Diabetes Lecture


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    Gr8 presntation! Will you allow me to download the same, or send it to my e mail id : vsdesai@rediffmail.com?
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    Dr Vidyadhar Desai
    Mumbai - India
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Diabetes Lecture

  1. 1. Learning Objectives:At the end of this lecture, you will be able to:1. Differentiate between type 1 and type 2 diabetes.2. Describe etiologic factors associated with diabetes.3. Relate the clinical manifestations of diabetes to theassociated pathophysiologic alterations.JOFRED M. MARTINEZ, RN
  2. 2. 4. Identify the diagnostic and clinical significance ofblood glucose tests.5. Explain the dietary modifications used formanagement of people diabetes.6. Describe the relationship between diet, exercise, andmedication (ie, insulin or oral hypoglycemic agents)for people with diabetes.7. Develop a plan for teaching insulin self-administration.8. Identify the role of oral antidiabetic agents in diabetictherapy.Learning Objectives (Cont’d.):
  3. 3. 9. Differentiate between hypoglycemia and diabeticketoacidosis, and hyperosmolar nonketotic syndrome.10.Describe management strategies for a person withdiabetes to use during “sick days.”11.Describe the major macrovascular, microvascular,and neuropathic complications of diabetes and theself-care behaviors important in their prevention.12.Identify the teaching aids and community supportgroups available for people with diabetes.13.Use the nursing process as a framework for care ofthe patient with diabetes.Learning Objectives (Cont’d.):
  4. 4. • Diabetes mellitus is a group of metabolic diseasescharacterized by elevated levels of glucose in the bloodresulting from defects in insulin secretion, insulin action,or both.American Diabetes Association, Expert Committee on the Diagnosis andClassification of Diabetes Mellitus, 2003• Insulin, a hormone produced by the pancreas, controlsthe level of glucose in the blood by regulating theproduction and storage of glucose.• Long-term effects of hyperglycemia contribute tomacrovascular complications, chronic microvascularcomplications, and neuropathic complications.Diabetes Mellitus
  5. 5. RISK FACTORS FOR DIABETES MELLITUS• Family history of diabetes• Obesity (ie, ≥20% over desired body weight or BMI ≥27kg/m2)• Race/ethnicity (eg, African Americans, HispanicAmericans, Native Americans, Asian Americans, PacificIslanders)• Age ≥45 years• Previously identified impaired fasting glucose orimpaired glucose tolerance• Hypertension (≥140/90 mm Hg)Diabetes Mellitus
  6. 6. RISK FACTORS FOR DIABETES MELLITUS• HDL cholesterol level ≤35 mg/dL (0.90 mmol/L) and/ortriglyceride level ≥250 mg/dL (2.8 mmol/L)• History of gestational diabetes or delivery of babies over9 lbsDiabetes Mellitus
  7. 7. CLASSIFICATION OF DIABETESThe major classifications of diabetes are:• Type 1 diabetes• Type 2 diabetes• Gestational diabetes mellitus• Diabetes mellitus associated with other conditions orsyndromesDiabetes Mellitus
  8. 8. TYPE 1 DIABETES• Approximately 5% to 10% of people with diabetes havetype 1 diabetes, in which the insulin-producingpancreatic beta cells are destroyed by an autoimmuneprocess.• As a result, they produce little or no insulin and requireinsulin injections to control their blood glucose levels.• Type 1 diabetes is characterized by an acute onset,usually before age 30.Diabetes Mellitus
  9. 9. TYPE 2 DIABETES• Approximately 90% to 95% of people with diabetes havetype 2 diabetes, which results from decreased sensitivityto insulin (called insulin resistance) and impaired betacell functioning resulting in decreased insulin production.• Type 2 diabetes is first treated with diet and exercise.• If elevated glucose levels persist, diet and exercise aresupplemented with oral hypoglycemic agents, andinsulin injections are required.• Type 2 diabetes occurs more among people who areolder than 30 years and obese.Diabetes Mellitus
  10. 10. TYPE 2 DIABETES• Borderline diabetes is classified as impaired glucosetolerance (IGT) or impaired fasting glucose (IFG) andrefers to a condition in which blood glucose levels fallbetween normal levels and levels considered diagnosticfor diabetes.Diabetes Mellitus
  11. 11. Pathophysiology
  12. 12. GESTATIONAL DIABETES• Gestational diabetes is any degree of glucoseintolerance with its onset during pregnancy.• Hyperglycemia develops during pregnancy because ofthe secretion of placental hormones, which causesinsulin resistance.• Selective screening for diabetes during pregnancy isnow being recommended between the 24th and 28thweeks of gestation: age 25 years or older; age 25 yearsor younger and obese; family history of diabetes in first-degree relatives; or member of an ethnic/racial groupwith a high prevalence of diabetesDiabetes Mellitus
  13. 13. GESTATIONAL DIABETES• Gestational diabetes occurs in up to 14% of pregnantwomen and increases their risk for hypertensivedisorders during pregnancy.• Initial management includes dietary modification andblood glucose monitoring. If hyperglycemia persists,insulin is prescribed.• Oral antidiabetic agents should not be used duringpregnancy.• Goals for blood glucose levels during pregnancy are 105mg/dL (5.8 mmol/L) or less before meals and 120 mg/dL(6.7 mmol/L) or less 2 hours after meals.Diabetes Mellitus
  14. 14. GESTATIONAL DIABETES• After delivery of the infant, blood glucose levels in thewoman with gestational diabetes return to normal.• All women who have had gestational diabetes should becounseled to maintain their ideal body weight and toexercise regularly to reduce their risk for type 2diabetes.Diabetes Mellitus
  15. 15. CLINICAL MANIFESTATIONS• Three Ps”: polyuria, polydipsia, and polyphagia.• Other symptoms include fatigue and weakness, suddenvision changes, tingling or numbness in hands or feet,dry skin, skin lesions or wounds that are slow to heal,and recurrent infections.• The onset of type 1 diabetes may also be associatedwith sudden weight loss or nausea, vomiting, orabdominal pains, if DKA has developed.Diabetes Mellitus
  16. 16. ASSESSMENT AND DIAGNOSTIC FINDINGS• An abnormally high blood glucose level is the basiccriterion for the diabetes diagnosis.• Fasting plasma glucose (FPG) levels of 126 mg/dL (7.0mmol/L) or more or random plasma glucose levelsexceeding 200 mg/dL (11.1 mmol/L) on more than oneoccasion are diagnostic of diabetes.Diabetes Mellitus
  17. 17. DIAGNOSIS OF DIABETES MELLITUS• Symptoms of diabetes plus casual plasma glucoseconcentration equal to or greater than 200 mg/dL (11.1mmol/L). The classic symptoms of diabetes includepolyuria, polydipsia, and unexplained weight loss.• Fasting plasma glucose greater than or equal to 126mg/dL (7.0 mmol/L).• 2-hour postload glucose equal to or greater than 200mg/dL (11.1 mmol/L) during an oral glucose tolerancetest. The test should be performed using a glucose loadcontaining the equivalent of 75 g anhydrous glucosedissolved in water.Diabetes Mellitus
  18. 18. DIABETES MANAGEMENT• The main goal of diabetes treatment is to normalizeinsulin activity and blood glucose levels to reduce thedevelopment of vascular and neuropathic complications.Five components of diabetes management:• Nutritional management• Exercise• Monitoring• Pharmacologic therapy• EducationDiabetes Mellitus
  19. 19. Diabetes Mellitus
