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NurseReview.Org Diabetes Mellitus NurseReview.Org Diabetes Mellitus Presentation Transcript

  • Nurse Licensure Examination Review Diabetes Mellitus
  • Diabetes Mellitus
    • A group of metabolic diseases characterized by elevated levels of glucose in the blood resulting from defects in insulin secretion, insulin action, insulin receptors or any combination of conditions.
  • Diabetes Mellitus
    • A chronic disorder of impaired glucose metabolism, protein and fat metabolism
  • Diabetes Mellitus
    • BASIC PATHOLOGY : Insulin problem (deficiency or impaired action)
  • Diabetes Mellitus
    • Insulin is a hormone secreted by the BETA cells of the pancreas
    • Stimulus of insulin- HYPERGLYCEMIA
  • Diabetes Mellitus
    • Action of insulin: it promotes entry of Glucose into the body cells by binding to the insulin receptor in the cell membrane
  • INSULIN : Physiology
    • Insulin Metabolic Functions:
    • 1. Transports and metabolizes GLUCOSE
    • 2. Promotes GLYCOGENESIS
    • 3. Promotes GLYCOLYSIS
    • 4. Enhances LIPOGENESIS
    • 5. Accelerates PROTEIN SYNTHESIS
  • Diabetes Mellitus
    • RISK FACTORS for Diabetes Mellitus
    • 1. Family History of diabetes
    • 2. Obesity
    • 3. Race/Ethnicity
  • Diabetes Mellitus
    • RISK FACTORS for Diabetes Mellitus
    • 4. Age of more than 45
    • 5. Previously unidentified IFG/IGT
    • 6. Hypertension
  • Diabetes Mellitus
    • RISK FACTORS for Diabetes Mellitus
    • 7. Hyperlipidemia
    • 8. History of Gestational Diabetes Mellitus
  • Diabetes Mellitus
    • CLASSIFICATION OF DM
    • 1. Type 1 DM
      • Insulin dependent Diabetes Mellitus
    • 2. Type 2 DM
      • Non-insulin dependent Diabetes Mellitus
    • 3. Gestational DM
      • Diabetes Mellitus diagnosed during pregnancy
    • 4. DM associated with other conditions or syndromes
  • Diabetes Mellitus
    • CLASSIFICATION OF DM
    • 1. Type 1 DM
      • Insulin dependent Diabetes Mellitus
  • Diabetes Mellitus
    • CLASSIFICATION OF DM
    • 2. Type 2 DM
      • Non-insulin dependent Diabetes Mellitus
  • Diabetes Mellitus
    • CLASSIFICATION OF DM
    • 3. Gestational DM
      • Diabetes Mellitus diagnosed during pregnancy
  • Diabetes Mellitus
    • CLASSIFICATION OF DM
    • 4. DM associated with other conditions or syndromes
  • Diabetes Mellitus
    • Other types of DM
    • 1. Impaired Glucose Tolerance
    • 2. Impaired Fasting Glucose
    • 3. Pre-diabetes
  • TYPE 1- Diabetes Mellitus
    • This type of DM is characterized by the destruction of the pancreatic beta cells
  • TYPE 1- Diabetes Mellitus
    • Etiology:
    • 1. Genetic susceptibility- HLA DR3 and DR4
    • 2. Autoimmune response
    • 3. Toxins, unidentified viruses and environmental factors
  • TYPE 1- Diabetes Mellitus
    • PATHOPHYSIOLOGY
    • Destruction of BETA cells  decreased insulin production  uncontrolled glucose production by the liver  hyperglycemia  signs and symptoms
  • TYPE 1- Diabetes Mellitus
    • PATHOPHYSIOLOGY
    • CLASSIC P’s
    • Polyuria
    • Polydipsia
    • Polyphagia
  • TYPE 2- Diabetes Mellitus
    • A type of DM characterized by insulin resistance and impaired insulin production
  • TYPE 2- Diabetes Mellitus
    • Etiology:
    • 1. Unknown
    • 2. Probably genetic and obesity
  • TYPE 2- Diabetes Mellitus
    • PATHOPHYSIOLOGY
    • Decreased sensitivity of insulin receptor to insulin  less uptake of glucose  HYPERGLYCEMIA
  • TYPE 2- Diabetes Mellitus
    • PATHOPHYSIOLOGY
    • Decreased insulin production  diminished insulin action  hyperglycemia  signs and symptoms
  • TYPE 2- Diabetes Mellitus
    • PATHOPHYSIOLOGY
    • BUT (+) insulin in small amount  prevent breakdown of fats  DKA is unusual
  • GESTATIONAL Diabetes Mellitus
    • Any degree of glucose intolerance with its onset during pregnancy
    • Usually detected between 24-28 th week gestation
  • GESTATIONAL Diabetes Mellitus
    • Blood glucose returns to normal after delivery of the infant
    • NEVER administer ORAL HYPOGLYCEMIC AGENTS to PREGNANT MOTHERS!
