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Diabetes

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  • Transcript

    • 1. DIABETES MELLITUS Nelia S. Bañaga – Perez RN, MSN, MAEd Northeastern College Nursing Department Santiago City, Philippines
    • 2. 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.
    • 3.  
    • 4.  
    • 5. 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.
    • 6. 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,
    • 7. 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
    • 8. 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
    • 9. 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
    • 10. 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
    • 11. 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)
    • 12. 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)
    • 13. Absence of Insulin
      • Hyperglycemia
      • Polyuria
      • Polydipsia
      • Polyphagia
      • Hemoconcentration, hypervolemia, hyperviscosity, hypoperfusion, and hypoxia
      • Acidosis, Kussmaul respiration
      • Hypokalemia, hyperkalemia, or normal serum potassium levels
    • 14. 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
    • 15. Urine Tests
      • Urine testing for ketones
      • Urine testing for renal function
      • Urine testing for glucose
    • 16. 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
    • 17.  
    • 18.  
    • 19.  
    • 20.  
    • 21.  
    • 22.  
    • 23. Hyperglycemia - Clinical Manifestations
      • Three P’s – polyuria, polydypsia,
      • polyphagia
      • Glycosuria
      • Dehydration
      • Hypotension
      • Mental Changes
      • Fever
      • Hypokalemia
      • Hyponatremia
      • Seizure
      • Coma
      • Life Threatening!!!
    • 24.  
    • 25.  
    • 26.  
    • 27. Risk for Injury Related to Hyperglycemia
      • Interventions include:
        • Dietary interventions, blood glucose monitoring, medications
        • Oral Drugs Therapy
          • (Continued)
    • 28. Risk for Injury Related to Hyperglycemia (Continued)
        • Oral therapy
          • Sulfonylurea agents
          • Meglitinide analogues
          • Biguanides
          • Alpha-glucosidase inhibitors
          • Thiazolinedione antidiabetic agents
    • 29. 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
    • 30.  
    • 31. 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
    • 32. Diabetes Mellitus Diet
      • American Diabetic Association
      • Food groups/ exchanges
      • Carbohydrates - 60%
      • Fats - 30%
      • Protein - 12-20%
    • 33. Diabetes - Monitoring Glucose Levels
      • Urine - Ketones
      • FSBS
      • Wear ID Bracelet
    • 34. Diabetes - Treatment Exercise
      • Purpose - controls blood glucose and lowers blood glucose
      • Purpose - reduce the amount of insulin needed
    • 35. Exercise Therapy
      • Benefits of exercise
      • Risks related to exercise
      • Screening before starting exercise program
      • Guidelines for exercise
      • Exercise promotion
    • 36.  
    • 37. Drug Therapy
      • Drug administration
      • Drug selection
      • Insulin therapy:
        • Insulin analogue
        • Short-acting insulin
        • Concentrated insulin
        • Intermediate
        • (Continued)
    • 38. Drug Therapy (Continued)
        • Fixed-combination
        • Long-acting
        • Buffered insulins
    • 39.  
    • 40. Insulin Regimens
      • Single daily injection protocol
      • Two-dose protocol
      • Three-dose protocol
      • Four-dose protocol
      • Combination therapy
      • Intensified therapy regimens
    • 41.  
    • 42. Pharmacokinetics of Insulin
      • Injection site
      • Absorption rate
      • Injection depth
      • Time of injection
      • Mixing insulins
    • 43.  
    • 44. Complications of Insulin Therapy
      • Hypoglycemia
      • Lipoatrophy
      • Dawn phenomenon
      • Somagyi's phenomenon
    • 45.  
    • 46. Alternative Methods of Insulin Administration
      • Continuous subcutaneous infusion of insulin
      • Implanted insulin pumps
      • Injection devices
      • New technology includes:
        • Inhaled insulin
        • Transdermal patch (being tested)
    • 47. Client Education
      • Storage and dose preparation
      • Syringes
      • Blood glucose monitoring
      • Interpretation of results
      • Frequency of testing
      • Blood glucose therapy goals
    • 48.  
    • 49.  
    • 50. Diabetic Education - Preventive Medicine
      • Proper skin and foot care
      • Proper Eye Exam
      • Proper diet and fluids
      • Diabetic Neuropathy
      • Diabetic Retinopathy
      • Diabetic Nephropathy
      • Diabetic gastroparesis
    • 51.  
    • 52. Diabetes Mellitus Complications
      • Hyperglycemia
      • Hypoglycemia
      • Diabetic Ketoacidosis
      • Hyperosmolar Hyperglycemic Nonketotic Syndrome
    • 53. Acute Complications of Diabetes
      • Diabetic ketoacidosis
      • Hyperglycemic-hyperosmolar-nonketotic syndrome
      • Hypoglycemia from too much insulin or too little glucose
    • 54. Diabetic Ketoacidosis
    • 55. 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)
    • 56. 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
    • 57. 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
    • 58.  
    • 59. 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!!!
    • 60. Chronic Complications of Diabetes
      • Cardiovascular disease
      • Cerebrovascular disease
      • Retinopathy (vision) problems
      • Diabetic neuropathy
      • Diabetic nephropathy
      • Male erectile dysfunction
    • 61.  
    • 62.  
    • 63.  
    • 64. 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
    • 65. 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
    • 66. Risk for Delayed Surgical Recovery
      • Interventions include:
        • Preoperative care
        • Intraoperative care
        • Postoperative care and monitoring includes care of:
          • Cardiovascular
          • Renal
          • Nutritional
    • 67. 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.
    • 68. Wound Care
      • Wound environment
      • Debridement
      • Elimination of pressure on infected area
      • Growth factors applied to wounds
    • 69. Chronic Pain
      • Interventions include:
        • Maintenance of normal blood glucose levels
        • Anticonvulsants
        • Antidepressants
        • Capsaicin cream
    • 70. 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
    • 71. 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
    • 72. 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
    • 73. 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
    • 74. Health Teaching
      • Assessing learning needs
      • Assessing physical, cognitive, and emotional limitations
      • Explaining survival skills
      • Counseling
      • Psychosocial preparation
      • Home care management
      • Health care resources
    • 75.  
    • 76. 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.
    • 77. DIABETES SELF CARE STAR
      • MEALS
      MONITORING * PLASMA *FEET MEDICATIONS *INSULIN *ORAL AGENTS MANAGEMENT *SICK DAY *HYPOGLYCEMIA * HYPERGYCEMIA MOTION
    • 78. Any Questions???