  20. 20. NUTRITIONAL MANAGEMENTNutritional management of the diabetic patient includesthe following goals :• Providing all the essential food constituents (eg, vitamins,minerals) necessary for optimal nutrition• Meeting energy needs• Achieving and maintaining a reasonable weight• Preventing wide daily fluctuations in blood glucose levels,with blood glucose levels as close to normal as is safe andpractical to prevent or reduce the risk for complications• Decreasing serum lipid levels, if elevated, to reduce therisk for macrovascular diseaseDiabetes Mellitus
  21. 21. NUTRITIONAL MANAGEMENTMEAL PLANNING AND RELATED TEACHING• The first step in preparing a meal plan is a thoroughreview of the patient’s diet history to identify his or hereating habits and lifestyle.• A thorough assessment of the patient’s need for weightloss, gain, or maintenance is also undertaken.• In most instances, the person with type 2 diabetesrequires weight reduction.Diabetes Mellitus
  22. 22. NUTRITIONAL MANAGEMENTMEAL PLANNING AND RELATED TEACHING• Initial education addresses the importance of consistenteating habits, the relationship of food and insulin, andthe provision of an individualized meal plan.• Follow-up education then focuses on managementskills, such as eating at restaurants, reading food labels,and adjusting the meal plan for exercise, illness, andspecial occasions.• The nurse plays an important role in communicatingpertinent information to the dietitian and reinforcing thepatient’s understanding.Diabetes Mellitus
  23. 23. NUTRITIONAL MANAGEMENTCALORIC REQUIREMENTS• Calorie-controlled diets are planned by first calculatingthe individual’s energy needs and caloric requirementsbased on the patient’s age, gender, height, and weight.• An activity element is then factored in to provide theactual number of calories required for weightmaintenance.• To promote a 1- to 2-pound weight loss per week, 500 to1,000 calories are subtracted from the daily total.• The calories are distributed into carbohydrates, proteins,and fats, and a meal plan is then developed.Diabetes Mellitus
  24. 24. NUTRITIONAL MANAGEMENTCALORIC REQUIREMENTS• The caloric distribution currently recommended is higherin carbohydrates than in fat and protein.• Currently, the ADA and the American DieteticAssociation recommend that for all levels of caloricintake, 50% to 60% of calories should be derived fromcarbohydrates, 20% to 30% from fat, and the remaining10% to 20% from protein.Diabetes Mellitus
  25. 25. NUTRITIONAL MANAGEMENTCALORIC REQUIREMENTS• The use of fiber in diabetic diets plays a role in loweringtotal cholesterol and low-density lipoprotein cholesterolin the blood.• Increasing fiber in the diet may also improve bloodglucose levels and decrease the need for exogenousinsulin.• There are two types of dietary fibers: soluble andinsoluble.Diabetes Mellitus
  26. 26. NUTRITIONAL MANAGEMENTCALORIC REQUIREMENTS• Soluble fiber in foods such as legumes, oats, and somefruits plays more of a role in lowering blood glucose andlipid levels than does insoluble fiber.• Insoluble fiber is found in whole-grain breads andcereals and in some vegetables. This type of fiber playsmore of a role in increasing stool bulk and preventingconstipation.Diabetes Mellitus
  27. 27. EXERCISE• Exercise is extremely important in managing diabetesbecause of its effects on lowering blood glucose andreducing cardiovascular risk factors.• Exercise lowers the blood glucose level by increasingthe uptake of glucose by body muscles and byimproving insulin utilization. It also improves circulationand muscle tone.• Resistance (strength) training, such as weight lifting, canincrease lean muscle mass, thereby increasing theresting metabolic rate.Diabetes Mellitus
  28. 28. EXERCISEDiabetes Mellitus
  29. 29. EXERCISEDiabetes Mellitus
  30. 30. EXERCISEDiabetes Mellitus
  31. 31. EXERCISE• Patients who have blood glucose levels exceeding 250mg/dL (14 mmol/L) and who have ketones in their urineshould not begin exercising until the urine tests negativefor ketones and the blood glucose level is closer tonormal.• Exercising with elevated blood glucose levels increasesthe secretion of glucagon, growth hormone, andcatecholamines. The liver then releases more glucose,and the result is an increase in the blood glucose level.• Another potential problem for patients who take insulin ishypoglycemia that occurs many hours after exercise.Diabetes Mellitus
  32. 32. EXERCISEGeneral Precautions for Exercise in Diabetics:• Use proper footwear and, if appropriate, other protectiveequipment.• Avoid exercise in extreme heat or cold.• Inspect feet daily after exercise.• Avoid exercise during periods of poor metabolic control.Diabetes Mellitus
  33. 33. MONITORING GLUCOSE LEVELS AND KETONES• Blood glucose monitoring and self-monitoring of bloodglucose (SMBG) levels by patients has dramaticallyaltered diabetes care.• Frequent SMBG enables people with diabetes to adjustthe treatment regimen to obtain optimal blood glucosecontrol.• This allows for detection and prevention ofhypoglycemia and hyperglycemia and plays a crucialrole in normalizing blood glucose levels, which in turnmay reduce the risk of long-term diabetic complications.Diabetes Mellitus
  37. 37. MONITORING GLUCOSE LEVELS AND KETONES• For most patients who require insulin, SMBG isrecommended two to four times daily (usually beforemeals and at bedtime).• For patients who take insulin before each meal, SMBGis required at least three times daily before meals todetermine each dose.• Patients not receiving insulin may be instructed toassess their blood glucose levels at least two or threetimes per week, including a 2-hour postprandial test.Diabetes Mellitus
  38. 38. MONITORING GLUCOSE LEVELS AND KETONESGLYCOSYLATED HEMOGLOBIN• Glycosylated hemoglobin (referred to as HgbA1C orA1C) is a blood test that reflects average blood glucoselevels over a period of approximately 2 to 3 months.• The longer the amount of glucose in the blood remainsabove normal, the more glucose binds to the red bloodcell and the higher the glycosylated hemoglobin level.• The normal values differ slightly from test to test andfrom laboratory to laboratory and normally range from4% to 6%.Diabetes Mellitus
  39. 39. Diabetes Mellitus
  40. 40. MONITORING GLUCOSE LEVELS AND KETONESTESTING FOR KETONES• Ketones in the urine signal that control of type 1diabetes is deteriorating, and the risk of DKA is high.• When there is almost no effective insulin available, thebody starts to break down stored fat for energy.• Urine testing is the most common method used for self-testing of ketone bodies by patients.• Most commonly, patients use a urine dipstick (Ketostixor Chemstrip uK) to detect ketonuria.• The reagent pad on the strip turns purplish whenketones are present.Diabetes Mellitus
  41. 41. MONITORING GLUCOSE LEVELS AND KETONESTESTING FOR KETONES• Other strips are available for measuring both urineglucose and ketones (Keto-Diastix or Chemstrip uGK).• Urine ketone testing should be performed wheneverpatients with type 1 diabetes have glucosuria orpersistently elevated blood glucose levels (more than240 mg/dL or 13.2 mmol/L for two testing periods in arow) and during illness, in pregnancy with pre-existingdiabetes, and in gestational diabetes.Diabetes Mellitus
  42. 42. PHARMACOLOGIC THERAPYINSULIN THERAPY AND INSULIN PREPARATIONS• Because the body loses the ability to produce insulin intype 1 diabetes, exogenous insulin must beadministered for life.• In type 2 diabetes, insulin may be necessary on a long-term basis to control glucose levels if diet and oralagents fail.• Some patients in whom type 2 diabetes is usuallycontrolled by diet alone or by diet and an oral agent mayrequire insulin temporarily during illness, infection,pregnancy, surgery, or some other stressful event.Diabetes Mellitus