  • Diabetes Mellitus
    • ASSESSMENT FINDINGS
    • 1. Classic 3 P’s
    • 2. Fatigue
    • 3. Body weakness
  • Diabetes Mellitus
    • ASSESSMENT FINDINGS
    • 4. Visual changes
    • 5. Slow wound healing
    • 6. Recurrent skin and mucus membrane infections
  • Diabetes Mellitus
    • DIAGNOSTIC TESTS
    • 1. FBS- > 126
    • 2. RBS- >200
    • 3. OGTT- > 200
  • Diabetes Mellitus
    • DIAGNOSTIC TESTS
    • 4. HgbA1- for monitoring!!
    • 5. Urine glucose
    • 6. Urine ketones
  • Diabetes Mellitus
    • DIAGNOSTIC CRITERIA
    • 1. FBS equal to or greater than 126 mg/dL (7.0mmol/L)
      • (Normal 8 hour FBS- 80-109 mg/dL)
  • Diabetes Mellitus
    • DIAGNOSTIC CRITERIA
    • 2. OGTT value 1 and 2 hours post-prandial equal to or greater than 200 mg/dL
    • Normal OGTT 1 and 2 hours post-prandial- is
      • 140 mg/dL
  • Diabetes Mellitus
    • DIAGNOSTIC CRITERIA
    • 3. RBS of equal to or greater than 200 mg/dL PLUS the 3 P’s
  • Diabetes Mellitus
    • NURSING MANAGEMENT OF DM
    • The main goal is to NORMALIZE insulin activity and blood glucose level by:
  • Diabetes Mellitus
    • NURSING MANAGEMENT OF DM
    • 1. Nutritional modification
    • 2. Regular Exercise
    • 3. Regular Glucose Monitoring
    • 4. Drug therapy
    • 5. Client Education
  • Diabetes Mellitus
    • The Patient with DM
    • HISTORY
      • Symptoms and characteristics
    • PHYSICAL EXAMINATION
      • VS, BMI, Fundoscopy, Neuro
    • LABORATORY EXAMINATION
      • FBS, RBS, HgbA1c, lipid profile, ECG, UA
    • REFERRALS
      • Ophthalmologist, Podiatrist, Dietician, etc..
  • Diabetes Mellitus
    • The Patient with DM
    • HISTORY
      • Symptoms and characteristics
    • PHYSICAL EXAMINATION
      • VS, BMI, Fundoscopy, and Neuro assessment
  • Diabetes Mellitus
    • The Patient with DM
    • LABORATORY EXAMINATION
      • FBS, RBS, HgbA1c, lipid profile, ECG, and Urinalysis
    • REFERRALS
      • Ophthalmologist, Podiatrist, Dietician, etc..
  • DM Nutritional management
  • Diabetes Mellitus
    • NUTRITIONAL MANAGEMENT
    • 1.Review the patient’s diet history to identify eating habits and lifestyle
    • 2. Coordinate with the dietician in meal planning for weight loss
  • Diabetes Mellitus
    • NUTRITIONAL MANAGEMENT
    • 3. Plan for the caloric intake distributed as follows- CHO 50-60%; Fats 20-30%; and Proteins 10-20%
    • 4. Advise moderation in alcohol intake
    • 5. Using artificial sweeteners is acceptable
  • DM Exercise management
  • Diabetes Mellitus
    • EXERCISE Management
    • 1. Teach that exercise can lower the blood glucose level
    • 2. Diabetics must first control the glucose level before initiating exercise programs.
  • Diabetes Mellitus
    • EXERCISE Management
    • 3. Offer extra food /calories before engaging in exercise
    • 4. Offer snacks at the end of the exercise period if patient is on insulin treatment.
