MED SURG diabetes topic 4 48

Clinical manifestations

Type 1: -onset is rapid, so the initial manifestations are acute -classic symptoms are polyuria, polydipsia, polyphagia -the osmotic effect of glucose produces the manifestations of polydipsia and polyuria -polyphagia is a consequence of cellular malnourishment -weight loss may occur because the body cannot get enough glucose and turns to other energy sources such as fat and protein -ketoacidosis Type 2: -nonspecific -some of the same signs as type 1 like the poly stuff -common: fatigue, recurrent infections, recurrent vaginal yeast or candidal infections, prolonged wound healing, and visual changes

infection

a person with diabetes is more susceptible to infections because of a defect in the mobilization of WBC candida albican as well as boils and furuncles in the undiagnosed pt often lead the HCP to suspect diabetes. loss of sensations may delay the detection of infection glycosuria may predispose the pt to bladder infections, especially pt with a neurogenic bladder. decreased circulation resulting from angiopathy can prevent or delay the immune response. antibiotic therapy hand washing, avoid exposure to ppl who have a communicable illness and getting an annual influenza vaccine and pneumococcal vaccine

Nephropathy

damage to the small blood vessels that supply the glomeruli of the kidney leading cause of end stage renal disease risk factors: HTN, genetic, smoking and chronic hyperglycemia pt with diabetes are screened annually with a random spot urine collection to assess for albuminuria and measure the albumin to creatinine ratio pt with diabetes who have albuminuria receive either ACE inhibitor drugs, lisinopril, or antiotension 2 receptor antagonists. used to tx HTN and have been found to delay the progression of nephropathy in pt with diabetes -aggressive BP management is indicated for all pt with diabetes

other specific types of diabetes

diabetes occurs in some people because of other medical condition or tx of a medical condition that causes abnormal blood glucose levels -conditions that may cause it include injury to, interference with, or destruction of the B cell function in the pancreas -these include cushion's, hyperthyroidism, recurrent pancreatitis, cystic fibrosis, hemochromatosis, and parenteral nutrition -commonly used medications that induce diabetes are corticosteroids, thiazides, and atypical antipsychotics. -diabetes caused by medical conditions or medications can resolve when the underlying condition is treated or the medication is discontinued

