Diabetes
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Diabetes Diabetes Presentation Transcript

  • DIABETES MELLITUS Nelia S. Bañaga – Perez RN, MSN, MAEd Northeastern College Nursing Department Santiago City, Philippines
  • DIABETES MELLITUS
    • An endocrine disorder in which there is insufficient amount or lack of insulin secretion to metabolize carbohydrates.
    • It is characterized by hyperglycemia, glycosuria and ketonuria.
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  • Diabetes Mellitus Pathophysiology
    • The beta cells of the Islets of Langerhan of the Pancreas gland are responsible for secreting the hormone insulin for the carbohydrate metabolism.
    • Remember the concept - sugar into the cells.
  • Diabetes Mellitus Types
    • Type 1 - IDDM
      • little to no insulin produced
      • 20-30% hereditary
      • Ketoacidosis
    • Gestational
      • overweight; risk for Type 2
    • Type 2 - NIDDM
      • some insulin produced
      • 90% hereditary
    • Other types include Secondary Diabetes :
      • Genetic defect beta cell or insulin
      • Disease of exocrine pancreas
      • Drug or chemical induced
      • Infections- pancreatitits
      • Others- steroids,
  • INSULIN
    • Insulin is a protein made of 2 chains- alpha and beta
    • Preproinsulin is produced initially
      • Precursor molecule that is inactive
      • Must be made smaller before becoming active
    • Proinsulin
      • Precursor that includes alpha and beta chains
      • Also has a C-peptide chain
      • C-peptide levels are used to measure rate that beta cells secrete insulin
  • INSULIN
    • Insulin allows glucose to move into cells to make energy
    • Liver is first major organ to be reached
      • Promotes production and storage of glycogen (glycogenisis)
      • Inhibits glycogen breakdown into glucose (glycogenolysis)
      • Increases protein and lipid synthesis
      • Inhibits tissue breakdown by inhibiting liver glycogenolysis (ketogenesis- converts fats to acids) & gluconeogenisis (conversion of proteins to glucose)
      • In muscle, promotes protein and glycogen synthesis
      • In fat cells, promotes triglyceride storage
  • INSULIN
    • Pancreas secretes 40-50 units of insulin daily in two steps:
      • Secreted at low levels during fasting ( basal insulin secretion
      • Increased levels after eating (prandial)
      • An early burst of insulin occurs within 10 minutes of eating
      • Then proceeds with increasing release as long as hyperglycemia is present
  • GLUCOSE HOMEOSTASIS
    • Glucose is main fuel for CNS
    • Brain cannot make or store, therefore needs continuous supply
    • Fatty acids can be used when glucose is not available ( triglycerides)
    • Need 68-105 mg/dL to support brain
    • Decreased levels of glucose, insulin release is stopped with glucagon released
  • GLUCOSE
    • Glucagon causes release of glucose from liver
      • Liver glucose is made thru glycogenolysis (glucogen to glucose) &
      • Gluconeogenesis
    • When liver glucose is not available, lypolysis occures ( breakdown of fat) OR
    • Proteinlysis (breakdown of amino acids)
  • ABSENCE OF INSULIN
    • Insulin needed to move glucose into cells
    • Without insulin, body enters a state of breaking down fats and proteins
    • Glucose levels increase (hyperglycemia)
  • Absence of Insulin
    • Hyperglycemia
    • Polyuria
    • Polydipsia
    • Polyphagia
    • Hemoconcentration, hypervolemia, hyperviscosity, hypoperfusion, and hypoxia
    • Acidosis, Kussmaul respiration
    • Hypokalemia, hyperkalemia, or normal serum potassium levels
  • Assessment
    • History
    • Blood tests
      • Fasting blood glucose test: two tests > 126 mg/dL
      • Oral glucose tolerance test: blood glucose > 200 mg/dL at 120 minutes
      • Glycosylated hemoglobin ( Glycohemoglobin test) assays
      • Glucosylated serum proteins and albumin
    • FSBS – (finger stick) monitoring blood sugar
  • Urine Tests
    • Urine testing for ketones
    • Urine testing for renal function
    • Urine testing for glucose
  • Diabetes Mellitus Clinical Manifestation
    • Hyperglycemia
      • Three P’s -
        • Polyuria
        • Polyphagia
        • Polydispsia
    • Gradual Onset
    • Hypoglycemia
      • Weak, diaphoretic, sweat, pallor, tremors, nervous, hungry, diplopia, confusion, aphasia, vertigo, convulsions
      • Treatment - OJ with sugar, or IV glucose
    • Sudden onset
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  • Hyperglycemia - Clinical Manifestations
    • Three P’s – polyuria, polydypsia,
    • polyphagia
    • Glycosuria
    • Dehydration
    • Hypotension
    • Mental Changes
    • Fever
    • Hypokalemia
    • Hyponatremia
    • Seizure
    • Coma
    • Life Threatening!!!