  43. 43. PHARMACOLOGIC THERAPYINSULIN THERAPY AND INSULIN PREPARATIONS• In many cases, insulin injections are administered two ormore times daily to control the blood glucose level.• Because the insulin dose required by the individualpatient is determined by the level of glucose in theblood, accurate monitoring of blood glucose levels isessential; thus, SMBG has become a cornerstone ofinsulin therapy.Diabetes Mellitus
  44. 44. PHARMACOLOGIC THERAPYINSULIN THERAPY AND INSULIN PREPARATIONS• Insulin preparations vary according to three maincharacteristics: time course of action, species (source),and manufacturer.Diabetes Mellitus
  45. 45. PHARMACOLOGIC THERAPYINSULIN THERAPY AND INSULIN PREPARATIONS• Insulin preparations vary according to three maincharacteristics: time course of action, species (source),and manufacturer.Diabetes Mellitus
  46. 46. COMPLICATIONS OF INSULIN THERAPY• A local allergic reaction (redness, swelling, tenderness,and induration or a 2- to 4-cm wheal) may appear at theinjection site 1 to 2 hours after the insulin administration.• The physician may prescribe an antihistamine to betaken 1 hour before the injection if such a local reactionoccurs.SYSTEMIC ALLERGIC REACTIONS• Immediate local skin reaction that gradually spreads intogeneralized urticaria (hives).Diabetes Mellitus
  47. 47. COMPLICATIONS OF INSULIN THERAPY• The treatment is desensitization, with small doses ofinsulin administered in gradually increasing amountsusing a desensitization kit.• These rare reactions are occasionally associated withgeneralized edema or anaphylaxis.INSULIN LIPODYSTROPHY• Lipodystrophy refers to a localized reaction, in the formof either lipoatrophy or lipohypertrophy, occurring at thesite of insulin injections.Diabetes Mellitus
  48. 48. Diabetes Mellitus
  49. 49. COMPLICATIONS OF INSULIN THERAPY• Lipoatrophy is loss of subcutaneous fat and appears asslight dimpling or more serious pitting of subcutaneousfat.• Lipohypertrophy, the development of fibrofatty masses atthe injection site, is caused by the repeated use of aninjection site.• If insulin is injected into scarred areas, absorption maybe delayed.• This is one reason that rotation of injection sites is soimportant.Diabetes Mellitus
  50. 50. Diabetes Mellitus
  51. 51. COMPLICATIONS OF INSULIN THERAPYINSULIN RESISTANCE• Clinical insulin resistance has been defined as a dailyinsulin requirement of 200 units or more.• In most diabetic patients taking insulin, immuneantibodies develop and bind the insulin, therebydecreasing the insulin available for use.• Treatment consists of administering a moreconcentrated insulin preparation, such as U500, which isavailable by special order.Diabetes Mellitus
  52. 52. COMPLICATIONS OF INSULIN THERAPYINSULIN RESISTANCE• Occasionally, prednisone is needed to block theproduction of antibodies.• This may be followed by a gradual reduction in insulinrequirement.Diabetes Mellitus
  54. 54. ALTERNATIVE METHODS OF INSULIN DELIVERYINSULIN PENS• These devices use small (150- to 300-unit) prefilledinsulin cartridges that are loaded into a penlike holder.• Insulin is delivered by dialing in a dose or pushing abutton for every 1- or 2-unit increment administered.• These devices are most useful for patients who need toinject only one type of insulin at a time (eg, premealregular insulin three times a day and bedtime NPHinsulin) or who can use the premixed insulins.Diabetes Mellitus
  55. 55. Diabetes Mellitus
  56. 56. Diabetes Mellitus
  57. 57. ALTERNATIVE METHODS OF INSULIN DELIVERYJET INJECTORS• Jet injection devices deliver insulin through the skinunder pressure in an extremely fine stream.• These devices are more expensive than otheralternative devices mentioned above and requirethorough training and supervision when first used.• In addition, patients should be cautioned that absorptionrates, peak insulin activity, and insulin levels may bedifferent when changing to a jet injector.Diabetes Mellitus
  58. 58. Diabetes Mellitus
  59. 59. Diabetes Mellitus
  60. 60. ALTERNATIVE METHODS OF INSULIN DELIVERYINSULIN PUMPS• Continuous subcutaneous insulin infusion involves theuse of small, externally worn devices that closely mimicthe functioning of the normal pancreas.• Insulin pumps contain a 3-mL syringe attached to a long(24- to 42-in), thin, narrow-lumen tube with a needle orTeflon catheter attached to the end.• The patient inserts the needle or catheter into thesubcutaneous tissue and secures it with tape or atransparent dressing.• The needle or catheter is changed at least every 3 days.Diabetes Mellitus
  61. 61. ALTERNATIVE METHODS OF INSULIN DELIVERYINSULIN PUMPS• The pump is then worn either on a belt or in a pocket.• The rapid-acting lispro insulin is used in the insulin pumpand is delivered at a basal rate and as a bolus withmeals.• A continuous basal rate of insulin is typically 0.5 to 2.0units/hour, depending on the patient’s needs.Diabetes Mellitus
  62. 62. Diabetes Mellitus
  63. 63. Diabetes Mellitus
  64. 64. ALTERNATIVE METHODS OF INSULIN DELIVERYIMPLANTABLE AND INHALANT INSULIN DELIVERY• Insulin pumps that can be externally programmedaccording to blood glucose test results.Diabetes Mellitus
  65. 65. Diabetes Mellitus
  66. 66. TRANSPLANTATION OF PANCREATIC CELLS• Transplantation of the whole pancreas or a segment ofthe pancreas is being performed on a limited population.Diabetes Mellitus
  67. 67. ORAL ANTIDIABETIC AGENTSSULFONYLUREAS• The sulfonylureas exert their primary action by directlystimulating the pancreas to secrete insulin.• These agents improve insulin action at the cellular leveland may also directly decrease glucose production bythe liver.• The sulfonylureas can be divided into first- and second-generation categories.Diabetes Mellitus
  68. 68. ORAL ANTIDIABETIC AGENTSBIGUANIDES• Metformin (Glucophage) produces its antidiabetic effectsby facilitating insulin’s action on peripheral receptorsites.• Biguanides have no effect on pancreatic beta cells.• Biguanides used with a sulfonylurea may enhance theglucose-lowering effect more than either medicationused alone.• Lactic acidosis is a potential and serious complication ofbiguanide therapy; the patient must be monitored closelywhen therapy is initiated or when dosage changes.Diabetes Mellitus
  69. 69. First-Generation Sulfonylureas• acetohexamide (Dymelor)• chlorpropamide (Diabinese)• tolazamide (Tolinase)• tolbutamide (Orinase)Second-Generation Sulfonylureas• glipizide (Glucatrol)• glipizide (Glucatrol XL)• glyburide (Micronase)• glimepiride (Amaryl)Diabetes Mellitus
  70. 70. Biguanides• metformin (Glucophage +• Glucophage XL)• metformin with glyburide• (Glucovance)Alpha Glucosidase Inhibitors• acarbose (Precose)• Thiazolidinediones• pioglitazone (Actos)• rosiglitazone (Avandia)Diabetes Mellitus
  71. 71. Meglitinides• repaglinide (Prandin)• nateglinide (Starix)Diabetes Mellitus
  72. 72. ALPHA GLUCOSIDASE INHIBITORS• They work by delaying the absorption of glucose in theintestinal system, resulting in a lower postprandial bloodglucose level.• As a consequence of plasma glucose reduction,hemoglobin A1C levels drop.• The advantage of oral alpha glucosidase inhibitors isthat they are not systemically absorbed and are safe touse.Diabetes Mellitus