Drug therapy

exogenous (injected) insulin is needed when a pt has inadequate insulin to meet specific metabolic needs -people with type require exogenous insulin to survive and often use multiple daily injections of insulin or continuous insulin infusion via an insulin pump to adequately manage blood glucose levels -type 2 is a progressive disease, overtime the combination of nutrition therapy, exercise, OAs, and non insulin injectable agents may no longer manage blood glucose levels -at that point exogenous insulin would be added -people with type 2 may also need up to 4 injections per day. insulin pumps can also be used Types of insulin: Rapid acting- lispro (humalog), aspart(novolog), glulisine(apidra) onset: 10-30min peak: 30min-3 hr duration: 3-5 hr short acting- regular (humulin R, Novolin R) onset: 30min-1 hr peak: 2-5 hr duration: 5-8 hr intermediate acting- NPH (humulin N, Novolin R) onset: 1.5-4 hr peak: 4-12hr duration: 12-18hr long acting- glargine (lantus), detemir(levemir), degludec(tresiba) onset: .8-4 hr peak: no duration: 16-24 hr insulin regimens: -the insulin regimen that most closely mimics endogenous insulin production is the basal bolus regimen which uses rapid or short acting (bolus) insulin before meals and intermediate or long acting (basal) background insulin once or twice a day -the basal bolus regimen is intensive or physiologic insulin therapy, consisting of multiple daily insulin injections together with frequent self monitoring of blood glucose -the goal is to achieve a glucose level of 80-130 before meals mealtime insulin (bolus): -to manage postprandial blood glucose, the timing of rapid and short acting insulin in relation to meals is crucial -rapid acting should be injected within 15 mins of meal time -short acting has an onset of 30-60 min and is injected 30-45 mins before a meal to ensure that the onset of action coincides with meal absorption -short acting is more likely to cause hypoglycemia because of a longer duration of action longer or intermediate acting (basal) background insulin: -in addition to mealtime insulin, people with type 1 use basal insulin to maintain blood levels in between meals and overnight -without 24 hour background insulin, people with type 1 are more prone to developing DKA -long acting is released steadily and continuously. no peak. Detemir is often given twice daily. with no peak, risk for hypoglycemia from this type is greatly reduced -if oral agents and long acting insulin are not adequate to achieve glycemic goes, mealtime insulin may also be added -NPH is also basal. duration of 12-18 hrs. Disadvantage is that is has a peak ranging from 4-12 hours, which can result in hypoglycemia. Never give IV. cloudy because it contain protamine combination therapy: -for those who want to use only one or to injections per day, a short to rapid acting insulin can be mixed with intermediate acting insulin in the same syringe. Storage of insulin: -insulin vials and pens currently in use may be left at room temp. for up to 4 weeks unless the room temp. is higher than 86F or below freezing 32F -avoid direct exposure to sunlight -traveling in hot climates may store them in thermos or cooler to keep it cool (not frozen) -store unopened insulin vials and pens in the fridge -prefiled syringes containing two different insulins are stable for up to 1 week when stored in the fridge, whereas syringes containing only one type of insulin are stable for up to 30 days -store syringes in vertical position with the needle pointed up to avoid clumping -before injection, roll profiled syringes between the palm 10-20 time to warm the insulin and resuspend particles Administration of insulin: -sub Q -regular can be given by IV when immediate onset of action is desired. -insulin is not taken orally because it is inactivated by gastric fluids -teach pt to avoid injecting IM because rapid and unpredictable absorption could result in hypogly. Insulin injection: never assume that because the pt already uses insulin, they know and practice correct insulin injection -the speed with which peal serum concentrations are reached varies with anatomic site for injection -fastest is abdomen followed by arm, thigh, and buttock -caution the patient about injecting into a site that is to be exercised -rotate the injection site with .5-1 inch from previous site -most are in U100 -the higher the gauge number, the smaller the diameter thus resulting in a more comfortable injection -never recap a needle used for a pt -the use of alcohol swab on the site before self injection is no longer recommended -insulin injections are typically given at 90 degree angle -for thin or muscular patients, use a 45 degree angle -pinching up the skin to avoid IM injection is no longer needed because of short needles - insulin pens offer convenience and flexibility, they are portable and compact -for pt w/ poor vision, the pen is a better option, since they can hear the clicks of the pen as the dose is selected insulin pump: delivers a continuous subcutaneous insulin infusion through a small device worn on the belt, in a pocket, or under clothing -they use rapid insulin -they deliver a continuous infusion of rapid acting insulin 24 hours a day known as the basal rate. Rate can be temporary increased or decreased based on carbohydrate intake, activity changes, or illness, many people require different rates at different points during the day -at mealtime, the pump delivers a bolus appropriate to the amount of carbohydrate ingested -the infusion is changed every 2-3 days and placed in a new site to avoid infection and to promote good insulin absorption -check blood glucose levels at least 4 times per day - a major advantage of the insulin pump is the potential for keeping blood glucose levels in a tighter range -pumps offer users more flexibility with meal and activity patterns -challenges include infection at site, increased risk for DKA if infusion is disrupted, and the increased cost Problems with insulin therapy: -hypoglycemia, allergic reactions, lipodystrophy, and the somogyi effect Allergic reactions: itching, erythema, and burning around site. Local reactions may be self limiting wishin 1-3 months or may improve with a low dose of antihistamine -systemic reaction- urticaria, possible anaphylactic shock lipodystrophy: atrophy or hypertrophy of SQ tissue. may occur if the same injection sites are used frequently. Use of human insulin has significantly reduced the risk. Atrophy is wasting of SQ tissue and presents as indentations at site. Hypertrophy is thickening of the SQ tissue, eventually regresses if the pt does not use the site for at least 6 months Somogyi effect: -hyperglycemia in the morning -a high dose of insulin produces a decline in blood glucose levels during the night -as a result, couterregualtory hormones stimulate lipolysis, gluconeogeneis, and glycogenesis which produces rebound hyperglycemia -HCP may then even increase the insulin dose -if experiencing morning hypergly. check levels at 2:00-4:00 AM for hypo. to determine if this is the cause -pt may report HA on awakening and night sweats - bedtime snack, reduction in insulin dose, or both can prevent -tx is less insulin the eventing The dawn phenomenon: -hyperglycemia that is present on awakening -GH and cortisol may cause this -tx is an increase in insulin or an adjustment in admin. time -if the predawn levels are less than 60 and s/s of hypo. are present, the insulin dose should be decreased. If the 2:00-4:00am bg. is high, the insulin dosage should be increased Inhaled insulin: -Afrezza, rapid acting is admin. at the beginning of each meal or within 20 mins after starting a meal -must be used in combo with long acting if type 1 -not recommend for the tx of DKA or in pt who smoke -adverse effects are hypo., cough, throat pain or irritation -should not be used in pt with chronic lung disease because bronchospasm can occur Drug therapy: -OAs and non insulin injectable agents -these drugs work on three defects of type 2: 1) insulin resistance 2) decreased insulin production 3) increased hepatic glucose production Biguanides: -metformin is the most effective first line tx for type 2 - the primary action is reduce glucose production by the liver. Also enhances insulin sensitivity at the tissue level and improves glucose transport into the cells -may cause weight loss, may be useful if overweight -discontinue before surgery or the procedure. -they should not resume the metformin until 48 hours after. Once their serum creatinine has been checked and is normal DRUG ALERT: -do not use in pt's with kidney disease, liver disease, or heart failure. Lactic acidosis is a rare complication of metformin accumulation -IV contrast media that contain iodine pose a risk of acute kidney injury, which could exacerbate metformin induced lactic acidosis -to reduce risk of kidney injury, discontinue a day or two before -may be resumed 48 hours after, assuming kidney function is normal -do not use in people who drink excessive amounts of alcohol -take with food to minimize GI side effects

integumentary complications

reddish brown, round or oval patches initially they are scaly then they flatten and then some become indented Acanthuses nigricans is a manifestations of insulin resistance. can appear velvety light brown to black skin thickening necrobiosis lipoidica diabeticorum usually appears as red yellow lesions, with atrophic skin that becomes shiny and transparent revealing tiny blood vessels under the surface

psychologic considerations

high rates of depression, anxiety, and eating disorders disordered eating behaviors (DEB) can occur in people with type 1 and type 2 includes anorexia, bulimia, binge eating, excessive restriction of calories, and intense exercise may decrease their dose of insulin, known as disabulimia and leads to weight loss, hyperglycemia, and glycosuria because the food ingested cannot be used for energy without adequate insulin