  • Diabetes Mellitus
    • EXERCISE Management
    • 5. Advise that exercise should be done at the same time every day, preferably when blood glucose levels are at their peak
  • Diabetes Mellitus
    • EXERCISE Management
    • 6. Regular exercise, not sporadic exercise, should be encouraged.
    • 7. For most patient, WALKING is the safe and beneficial form of exercise
  • Glucose Self Monitoring
  • Diabetes Mellitus
    • GLUCOSE MONITORING
    • Self-monitoring of blood glucose (SMBG) enables the patient to adjust the treatment regimen to obtain optimal glucose control
  • Diabetes Mellitus
    • GLUCOSE MONITORING
    • Most common method involves obtaining a drop of capillary blood applied to a test strip.
    • The usual recommended frequency is TWO-FOUR times a day.
  • Diabetes Mellitus
    • When is it done?
    • At the peak action time of the medication to evaluate the need for adjustments.
    • To evaluate BASAL insulin  test before meals
  • Diabetes Mellitus
    • When is it done?
    • To titrate bolus or regular and lispro  test 2 hours after meals.
    • To evaluate the glucose level of those taking ORAL hypoglycemics  test before and two hours after meals.
  • Diabetes Mellitus Monitoring therapy
    • Testing the glycosylated hemoglobin (HbA1c)
    • This glycosylated hemoglobin refers to the blood test that reflects the average blood glucose over a period of TWO to THREE months.
  • Diabetes Mellitus Monitoring therapy
    • Normal value is 4 to 6 %
    • No patient preparation is needed for this testing
    • Done to monitor therapy
  • Diabetes Mellitus
    • Urine testing for glucose
      • Benedict’s test
  • Diabetes Mellitus
    • Urine testing for ketones
      • Ketones are by-products of fat breakdown
  • Diabetes Mellitus
    • Urine testing for ketones
      • This is performed whenever TYPE 1 DM have glucosuria or persistent elevation of blood glucose, during illness, and in gestational diabetes
  • DM Drug therapy
  • Diabetes Mellitus
    • DRUG THERAPY and MANAGEMENT
    • Usually, this type of management is employed if diet modification and exercise cannot control the blood glucose level.
  • Diabetes Mellitus
    • DRUG THERAPY and MANAGEMENT
    • Because the patient with TYPE 1 DM cannot produce insulin, exogenous insulin must be administered for life.
  • Diabetes Mellitus
    • DRUG THERAPY and MANAGEMENT
    • TYPE 2 DM may have decreased insulin production, ORAL agents that stimulate insulin production are usually employed.
  • Diabetes Mellitus
    • PHARMACOLOGIC INSULIN
    • This may be grouped into several categories according to:
    • 1. Source- Human, pig, or cow
    • 2. Onset of action- Rapid-acting, short-acting, intermediate-acting, long-acting and very long acting
  • Diabetes Mellitus
    • PHARMACOLOGIC INSULIN
    • This may be grouped into several categories according to:
    • 3. Pure or mixed concentration
    • 4. Manufacturer of drug
  • Diabetes Mellitus
    • GENERALITIES
    • 1. Human insulin preparations have a shorter duration of action than animal source
  • Diabetes Mellitus
    • GENERALITIES
    • 2. Animal sources of insulin have animal proteins that may trigger allergic reaction and they may stimulate antibody production that may bind the insulin, slowing the action
  • Diabetes Mellitus
    • 3. ONLY Regular insulin can be used INTRAVENOUSLY!