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  • Risk for Injury Related to Hyperglycemia
    • Interventions include:
      • Dietary interventions, blood glucose monitoring, medications
      • Oral Drugs Therapy
        • (Continued)
  • Risk for Injury Related to Hyperglycemia (Continued)
      • Oral therapy
        • Sulfonylurea agents
        • Meglitinide analogues
        • Biguanides
        • Alpha-glucosidase inhibitors
        • Thiazolinedione antidiabetic agents
  • Oral Hypoglcemias Key Points
    • Monitor serum glucose levels
    • Teach patient signs and symptoms of hyper/hypoglycemia
    • Altered liver, renal function will affect medication action
    • Avoid OTC meds without MD approval
    • Assess for GI distress and sensitivity
    • Know appropriate time to administer med
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  • Diet Therapy
    • Goals of diet therapy
    • Principles of nutrition in diabetes
      • Protein, fats and carbohydrates, fiber, sweeteners, fat replacers
      • Alcohol
      • Food labeling
      • Exchange system, carbohydrate counting
      • Special considerations for type 1 and type 2 diabetes
  • Diabetes Mellitus Diet
    • American Diabetic Association
    • Food groups/ exchanges
    • Carbohydrates - 60%
    • Fats - 30%
    • Protein - 12-20%
  • Diabetes - Monitoring Glucose Levels
    • Urine - Ketones
    • FSBS
    • Wear ID Bracelet
  • Diabetes - Treatment Exercise
    • Purpose - controls blood glucose and lowers blood glucose
    • Purpose - reduce the amount of insulin needed
  • Exercise Therapy
    • Benefits of exercise
    • Risks related to exercise
    • Screening before starting exercise program
    • Guidelines for exercise
    • Exercise promotion
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  • Drug Therapy
    • Drug administration
    • Drug selection
    • Insulin therapy:
      • Insulin analogue
      • Short-acting insulin
      • Concentrated insulin
      • Intermediate
      • (Continued)
  • Drug Therapy (Continued)
      • Fixed-combination
      • Long-acting
      • Buffered insulins
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  • Insulin Regimens
    • Single daily injection protocol
    • Two-dose protocol
    • Three-dose protocol
    • Four-dose protocol
    • Combination therapy
    • Intensified therapy regimens
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  • Pharmacokinetics of Insulin
    • Injection site
    • Absorption rate
    • Injection depth
    • Time of injection
    • Mixing insulins
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  • Complications of Insulin Therapy
    • Hypoglycemia
    • Lipoatrophy
    • Dawn phenomenon
    • Somagyi's phenomenon
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  • Alternative Methods of Insulin Administration
    • Continuous subcutaneous infusion of insulin
    • Implanted insulin pumps
    • Injection devices
    • New technology includes:
      • Inhaled insulin
      • Transdermal patch (being tested)
  • Client Education
    • Storage and dose preparation
    • Syringes
    • Blood glucose monitoring
    • Interpretation of results
    • Frequency of testing
    • Blood glucose therapy goals
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  • Diabetic Education - Preventive Medicine
    • Proper skin and foot care
    • Proper Eye Exam
    • Proper diet and fluids
    • Diabetic Neuropathy
    • Diabetic Retinopathy
    • Diabetic Nephropathy
    • Diabetic gastroparesis
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  • Diabetes Mellitus Complications
    • Hyperglycemia
    • Hypoglycemia
    • Diabetic Ketoacidosis
    • Hyperosmolar Hyperglycemic Nonketotic Syndrome
  • Acute Complications of Diabetes
    • Diabetic ketoacidosis
    • Hyperglycemic-hyperosmolar-nonketotic syndrome
    • Hypoglycemia from too much insulin or too little glucose
  • Diabetic Ketoacidosis
  • Potential for Diabetic Ketoacidosis
    • Interventions include:
      • Monitoring for manifestations
      • Assessment of airway, level of consciousness, hydration status, blood glucose level
      • Management of fluid and electrolytes
      • (Continued)
  • Potential for Diabetic Ketoacidosis (Continued)
      • Drug therapy goal: to lower serum glucose by 75 to 150 mg/dL/hr
      • Management of acidosis
      • Client education and prevention
  • Complication – Ketoacidosis Treatment
    • Patent airway
    • Suctioning
    • Cardiac monitoring
    • Vital Signs
    • Central venous pressure
    • Blood work – ABG, BS, chemistry panel
    • Administration of Na Bicarb
    • Foley – monitor urinary output
    • I & O
    • Frequent Repositioning
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  • Complication – HHNC Hyperosmolar Hyperglycemic Non-Ketotic Coma
    • Fluid moves from inside to outside cell vausing diuresis and loss of Na+ and K+
    • Treatment - Give insulin and correct fluid and electrolytes imbalance
    • Signs and Symptoms
      • Hypotension
      • Mental changes
      • Dehydration
      • Hypokalemia
      • Hyponatremia
      • Life Threatening!!!