Bariatric surgery

may be considered for pt with type 2 will need lifelong support and monitoring

Hyperosmolar Hyperglycemic syndrome

(HHS) -is a life threatening syndrome that can occur in the pt with diabetes who is able to produce enough insulin to prevent DKA, but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion -often occurs in pt over 60 with type 2 -common causes are UTI, pneumonia, sepsis, any acute illness, and newly diagnosed type 2 diabetes -often related to impaired thirst sensation and/ or a functional inability to replace fluids -pt with HHS usually has enough circulating insulin so that ketoacidosis does not occur -BG levels can climb high before problem is found -the higher BG, increase serum osmolarity and more neurologic manifestation like somnolence, coma, seizures, hemiparesis, and aphasia -lab values include a BG level greater than 600 and a marked increase serum osmolarity. Ketone bodies are absent or minimal in both blood and urine interprofessional care: -immediate IV administration of insulin and either 0.9% or 0.45% NaCl -requires large volumes of fluid replacement, should be done slowly -hemodynamic monitoring to avoid fluid overload during replacement -when BG levels fall to 250, IV fluids contains dextrose are administered to prevent hypo- -assess vitals, in/out, tissue turgor, lab values, and cardiac monitoring to check the efficacy of fluid and electrolyte replacement, this include monitoring serum osmolarity and frequently assessing cardiac, renal, and mental status

Normal glucose and insulin metabolism:

- insulin is a hormone produced by the B cells in the islets of Langerhans of the pancreas. -Insulin lowers blood glucose and facilitates a stable, normal glucose range of appx. 70-110. -Insulin promotes glucose transport from the bloodstream across the cell membrane to the cytoplasm of the cell -cells break down glucose to make energy and liver and muscle cells store excess glucose as glycogen -the rise in plasma insulin after a meal inhibits glucongenesis, enhances fat deposition of adipose fat tissue, and increases protein synthesis -insulin is an anabolic, or storage hormone -skeletal muscle and adipose tissue have specific receptors for insulin and are considered insulin dependent tissues -insulin receptor sites on the liver facilitate hepatic uptake of glucose and its conversion to glycogen - other hormones (glucagon, epi, GH, and cortisol) work to oppose the effects of insulin and are referred to as counter regulatory hormones -these hormones increase blood glucose by: 1) stimulating glucose production and release by the liver 2) decreasing the movement of glucose into the cells

Acute complications of DM

-arise from events associated with hyperglycemia and hypoglycemia -hypo- worsens rapidly and is a serious threat if action is not immediately taken Hyperglycemia: -manifestations: elevated BG, increase in urination, increase in appetite followed by lack, weakness, blurred vision, HA, glycosuria, n/v, abd. cramps, progression to DKA or HHS -causes: illness, infection, corticosteroids, too much food, too little or no diabetes medication, inactivity, emotional/physical stress, poor absorption of insulin tx: get medical care, continue diabetes medication, check BG frequently and check urine for ketones;record results, drink fluids at least on an hourly basis, contact HCP regarding ketonuria preventative measures: take prescribed dose of medication at proper time, accurately administer insulin, non insulin injectables, OA. Make healthy food choices, check bg regular, ID Hypoglycemia: -manifestations: blood glucose less than 70, cold clammy skin, numb fingers/toes/mouth, rapid heartbeat, emotional changes, HA, nervousness, tremors, faintness, dizzy, unsteady gait, slurred speech, hunger, changes in vision, seizures, coma causes: alcohol intake w/o food, too little food, too much diabetes medication, too much exercise without adequate food intake, diabetes medication or food taken at wrong time, loss of weight w/o change in medication, use of B adrenergic blockers interfering with recognition of symptoms tx: rule of 15, etc. preventative measures: take prescribed dose of medication at proper time, accurately administer insulin, non insulin injectable, OA. coordinate eating with medications, eat adequate food intake needed for calories for exercise, be able to recognize and know symptoms and treat them immediately, carry simple carbs, teach family and caregivers about symptoms and tx, check blood glucose routinely, wear or carry ID

pancreas transplantation

-can be used as a tx option for type 1 - usually if they have end stage renal disease -kidney and pancreas transplants are often done together -ADA says pt usually need to have the 3 criteria: 1) a history of frequent, acute, and severe metabolic complications requiring medical attention 2) clinical and emotional problems with the use of exogenous insulin therapy that are so severe as to be incapacitating 3) consistent failure of insulin based management to prevent acute complications -elimiantes need for exogenous insulin, frequent glucose measurements and the risks involved with hyper-and hypo-. -pt will require lifelong immunosuppression to prevent rejection of the organ -pancreatic islet cell translation is another potential measure -islets are harvested from the pancreas of a decreased organ donor. Most recipients require the use of two or more pancreas -islets are infused via a catheter through the upper abdomen into the portal vein of the liver

gestational diabetes

-develops during pregnancy -women with this have a higher rate for cesarean delivery, and their babies have increased risk for perinatal death, birth injury, and neonatal complications women who have a higher risk are screened at the first prenatal visit -high risk: obese, advanced age, family history of diabetes -women who are at risk are screened using an OGTT at 24-28 weeks of gestation -most women with this have normal glucose levels within 6 weeks postpartum. -63% of women with a history of this have a chance of developing type 2 within 16 years