  • Diabetes Mellitus
    • 4. Insulin are measured in INTERNATIONAL UNITS or “iu”
    • 5. There is a specified insulin injection calibrated in units
  • Diabetes Mellitus
    • RAPID ACTING INSULIN
    • Lispro (Humalog) and Insulin Aspart (Novolog)
    • Produces a more rapid effect and with a shorter duration than any other insulin preparation
  • Diabetes Mellitus
    • RAPID ACTING INSULIN
    • ONSET- 5-15 minutes
    • PEAK- 1 hour
    • DURATION- 3 hours
    • Instruct patient to eat within 5 to 15 minutes after injection
  • Diabetes Mellitus
    • REGULAR INSULIN
    • Also called Short-acting insulin
    • “ R”
    • Usually Clear solution administered 30 minutes before a meal
  • Diabetes Mellitus
    • REGULAR INSULIN
    • ONSET- 30 minutes to 1 hour
    • PEAK- 2 to 3 hours
    • DURATION- 4 to 6 hours
  • Diabetes Mellitus
    • INTERMEDIATE ACTING INSULIN
    • Called “NPH” or “LENTE”
    • Appears white and cloudy
  • Diabetes Mellitus
    • INTERMEDIATE ACTING INSULIN
    • ONSET- 2-4 hours
    • PEAK- 4 to 6-12 hours
    • DURATION- 16-20 hours
  • Diabetes Mellitus
    • LONG- ACTING INSULIN
    • “ UltraLENTE”
    • Referred to as “peakless” insulin
  • Diabetes Mellitus
    • LONG- ACTING INSULIN
    • ONSET- 6-8 hours
    • PEAK- 12-16 hours
    • DURATION- 20-30 hours
  • Diabetes Mellitus
    • HEALTH TEACHING
    • Regarding Insulin SELF- Administration
    • 1. Insulin is administered at home subcutaneously
  • Diabetes Mellitus
    • HEALTH TEACHING Regarding Insulin SELF- Administration
    • 2. Cloudy insulin should be thoroughly mixed by gently inverting the vial or ROLLING between the hands
  • Diabetes Mellitus
    • HEALTH TEACHING Regarding Insulin SELF- Administration
    • 3. Insulin NOT IN USE should be stored in the refrigerator, BUT avoid freezing/extreme temperature
  • Diabetes Mellitus
    • 4. Insulin IN USE should be kept at room temperature to reduce local irritation at the injection site
  • Diabetes Mellitus
    • 5. INSULIN may be kept at room temperature up to 1 month
  • Diabetes Mellitus
    • 6. Select syringes that match the insulin concentration.
      • U-100 means 100 units per mL
  • Diabetes Mellitus
    • 7. Instruct the client to draw up the REGULAR (clear) Insulin FIRST before drawing the intermediate acting (cloudy) insulin
  • Diabetes Mellitus
    • 8. Pre-filled syringes can be prepared and should be kept in the refrigerator with the needle in the UPRIGHT position to avoid clogging the needle
  • Diabetes Mellitus
    • 9. The four main areas for insulin injection are- ABDOMEN, UPPER ARMS, THIGHS and HIPS
  •  
  • Diabetes Mellitus
    • Insulin is absorbed fastest in the abdomen and slowest in the hips
    • Instruct the client to rotate the areas of injection, but exhaust all available sites in one area first before moving into another area.
  • Diabetes Mellitus
    • 10. Alcohol may not be used to cleanse the skin
    • 11. Utilize the subcutaneous injection technique- commonly, a 45-90 degree angle.
  • Diabetes Mellitus
    • 12. No need to instruct for aspirating the needle
    • 13. Properly discard the syringe after use.
  • Diabetes Mellitus
    • T-I-E
    • T est blood  I nject insulin  E at food
  • Diabetes Mellitus
    • COMPLICATIONS OF INSULIN THERAPY
    • 1. Local allergic reactions
    • Redness, swelling, tenderness and induration appearing 1-2 hours after injection
    • Usually occurs in the beginning stage of therapy
  • Diabetes Mellitus
    • COMPLICATIONS OF INSULIN THERAPY
    • 1. Local allergic reactions
    • Disappears with continued use
    • Antihistamine can be given 1 hour before injection time
    • Porcine and bovine insulin preparations have a higher tendency to produce this reaction.
