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124 Cards in this Set
- Front
- Back
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DKA
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Diabetic Ketoacidosis
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Gestational Diabetes
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Diabetes during pregnancy
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HHNKS
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Hyperosmolar hyperglycemic non-ketotic syndrome
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HLA
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Human leukocyte antigen
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Hyperglycemia
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High blood glucose
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Hypoglycemia
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Low blood glucose
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ICA
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Islet Cell Antibody
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Ketonuria
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Ketones present in urine
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Lipodystrophy
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Atrophy of SC tissue
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Polydipsia
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Excessive thirst
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Polyphagia
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Excessive hunger
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Polyuria
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Excessive urination
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Introduction
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*Lesson objectives: recall list given during orientation
*Vocabulary: see handout *Historical Perspectives: clinical trials, ADA, Joslin clinic, & recall from video |
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Commonalities
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*All diabetics (Type I and Type II)have high blood sugar
*All are at risk for developing complications *All have the same diagnostic studies to dx. DM |
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Health Promotion
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*Diabetes Mellitus: Definition
*Chronic disorder of altered fat, carbohydrate and protein metabolism caused either by a relative or absolute lack of insulin or inability of tissues to respond to insulin |
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Statistics
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*18 million have DM in the U.S.
*210,000 deaths occur annually *increase risk of CAD *More than 65% have HTN as well *5th leading cause of death in U.S. *1/3 do not know have it (PreDiabetes) |
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Pathophysiology of Diabetes
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*Production of insulin is the main issue in DM
*Known as endogenous insulin (within your body) *Decreased or no insulin leads to hyperglycemia *Chronic hyperglycemia leads to many complications |
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Pathophysiology of Normal Insulin Metabolism
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*Usually insulin is constantly released into the blood
*Release of insulin is regulated by blood glucose *Insulin facilitates glucose transport into skeletal muscles, adipose tissue and body cells |
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Normal Insulin Production
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*Cells have insulin receptors where insulin attaches and transports the glucose across the cell membrane and into the cell
*When glucose enters the cell, blood glucose is decreased |
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Patho. of Type I DM
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*Autoimmune disease triggered by environmental factors (i.e. virus)
*>90% Type I have islet cell antibodies, an indication of autoimmune response *Many also have HLA's: human leukocyte antigens (indicative of autoimmune response) |
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Patho. of Type I DM
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*As islets are destroyed, ICA's and insulin antibodies increase, which lowers circulating insulin, which increases blood glucose
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Pre-Diabetes
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*Blood glucose is higher than normal but not high enough to be dx. w/ diabetes
*More common Type II and gestational DM *Can prevent getting Type II *OGTT will be done to dx. this *At least 20.1 million have this in U.S. |
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Gestational Diabetes
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*Occurs only during pregnancy
*Caused by hormonal changes *Disappears after delivery |
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Patho of Type II DM
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*No autoimmune disease: no ICA's, HLA's
*90% have Type II *Usually older than 30 body (1/2 older than 55) *Obesity is a major factor |
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Type II
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*May require insulin in times of stress
*Onset of symptoms is usually slow *Highest prevalence in Native Americans *Low incidence of diabetic ketoacidosis |
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Type II Patho. R/T Age
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*BS increases w/ age
*Decline in release of glucose regulating hormones: insulin, glucagon, epinephrine *Body mass decreases with age |
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Treatment Procedures/Modalities (Type I)
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*Health promotion & maintenance is crucial
*Goal is prevent development of complications *Insulin *Diet *Exercise |
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Treatment (Type II)
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*Goal is reduce risk of developing it:
*Recall pre-diabetes *Reduce and maintain ideal weight *Adhere to nutritional plan *Increase physical activity |
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Health Promotion of all clients
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*Early detection: test everyone over 45
*Test younger when risk factors present *Educate clients about early S&S to watch for and ways to reduce risk factors (obesity) |
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Collaborative Care
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*Nutritional Therapy
*Drug therapy *Exercise *Monitoring blood glucose |
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Risk factors: Type I
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*Genetic: HLA and ICA common
*Environmental (virus) *Ethnic: more common among whites |
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Risk factors: Type II
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*Genetic but no HLA's or ICA's