Nutritional therapy

-have a dietitian work with them to make an individualize plan -ADA says that within the context of an overall healthy eating plan, a person with diabetes can eat the same foods as a person who does not have diabetes type 1: -base their meal planning on usual food intake and preferences balanced with insulin and exercise patterns type 2: -emphasizes achieving glucose, lipid, and BP goals -weight loss is recommended -meal plan with appropriate serving sizes, reduction of saturated and trans fats, and low carbs. can decrease calorie consumption -space meals -weight loss of 5-7% of body weight often improves glucose levels food composition: -health balance of nutrient is essential to maintain blood glucose levels and overall health -carbs: whole grains, fruits, vegetables, and low fat dairy, fiber, nutritive and nonnutritive sweeteners may be included in moderation fats: decrease the bad to reduce risk of CVD -protein: same for healthy people -alcohol: inhibits gluconeogenesis by the liver. can cause hypoglycemia for ppl who take insulin. moderate intake can be safe if they monitor and if they are not a risk of other alcohol problems. can decrease hypoglycemia risk if they eat carbs with alcohol. To decrease the carb content, use sugar free mies and drinking dry light wines Patient teaching: -carb. counting: is a meal planning technique used to keep track of the amount of carbs. eaten with each meal -diabetes exchange lists are another method for meal planning. The individual is given a meal plan with specific numbers of helping from a list of exchanges for each meal and snacks -whenever possible, include family members and caregivers in teaching especially the person who cooks

Pre diabetes

-have an increased risk for type 2 -is defined as impaired glucose tolerance (IGT), impaired fasting glucose (IFG), or both -it is an intermediate stage between normal glucose homeostasis and diabetes, in which the glucose levels are elevated but not high enough to meet diagnostic criteria for diabetes -diagnosis for IGT is made if the 2 hour oral glucose tolerance test (OGTT) values are 140-199. IFG is diagnosed when fasting glucose levels are 100-125 -person with pre diabetes usually do not have symptoms -long term damage to the body, especially the heart and blood vessels may already be occurring -encourage those with pre- to have their blood glucose and A1C checked regularly and monitor for symptoms of diabetes, such as fatigue, frequent infections, or slow healing wounds

Diabetes ketoacidosis

-is caused by a profound deficiency of insulin and is characterized by hyperglycemia, ketosis, acidosis, and dehydration -occurs mostly in type 1 but can be in type 2 -precipitating factors include illness and infection, inadequate insulin dosage, undiagnosed type 1 diabetes, poor self management, and neglect -when insulin is low, glucose cannot be used for energy -the body compensates by breaking down fat stores as a secondary source of fuel -ketones are acidic by-products of fat metabolism that can cause serious problems when they become excessive in the blood -ketosis alters the pH balance, causing metabolic acidosis to develop -ketonuria is a process that occurs when ketone bodies are excreted in the urine -electrolytes become depleted as attempt to maintain neutrality -insulin deficiency impairs protein synthesis and causes excessive protein degradation -this results in nitrogen losses from the tissues -production of glucose from amino acids to further hyperglycemia. glucose cannot be used and the blood level rise further adding to the osmotic diuresis -will develop severe depletion of Na, K, Cl, Mg, phos. vomiting caused by ketosis results in more fluid/electrolyte loss. eventually hypovolemia followed by shock. renal failure causes the retention of ketones and glucose and the acidosis progresses -untreated, pt becomes comatose as a result of dehydration, electrolyte imbalance, and acidosis. death possible Clinical manifestations: -dehydration with poor skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension. -early symptoms are lethargy and weakness -skin becomes dry and losses, and eyes become soft and sunken. -abdominal pain may be present with anorexia, n/v. -kussmaul respiration are the body's attempt to reverse metabolic acidosis through the exhalation of excess CO2 -acetone is noted on the breath as sweet, fruity odor -lab findings are: BG level greater than or equal to 250, pH less than 7.3, bicarb level less than 16, and moderate to large ketones in urine interprofessional care: -can be managed outpatient -setting factors depend on if there is fever, n/v, diarrhea, alerted mental status; the cause of the ketoacidosis, and availability of frequent communication with HCP -DKA is rapid and must be treated promptly - the initial goal of therapy is to establish IV access and begin fluid and electrolyte replacement -typically an infusion rate of 0.45% or 0.9% NaCl at a rate to restore urine output to 30-60 mL/hr and to raise BP constitutes the initial fluid therapy regimen -when BG approach 250, add 5% to 10% dextrose to prevent hypoglycemia and a sudden drop in glucose can be associated with cerebral edema -overzelous rehydration, esp. hypotonic IV solution can result in cerebral edema -the aim of fluid and electrolyte therapy is to replace extracellular and intracellular water to correct deficits of Na, Cl, bicarb, K, phos, mg, and nitrogen. -obtain a serum K before staring insulin , if low K the insulin will further decrease this -insulin is started at 0.1 U/kg/hr by continuous infusion -a blood glucose reduction of 36-54 mg/dL/hr will avoid complications Emergency management: inventions- -intial: (in order) -ensure patent airway -administer 02 via nasal cannula or nonrebreather mask -establish IV access with large bore catheter -begin fluid resuscitation with 0.9% NaCl solution 1 L/hr until BP stabilized and urine output 30-60mL/hr, -begin continuous regular insulin drip 0.1 U -identify history of diabetes, time of last food, and time of last insulin injection ongoing monitoring- -monitor vital signs, LOC, cardiac rhythm, 02 sat, and urine output -assess breath sounds for fluid overload -monitor serum glucose and serum potassium -adminiser K to correct hypokalemia -administer Na bicarb if severe acidosis ,7.0 -add dextrose to IV fluid for blood glucose <250