    • 2. SYSTEMIC ALLERGIC REACTIONS
    • Very rare
    • Generalized urticaria is the manifestation
    • Treatment is desensitization
    Diabetes Mellitus
    • COMPLICATIONS OF INSULIN THERAPY
    • 3. INSULIN DYSTROPHY
    • A localized reaction in the form of lipo atrophy or lipo hypertrophy
    Diabetes Mellitus
    • Lipoatrophy- loss of subcutaneous fat usually caused by the utilization of animal insulin
    Diabetes Mellitus
    • Lipohypertrophy- development of fibrofatty masses, usually caused by repeated use of injection site
    Diabetes Mellitus
    • 4. INSULIN RESISTANCE
    • Most commonly caused by OBESITY
    • Defined as daily insulin requirement of more than 200 units
    • Management- Steroids and use of more concentrated insulin
    Diabetes Mellitus
    • 5. MORNING HYPERGLYCEMIA
    • Elevated blood sugar upon arising in the morning
    • Caused by insufficient level of insulin
      • DAWN phenomenon
      • SOMOGYI effect
      • INSULIN WANING
    Diabetes Mellitus
  • Diabetes Mellitus
    • DAWN PHENOMENON
    • Relatively normal blood glucose until about 3 am, when the glucose level begins to RISE
    • Results from the nightly surges of GROWTH HORMONE secretion
    • Management: Bedtime injection of NPH
  • Diabetes Mellitus
    • SOMOGYI EFFECT
    • Normal or elevated blood glucose at bedtime, decrease blood glucose at 2-3 am due to hypoglycemic levels and a subsequent increase in blood glucose (rebound hypergycemia)
  • Diabetes Mellitus
    • SOMOGYI EFFECT
    • Nocturnal hypoglycemia followed by rebound hyperglycemia
  • Diabetes Mellitus
    • SOMOGYI EFFECT
    • Due to the production of counter regulatory hormones- glucagon. cortisol and epinephrine
    • Management- decrease evening dose of NPH or increase bedtime snack
  • Diabetes Mellitus
    • INSULIN WANING
    • Progressive rise in blood glucose from bedtime to morning
    • Seen when the NPH evening dose is administered before dinner
    • Management: Move the insulin injection to bedtime
  • Diabetes Mellitus
    • ORAL HYPOGLYCEMIC AGENTS
    • These may be effective when used in TYPE 2 DM that cannot be treated with diet and exercise
    • These are NEVER used in pregnancy!
  • Diabetes Mellitus
    • ORAL HYPOGLYCEMIC AGENTS
    • There are several agents:
      • Sulfonylureas
      • Biguanides
      • Alpha-glucosidase inhibitors
      • Thiazolidinediones
      • Meglitinides
  • Diabetes Mellitus
    • SULFONYLUREAS
    • MOA- stimulates the beta cells of the pancreas to secrete insulin
    • Classified as to generations- first and second generations
  • Diabetes Mellitus
    • SULFONYLUREAS
    • FIRST GENERATION- Acetoheximide, Chlorpropamide, Tolazamide and Tolbutamide
    • SECOND GENERATION- Glipizide, Glyburide, Glibenclamide, Glimepiride
  • Diabetes Mellitus: Sulfonylureas
    • The most common side –effects of these medications are Gastro-intestinal upset and dermatologic reactions.
    • HYPOGLYCEMIA is also a very important side-effect
  • Diabetes Mellitus: Sulfonylureas
    • Chlorpropamide has a very long duration of action. This also produces a disulfiram-like reaction when taken with alcohol
    • Second generation drugs have shorter duration with metabolism in the kidney and liver and are the choice for elderly patients
  • Diabetes Mellitus
    • BIGUANIDES
    • MOA- Facilitate the action of insulin on the peripheral receptors
    • These can only be used in the presence of insulin
  • Diabetes Mellitus
    • BIGUANIDES= “ formin”
    • They have no effect on the beta cells of the pancreas
    • Metformin (Glucophage) and Phenformin are examples
  • Diabetes Mellitus: Biguanides
    • The most important side effect is LACTIC ACIDOSIS!
    • These are not given to patient with renal impairment
  • Diabetes Mellitus: Biguanides
    • These drugs are usually given with a sulfonylurea to enhance the glucose-lowering effect more than the use of each drug individually
  • Diabetes Mellitus
    • ALPHA-GLUCOSIDASE INHIBITORS
    • MOA- Delay the absorption of glucose in the GIT
    • Result is a lower post-prandial blood glucose level
    • They do not affect insulin secretion or action!