*Major: obesity, aging, sedentary lifestyle *Environmental *Ethnic *Gestational |
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Basic Care and Comfort
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*Exercise: current regiment
*Nutrition: current diet |
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Pharmacological Therapies
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*Current medication regimen
*1. Insulin *2. Oral hypoglycemic agents *Adverse effects *Expected effects |
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Reduction of Risk Potential: Diagnostic Studies
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*Complete H&P
*Fasting blood glucose >126mg/dl *Sx & plasma glucose >200 *2 hour post-load >200 during OGTT *Not one test to diagnose, look at whole picture |
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Diagnostic Studies/Lab Studies:
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*Postprandial blood glucose
*Glycosylated hemoglobin (HgbA1X) last 120 days measurement of blood glucose *Urinalysis *Electrolytes, BUN, creatinine |
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System specific: clinical manifestations of Type I
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*3 P's: polydypsia, polyphagia, polyuria
*Weight loss, ketonuria, weakness, fatigue, dizziness *Blurred vision, pruritis, skin infection, vaginitis |
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Clinical manifest. of Type II
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*Can be asymptomatic
*Recurrent blurred vision, pruritis, skin infection, vaginitis are common *Cardinal sx: 3 P's, weakness, fatigue, dizziness *NOT COMMON: weight loss, ketonuria |
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Part II
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*Sequelae/Complications of DM
*Including Nursing Process *Care of the diabetic patient in special situations |
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Acute Complications
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*DKA: Diabetic Ketoacidosis
*HHNK: Hyperglycemic Hyperosmolar Nonketosis *Hypoglycemia |
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DKA
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*Caused by physical or emotional stress
*Often undiagnosed Type I diabetic *Rare with type II *Blood sugar high >300 |
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Pathophysiology of DKA
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*Cells are deprived of glucose because of lack of insulin
*Body responds by liver making glucose and breaking down protein and fat for energy (causes ketones to form) *Ketones in blood cause acidosis in the body *Rapid lowering of pH level causes DKA |
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Symptoms of DKA
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*Anorexia, fatigue, headache, then 3 P's, blurred vision
*Increased HR & RR, fruity breath, flushed skin, abdominal pain, n/v *Late Signs: lethargy, coma and Kussmaul's respirations (deep rapid breathing)--death |
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Treatment of DKA
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*Correct:
*Hyperglycemia *Fluid volume depletion (hypovolemic) *Hyperosmolality *Acidosis *electrolyte imbalance |
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HHNKS
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*Usually only Type II
*Caused by stress, acute illness, surgery *Often symptoms missed, mortality rate high *No acidosis with HHNKS *Elderly and hospitalized patients at higher risk |
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HHNKS: pathophysiology
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*Insulin not completely absent and fat breakdown does not occur (no ketones)
*Insulin needs are increased and body cannot compensate *Major infection, kidney failure, shock can lead to HHNKS 600-1200 blood sugar |
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HHNKS: clinical manifestations
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*Extremely high BS 600-1200mg/dL
*Neuro changes: confusion *Often missed: 3 P's, dehydration, electrolyte loss, hypovolemia |
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Treatment of HHNKS
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*IV regular insulin drip
*Fluid volume replacement based on age and cardiovascular Hx *Electrolyte replacement *Monitor mental status *No n/v different from DKS |
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Hypoglycemia: Causes
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*Action of insulin
*Decreased dietary intake *Medications can decrease BS *Onset of menses *Change from and animal source to human insulin *ETOH |
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Hypoglycemia: Pathophysiology
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*Brain relies on glucose for energy and cannot use it from fats
*BS < 50-60mg/dL *Severe if < 40mg/dL Every patient is different |
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Symptoms of Hypoglycemia
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*MILD: pallor, diaphoresis, tachycardia, palpitations, hunger, parestheisias, tremors, apprehension
*MODERATE: H/A, mood changes, inability to concentrate, confusion, slurred speech, blurred vision, impaired judgement, drowsiness, difficulty walking (appear to be drunk) |
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Symptoms of Hypoglycemia
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*SEVERE: disorientation, seizures, unconscious, shallow respirations
*Symptoms can vary from client to client |
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Treatment for Hypoglycemia
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*CONSCIOUS: simple carbohydrates
*UNCONSCIOUS: at home 1 mg of glucagon IM *UNCONSCIOUS: hospital D50 IV push Once they wake up give something to eat, drink and recheck BS *15 grams carbohydrates, wait 15 minutes, recheck BS if not > 100 or they are still symptomatic give another 15 grams carbs. CALL MD |
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Symptoms of Hypoglycemia
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MILD: pallor, diaphoresis, tachycardia, palpitations, hunger, paresthesias, tremors, apprehension
MODERATE: H/A, mood changes, inability to concentrate, confusion, slurred speech, blurred vision, impaired judgement, drowsiness, difficulty walking (appear to be drunk) |
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Symptoms of Hypoglycemia
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SEVERE: disorientation, seizures, unconscious, shallow respirations
SYMPTOMS can vary from client to client |
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Treatment for Hypoglycemia
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CONSCIOUS: simple carbohydrates (candy, juice, glucose tablets)
UNCONSCIOUS: at home 1 mg of glucagon IM UNCONSCIOUS: hospital D50 IV push (once they wake up give something to eat, drink and recheck BS) |
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15 - 15 - 15 Rule
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15g carbs, wait 15 minutes, recheck BS if not >100 or patient is still symptomatic give another 15grams card. CALL MD