neuropathy

-nerve damage that occurs because of the metabolic derangements associated with DM -can lead to loss of protective sensation in the lower extremities increase risk for lower limb amputation etiology: -hyperglycemia leads to an accumulation of sorbitol and fructose in the nerves that causes damages by an unknown mechanism. result is reduced nerve conduction and demyelination classifications: sensory neuropathy: affects the peripheral ns. -most common is distal symmetric polyneuropathy which affects hands and/or feet bilaterally, referred to as stocking glove neuropathy -characteristics include loss of sensation, abnormal sensations, pain, and paresthesia. pain is burning/cramping/crushing/or tearing, worse at night. The paresthesia may be associated with tingling/burning/itching sensations. feeling of walking on pillows or numb feet -skin becomes so sensitive (hyperesthesia) that even light pressure from bed sheets cannot be tolerated -can also cause atrophy of the small muscles of the hands and feet, causing deformity and limiting fine movement -managing bg is the only tx for diabetes related neuropathy -at the start of therapy, symptoms usually increase and relief in 2-3 weeks Autonomic neuropathy: can affect nearly all body systems and lead to hypoglycemia unawareness, bowel incontinence, and diarrhea, and urinary retention -gastroparesis (delayed gastric emptying) is a complication of autonomic neuropathy that can produce anorexia, n/v, gastrophageal reflux, and persistent feelings of fullness -cardiovascular abnormalities are postural hypotension, resting tachycardia, and painless myocardial infarction -diabetes can affect sexual function in men and women. ED in men -candial and nonspecific vaginitis is common -neurogenic bladder may develop as the sensation in the inner bladder wall decreases, causing urinary retention -emptying bladder every 3 hours in a sitting position helps prevent stasis and subsequent infection -tightening of abdominal muscles during voiding and using the Crede maneuver may also help with complete emptying

Monitoring blood glucose

-self monitoring is a critical management -enables the pt to make decisions regarding food intake, activity patterns, and medication dosages -produces accurate records of daily glucose fluctuations and trends and it alerts the pt to acute episodes of hyper or hypogly. -if they have multiple insulin injections or pumps, then monitor 4 or more times a day -pt who perform SMBG use portable blood glucose monitors -continuous glucose monitoring (CGM) systems provide another route for monitoring -using a sensor inserted subQ, the systems display glucose values that are updated every 1-5 mins. CMG assesses interstitial glucose which lags behind blood glucose by up to 20 mins -CMGs assist the pt an d HCP to identify trends and patterns in glucose level -plasma samples done in labs are apprx. 10-15 % higher -control solution should be used when first using a blood glucose meter, when a new bottle of strips is used, or when there a reason to believe that the readings are not correct -people with type 1 often check their blood glucose before meals -checking blood glucose 2 hours after the first bite of food helps a person determine if the bolus insulin dose was adequate for that meal -teach pt. to monitor blood glucose whenever hypoglycemia is suspected so that immediate action can be taken -teach the pt to monitor blood glucose before and after exercise to determine the effects of exercise on blood glucose levels

Chronic complications of diabetes mellitus

-stroke, hypertension, dermopathy, atherosclerosis, nephropathy, peripheral neuropathy, neurogenic bladder, retinopathy, cataracts, glaucoma, blindness, coronary artery disease, gastroparesis, islet cell loss, peripheral vascular atherosclerosis, gangrene, infections, erectile dysfunction

inter professional care

-the goal of diabetes management are to reduce symptoms, promote well being, prevent acute complications related to hyper- and hypoglycemia, and prevent or delay the onset and profession of long term complications -requires daily decisions about food intake, blood glucose monitoring, medication, and exercise -nutriton therapy, drug therapy, exercise and self monitoring of blood glucose are the tools used in the management of diabetes -three major types of glucose lowering agent (GLAs) are insulin, oral agents (OAs), and non insulin injectable agents -all pt with type 1 require insulin -for some people with type 2, a healthy eating plan, regular exercise, and maintenance of healthy body weight are sufficient to attain optimal blood glucose levels