  73. 73. THIAZOLIDINEDIONES• They are indicated for patients with type 2 diabetes whotake insulin injections and whose blood glucose controlis inadequate (hemoglobin A1C level greater than 8.5%).• They have also been approved as firstline agents totreat type 2 diabetes, in combination with diet.• Thiazolidinediones enhance insulin action at thereceptor site without increasing insulin secretion fromthe beta cells of the pancreas.• These medications may affect liver function; therefore,liver function studies must be performed at baseline andat frequent intervals.Diabetes Mellitus
  74. 74. MEGLITINIDES• Lowers the blood glucose level by stimulating insulinrelease from the pancreatic beta cells. Its effectivenessdepends on the presence of functioning beta cells.• Patients must be taught the signs and symptoms ofhypoglycemia and should understand that themedication should not be taken unless the patient eats ameal.Diabetes Mellitus
  75. 75. NURSING MANAGEMENTEDUCATION• Patients must learn daily self-care skills to preventacute fluctuations in blood glucose, and they must alsoincorporate into their lifestyle many preventive behaviorsfor avoidance of long-term diabetic complications.• Diabetic patients must become knowledgeable aboutnutrition, medication effects and side effects, exercise,disease progression, prevention strategies, bloodglucose monitoring techniques, and medicationadjustment.Diabetes Mellitus
  76. 76. NURSING MANAGEMENTEDUCATION• In addition, they must learn the skills associated withmonitoring and managing diabetes and must incorporatemany new activities into their daily routines.Diabetes Mellitus
  77. 77. TEACHING PATIENTS TO SELF-ADMINISTER INSULIN• Insulin injections are administered into thesubcutaneous tissue with the use of special insulinsyringes.STORING INSULIN• Cloudy insulins should be thoroughly mixed by gentlyinverting the vial or rolling it between the hands beforedrawing the solution into a syringe or a pen.• Whether insulin is the short- or long-acting preparation,the vials not in use should be refrigerated and extremesof temperature should be avoided; insulin should not beallowed to freeze and should not be kept in directsunlight or in a hot car.Diabetes Mellitus
  78. 78. TEACHING PATIENTS TO SELF-ADMINISTER INSULINSTORING INSULIN• The insulin vial in use should be kept at roomtemperature to reduce local irritation at the injection site,which may occur when cold insulin is injected.• Patients should be instructed to always have a sparevial of the type or types of insulin they use.• Insulin bottles should also be inspected for flocculation.Diabetes Mellitus
  79. 79. TEACHING PATIENTS TO SELF-ADMINISTER INSULINSELECTING SYRINGES• Syringes must be matched with the insulinconcentration. 1-mL (cc) syringes that hold 100 units 0.5-mL syringes that hold 50 units 0.3-mL syringes that hold 30 unitsDiabetes Mellitus
  80. 80. TEACHING PATIENTS TO SELF-ADMINISTER INSULINPREPARING THE INJECTION: MIXING INSULINS• When rapid- or short-acting insulins are to be givensimultaneously with longer-acting insulins, they areusually mixed together in the same syringe; the longer-acting insulins must be mixed thoroughly before use.Diabetes Mellitus
  81. 81. TEACHING PATIENTS TO SELF-ADMINISTER INSULINWITHDRAWING INSULINSELECTING AND ROTATING THE INJECTION SITE• The four main areas for injection are the abdomen, arms(posterior surface), thighs (anterior surface), and hips.• The speed of absorption is greatest in the abdomen anddecreases progressively in the arm, thigh, and hip.• Systematic rotation of injection sites within an anatomicarea is recommended to prevent localized changes infatty tissue (lipodystrophy).Diabetes Mellitus
  82. 82. Diabetes Mellitus
  83. 83. TEACHING PATIENTS TO SELF-ADMINISTER INSULINPREPARING THE SKIN• Use of alcohol to cleanse the skin is not recommended.INSERTING THE NEEDLE• Injection that is too deep or too shallow may affect therate of absorption of the insulin.• Aspiration is generally not recommended with self-injection of insulin.Diabetes Mellitus
  84. 84. Diabetes Mellitus
  85. 85. Diabetes Mellitus
  86. 86. Diabetes Mellitus
  87. 87. Diabetes Mellitus
  88. 88. Diabetes Mellitus
  89. 89. ACUTE COMPLICATIONS OF DIABETESHYPOGLYCEMIA• Hypoglycemia (abnormally low blood glucose level)occurs when the blood glucose falls to less than 50 to 60mg/dL (2.7 to 3.3 mmol/L).• It can be caused by too much insulin or oralhypoglycemic agents, too little food, or excessivephysical activity.Diabetes Mellitus
  90. 90. CLINICAL MANIFESTATIONS• The clinical manifestations of hypoglycemia may begrouped into two categories: adrenergic symptoms andcentral nervous system symptoms.• In mild hypoglycemia, as the blood glucose level falls,the sympathetic nervous system is stimulated, resultingin a surge of epinephrine and norepinephrine. Thiscauses symptoms such as sweating, tremor,tachycardia, palpitation, nervousness, and hunger.• In moderate hypoglycemia, the fall in blood glucose leveldeprives the brain cells of needed fuel for functioning.Diabetes Mellitus
  91. 91. CLINICAL MANIFESTATIONS• Signs of impaired function of the CNS may includeinability to concentrate, headache, lightheadedness,confusion, memory lapses, numbness of the lips andtongue, slurred speech, impaired coordination,emotional changes, irrational or combative behavior,double vision, and drowsiness.• In severe hypoglycemia, CNS function is so impairedthat the patient needs the assistance of another personfor treatment of hypoglycemia.• Symptoms may include disoriented behavior, seizures,difficulty arousing from sleep, or loss of consciousnessDiabetes Mellitus
  92. 92. MANAGEMENT• The usual recommendation is for 15 g of a fast-actingconcentrated source of carbohydrate such as thefollowing, given orally: Three or four commercially prepared glucose tablets 4 to 6 oz of fruit juice or regular soda 6 to 10 Life Savers or other hard candies 2 to 3 teaspoons of sugar or honey• Once the symptoms resolve, a snack containing proteinand starch is recommended unless the patient plans toeat a regular meal or snack within 30 to 60 minutes.Diabetes Mellitus
  93. 93. INITIATING EMERGENCY MEASURES• For patients who are unconscious and cannot swallow,an injection of glucagon 1 mg can be administered eithersubcutaneously or intramuscularly.• Injectable glucagon is packaged as a powder in 1-mgvials and must be mixed with a diluent before beinginjected.• After injection of glucagon, it may take up to 20 minutesfor the patient to regain consciousness.• A concentrated source of carbohydrate followed by asnack should be given to the patient on awakening toprevent recurrence of hypoglycemia.Diabetes Mellitus
  94. 94. INITIATING EMERGENCY MEASURES• In the hospital or emergency department, patients whoare unconscious or cannot swallow may be treated with25 to 50 mL 50% dextrose in water (D50W)administered intravenously.• The effect is usually seen within minutes.Diabetes Mellitus
  95. 95. DIABETIC KETOACIDOSIS• DKA is caused by an absence or markedly inadequateamount of insulin. This deficit in available insulin resultsin disorders in the metabolism of carbohydrate, protein,and fat.• The three main clinical features of DKA are: Hyperglycemia Dehydration and electrolyte loss AcidosisDiabetes Mellitus
  96. 96. DIABETIC KETOACIDOSISCLINICAL MANIFESTATIONS• The hyperglycemia of DKA leads to polyuria andpolydipsia.• In addition, patients may experience blurred vision,weakness, and headache.• Patients with marked intravascular volume depletionmay have orthostatic hypotension. It may also lead tofrank hypotension with a weak, rapid pulse.• The ketosis and acidosis of DKA lead to GI symptomssuch as anorexia, nausea, vomiting, and abdominalpain.Diabetes Mellitus