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Chronic/Long-Term Complications
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*Major cause of morbidity & mortality in DM
*Common degenerative change that occur in the general population *Much earlier in diabetics |
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Complications include
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*Blindness
*Risk for MI or stroke *Destruction of the kidneys *Destruction of nerve cells *Slower wound healing and infections *Impotence *Foot injuries/amputation |
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Classification of Complications
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MACROANGIOPATHY: disease of the large and medium sized blood vessels (artherosclerosis)
MICROANGIOPATHY: disease of the small blood vessels (specific to diabetes) |
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Complications: MACROANGIOPATHY
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MACROANGIOPATHY:
1. Cardiovascular 2. Cerebrovascular 3. PVD |
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Complications: MICROANGIOPATHY
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MICROANGIOPATHY
1. Retinopathy 2. Nephropathy 3. Neuropathy |
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Retinopathy (Most common complication)
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*Major cause of blindness in DM
*10 years = 50%, 15 years = 80% *Microvascular damage & occlusion of retinal capillaries |
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2 classes of retinopathy
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NONPROLIFERATIVE: most common, partial occlusion of sm. vessels causing microaneurysms, may not affect vision
PROLIFERATIVE: most severe, involves retina & vitreous, sees black or red spots, lines (w/out tx will become blind) |
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Nurse's Role
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ASSESS: for blurred vision, Hx of cataract or glaucoma and what was done
*If no Hx, assess for changes in visual acuity *Ophthalmologist consult (yearly) *Educate patients regarding routine eye exams |
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Nurse's Role
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DIAGNOSIS: Risk for injury r/t decreased vision secondary to diabetic retinopathy
PLAN: recognize the psychosocial impact of altered vision, address health promotion & maintainance issues |
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Nurse's Role
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IMPLEMENTATION: normal blood glucose, eye exams, refer to agencies, teach visual S&S to watch for when they should notify MD
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Nurse's Role: Evaluation
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*pt. will describe S&S of diabetes related eye problems and what to do about them
*pt. will avoid activities that cause straining *pt. will normalize blood glucose levels in an effort to clear blurred vision *pt. will adapt to lifestyle with decreased vision |
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Nephropathy
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*Most common cause of ESRD
*Test yearly for microalbuminuria (MAU) *Proteinuria develops in 70% of pt.'s (indicative of kidney problems) *Risk factors include HTN, genetic, smoking, and chronic hyperglycemia *Controlling HTN affects renal status *ACE inhibitors standard of care (Protective effect on kidneys, ex: Lisinopril) |
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Nephropathy
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*Can progress to UREMIA=lower GFR (amount of blood that gets filtered) & high BUN & creatinine
*Protein restricted diet, dialysis, renal transplant *Avoid nephrotoxic meds (ex: Gentamycin), caution IVP dyes, hydration is critical |
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Nurse's Role
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*ASSESS for proteinuria, lab results, monitor diet, review medications
*DIAGNOSIS: Ridk for injury r/t renal damage secondary to DM *PLAN: Maintain physiologic integrity, address health maintenance & promotion issues |
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Nurse's Role
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*IMPLEMENTATION: educate, refer to PCP for HTN
*EVALUATION: -pt. will not experience diabetic nephropathy -pt. will follow prescribed diet |
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Neuropathy
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*Most common complication of DM
*2 categories: 1. Sensory 2. Autonomic |
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Sensory
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*Distal Symmetry Neuropathy: affect hands and/or feet bilaterally
*S&S: pain, parethesias (tingling, itching), loss of sensation (numbness) *DM is responsible for 50% of lower limb amputations in U.S. *FOOT CARE IS KEY! *PAIN = burning sensation worse at night *5 C's of foot care in handout p. 10 |
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Treatment
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*Might start w/ NSAIDS
*Tricyclic antidepressants: Elavil *Antiseizure meds: Neurontin *Topical creams: Zostrix *Control blood glucose (improve neuropathy) |
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Autonomic
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*Orthostatic BP, resting tachycardia
*GI: gastroparesis (delayed gastric emptying causes abd. distention Treatment = Reglan *Urinary retention *Bowel incontinence *Impotence, decreased libido *Monilial & nonspecific vaginitis common |
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Nurse's Role
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*ASSESS
*Clinical manifestations *foot inspection *blood glucose *postural vital signs |
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Nursing Diagnosis
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*Chronic pain r/t diabetic neuropathy
*Impaired skin integrity *Knowledge deficit *Sexual dysfunction *Risk for Injury |
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Nurse's Role
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*IMPLEMENTATION: teach patient to assess feet daily (5C's of foot care)
*maintain blood glucose levels, teach patient to get up slowly from sitting/lying positions *medication teaching *EVALUATE: client will have minimal Sx *client will remain free of skin breakdown |
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PVD
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*Common with diabetic clients
*complications: gangrene, infection & amputation *Sx: claudication, absent pulses, pain at rest, cool, no hair, delayed capillary refill, dependent rubor (tan, red color) |
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Nurse's Role
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*ASSESS: LE's for open areas, pulses, pain, skin color, temperature
*Dx: Altered peripheral perfusion *Impaired skin integrity *PLAN: Maintain physiological integrity |
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Nurse's Role
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*IMPLEMENT: Teach FOOT CARE!