Nursing Implemenation

health promotion: identify, monitor, and teach the patient at risk for diabetes. Obesity is the primary risk factor for type 2 diabetes. regular 30 minutes five times a week of exercise. -The ADA recommends routine screening for type 2 diabetes for all adults who are overweight or obese or have one or more risk factors -for people who are not a risk, screening should begin at age 45 -having a baby that weighed more than 9lbs is risk Acute care: -situation are hypoglycemia, DKA, and hyperosmolar hyperglycemia syndrome (HHS) acute illness and surgery: -both emotional and physical stress can increase blood glucose level and result in hyperglycemia -acute illness, injury, and surgery are situations that may evoke a counter regulatory hormone response, resulting in hyperglycemia -encourage them to check blood glucose every 4 hours -acutely ill pt with type 1 with a blood glucose higher than 240 should also check urine for ketones every 3-4hrs -teach to report to HCP when glucose levels are over 300 twice in a row or urine ketone levels are moderate to high -elevated glucose can lead to poor wound healing -pt is given IV fluids and insulin immediately before, during, and after surgery when there is no oral intake -when caring for an unconscious surgical pt receiving insulin, be alert for signs of hypoglycemia such as sweating, tachycardia, and tremors Ambulatory care: -the major goal in these settings is to enable the pt to reach an optimal level of independence in self-care activities. -diabetes increases the risk for other chronic conditions that can affect self care activities. these include visual impairment, lower extremity problems that affect mobility, and other functional limitations related to a stroke -assess the ability of the pt and caregiver in performing activities such as SMBG and insulin injection -self management of the disease is demanding -requirements may interfere with the patient's other responsibilities -careful assessment of what it means to the pt to have diabetes is a good starting point for teaching -identify the patient's support system and include them Insulin therapy: -proper admin., assessment of the pt. response to therapy, and teaching the pt about admin., storage, and side effects of insulin. -if new user, assessment includes an eval. of their ability to safely manage this theory. This include the ability to understand the interaction of insulin, food, and activity and to recognize and tx the symptoms of hypoglycemia appr. -if no cognitive skills, identify and teach another responsible person -explore fears before beginning teaching -assessment of their beliefs and concert help -follow up assessment includes an inspection of injection sites for signs of lipodystrophy and other reactions, review of insulin preparation and injection technique, a history pertaining to the occurrence of hypoglycemia, and assessment of the patient's method for handling hypoglycemia oral and non insulin injectable agents: -factors such as the patients mental status, eating habits, home environment, attitude toward diabetes, and medication history all play a significant role in determining the most appr. drug -for frail older adults who live alone and cognitive impaired adults, OA that does not cause hypoglycemia or a shorter acting OA would be best -pt teaching is essential. -OAs and non insulin injectable agents are used in addition to food choices and activity as therapy for diabetes and the importance of following their meal and activity plans Personal hygiene: -the potential for infection requires diligent skin and dental hygiene practices -possible periodontal disease, daily brushing and flossing in addition to regular visits to the dentist. have them inform the dentist they have diabetes -routine care includes regular bathing with emphasis on foot care. Inspect feet daily, avoid going barefoot, and wear shoes that are supportive and comfortable. -if cuts, scrapes, or burns occur, tx them and monitor them. Wash the are and apply a nonabrasive or nonirritating antiseptic ointment. cover the area with a dry, sterile pad. -report to HCP if injury does not begin to heal within 24 hours or if signs of infection develop Medical ID and travel: -carry a medical ID at all times -travel requires planning -encourage pt to get up and walk at least every 2 hours to lower the risk for DVT and to prevent elevation of blood glucose -for pt who use insulin or OAs that can cause hypo-, keep snake items and quick acting carb source for tx in carry on -for long trips, carry a full day's supply of food -when travel involves time changes, plan appr. insulin schedule Pt and caregiver teaching: -pt who actively manage their diabetes care have better outcomes than those who do not. -empowerment approach -may encounter barriers including feelings of inadequacy about one's own abilities, unwillingness to make the necessary behaviors changes, ineffective coping strategies, and cognitive deficits -assess pt knowledge base frequently so that gaps in knowledge or incorrect or inaccurate ideas can be corrected -pamphlets, booklets, books, and a monthly magazine called diabetes forecast

Nursing Management

The overall goals are: 1) engage in self care behaviors to actively manage his or her diabetes, 2) experience few or no hyperglycemia or hypoglycemia emergencies, 3) maintain blood glucose levels at normal or near normal levels, 4) prevent or minimize chronic complications related to diabetes, 5) adjust lifestyle to accommodate the diabetes plan with a minimum of stress

Teamwork and collaboration

UAP: -check capillary blood glucose levels (after being trained and evaluated in this procedure) and report to the RN -report changes in pt vital signs, urine output, behavior, or LOC to the RN -in a community or home care setting, administer OAs and insulin to a stable pt

angiopathy

chronic complications associated with diabetes are primarily those of end organ disease from damage to blood vessels (angiopathy) secondary to chronic hyperglycemia one of the leading causes of diabetes related deaths, with about 68% caused by CVD and 16% caused by stroke vessel dysfunctions are divided in two categories: macrovascular and microvascular complications possible causes: 1) the accumulation of damaging by-products of glucose metabolism such as sorbitol 2) the formation of abnormal glucose molecules in the basement membrane of small blood vessels such as those that circulate to the eyes and kidneys 3) a derangement in RBC function that leads to a decrease in 02 to the tissues tight or intensive therapy- those who maintain tight glucose levels reduce their risk of developing microvascular complications Macrovascular complications: are diseases of the large and medium sized blood vessels that occur with greater frequency and with an earlier onset in people with diabetes -macro diseases include cerebrovascular, cardiovascular, and peripheral vascular disease -risk factors: obesity, smoking, hypertension, high fat intake, and sedentary lifestyle -optimizing BP control in pt with diabetes is significant for the prevention of CVD and renal disease. target BP of less than 140/90 is recommended -pt with diabetes have an increase in lipid abnormalities -take statin. -BP screening at every routine visit for people with diabetes -insulin resistance has an important role in the development of CVD and is implicated in the patho of essential hypertension and dyslipidemia cardiovascular disease: macro -type of exam: risk for assessment (at least annually) - HTN, dyslipidemia, smoking, family history, presence of albuminuria or exercise stress testing (as needed based on risk factors) Microvascular complications: results from thickening of the vessel membranes in the capillaries and arterioles in response to conditions of chronic hyperglycemia. They are specific to diabetes. Most noticeably affect the eyes (retinopathy), kidneys (nephropathy), and nerves (neuropathy) retinopathy: type of exam- funduscopic (dilated eye exam, done annually), fundus photography (annual) nephropathy: type of exam- urine for albuminuria (annual), serum creatinine (annual) neuropathy (foot and lower extremities): type of exam- visual exam of foot (daily by pt), comprehensive foot: visual exam, sensory exam w/ monofilament and tuning fork, palpitations (pulse, temp., callus formation) (annual unless they have history of foot ulcers, loss of sensations, or other abnormalities then foot exam every visit).