    • Side-effect: DIARRHEA and FLATULENCE
  • Diabetes Mellitus
    • Examples of AGI are Acarbose and Miglitol
    • They are not absorbed systemically and are very safe
    • They can be used alone or in combination with other OHA
  • Diabetes Mellitus
    • Side-effect if used with other drug is HYPOGLYCEMIA
    • Note that sucrose absorption is impaired and IV glucose is the therapy for the hypoglycemia
  • Diabetes Mellitus
    • THIAZOLIDINEDIONES
    • MOA- Enhance insulin action at the receptor site
    • They do not stimulate insulin secretion
  • Diabetes Mellitus
    • THIAZOLIDINEDIONES
    • Examples- Rosiglitazone, Pioglitazone
    • These drugs affect LIVER FUNCTION
    • Can cause resumption of OVULATION in peri-menopausal anovulatory women
  • Diabetes Mellitus
    • MEGLITINIDES
    • MOA- Stimulate the secretion of insulin by the beta cells
    • Examples- Repaglinide and Nateglinide
  • Diabetes Mellitus
    • MEGLITINIDES
    • They have a shorter duration and fast action
    • Should be taken BEFORE meals to stimulate the release of insulin from the pancreas
  • Diabetes Mellitus
    • MEGLITINIDES
    • Principal side-effect of meglitinides- hypoglycemia
    • Can be used alone or in combination
  • Diabetes Mellitus
    • ACUTE COMPLICATIONS OF DM
    • Hypoglycemia
    • Diabetic ketoacidosis
    • Hyperglycemic hyperosmolar non-ketotic syndrome (HHNS)
  • Diabetes Mellitus
    • CHRONIC COMPLICATIONS OF DM
    • Macrovascular complications- MI, Stroke, Atherosclerosis, CAD, and Peripheral vascular disease
    • Microvascular complications- micro-angiopathy, retinopathy, nephropathy
    • Peripheral neuropathy
  •  
  • Diabetes Mellitus
    • HYPOGLYCEMIA
    • Blood glucose level less than 50 to 60 mg/dL
    • Causes: Too much insulin/OHA, too little food and excessive physical activity
    • Mild- 40-60
    • Moderate- 20-40
    • Severe- less than 20
  • HYPOGLYCEMIA
    • ASSESSMENT FINDINGS
    • 1. Sympathetic manifestations- sweating, tremors, palpitations, nervousness, tachycardia and hunger
  • HYPOGLYCEMIA
    • ASSESSMENT FINDINGS
    • 2. CNS manifestations- inability to concentrate, headache, lightheadedness, confusion, memory lapses, slurred speech, impaired coordination, behavioral changes, double vision and drowsiness
  • HYPOGLYCEMIA
  • HYPERGLYCEMIA
  • HYPOGLYCEMIA
    • DIAGNOSTIC FINDINGS
    • RBS- less than 50-60 mg/dL level
  • HYPOGLYCEMIA
    • Nursing Interventions
    • 1. Immediate treatment with the use of foods with simple sugar- glucose tablets, fruit juice, table sugar, honey or hard candies
  • HYPOGLYCEMIA
    • Nursing Interventions
    • 2. For unconscious patients- glucagon injection 1 mg IM/SQ; or IV 25 to 50 mL of D50/50
  • HYPOGLYCEMIA
    • Nursing Interventions
    • 3. re-test glucose level in 15 minutes and re-treat if less than 75 mg/dL
    • 4. Teach patient to refrain from eating high-calorie, high-fat desserts
  • HYPOGLYCEMIA
    • Nursing Interventions
    • 5. Advise in-between snacks, especially when physical activity is increased
    • 6. Teach the importance of compliance to medications
  • Diabetic Ketoacidosis
    • This is cause by the absence of insulin leading to fat breakdown and production of ketone bodies
    • Three main clinical features:
      • 1. HYPERGLYCEMIA
      • 2. DEHYDRATION & electrolyte loss
      • 3. ACIDOSIS
  • DKA
    • PATHOPHYSIOLOGY
    • No insulin  reduced glucose breakdown and increased liver glucose production  Hyperglycemia
  • DKA
    • PATHOPHYSIOLOGY
    • Hyperglycemia  kidney attempts to excrete glucose  increased osmotic load  diuresis  Dehydration
  • DKA
    • PATHOPHYSIOLOGY
    • No glucose in the cell  fat is broken down for energy  ketone bodies are produced  Ketoacidosis
  • DKA
    • Risk factors
    • 1. infection or illness- common
    • 2. stress
    • 3. undiagnosed DM
    • 4. inadequate insulin, missed dose of insulin
  • DKA
    • ASSESSMENT FINDINGS
    • 1. 3 P’s
    • 2. Headache, blurred vision and weakness
    • 3. Orthostatic hypotension
  • DKA
    • ASSESSMENT FINDINGS
    • 4. Nausea, vomiting and abdominal pain
    • 5. Acetone (fruity) breath
    • 6. Hyperventilation or KUSSMAUL’s breathing
  • HYPERGLYCEMIA
  • Hyperglycemia
  • DKA
    • LABORATORY FINDINGS
    • 1. Blood glucose level of 300-800 mg/dL
    • 2. Urinary ketones
  • DKA
    • LABORATORY FINDINGS
    • 3. ABG result of metabolic acidosis- LOW pH, LOW pCO2 as a compensation, LOW bicarbonate
    • 4. Electrolyte imbalances- potassium levels may be HIGH due to acidosis and dehydration
  • DKA
    • NURSING INTERVENTIONS
    • 1. Assist in the correction of dehydration
      • Up to 6 liters of fluid may be ordered for infusion, initially NSS then D5W
      • Monitor hydration status
      • Monitor I and O
      • Monitor for volume overload
  • DKA
    • NURSING INTERVENTIONS
    • 2. Assist in restoring Electrolytes
      • Kidney function is FIRST determined before giving potassium supplements!