*EVALUATION: client will inspect feet daily *Client will be free of ulcers |
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Managing diabetes in special situations
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*Illness
*Surgery *Travel |
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Care of the diabetic with an illness (Flu)
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*Should continue to take insulin or Oral Agents (OA)
*Drink plenty of fluids *Test urine for ketones & BS q 4 hours *Call doctor if BS >250, fever, ketonuria, N/V *High risk for developing DKA *Stay away from caffeine - diuretic *Replace carbs w/liquids Gatoraid, soups, jello |
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Care of the diabetic having surgery
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*IV fluids
*hold insulin and OA's day of surgery *may need to stop OA's 48 hours pre and post surgery Ex: Glucaphage *Type II: usually receive insulin during hospitalization *Monitor BS q 2 hours, u.o., ketones *Increased risk of developing DKA *Type I: 1/2 dose of insulin (long acting) Ex: 20 units NPH |
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Care of Diabetic client traveling
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*Always wear medical bracelet
*Bring extra supplies (insulin etc.) *Always carry snack (carry on) *Stick with dietary regimen *Keep watch on “home” time if w/in 1 to 2 hours *Check with MD if big difference in time zones (Example: 6 hour difference) |
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Assessment: Safe, effective care environment
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*Manage care
1. Case management *Safety and infection control |
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Assessment: Psychosocial Integrity
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1. Coping mechanisms
2. Religious + spiritual influences on health 3. Situational role changes 4. Support Systems 5. Stress management |
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Assessment: Promotion of wellness
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1. Health and wellness
2. Aging process 3. Health screening 4. Lifestyle choices |
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Nursing Diagnosis: Actual
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*Imbalanced nutrition: more than body requirements
*Powerlessness |
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Nursing Diagnosis: Risk
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*Risk for ineffective management of therapeutic regimen
*Risk for noncompliance *Risk for ineffective coping *Risk for injury |
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Nursing Diagnosis: PC
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*Ketoacidosis
*HHNKS *Hypoglycemia *Infection *CAD *PVD *Retinopathy *Neuropathy *Nephropathy |
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Plan
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*Maintain physiological integrity
*Provide a safe, effective care environment *Recognize the psychosocial impact (get them involved in groups) *Address health maintenance issues *Establish outcomes * |
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Implementation: Physiological Integrity
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*BASIC CARE AND COMFORT
1. Foot care (recall) *Nutrition and oral hydration: education *Pharmacological therapies |
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Pharmacological Therapy
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*2 Types of GLA's
1. Insulin: Intravenous or subcutaneous 2. Oral hypoglycemic agents |
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Types of Insulin
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1. RAPID ACTING: Lispro, Aspart, Glulisine
2. SHORT ACTING: Regular SC, Exubera 3. INTERMEDIATE ACTING: NPH, Levemir 4. LONG ACTING: Glargine 5. COMBINATION THERAPY: 70/30, 50/50 **Regular insulin is only type of insulin that can be given IV** |
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Rapid Acting:
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*Lispro (Humalog)
*Aspart (Novalog) *Glulisine (Aprida) *See handout |
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Short Acting: Regular
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*Natural (unmodified)
*Clear solution *Only type than can be given IV or IM *Can also be given SC *Used for sliding scale coverage |
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Intermediate: NPH, Levemir
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*Onset delayed & duration longer
*NPH: allergic reaction possible due to protamine (rare) *NPH: Cloudy in appearance |
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Long acting: Lantus
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*Glargine (Lantus): does not have peak
*Given once a day usually at bedtime *Not compatible with any other insulin |
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Administering Insulin
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*Most common: SC
*IV *only regular insulin* *Recommended injection sites (know these) *Rotate sites within an area *Abdomen is fastest absorption |
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Administering Insulin
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*Standard syringe U-100 (US)
*Patients may use more than once (not a practice in the hospital) not more than 2-3 times *Pen & Jet Injectors *SC Insulin Pumps (portable and implanted)rapid or short acting only *Inhalation http://www.exubera.com |
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Insulin Pump
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An insulin pump administers insulin through a catheter in the abdominal fat to help control a person's blood sugar levels
