating habits, the relationship of food & insulin, & the provision of an individualized meal plan - in depth follow-up education then focuses on management skills (eating at restaurants, reading food labels, adjusting the meal plan for exercise, illness, & special occasions) - Nurse plays an important role in communication pertinent info to the dietitian & reinforcing the pt's understanding - For some pts, certain aspects of meal planning may be difficult to learn--> may be r/t limitations in intellectual lvl or to emotional issues (difficulty accepting the dx of diabetes or feelings of deprivation)-->it helps to emphasize that nutritional management of diabetes provides a new way of thinking about food, rather than a new way of eating - It also is important to simplify info as much as possible & to provide opportunities for pt to practice & repeat activities & info

Diabetes: Medical Management: Nutrition

- The most important objectives in the dietary management of diabetes are control of total caloric intake to attain or maintain a reasonable body weight, control of blood glucose lvls, & normalization of lipids &BP to prevent heart disease - B/c nutritional therapy for diabetes is complex, a registered dietitian who understands diabetes management has the primary responsibility for designing & teaching this aspect of the therapeutic plan; Nurses & other members of the health care team must be knowledgeable about nutrition therapy & supportive of pts who need to implement diet & lifestyle changes - Nutrition management of diabetes includes the following guidelines: (1) Provide all essential food constituents necessary for optimal nutrition (2) Meet & maintain energy needs (3) Achieve & maintain a reasonable weight (4) Prevent wide daily fluctuations in blood glucose lvls, w/ blood glucose lvls as close to normal as is safe & practical to prevent/ reduce risk for complications (5) Decrease serum lipid lvls, if elevated, to reduce risk for macrovascular disease (coronary artery, cerebrovascular & peripheral vascular disease) - For pts who require insulin to help control blood glucose lvls, maintaining as much consistency as possible in the amount of calories & carbs ingested at each meal is essential; Consistency in the approximate time intervals b/w meals, w/ the addition of snacks if necessary, helps prevent hypoglycemic reactions & maintain overall blood glucose control -W/ type 2 diabetes, a weight loss as small as 10% of total weight may significantly improve blood glucose lvls ;Some pts w/ type 2 diabetes who require insulin or oral agents to control blood glucose lvls may be able to reduce/ eliminate the need for meds through weight loss - For obese pts w/ diabetes who don't take insulin or oral agents, consistent meal content or timing is important but not as critical; Rather, decreasing overall caloric intake is most important; But, meals shouldn't be skipped-->Pacing food intake throughout the day places more manageable demands on the pancreas

Hyperglycemia Hyperosmolar Nonketonic Syndrome: Medical Management

- The overall approach to tx of HHNS is similar to that of DKA: fluid replacement, correction of electrolyte imbalances, & insulin admin. - B/c pts w/ HHNS are typically older, close monitoring of volume & electrolyte status is important for prevention of fluid overload, HF, & cardiac dysrhythmias; Fluid treatment is started w/ 0.9% or 0.45% NS, depending on pt's sodium lvl & severity of volume depletion - Central venous or hemodynamic pressure monitoring guides fluid replacement; K+ is added to IV fluids when urinary output is adequate & is guided by continuous ECG monitoring & frequent lab determinations of potassium - Extremely elevated blood glucose concentrations decrease as pt is rehydrated - Insulin plays a less important role in the tx of HHNS b/c it is not needed for reversal of acidosis. Insulin is administered at a continuous low rate to treat hyperglycemia; As in DKA, replacement IV fluids w/ dextrose are administered after the glucose lvl has decreased to 250-300 mg/dL - Other therapeutic modalities are determined by the underlying illness & results of continuing clinical & lab evaluation - It may take 3-5 days for neuro sx's to clear; tx of HHNS usually continues well after metabolic abnormalities are resolved - After recovery from HHNS, many pts can control their diabetes w/ diet alone or w/ diet & oral anti diabetic meds--> Insulin may not be needed once pt has recovered from acute hyperglycemic episode; Frequent SBGM is important in preventing recurrence of HHNS.