  • DKA
    • NURSING INTERVENTIONS
    • 3. Reverse the Acidosis
      • REGULAR insulin injection is ordered IV bolus 5-10 units
      • The insulin is followed by drip infusion in units per hour
      • BICARBONATE is not used!
  • HHNS
    • A serious condition in which hyperosmolarity and extreme hyperglycemia predominate
    • Ketosis is minimal
    • Onset is slow and takes hours to days to develop
  • HHNS
    • PATHOPHYSIOLOGY
    • Lack of insulin action or Insulin resistance  hyperglycemia
    • Hyperglycemia  osmotic diuresis  loss of water and electrolytes
  • HHNS
    • PATHOPHYSIOLOGY
    • Insulin is too low to prevent hyperglycemia but enough to prevent fat breakdown
    • Occurs most commonly in type 2 DM, ages 50-70
  • HHNS
    • Precipitating factors
    • 1. Infection
    • 2. Stress
    • 3. Surgery
    • 4. Medication like thiazides
    • 5. Treatment like dialysis
  • HHNS
    • ASSESSMENT FINDINGS
    • 1. Profound dehydration
    • 2. Hypotension
    • 3. Tachycardia
    • 4. Altered sensorium
    • 5. Seizures and hemiparesis
  • HHNS
    • DIAGNOSTIC TESTS
    • 1. Blood glucose- 600 to 1,200 mg/dL
    • 2. Blood osmolality- 350 mOsm/L
    • 3. Electrolyte abnormalities
  • HHNS
    • NURSING INTERVENTIONS
    • Approach is similar to the DKA
    • 1. Correction of Dehydration by IVF
    • 2. Correction of electrolyte imbalance by replacement therapy
  • HHNS
    • NURSING INTERVENTIONS
    • 3. Administration of insulin injection and drips
    • 4. Continuous monitoring of urine output
  • MACROVASCULAR CX
    • Nursing management
    • 1. Diet modification
    • 2. Exercise
  • MACROVASCULAR CX
    • Nursing management
    • 3. Prevention and treatment of underlying conditions such as MI, CAD and stroke
    • 4. Administration of prescribed medications for hypertension, hyperlipidemia and obesity
  • MICROVASCULAR CX
    • Retinopathy- a painless deterioration of the small blood vessels in the retina, may be classified as to background retinopathy, pre-proliferative and proliferative retinopathy
    • Permanent vision changes and blindness can occur
  • MICROVASCULAR CX
    • Retinopathy-ASSESSMENT FINDINGS
    • Blurry vision
    • Spotty vision
    • Asymptomatic
  • MICROVASCULAR CX
    • Retinopathy: Diagnostic findings
    • 1. Fundoscopy
    • 2. Fluorescein angiography
      • Painless procedure
      • Side-effects- discoloration of the skin and urine for 12 hours, some allergic reactions, nausea
      • Flash of camera may be slightly uncomfortable
  • MICROVASCULAR CX
    • NURSING INTERVENTIONS
    • 1. Assist in diagnostic procedure
    • 2. Assist in the preparation for surgery- laser photocoagulation
  • MICROVASCULAR CX
    • NURSING INTERVENTIONS
    • 3. Health teaching regarding prevention of retinopathy by regular ophthalmic examinations, good glucose control and self-management of eye care regimens
    • 4. Maintain client safety
  • MICROVASCULAR CX
    • DIABETIC NEPHROPATHY
    • Progressive deterioration of kidney function
  • MICROVASCULAR CX
    • DIABETIC NEPHROPATHY
    • HYPERGLYCEMIA  causes the kidney filtration mechanism to be stressed  blood proteins leak into the urine
    • Pressure in the kidney blood vessels increases  stimulate the development of nephropathy
  • MICROVASCULAR CX