  • Chronic Complications of Diabetes
    • Cardiovascular disease
    • Cerebrovascular disease
    • Retinopathy (vision) problems
    • Diabetic neuropathy
    • Diabetic nephropathy
    • Male erectile dysfunction
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  • Diabetes Mellitus Nursing Process
    • Assessment – Medicines, Allergies, Symptoms, Family Hx
    • Nursing Diagnosis- Anxiety and Fear, Altered Nutrition, Pain, Fluid Volume Deficit
    • Planning – Address the nursing diagnosis
    • Implementation – Prevent complications, monitor blood sugars, administer meds and diet, teach diet and meds, Asess , Assess, Assess
    • Evaluation- Goals, EOC’s
  • Whole-Pancreas Transplantation
    • Operative procedure
    • Rejection management
    • Long-term effects
    • Complications
    • Islet cell transplantation hindered by limited supply of beta cells and problems caused by antirejection drugs
  • Risk for Delayed Surgical Recovery
    • Interventions include:
      • Preoperative care
      • Intraoperative care
      • Postoperative care and monitoring includes care of:
        • Cardiovascular
        • Renal
        • Nutritional
  • Risk for Injury Related to Sensory Alterations
    • Interventions and foot care practices:
      • Cleanse and inspect the feet daily.
      • Wear properly fitting shoes.
      • Avoid walking barefoot.
      • Trim toenails properly.
      • Report nonhealing breaks in the skin.
  • Wound Care
    • Wound environment
    • Debridement
    • Elimination of pressure on infected area
    • Growth factors applied to wounds
  • Chronic Pain
    • Interventions include:
      • Maintenance of normal blood glucose levels
      • Anticonvulsants
      • Antidepressants
      • Capsaicin cream
  • Risk for Injury Related to Disturbed Sensory Perception: Visual
    • Interventions include:
      • Blood glucose control
      • Environmental management
        • Incandescent lamp
        • Coding objects
        • Syringes with magnifiers
        • Use of adaptive devices
  • Ineffective Tissue Perfusion: Renal
    • Interventions include:
      • Control of blood glucose levels
      • Yearly evaluation of kidney function
      • Control of blood pressure levels
      • Prompt treatment of UTIs
      • Avoidance of nephrotoxic drugs
      • Diet therapy
      • Fluid and electrolyte management
  • Potential for Hypoglycemia
    • Blood glucose level < 70 mg/dL
    • Diet therapy: carbohydrate replacement
    • Drug therapy: glucagon, 50% dextrose, diazoxide, octreotide
    • Prevention strategies for:
      • Insulin excess
      • Deficient food intake
      • Exercise
      • Alcohol
  • Potential for Hyperglycemic-Hyperosmolar Nonketotic Syndrome and Coma
    • Interventions include:
      • Monitoring
      • Fluid therapy: to rehydrate the client and restore normal blood glucose levels within 36 to 72 hr
      • Continuing therapy with IV regular insulin at 10 units/hr often needed to reduce blood glucose levels
  • Health Teaching
    • Assessing learning needs
    • Assessing physical, cognitive, and emotional limitations
    • Explaining survival skills
    • Counseling
    • Psychosocial preparation
    • Home care management
    • Health care resources
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  • Diabetes Mellitus Summary
    • Treatable, but not curable.
    • Preventable in obesity, adult client.
    • Diagnostic Tests
    • Signs and symptoms of hypoglycemia and hyperglycemia.
    • Treatment of hypoglycemia and hyperglycemia – diet and oral hypoglycemics.
    • Nursing implications – monitoring, teaching and assessing for complications.
  • DIABETES SELF CARE STAR
    • MEALS
    MONITORING * PLASMA *FEET MEDICATIONS *INSULIN *ORAL AGENTS MANAGEMENT *SICK DAY *HYPOGLYCEMIA * HYPERGYCEMIA MOTION
  • Any Questions???