Diabetes: Medical Management

- Therapeutic goal for diabetres management is to achieve normal blood glucose lvls (auglycemia) w/o hypoglycemia while maintaining a high quality of life - Diabetes management has 5 components: (1) Nutrition (2)Exercise (3) Monitoring (4) Medication (5) Education - Pts w/ type 1 diabetes required daily insulin injections to control blood glucose lvls - Primary tx of type 2 diabetes is weight loss - Pt's tx depends on the severity of the hyperglycemia at the time of dx - Tx varies b/c of changes in lifestyle & physical & emotional status, as well as b/c o advances on tx methods - Diabetes management involves ongoing assessment & modification of the tx plan as needed - Pt must manage the complex therapeutic regimen-->Pt & family education is an essential component of diabetes tx

Diabetes: Medical Management: Nutrition (Food Classification Systems) (Table 30-2)

- To teach diet principles & to help pts w/ meal planning, several systems have been developed in which foods are organized into groups w/ common characteristics, like # of calories, composition of foods, or effect on blood glucose lvls; Food intake can be managed several ways (carb counting, exchange lists, food lists, & calorie counting - Carb Intake: monitoring carb intake by carb counting, exchange lists, or experienced-based estimation can be effective ways to achieve blood glucose control; provides flexibility in food choice & is less complicated that other systems; Allows for more accurate management w/ meds & exercise; For pts who take insulin, 1 unit of insulin for every 10-15 grams of carbs may be prescribed; Pts who can manage insulin-to-carb calculations have the potential to enjoy a more flexible lifestyle & more predictable diabetes control; Exchange lists also are used for nutritional management of diabetes; The Exchange Lists for Meal Planning consist of 6 main exchange lists: (1) starch, (2) fruit, (3) milk (4) veggie, (5) meat, & (6) fat; Foods included on each list, in the amounts specified, contain equal #s of calories & are approx equal in grams of protein, fat, & carb; Meal plans are based on a recommended # of choices from each exchange list; Foods on one list may be interchanged w/ one another, allowing pt to choose a variety while maintaining as much consistency as possible in the nutrient content of foods eaten - Diabetes Food Guide Pyramid: consists of the following food groups: (1) grains & starches, (2) veggies, (3) fruits, (4) milk & other dairy products, & (5) meats & beans; The smallest group, fats, sweets, & alcohol, is at the top of the pyramid; Starches, fruits, & vegetables, which are lowest in calories & fat & highest in fiber, should make up the basis of the diet; 50%- 60% of the daily caloric intake should be from those 3 food groups; Foods higher in fat, esp sat fat, should account for a smaller %age of the daily caloric intake; Fats, oils, & sweets should be used sparingly by people w/ diabetes to obtain weight & blood glucose control & to reduce risk for CV disease; Calorie counting or point systems are methods that can be used for weight management in type 2 diabetes

Teaching Patients to Self-Administer Insulin: Preparing the Injection-Mixing Insulins (Figure 30-3)

- When rapid or short acting insulins are given w/ longer acting insulins, they are usually mixed together in the same syringe - Regular (short acting) insulin must be inspected for clarity & not used unless it's crystal clear; Modified insulins will be cloudy & should be carefully mixed by gently rolling the vial-->injecting cloudy insulin into a vial of clear insulin contaminates the entire vial of clear insulin & alters its action - Regular insulin is drawn into the syringe 1st, followed by modified insulin - Pts who have difficulty mixing insulins have 2 options--> they may use premixed insulin in a vial or in a prefilled syringe; Premixed insulins are available in different ratios of NPH insulin & regular insulin (70/30 is common, which is 70%NPH & 30% regular) - For pts who can inject insulin but who have difficulty drawing up a single or mixed dose, syringes may be prefilled w/ the help of home care nurses or family & friends; A 3-wk supply of insulin syringes may be prepared & kept in the refrigerator - Prefilled syringes should be stored w/ the needle in an upright position to avoid clogging of the needle; Like insulin in vials, prefilled syringes should be rotated gently b/w the hands to mix & warm the insulin before injection