NUR 310: Complications of Diabetes PowerPoint, Exam 1

Diabetic Ketoacidosis (DKA) is caused by a profound deficiency of insulin, so who's mostly likely to develop it?

-Type 1 Diabetics

You're are nurse in an acute care settings, & if your patient is NPO & is Hypoglycemic, give them:

-50% dextrose, 20 to 50 mL, IV push. Then recheck blood glucose again in 15 mins

What is Hyperosmolar Hyperglycemic Syndrome (HHS) caused by?

-Caused by mild to moderate insulin insufficiency meaning individual doesn't have enough insulin to not break down fats for energy. No ketones will be present. *BG levels tend to be higher with HHS than with DKA

If a person is unconscious or not alert enough to swallow & has Hypoglycemia, give them:

-Glucagon, 1 mg, IM or subcutaneously

Definition of Hyperosmolar Hyperglycemic Syndrome (HHS):

-Life-threatening syndrome w/ insidious onset *Much greater morbidity rate than DKA

If a person is conscious & has Hypoglycemia, give them:

-Oral fruit juice -regular soda, or glucose tabs

True or False, the brain needs glucose to function:

-True. -If don't have glucose, this is why a coma or death may result from hypoglycemia

If a person has Hyperosmolar Hyperglycemic Syndrome (HHS), why don't we see the obvious signs & symptoms?

-because this complication develops slowly over weeks, usually after infection

What is Hyopglycemic Unawareness?

-condition where a person doesn't experience warning signs & symptoms until glucose level becomes critically low -Is related to autonomic neuropathy and lack of counterregulatory hormones

What general population is more susceptible of getting Hyperosmolar Hyperglycemic Syndrome (HHS)?

-individuals with type 2 diabetes -older pts w/ pre-existing diseases &/or do not have adequate fluid intake & have CHF or COPD

You are a nurse & suspect your patient to be Hypoglycemic, what do you do if you get a blood glucose reading of more than 70 mg/dL?

-investigate further for cause of signs/symptoms -could be a different problem or condition such as a myocardial infarction for example

As a nurse, what do we teach our patients that have Diabetic Ketoacidosis?

-monitor BG more frequently in times of stress/illness & monitor for ketones in urine, etc

Treatment guidelines for Diabetic Ketoacidosis (DKA):

-severe fluid and electrolyte imbalance -Fever -N/V -diarrhea -altered mental state or if not able to "be in touch" with the HCP *Less severe cases are often treated on outpatient basis

Clinical Manifestations of Diabetic Ketoacidosis (DKA):

1) Dehydration leading to: poor skin turgor, dry mucous membranes, tachycardia, & orthostatic hypotension *As dehydration gets worse, the skin becomes dry & loose & eyes become soft & sunken 2) Lethargy and weakness early on in complication 3) Three P's: polydipsia, polyuria, polyphagia, but this only last 1-2 days. 4) Fluid shift: kidneys are working harder to excrete as much glucose as possible. Electrolytes are also excreted with the glucose 5) Abdominal pain, anorexia, N/V due to sate of acidosis 6) Kussmaul respirations—fast & deep breathing. This occurs because your body is trying to compensate for what is going on--trying to breath off more CO2 7) Sweet, fruity breath odor due to acetone in blood 8) Blood glucose level of 250 mg/dL or higher 9) Blood pH lower than 7.30. This is considered Acidosis. Normal pH is: 7.35-7.45 10) Serum bicarbonate level lower than 16 mEq/L 11) Moderate to high ketone levels in urine or serum *The onset/progression of this occurs VERY fast

What are 3 ACUTE complications of Diabetes?

1) Diabetic ketoacidosis (DKA) 2) Hyperosmolar hyperglycemic syndrome (HHS) 3) Hypoglycemia *DKA & HHS involve HIGH blood sugars

What patients are at risk in developing Hypoglycemic Unawareness?

1) Elderly 2) Patients who use Beta-Blockers: these mask symptoms of tachycardia 3) those with long history of diabetes 4) multiple hyperglycemic events. The body doesn't respond like it would have for the first hypoglycemic event that had occur. *Patients at risk should keep blood glucose levels somewhat higher overall, BUT STILL IN CONTROL

Treatment steps for Diabetic Ketoacidosis (DKA) in emergency... A,B,C s:

1) Establish IV access: begin fluid resuscitation. NaCl 0.45% or 0.9% at a rate to restore u/o 30-60 mL/hr and raise BP 2) Administer IV Insulin drip—Regular insulin (fast-acting) 3) Potassium replacement as needed. Check K+ before starting insulin! K+ will move into cells with insulin, causing Hypokalemia! 4) Add 5% to 10% dextrose when blood glucose level approaches 250 mg/dL. Doing this prevents Hypoglycemia from occurring.

5 Ways to Treat Hypoglycemia:

1) Have patient consume 15 grams of a simple carb -Example: 4-6 oz fruit juice or REGULAR soda--not diet. We want something that will be quickly absorbed 2) Then recheck in 15 minutes. Repeat another 15 g carbs if still less than 70 mg/dL 3) Avoid foods with fat. These foods decrease the absorption of the sugar/carbs -Example: candy bars 4) Give complex CHO; carbohydrates after recovery such as: bread, pasta, crackers, or starchy vegetables. Something that will last longer & maintain/raise blood glucose over a prolonged period of time 5) Lastly, avoid overtreatment

4 Characteristics that someone has Diabetic Ketoacidosis (DKA):

1) Hyperglycemia 2) Ketosis: breaking down fats for energy. Ketones in blood & urine resulting in signs & symptoms of abdominal pain, nausea & vomiting 3) Acidosis 4) Dehydration

What are the 6 precipitating factors that may cause someone to get Diabetic Ketoacidosis (DKA)?