    • ASSESSMENT findings for diabetic nephropathy
    • 1. Albuminuria
    • 2. Anemia
    • 3. Acidosis
  • MICROVASCULAR CX
    • ASSESSMENT findings for diabetic nephropathy
    • 4. Fluid volume overload
    • 5. Oliguria
    • 6. Hypertension
    • 7. UTI
  • MICROVASCULAR CX
    • NURSING MANAGEMENT 1. Assist in the control of hypertension- use of ACE inhibitor
    • 2. Provide a low sodium and low protein diet
    • 3. Administer prescribed medication for UTI
  • MICROVASCULAR CX
    • NURSING MANAGEMENT
    • 4. Assist in dialysis
    • 5. Prepare patient for renal transplantation, if indicated
  • MICROVASCULAR CX
    • Diabetic Neuropathy
    • A group of disorders that affect all type of nerves including the peripheral, autonomic and spinal nerves
  • MICROVASCULAR CX
    • Diabetic Neuropathy
    • Two most common types of Diabetic Neuropathy are sensori-motor polyneuropathy and autonomic neuropathy
  • MICROVASCULAR CX
    • Peripheral neuropathy- ASSESSMENT findings
    • 1. paresthesias- prickling, tingling or heightened sensation
    • 2. decreased proprioception
    • 3. decreased sensation of light touch
    • 4. unsteady gait
    • 5. decreased tendon reflexes
  • MICROVASCULAR CX
    • Peripheral neuropathy- Nursing Management
    • 1. Provide teaching that good glucose control is very important to prevent its development
    • 2. Manage the pain by analgesics, antidepressants and nerve stimulation
  • MICROVASCULAR CX
    • Autonomic Neuropathy- ASSESSMENT findings
    • 1. Silent, painless ischemia
    • 2. delayed gastric emptying
    • 3. orthostatic hypotension
    • 4. N/V and bloating sensation
    • 5. urinary retention
    • 6. sexual dysfunction
  • MICROVASCULAR CX
    • Autonomic Neuropathy-Nursing management
    • 1. Educate about the avoidance of strenuous physical activity
    • 2. Stress the importance of good glucose control to delay the development
  • MICROVASCULAR CX
    • Autonomic Neuropathy-Nursing management
    • 3. Provide LOW-fat, small frequent feedings
    • 4. Administer bulk-forming laxatives for diabetic diarrhea
    • 5. Provide HIGH-fiber diet for diabetic constipation
  • MICROVASCULAR CX
    • MANAGEMENT OF FOOT AND LEG PROBLEMS
    • Soft tissue injury in the foot/leg  formation of fissures and callus  poor wound healing  foot/leg ulcer
  • MICROVASCULAR CX
    • RISK FACTORS for the development of foot and leg ulcers
    • 1. More than 10 years diabetic
    • 2. Age of more than 40
    • 3. Smoking
    • 4. Anatomic deformities
    • 5. History of previous leg ulcers or amputation
  • MICROVASCULAR CX
    • MANAGEMENT of Foot Ulcers
    • Teach patient proper care of the foot
    • Daily assessment of the foot
    • Use of mirror to inspect the bottom
  • MICROVASCULAR CX
    • MANAGEMENT of Foot Ulcers
    • Inspect the surface of shoes for any rough spots or foreign objects
    • Properly dry the feet
    • Instruct to wear closed-toe shoes that fit well, recommend use of low-heeled shoes
  • MICROVASCULAR CX
    • MANAGEMENT
    • Instruct patient NEVER to walk barefoot, never to use heating pads, open-toed shoes and soaking feet
    • Trim toenails STRAIGHT ACROSS and file sharp corners
    • Instruct to avoid smoking and over-the counter medications and home remedies for foot problems
  • End of DM