  97. 97. DIABETIC KETOACIDOSISCLINICAL MANIFESTATIONS• The abdominal pain and physical findings onexamination can be so severe that they resemble anacute abdominal disorder that requires surgery.• Patients may have acetone breath, which occurs withelevated ketone levels. In addition, hyperventilation (withvery deep, but not labored, respirations) may occur.• Patients may be alert, lethargic, or comatose, most likelydepending on the plasma osmolarity.Diabetes Mellitus
  98. 98. DIABETIC KETOACIDOSISPREVENTION• The most important issue to teach patients is not toeliminate insulin doses when nausea and vomitingoccur.• They should take their usual insulin dose and thenattempt to consume frequent small portions ofcarbohydrates .• Drinking fluids every hour is important to preventdehydration.• Blood glucose and urine ketones must be assessedevery 3 to 4 hours.Diabetes Mellitus
  99. 99. DIABETIC KETOACIDOSISPREVENTION• If the patient cannot take fluids without vomiting, or ifelevated glucose or ketone levels persist, the physicianmust be contacted.Diabetes Mellitus
  100. 100. MEDICAL MANAGEMENTREHYDRATION• In dehydrated patients, rehydration is important formaintaining tissue perfusion.• Patients may need up to 6 to 10 liters of IV fluid toreplace fluid losses caused by polyuria, hyperventilation,diarrhea, and vomiting.• Initially, 0.9% sodium chloride (normal saline) solution isadministered at a rapid rate, usually 0.5 to 1 L per hourfor 2 to 3 hours.Diabetes Mellitus
  101. 101. MEDICAL MANAGEMENTREHYDRATION• Half-strength normal saline (0.45%) solution (also knownas hypotonic saline solution) may be used for patientswith hypertension or hypernatremia or those at risk forheart failure.• Monitoring fluid volume status involves frequentmeasurements of vital signs, lung assessment, andmonitoring intake and output.• Monitoring for signs of fluid overload is especiallyimportant for older patients, those with renal impairment,or those at risk for heart failure.Diabetes Mellitus
  102. 102. MEDICAL MANAGEMENTRESTORING ELECTROLYTES• The major electrolyte of concern during treatment ofDKA is potassium.Some of the factors related to treating DKA that reducethe serum potassium concentration include:• Rehydration, which leads to increased plasma volumeand subsequent decreases in the concentration ofserum potassium.• Insulin administration, which enhances the movement ofpotassium from the extracellular fluid into the cells.Diabetes Mellitus
  103. 103. MEDICAL MANAGEMENTRESTORING ELECTROLYTES• Cautious but timely potassium replacement is vital toavoid dysrhythmias that may occur with hypokalemia.Diabetes Mellitus
  104. 104. MEDICAL MANAGEMENTREVERSING ACIDOSIS• The acidosis that occurs in DKA is reversed with insulin,which inhibits fat breakdown, thereby stopping acidbuildup.• Insulin is usually infused intravenously at a slow,continuous rate (eg, 5 units per hour).• Hourly blood glucose values must be measured.• IV fluid solutions with higher concentrations of glucose,such as normal saline (NS) solution (eg, D5NS orD50.45NS), are administered when blood glucose levelsreach 250 to 300 mg/dL (13.8 to 16.6 mmol/L) to avoidtoo rapid a drop in the blood glucose level.Diabetes Mellitus
  105. 105. MEDICAL MANAGEMENTNURSING MANAGEMENT• Nursing care of the patient with DKA focuses onmonitoring fluid and electrolyte status as well as bloodglucose levels; administering fluids, insulin, and othermedications; and preventing other complications suchas fluid overload.• Urine output is monitored to ensure adequate renalfunction before potassium is administered to preventhyperkalemia.• The electrocardiogram is monitored for dysrhythmiasindicating abnormal potassium levels.Diabetes Mellitus
  106. 106. MEDICAL MANAGEMENTNURSING MANAGEMENT• Vital signs, arterial blood gases, and other clinicalfindings are recorded on a flow sheet.• The nurse documents the patient’s laboratory valuesand the frequent changes in fluids and medications thatare prescribed and monitors the patient’s responses.• The nurse makes sure that there are no signs ofhyperkalemia on the electrocardiogram, the laboratoryvalues of potassium are normal or low and, the patient isurinating (ie, no renal shutdown).Diabetes Mellitus
  107. 107. HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC SYNDROME• HHNS is a serious condition in which hyperosmolarity andhyperglycemia predominate, with alterations of thesensorium.• The basic biochemical defect is lack of effective insulin.• The patient’s persistent hyperglycemia causes osmoticdiuresis, resulting in losses of water and electrolytes.• This condition occurs most often in older people (ages 50to 70) with no known history of diabetes or with mild type 2diabetes.• HHNS can be traced to a precipitating event such as anacute illness, medications that exacerbate hyperglycemia(thiazides), or treatments, such as dialysis.Diabetes Mellitus
  108. 108. • The history includes days to weeks of polyuria withadequate fluid intake.• What distinguishes HHNS from DKA is that ketosis andacidosis do not occur in HHNS partly because ofdifferences in insulin levels.• In DKA no insulin is present, and this promotes thebreakdown of stored glucose, protein, and fat, whichleads to the production of ketone bodies andketoacidosis.Diabetes Mellitus
  109. 109. CLINICAL MANIFESTATIONS• The clinical picture of HHNS is one of hypotension,profound dehydration (dry mucous membranes, poorskin turgor), tachycardia, and variable neurologic signs(eg, alteration of sensorium, seizures, hemiparesis).• The mortality rate ranges from 10% to 40%, usuallyrelated to an underlying illness.Diabetes Mellitus
  110. 110. ASSESSMENT AND DIAGNOSTIC FINDINGS• Diagnostic assessment includes a range of laboratorytests, including blood glucose, electrolytes, BUN,complete blood count, serum osmolality, and arterialblood gas analysis.• The blood glucose level is usually 600 to 1,200 mg/dL,and the osmolality exceeds 350 mOsm/kg.• Electrolyte and BUN levels are consistent with theclinical picture of severe dehydration.• Mental status changes, focal neurologic deficits, andhallucinations are common secondary to the cerebraldehydration that results from extreme hyperosmolality.Diabetes Mellitus
  111. 111. MEDICAL MANAGEMENT• The overall approach to the treatment of HHNS is similarto that of DKA: fluid replacement, correction ofelectrolyte imbalances, and insulin administration.• Close monitoring of volume and electrolyte status isimportant for prevention of fluid overload, heart failure,and cardiac dysrhythmias.• Fluid treatment is started with 0.9% or 0.45% NS,depending on the patient’s sodium level and the severityof volume depletion.• Central venous or arterial pressure monitoring guidesfluid replacement.Diabetes Mellitus
  112. 112. MEDICAL MANAGEMENT• Potassium is added to IV fluids when urinary output isadequate and is guided by continuouselectrocardiographic monitoring and frequent laboratorydeterminations of potassium.• Other therapeutic modalities are determined by theunderlying illness of the patient and the results ofcontinuing clinical and laboratory evaluation.• Treatment is continued until metabolic abnormalities arecorrected and neurologic symptoms clearDiabetes Mellitus
  113. 113. NURSING MANAGEMENT• Nursing care of the patient with HHNS includes closemonitoring of vital signs, fluid status, and laboratoryvalues.• Strategies are implemented to maintain safety andprevent injury related to changes in the patient’ssensorium secondary to HHNS.• Fluid status and urine output are closely monitoredbecause of the high risk for renal failure secondary tosevere dehydration.Diabetes Mellitus