1) Illness 2) Infection 3) Inadequate insulin dosage 4) Undiagnosed type 1 diabetes 5) Poor self-management 6) Neglect Additional reason, not having enough insulin in the body

What are 2 subgroups of Angiopathy that occurs that is considered to be a CHRONIC complication of Diabetes?

1) Macrovascular which includes: cerebral vascular, cardiovascular, & peripheral vascular 2) Microvascular which includes: retinopathy, nephropathy, & neuropathy

Therapy things to do for Hyperosmolar Hyperglycemic Syndrome (HHS) is similar to that for DKA & are:

1) Monitor IV fluids. More fluid replacement needed for HHS 2) Administer IV insulin 3) Monitor serum potassium and replace as needed. Hypokalemia not as severe/big of an issue as it is with DKA.

What are 4 clinical manifestations of Hyperosmolar Hyperglycemic Syndrome (HHS) that differ from Diabetic Ketoacidosis clinical manifestations?

1) More profound dehydration 2) More severe neurologic manifestations: confusion, lethargy, & coma, because of ↑ serum osmolality 3) Ketones absent or minimal in blood & urine 4) Blood Glucose often higher, greater than 600 mg/dL

What is a normal hormonal response in a person who doesn't have Diabetes when experiencing Hypoglycemia?

1) Neuroendocrine hormones released: Glucagon, epinephrine, cortisol 2) Autonomic nervous system activated BUT, with diabetics, they have an impaired hormonal response!

7 Clinical manifestations of Hypoglycemia:

1) Shakiness 2 Palpitations/Tachycardia 3) Nervousness/Irritable 4) Diaphoresis: sweating 5) Anxiety 6) Hunger & Nausea 7) Pallor 8) 8) Altered mental functioning such as: difficulty speaking, a headache, visual disturbances, anger or stubbornness, & stupor or confusion *These all occur due to release of epinephrine *It doesn't mean someone has to have to have all these symptoms to be Hypoglycemic, but only just a couple. People react differently!

Characteristics someone may have Diabetic Ketoacidosis:

1) Signs/symptoms of dehydration 2) abdominal pain 3) N&V 4) increased BG 5) Kussmal respirations

What are the 4 causes of Hypoglycemia occurring?

1) Too much insulin or oral hypoglycemic agents; OA's that increase endogeneous insulin production 2) Too little food 3) Delaying time of eating 4) Too much exercise *Symptoms can also occur when high glucose level falls too rapidly. Even if blood glucose was at 200 mg/dL and drops to 100 mg/dL, although this is good, the rapid drop can cause signs & symptoms of Hypoglycemia

6 precipitating factors that leads to someone having Hyperosmolar Hyperglycemic Syndrome (HHS):

1) UTIs 2) Pneumonia 3) Sepsis 4) any acute illness 5) Newly diagnosed type 2 diabetes 6) Impaired thirst sensation and/or inability to replace fluids

Since Hyperosmolar Hyperglycemic Syndrome (HHS) has a high mortality rate, what is the actual percentage?

15%

What is the morality rate of Diabetic Ketoacidosis (DKA) occurring in individuals today?

5%

Diabetic Ketoacidosis (DKA) is caused by:

profound deficiency of insulin & a blood glucose of greater than 250

As a nurse, what will happen to your patient if don't treat them when they are Hypoglycemia?

progression to loss of consciousness, seizures, coma, and finally death *DON'T WANT THIS TO HAPPEN SO TREAT ASAP!

What does it mean by someone has Hypoglycemia like what is going on?

Too much insulin in proportion to glucose in the blood

True or False, Diabetic Ketoacidosis (DKA) is most likely to occur with type I diabetics:

True

True or False, because there is enough circulating insulin to prevent ketoacidosis, patients have fewer symptoms with Hyperosmolar Hyperglycemia Syndrome (HHS) showing no abdominal pain or Kussmaul breathing so we don't necessarily seek treatment as soon, which leads to higher glucose levels:

True

True or False, signs & symptoms occur more quickly in individuals whom are HYPOglycemia rather than HYPERglycemia:

True

True or False, you have to be a diabetic to have Hyperosmolar Hyperglycemic Syndrome (HHS)?

True, Yes, you do

As a nurse, do we want to correct the underlying precipitating cause to prevent HHS from reoccurring in future?

YES!

Is Hyperosmolar Hyperglycemic Syndrome considered a medical emergency?

Yes

What do you if monitoring equipment is not available & you suspect your patient to be Hypoglycemic based on your assessment?

assume hypoglycemic and initiate treatment

You are a nurse & suspect your patient to be Hypoglycemic, what do you do if you get a blood glucose reading of of less than 70 mg/dL?

begin treatment

You found out your patient has Hypoglycemia. If you were to take a blood glucose, what reading would you get?

blood glucose < 70 mg/dL

As a nurse, how do we watch or monitor someone whom has Diabetic Ketoacidosis?

check BG and check for ketones in urine/blood

As a nurse or a diabetic patient, what are you going to do when you discover a reading of a blood glucose of greater than 300?

check urine for ketones

As a nurse, what is crucial when it comes to Hypoglycemia in making your patient's stay therapeutic?

exploring the reason why it occurred and educate the patient to prevent it from happening again in the future

What precipitates Diabetic Ketoacidosis (DKA) from occurring?

inadequate insulin intake or illness