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Mixing Insulins
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*Mix in one syringe *one injection*
*“Clear to cloudy” |
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Mixing Insulins
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*Benefits client, only one shot
*NPH: can be mixed with regular, lispro, aspart & glulisine *Call pharmacy for any recent updates (don't assume) *Many premixed combinations available (see Lehne) |
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Storing Insulin
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*Unopened bottles s/be kept in refrigerator
*Okay at room temperature for 1 month *Mixed syringes need to be in fridge, good for 1 week, keep vertical *Check expiration date on bottle |
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Complications of Insulin Therapy
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*Allergic reactions
*Hypoglycemia *Lipodystrophy *Somogyi *Dawn phenomenon |
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Somogyi (rebound hyperglycemia)
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*Called “Rebound Hyperglycemia”
*More common with Type I (IDDM) *HYPOGLYCEMIA while asleep, then body reacts by releasing glucose from muscle, liver & fat causing rebound HYPERGLYCEMIA *CAUSE is too much insulin *Symptoms: H/A, restless sleep, night sweats, nightmares, N/V *Check BS between 2-3 AM |
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Somogyi (rebound hyperglycemia)
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*Need to check BS between 2-3 am, then recheck when wake up (7-8am)
*If low at 2-3am and high when wake up then Somogyi has occurred *Tx: decrease P.M. insulin and/or eat more carbs & fat with dinner or bedtime snack to prevent low BS while asleep |
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Dawn Phenomenon (Acute Complication)
Wake up w/ very high BS |
*Cause counter-regulatory hormones are released in all people while sleeping which causes BS to rise
*Check BS at 2-3am. If HIGH at this time then HIGH at 7-8am then Dawn P. has occurred *Tx: delay intermediate insulin until 10P.M. or increase dose of pills, limit carbs at night and eat bedtime snack of fat & protein, exercise in the P.M. (exercise before bed) |
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Summary
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*Somogyi (rebound hyperglycemia)
*BG are low and high (too much insulin) *Dawn (Hyperglycemia) *BG are high and high |
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Pharmacological Therapies: Oral antidiabetic agents
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*Sulfonyureas
*Meglitinides *Biguanides *Alpha glucoidase inhibitors *Thiazokidinediones KNOW ACTIONS |
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Medications that affect BS
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DECREASE
*ETOH *MAO's *Tricyclic antidepressants *Tylenol *Allopurinol |
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Medications that affect BS
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INCREASE
*Birth Control *Corticosteroids *Morphine *Lasix *Thiazide Diuretics *Dilantin |
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Reduction of Risk Potential: Exercise
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*Weight loss
*Decreases cholesterol *Improves circulation *Timing of exercise is important for all diabetics -Snack before exercise good idea to take BS prior to exercising |
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Reduction of Risk Potential: Monitoring blood glucose
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*Capillary sample
*Self or by nurse/nursing assistant *Patient teaching *Easy way to frequently monitor BS *Now have monitors for the visually impaired |
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Physiological Adaptation
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*Illness management
*Medical emergencies (recall) 1. Hypoglycemic reaction 2. DKA 3. HHNKS |
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Implementation: safe, effective care environment
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*Management of care
1. Collaboration with the multidisciplinary team (includes family) 2. Case management (discharge planning) 3. Referrals *Safety and infection control 1. Injury prevention 2. Home safety |
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Implementation: Psychosocial
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*Coping mechanisms
*Religious + spiritual influences on health *Situational Role Changes *Support systems *Stress management |
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Implementation: Promotion of wellness
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1. Educate: disease prevention, early detection
2. Health screening 3. Self care: foot care |
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Evaluation
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1. Outcomes
2. Interventions |
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Critical Knowledge Application
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Handout on critical thinking
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Current Trends and Research
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*Several national organizations (inside Living Your Life)
*www.joslin.harvard.edu *www.diabetes.org *See article |
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Summary
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*Nurse plays a major role in the Health promotion, maintenance and restoration of DM
*Assessing, Dx, planning, implementing(collaborative & independent) & evaluation *Early prevention, education and treatment are the key components of DM |