  114. 114. MACROVASCULAR COMPLICATIONS• Blood vessel walls thicken, sclerose, and becomeoccluded by plaque that adheres to the vessel walls.Eventually, blood flow is blocked.• These atherosclerotic changes are indistinguishablefrom atherosclerotic changes in people without diabetes,but they tend to occur more often and at an earlier agein diabetes.• Coronary artery disease, cerebrovascular disease, andperipheral vascular disease are the three main types ofmacrovascular complications that occur more frequentlyin the diabetic population.Diabetes Mellitus
  115. 115. MACROVASCULAR COMPLICATIONS• Myocardial infarction is twice as common in diabeticmen and three times as common in diabetic women.• Coronary artery disease may account for 50% to 60% ofall deaths in patients with diabetes.• One unique feature of coronary artery disease inpatients with diabetes is that the typical ischemicsymptoms may be absent. Thus, patients may notexperience the early warning signs of decreasedcoronary blood flow and may have “silent” myocardialinfarctions.Diabetes Mellitus
  116. 116. MACROVASCULAR COMPLICATIONS• Occlusive changes or the formation of an emboluselsewhere in the vasculature that lodges in a cerebralblood vessel can lead to transient ischemic attacks andstrokes.• Atherosclerotic changes in the large blood vessels of thelower extremities are responsible for the increasedincidence of occlusive peripheral arterial disease inpatients with diabetes.• Signs and symptoms of peripheral vascular diseaseinclude diminished peripheral pulses and intermittentclaudication.Diabetes Mellitus
  117. 117. MACROVASCULAR COMPLICATIONS• The severe form of arterial occlusive disease in thelower extremities is largely responsible for the increasedincidence of gangrene and subsequent amputation indiabetic patients.• Neuropathy and impairments in wound healing also playa role in diabetic foot disease.Diabetes Mellitus
  118. 118. MANAGEMENT• Management of macrovascular complications involvesprevention and treatment of the commonly accepted riskfactors for atherosclerosis.• Diet and exercise are important in managing obesity,hypertension, and hyperlipidemia.• The use of medications to control hypertension andhyperlipidemia may be indicated.• Smoking cessation is essential.• Control of blood glucose levels may reduce triglyceridelevels and can significantly reduce the incidence ofcomplications.Diabetes Mellitus
  119. 119. MICROVASCULAR COMPLICATIONSDIABETIC RETINOPATHY• Diabetic microvascular disease is characterized bycapillary basement membrane thickening.• Two areas affected by these changes are the retina andthe kidneys.• The eye pathology referred to as diabetic retinopathy iscaused by changes in the small blood vessels in theretina.• There are three main stages of retinopathy:nonproliferative retinopathy, preproliferative retinopathy,and proliferative retinopathy.Diabetes Mellitus
  120. 120. MICROVASCULAR COMPLICATIONSDIABETIC RETINOPATHY• Changes in the microvasculature includemicroaneurysms, intraretinal hemorrhage, hardexudates, and focal capillary closure.• Proliferative retinopathy is characterized by theproliferation of new blood vessels growing from theretina into the vitreous.Diabetes Mellitus
  121. 121. Diabetes Mellitus
  122. 122. Diabetes Mellitus
  123. 123. Diabetes Mellitus
  124. 124. CLINICAL MANIFESTATIONS• In nonproliferative and preproliferative retinopathy, blurryvision secondary to macular edema occurs in somepatients, although many patients are asymptomatic.• Even patients with a significant degree of proliferativeretinopathy and some hemorrhaging may not experiencemajor visual changes.• Symptoms indicative of hemorrhaging include floaters orcobwebs in the visual field, or sudden visual changesincluding spotty or hazy vision, or complete loss ofvision.Diabetes Mellitus
  125. 125. ASSESSMENT AND DIAGNOSTIC FINDINGS• Diagnosis is by direct visualization with anophthalmoscope or with a technique known asfluorescein angiography.Diabetes Mellitus
  126. 126. MEDICAL MANAGEMENT• The first focus of management is on primary andsecondary prevention.• Maintenance of blood glucose to a normal or near-normal level in type 1 diabetes through intensive insulintherapy and patient education decreased the risk fordevelopment of retinopathy by 76% when comparedwith conventional therapy in patients without preexistingretinopathy.• For advanced cases, the main treatment of diabeticretinopathy is argon laser photocoagulation.Diabetes Mellitus
  127. 127. Diabetes Mellitus
  128. 128. NURSING MANAGEMENT• Education focuses on prevention through regularophthalmologic examinations and blood glucose controland self-management of eye care regimens.• The effectiveness of early diagnosis and prompttreatment is emphasized in teaching the patient andfamily.• If vision loss occurs, nursing care must also address thepatient’s adjustment to impaired vision and use ofadaptive devices for diabetes self-care as well asactivities of daily living.Diabetes Mellitus
  129. 129. NEPHROPATHY• Nephropathy, or renal disease secondary to diabeticmicrovascular changes in the kidney, is a commoncomplication of diabetes.• About 20% to 30% of people with type 1 or type 2diabetes develop nephropathy, but fewer of those withtype 2 diabetes progress to ESRD.Diabetes Mellitus
  130. 130. CLINICAL MANIFESTATIONS• As renal failure progresses, the catabolism of bothexogenous and endogenous insulin decreases, andfrequent hypoglycemic episodes may result.• The stress of renal disease affects self-esteem, familyrelationships, marital relations, and virtually all aspectsof daily life.• As renal function decreases, the patient commonly hasmultiple-system failure (eg, declining visual acuity,impotence, foot ulcerations, heart failure, and nocturnaldiarrhea).Diabetes Mellitus
  131. 131. ASSESSMENT AND DIAGNOSTIC FINDINGS• Early microalbuminuria may also be discovered in a 24-hour urine sample.• When a urine dipstick test reads consistently positive forsignificant amounts of albumin, serum creatinine andBUN levels are obtained.• Hypertension often develops in patients (both diabeticand nondiabetic) who are in the early stages of renaldisease.Diabetes Mellitus
  132. 132. MEDICAL MANAGEMENT• Control of hypertension (the use of angiotensin-converting enzyme [ACE] inhibitors, such as captopril,because control of hypertension may also decrease ordelay the onset of early proteinuria)• Prevention or vigorous treatment of urinary tractinfections• Avoidance of nephrotoxic substances• Adjustment of medications as renal function changes• Low-sodium diet• Low-protein dietDiabetes Mellitus
  133. 133. DIABETIC NEUROPATHIES• Diabetic neuropathy refers to a group of diseases thataffect all types of nerves, including peripheral(sensorimotor), autonomic, and spinal nerves.• The prevalence increases with the age of the patientand the duration of the disease and may be as high as50% in patients who have had diabetes for 25 years.• Capillary basement membrane thickening and capillaryclosure may be present.• There may be demyelinization of the nerves, which isthought to be related to hyperglycemia. Nerveconduction is disrupted when there are aberrations ofthe myelin sheaths.Diabetes Mellitus