Nursing management for ketoacidosis and HHS

closely monitor with appr. blood and urine tests monitor administer admin of 1) IV fluids to correct dehydration, 2) insulin therapy to reduce blood glucose and serum ketone levels, 3) electrolytes given to correct electrolyte imbalance -assess renal status and cardiopulmonary status -monitor LOC -serum K may decrease rapidly as K moves into the cells once insulin becomes available, this can influence cardiac functioning. ECG

Diagnostic studies

diagnosis of diabetes mellitus is made using one of the four methods: 1) A1C of 6.5% of higher 2) fasting glucose (FPG) level greater than or equal to 126mg/dL 3) two hour plasma glucose level greater than or equal to 200mg/dL during an OGTT using a glucose load of 75g 4) in a pt with classic symptoms of hyperglycemia (poly-) or hyperglycemic crisis, a random plasma glucose greater than or equal to 200mg/dL if a pt is seen with a hyperglycemic crisis or clear symptoms of hyperglycemia with a random plasma glucose greater than or equal to 200 repeat testing is not warranted. Otherwise, criteria 1-3 should be confirmed by repeat testing to rule out laboratory error. It is preferable for the repeat test to be the same test used -the accuracy of lab results depends on adequate pt preparation and attention to many factors that may influence the results -factors that can falsely elevate values include recent severe restrictions of dietary carbohydrate, acute illness, medications, and resisted activity -A1C measures the amount of glycosated hemoglobin -when blood glucose levels are elevated over time, the amount of glucose attached to hemoglobin molecules increases -A1C provides a measurement of blood glucose levels over the previous 2-3 months -A1C has greater convince, since fasting is not required -diseases affecting RBCs can influence A1C -Teach pt to have their A1C monitored regularly to determine the success of the current tx plan and make changes in the plan is goals are not gained -ADA identifies an A1C goal for pt with diabetes of less than 7% -fructosamine is another way to assess glucose levels. It reflects glycemic in the previous 1-3 weeks -Islet cell autoantibody testing is primarily ordered to help distinguish between autoimmune type 1 diabetes and diabetes from other causes

Hypoglycemia

drop less than 70 coutnerreg. hormones are released and the ANS is activated epinephrine releases causes manifestations that include shakiness, palpitations, nervousness, diaphoresis, anxiety, hunger, and pallor can affect mental function: difficulty speaking, visual disturbances, stupor, confusion, and coma can mimic alcohol intoxication can lead to LOC, seizures, coma, and death hypoglycemia unawareness: person does not experience the warning signs of hypo- until the glucose levels reach a critical point -often related to autonomic neuropathy -pt at risk are those who have had repeated episodes of hypo-, older pt, and pt who use B adrengeric blockers -balance between blood glucose and insulin can be disrupted by administering too much insulin or medication, ingesting too little food, delaying the time of eating, and performing unusual amounts of exercise -hypo- can occur at any time, but most episodes occur when the OA or insulin is at its peak of action or when the pt's daily round is disrupted w/o adequate adjustments in diet, medication, and activity symptoms of hypo- may occur when a very high glucose level falls too rapidly nursing management: -check the blood glucose if possible . if it less than 70, immediately begin tx for hypoglycemia -if the blood glucose is greater than 70, investigate other possible causes of the signs -if pt has signs and no equipment is there, suspect hypo- and tx should be done -rule of 15: treat by eating or drinking 15g of simple (fast acting) carb. wait 15 mins then check bg again. if still less than 70, repeat 15g of carb. if no improvement after two or three doses, contact HCP -avoid tx with carbs that contain fat, it will slow absorption of the glucose and delay response -in acute care settings, pt with hypo- may be treated 20-50 mL of 50% dextrose IV push -if pt is not alert and can't swallow and no IV is available then give 1mg of glucagon by IM or subQ -deltoid is quick -nausea is common reaction after glucagon injection, to prevent aspiration turn pt on side until they become alert -pt with minimal glycogen stores will not respond to glucagon

Type 2 diabetes

formerly known as adult onset diabetes (AODM) or non insulin dependent diabetes (NIDDM) -risk factors include being overweight or obese, being older, and having family history of type 2 diabetes etiology/patho: -combination of inadequate insulin secretion and insulin resistance -the pancreas usually produces endogenous insulin -the body either does not produce enough insulin or does not use it effectively or both -the presence of endogenous insulin is the major distinction between type 1 and type 2 genetic link: -multiple genes are involved -genetic mutations that lead to insulin resistance and higher risk for obesity have been found in many people with type 2 diabetes -the first factor is insulin resistance, a condition in which body tissues do not respond to the action of insulin because insulin receptors are unresponsive, are insufficient in #, or both -in the early stages of insulin resistance, the pancreas responds to high blood glucose by producing greater amounts of insulin (if B cell function is normal). This creates a temporary state of hyperinsulinemia that coexists -a second factor in the development is a marked decrease in the ability of the pancreas to produce insulin, as the B cells become fatigued from the compensatory overproduction of insulin or when B cell mass is lost -Third factor is inappropriate glucose production by the liver -a fourth factor is altered production of hormones and cytokines by adipose tissue (adipokines). play a role in glucose and fat metabolism. Adipokines are thought to cause chronic inflammation, a factor involved in insulin resistance -individuals with metabolic syndrome are at an increased risk for the development of type 2. Has five competes: 1) elevated glucose levels 2) abdominal obesity 3) elevated BP 4) high levels of triglycerides 5) decreased levels of HDLs -an individual with 3/5 of the components is considered to have metabolic syndrome onset of disease: -the disease is gradual -the person may go for many years with undetected hyperglycemia -many people are diagnosed on routine laboratory testing or when they undergo tx for other conditions, and elevated glucose or glycosylated hemoglobin (A1C) levels are founds -at the time of diagnosis, the average person has had type 2 for 6.5 years

Type 1 Diabetes

formerly known as juvenile onset diabetes or insulin dependent diabetes etiology: -is an autoimmune disorder, in which the body develops antibodies against insulin and/or pancreatic B cells that produce insulin -a genetic predisposition and exposure to a virus are factors that may contribute to the pathogenesis of immune related type 1 diabetes genetic link: -predisposition to type 1 diabetes is related to human leukocyte antigens (HLAs) -HLA types is exposed to a viral infection, the B cells of the pancreas are destroyed -idiopathic diabetes: is a form of type 1 diabetes that is strongly inherited and not related to autoimmunity -latent autoimmune diabetes in adults (LADA): a slowly progressing autoimmune form of type 1 diabetes, occurs in adults and is often mistaken for type 2 diabetes onset of disease: the islet cell autoantibodies responsible for B cell destruction are present for months to years before the onset of symptoms -manifestations develop when the person's pancreas can no longer produce sufficient amounts of insulin to maintain normal glucose -once this occurs, the symptoms are rapid and pt are usually seen with impending or actual ketoacidosis -recent weight loss -class symptoms of: polydipsia, polyuria, and polyphagia -the individual requires insulin from an outside source (exogenous insulin) -without insulin, the pt with develop diabetic ketoacidosis (DKA, a life threatening in metabolic acidosis -newly diagnosed pt may experience remission or "honeymoon period" for 3-12 months after tx is initiated -during this time, the pt requires little injected insulin because B cell insulin production remains sufficient for healthy blood glucose levels

Diabetes mellitus

is a chronic multi system disease characterized by hyperglycemia related to abnormal insulin production, impaired insulin utilization,or both Leading cause of adult blindness, end stage renal disease, and non traumatic lower limb amputations. Heart disease death rates are 2-4x higher. More than half of the adults with diabetes have hypertension and high cholesterol levels Etiology/Patho: -causes of diabetes singly or in combination of genetic, autoimmune, and environmental factors Four classes of diabetes: two most common are type 1 and 2. The other two are gestational and other specific types

Diabetic retinopathy

refers to the process of microvascular damage to the retina as a result of chronic hyperglycemia, nephropathy, and HTN in pt with diabetes most common cause of adult blindness non proliferative retinopathy: most common form, partial occlusion of the small blood vessels in the retina cause micro aneurysms to develop in the capillary walls. fluid leaks out causing retinal edema and eventually hard exudates or intrarentinal hemorrhages. This may cause mild to severe vision loss proliferative retinopathy: the most severe form. involves the retina and vitreous. capillaries become occluded, the body compensates by forming new blood vessels to supply the retina with blood, this is known as neovascularization. These new vessels are extremely fragile and hemorrhage easily. Eventually light is prevented from reaching the retina as the vessels become torn and bleed into the vitreous cavity. Pt sees black or red spots. partial or complete retinal detachment could occur. Blindness. glaucoma occurs as a result of the occlusion of the outflow channels secondary to neovascularization inter professional care: - earliest stages produce no changes in visions -pt with type 2 should have a dilated eye exam at diagnosis time and annually -type 1 person should have eye exam within 5 years after onset of diabetes then repeated annually -prevent by maintaining glucose levels and manage hypertension -laser photocoagulation therapy is indicated to reduce the risk of vision loss. It destroys the ischemic areas of the retina that produce growth factors that encourage neovascularization -vitrectomy: the aspiration of blood, membrane, and fibers from the inside of the eye through small incision just behind the cornea -Illuvien is used to tx retinopathy. for 36 month. injected in the back of the eye -vascular growth factor (VEGF) in the development of diabetic retinopathy. Drugs injected into the eye that block the action of VEGF and reduce inflammation are being studied

Exercise

regular, consistent exercise is an essential part of diabetes and pre diabetes management -resistance training tree times a week -decreases insulin resistance and can lower blood glucose level s -weight loss, which further decrease insulin resistance -decreases need for medication -schedule exercise about 1 hour after a meal or that they have a 10g-15g carb. snack and check every 30 mins to prevent hypoglycemia. -carry a fast acting source of carbs. such as glucose tablets or hard candies -activity can be seen as stress, hormones can be released that temporary raise blood glucose. -in type 1 who have hyperglycemia and ketones, exercise can worsen these conditions -teach pt to delay activity if blood glucose is over 250 and ketones are present in the urine -if hyperglycemia is present w/o ketosis, it not necessary to postpone exercise

complications with feet and lower extremities

risk for ulcerations and lower extremity amputatuons -sensory neuropathy and peripheral artery disease (PAD) are risk factors for foot complications loss of protective sensation (LOPS) prevents the pt from being aware that a foot injury has occurred . Apply annual screening using monofilament . This is done by applying a thin, flexible flimanet to several spots on the plantar surface of the foot and ask pt to report if it is felt. PAD increases the risk for amputation by causing a reduction in blood flow to the lower extremities. when blood flow is decreased, 02, WBC, and vital nutrients are not available to the tissues. Wounds take longer to heal and the risk of infection increases. Signs include claudication, pain at rest, cold feet, loss of hair, delayed capillary filling, and dependent rumor -management includes reduction of risk factors like smoking, cholesterol intake, and HTN -bypass or graft surgery is indicated in some pt -if the pt has LOPS or PAD, aggressive measures must be taken to teach the pt how to prevent foot ulcers. proper footwear, carefully avoid injury, practice diligent skin and nail care, inspect the foot each day -casting can be done to redistribute the weight n the plantar surface of the foot -wound care -charcot's foot: results in able and foot changes that ultimately lead to joint dysfunction and foot drop