  134. 134. DIABETIC NEUROPATHIES• The two most common types of diabetic neuropathy aresensorimotor polyneuropathy and autonomicneuropathy.• Cranial mononeuropathies, for example, those affectingthe oculomotor nerve, also occur in diabetes, especiallyamong the elderly.• Sensorimotor polyneuropathy is a diabetic neuropathyalso called peripheral neuropathy. It most commonlyaffects the distal portions of the nerves, especially thenerves of the lower extremities.It affects both sides ofthe body symmetrically and may spread in a proximaldirection.Diabetes Mellitus
  135. 135. PERIPHERAL NEUROPATHYCLINICAL MANIFESTATIONS• Initial symptoms include paresthesias (prickling, tingling,or heightened sensation) and burning sensations(especially at night).• As the neuropathy progresses, the feet become numb.• In addition, a decrease in proprioception and adecreased sensation of light touch may lead to anunsteady gait.• Decreased sensations of pain and temperature placepatients with neuropathy at increased risk for injury andundetected foot infections.Diabetes Mellitus
  136. 136. PERIPHERAL NEUROPATHYCLINICAL MANIFESTATIONS• Deformities of the foot may also occur, with neuropathy-related joint changes producing Charcot joints. Thesejoint deformities result from the abnormal weightdistribution on joints due to lack of proprioception.• On physical examination, a decrease in deep tendonreflexes and vibratory sensation is found.Diabetes Mellitus
  137. 137. Diabetes Mellitus
  138. 138. Diabetes Mellitus
  139. 139. PERIPHERAL NEUROPATHYMANAGEMENT• Intensive insulin therapy and control of blood glucoselevels delay the onset and slow the progression ofneuropathy.• Various approaches to pain management can be tried.These include analgesics (preferably nonopioid); tricyclicantidepressants; phenytoin, carbamazepine, orgabapentin (antiseizure medications); mexiletine (anantiarrhythmic); or transcutaneous electrical nervestimulation (TENS).Diabetes Mellitus
  140. 140. PERIPHERAL NEUROPATHYMANAGEMENT• The topical medication capsaicin (Axscain) also hasbeen shown in preliminary reports to decrease lower-extremity neuropathic pain.Diabetes Mellitus
  141. 141. Diabetes Mellitus
  142. 142. AUTONOMIC NEUROPATHIES• Neuropathy of the autonomic nervous system results ina broad range of dysfunctions affecting almost everyorgan system of the body.• Three manifestations of autonomic neuropathy arerelated to the cardiac, GI, and renal systems• Cardiovascular symptoms range from fixed, slightlytachycardic heart rate; orthostatic hypotension; andsilent, or painless, myocardial ischemia and infarction.• Delayed gastric emptying may occur with the typicalsymptoms of early satiety, bloating, nausea, andvomiting.Diabetes Mellitus
  143. 143. AUTONOMIC NEUROPATHIES• Urinary retention, a decreased sensation of bladderfullness, and other urinary symptoms of neurogenicbladder result from autonomic neuropathy.• Patients with a neurogenic bladder are predisposed todeveloping urinary tract infections due to inability tocompletely empty the bladder.Diabetes Mellitus
  144. 144. AUTONOMIC NEUROPATHIESHYPOGLYCEMIC UNAWARENESS• Autonomic neuropathy of the adrenal medulla isresponsible for diminished or absent adrenergicsymptoms of hypoglycemia.• Patients may report that they no longer feel the typicalshakiness, sweating, nervousness, and palpitationsassociated with hypoglycemia.SUDOMOTOR NEUROPATHY• This neuropathic condition refers to a decrease orabsence of sweating (anhidrosis) of the extremities, witha compensatory increase in upper body sweating.Diabetes Mellitus
  145. 145. AUTONOMIC NEUROPATHIES• Dryness of the feet increases the risk for thedevelopment of foot ulcers.SEXUAL DYSFUNCTION• Sexual dysfunction, especially impotence in men, is acomplication of diabetes.• Reduced vaginal lubrication has been mentioned as apossible neuropathic effect; other possible changes insexual function in women with diabetes includedecreased libido and lack of orgasm.• Vaginal infection, increased in incidence in women withdiabetes, may be associated with decreased lubricationand vaginal itching and tenderness.Diabetes Mellitus
  146. 146. MANAGEMENT• There is no treatment for painless cardiac ischemia, andthe prognosis is poor. Detection, however, is importantso that education about avoiding strenuous exercise canbe provided.• Orthostatic hypotension may respond to a diet high insodium, the discontinuation of medications that impedeautonomic nervous system responses, the use ofsympathomimetics and other agents (eg, caffeine) thatstimulate an autonomic response, and the use of lower-body elastic garments that maximize venous return andprevent pooling of blood in the extremities.Diabetes Mellitus
  147. 147. MANAGEMENT• Treatment of delayed gastric emptying includes a low-fatdiet, frequent small meals, close blood glucose control,and use of agents that increase gastric motility (eg,metoclopramide, bethanechol).• Treatment of diabetic diarrhea may include bulkforminglaxatives or antidiarrheal agents.• Constipation is treated with a high-fiber diet andadequate hydration; medications, laxatives, and enemasmay be necessary when constipation is severe.• Treatment of sudomotor dysfunction focuses oneducation about skin care and heat intolerance.Diabetes Mellitus
  148. 148. FOOT AND LEG PROBLEMS• From 50% to 75% of lower extremity amputations areperformed on people with diabetes.Increased risk of foot infections include:• Neuropathy: Sensory neuropathy leads to loss of painand pressure sensation, and autonomic neuropathyleads to increased dryness and fissuring of the skin.Motor neuropathy results in muscular atrophy, whichmay lead to changes in the shape of the foot.• Peripheral vascular disease: Poor circulation of thelower extremities contributes to poor wound healing andthe development of gangrene.Diabetes Mellitus
  149. 149. FOOT AND LEG PROBLEMS• Immunocompromise: Hyperglycemia impairs the abilityof specialized leukocytes to destroy bacteria. Thus, inpoorly controlled diabetes, there is a lowered resistanceto certain infections.Diabetes Mellitus
  150. 150. Diabetes Mellitus
  151. 151. Diabetes Mellitus
  152. 152. FOOT AND LEG PROBLEMS• The typical sequence of events in the development of adiabetic foot ulcer begins with a soft tissue injury of thefoot, formation of a fissure between the toes or in anarea of dry skin, or formation of a callus.• Injuries are not felt by the patient with an insensitive footand may be thermal, chemical, or traumatic.Diabetes Mellitus
  153. 153. MANAGEMENT• Teaching patients proper foot care is a nursingintervention that can prevent costly, painful, anddebilitating complications.• Preventive foot care begins with careful dailyassessment of the feet.• The feet must be inspected on a daily basis for anyredness, blisters, fissures, calluses, ulcerations,changes in skin temperature, and the development offoot deformities (ie, hammer toes, bunions).• The interior surfaces of shoes should be inspected forany rough spots or foreign objects.Diabetes Mellitus
  154. 154. Diabetes Mellitus
  155. 155. Diabetes Mellitus
  156. 156. Diabetes Mellitus
  157. 157. Diabetes Mellitus
  158. 158. Diabetes Mellitus
  159. 159. MANAGEMENT• In addition to the daily visual and manual inspection ofthe feet, the feet should be examined during everyhealth care visit or at least once per year by a podiatrist,physician, or nurse.• Patients with neuropathy should also undergo evaluationof neurologic status using a monofilament device by anexperienced examinerAdditional aspects of preventive foot care that are taughtto the patient and family include the following:• Properly bathing, drying, and lubricating the feet, takingcare not to allow moisture (water or lotion) toaccumulate between the toesDiabetes Mellitus
  160. 160. Diabetes Mellitus
  161. 161. MANAGEMENT• Wearing closed-toe shoes that fit well. Podiatrists canprovide patients with inserts (orthotics) to removepressure from pressure points on the foot.• High-risk behaviors should be avoided, such as walkingbarefoot, using heating pads on the feet, wearing open-toed shoes, soaking the feet, and shaving calluses.• Trimming toenails straight across and filing sharpcorners to follow the contour of the toe• Reducing risk factors, such as smoking and elevatedblood lipids, that contribute to peripheral vasculardiseaseDiabetes Mellitus
  162. 162. MANAGEMENT• Avoiding home remedies or over-the-counter agents orselfmedicating to treat foot problems• Blood glucose control is important for avoidingdecreased resistance to infections and for preventingdiabetic neuropathy.• The patient may be referred by the physician to a woundcare center for managing persistent wounds of the feetor legs.Diabetes Mellitus
  163. 163. …although the days are busy and the workload isalways growing, there are still those specialmoments when someone says or does somethingand you know you’ve made a difference insomeone’s life.That’s why I became a nurse.- Diane McKenty
  164. 164. 1. The non-insulin-dependent diabetic who isobese is best controlled by weight lossbecause obesitya. Reduces the number of insulin receptors.b. Causes pancreatic islet cell exhaustion.c. Reduces pancreatic insulin production.d. Reduces insulin binding at receptor sites.Exam 4
  165. 165. 2. For a client with the diagnosis of acutepancreatitis, the nurse would plan for whichcritical component of his care?a. Testing for Homans sign.b. Measuring the abdominal girth.c. Straining the urine.d. Performing a glucometer test.Exam 4
  166. 166. 3. A person with a diagnosis of adult diabetes,type 2, should understand the symptoms of ahyperglycemic reaction. The nurse will knowthis client understands if she says thesesymptoms area. Weight gain, normal breath, and thirst.b. Nausea, vomiting, and diarrhea.c. Thirst, polyuria, and decreased appetite.d. Flushed cheeks, acetone breath, andincreased thirst.Exam 4
  167. 167. 4. A client has a bile duct obstruction and isjaundiced. Which intervention will be mosteffective in controlling the itching associatedwith his jaundice?a. Keep the clients nails clean and short.b. Provide tepid water for bathing.c. Maintain the clients room temperature at72 to 75°F.d. Use alcohol for back rubs.Exam 4
  168. 168. 5. A female client had a laparoscopiccholecystectomy this morning. She is nowcomplaining of right shoulder pain. The nursewould explain to the client this symptom isa. Unusual and will be reported to thesurgeon.b. Common following this operation.c. Expected after general anesthesia.d. Indicative of a need to use the incentivespirometer.Exam 4
  169. 169. 6. The nurse explains to a client who has just receivedthe diagnosis of type 2 non-insulin-dependentdiabetes mellitus (NIDDM) that sulfonylureas, onegroup of oral hypoglycemic agents, act bya. Stimulating the pancreas to produce or releaseinsulin.b. Making the insulin that is produced moreavailable for use.c. Altering both fat and protein metabolism.d. Lowering the blood sugar by facilitating theuptake and utilization of glucose.Exam 4
  170. 170. 7. A client with a history of cholecystitis is now beingadmitted to the hospital for possible surgicalintervention. The orders include NPO, IV therapy,and bedrest. In addition to assessing for nausea,vomiting and anorexia, the nurse should observe forpaina. In the right lower quadrant.b. Radiating to the left shoulder.c. After ingesting food.d. In the right upper quadrant.Exam 4
  171. 171. 8. When a client is in liver failure, which of thefollowing behavioral changes is the mostimportant assessment to report?a. Nausea.b. Fatigue.c. Shortness of breath.d. Lethargy.Exam 4
  172. 172. 9. A nursing assessment for initial signs ofhypoglycemia will includea. Frequent urination, flushed face, pleuralfriction rub.b. Weakness, lassitude, irregular pulse,dilated pupils.c. Pallor, blurred vision, weakness, behavioralchanges.d. Abdominal pain, diminished deep tendonreflexes, double vision.Exam 4
  173. 173. 10. A client has the diagnosis of diabetes. His physicianhas ordered short- and long-acting insulin. Whenadministering two types of insulin, the nurse woulda. Draw up in two separate syringes, then combineinto one syringe.b. Withdraw the long-acting insulin into the syringebefore the short-acting insulin.c. Withdraw the short-acting insulin into the syringebefore the long-acting insulin.d. Withdraw long-acting insulin, inject air intoregular insulin, and withdraw insulin.Exam 4
  174. 174. 11. Following a liver biopsy, the highest priorityassessment of the clients condition is tocheck fora. Uneven respiratory pattern.b. Pulmonary edema.c. Hemorrhage.d. Pain.Exam 4
  175. 175. 12. The assessment finding that should bereported immediately should it develop in theclient with acute pancreatitis isa. Nausea and vomiting.b. Decreased bowel sounds.c. Abdominal pain.d. Shortness of breath.Exam 4
  176. 176. 13. Peritoneal reaction to acute pancreatitisresults in a shift of fluid from the vascularspace into the peritoneal cavity. If thisoccurs, the nurse would evaluate fora. Decreased serum albumin.b. Oliguria.c. Abdominal pain.d. Peritonitis.Exam 4
  177. 177. 14. The nurse is teaching a diabetic client to monitorher blood glucose using a glucometer. The nursewill know the client is competent in performing herfinger-stick to obtain blood when shea. Avoids using the thumbs as puncture sites.b. Uses the side of a fingertip as the puncturesite.c. Uses the ball of a finger as the puncture site.d. Avoids using the fingers of her dominant handas puncture sites.Exam 4
  178. 178. 15. The nurse analyzes the results of the bloodchemistry tests done on a client with acutepancreatitis. Which of the following results wouldthe nurse expect to find?a. Low glucose.b. Elevated amylase.c. Elevated creatinine.d. Low alkaline phosphatase.Exam 4
  179. 179. 16. Which instruction about insulin administrationshould a nurse give to a client?a. “Always follow the same order when drawingthe different insulin into the syringe.”b. “Shake the vials before drawing the insulin.”c. “Store unopened vials in the freezer attemperatures well below freezing.”d. “Discard the intermediate acting insulin if itappears to be cloudy.”Exam 4
  180. 180. 17. A client with advanced cirrhosis has a prothrombintime (PT) of 15 secsonds, compared with acontrolled time of 11 seconds. The nurse expectsto administer?a. Spironolactone (Aldactone)b. Phytonadione (Mephyton)c. Furosemide (Lasix)d. Warfarin (Coumadin)Exam 4
  181. 181. 18. Which statement indicates that a client withdiabetes understands proper foot care?a. “I’ll schedule an appointment with myphysician if my foot starts to ache.”b. “I’ll rotate insulin injection sites from my leftfoot to my right foot.”c. “I’ll go barefoot around the house to avoidpressure areas on my feet.”d. “I’ll wear cotton socks with well fitting shoes.”Exam 4
  182. 182. 19. A physician orders spironolactone (Aldactone), 50mg per orem four times a day, for a client withfluid retention caused by cirrhosis. Which findingindicates that the drug is having its therapeuticeffect?a. Serum potassium level of 3.5 mEq/Lb. Loss of 2.2 lbs (1 kg) in 24 hoursc. Serum sodium level of 135 mEq/Ld. Blood pH of 7.25Exam 4
  183. 183. 20. After undergoing a liver biopsy, a client shouldbe placed in what position?a. Semi-Fowler’s positionb. Right lateral decubitus positionc. Supine positiond. Prone positionExam 4