DIABETES MELLITES Diabetes mellitus is a group of metabolic disease results from the production of insufficient amount of insulin by the pancreas. Without insulin the body cannot utilize glucose. So creating high level of glucose in the blood and a low level of glucose absorption by the tissue. Type 1 diabetes -- insulin dependant diabetes Type2 diabetes-- Non insulin dependant diabetes
DIABETIC KETOACIDOSISDiabetic keto acidosis is an acute state of severeuncontrolled diabetic that requires emergencytreatment with insulin and intravenous fluids.biochemically DKA is defined as an increase in theserum concentration of ketons greater than 5meq/l a blood glucose level of greater than 250mg/l,blood PH less than 7.2 and HCO3 is 18meq/lor less.
PRECIPITATING FACTORS Infections Acute stroke Pancreatitis Myocardial infarction Interruption of insulin Pregnancy Dietery indiscretion Trauma and stress
INFECTION MISSED INSULIN DOSE STRESS NEW-ONSET DIABETES EXCESS SECRETION OF INADEQUATEGLYCOGEN AND OTHER INSULINCOUNTER REGULATORY HORMONES DCREASEINCREASED LIPOLYSIS GLYCOGENENOLYSIS GLUCOSE UPTAKE OF ADIPOSE TISSUE AND GLUCONEOGENESIS BY THE LIVER HYPERGLYCEMIA KETOGENESIS OSMOTIC KETOSIS DIURESIS VOMITING ACIDOSIS POTASSIUM LOSS DEHYDRATION
LACK OF INSULINDECREASED UTILIZATION INCREASEDOF GLUCOSE BY MUSCLE, BREAKDOWNFAT AND LIVER OF FATINCREASED PRODUCTION •ACETONEOF GLUCOSE BY LIVER BREATH INCREASED •POOR APPETITE FATTY ACIDS •NAUSEA HYPERGLYCEMIA INCREASED KETONE •NAUSEA BODIESBLURRED POLYURIA •VOMITING VISION •ABDOMINAL PAIN ACIDOSISWEAKNESS DEHYDRATIONHEADACHE INCREASINGLY INCREASED THIRST RAPID (POLYDIPSIA) RESPIRATIONS
COMMON CLINICAL FEATURES Poly urea ,poly dipsia,poly phagia Weight loss Nausea and vomiting weakness Abdominal pain Clouding of sensorium Coma Hyper ventillation –kuss mual pattern Dehydration and shock s
LABORATORY FINDINGS Blood glucose greater than 14mmol/L[250 mg/l] Arterial pH less than 7.3 Anion gap less than 10 Ketone urea Arterial bicarbonate less than 15 Hyper magnesimia Hypokalemia Cardiac enzymes Pco2-35it reflects respiratory compensation .
NURSING ASSESSMENT Assess skin for dehydration like poor turgour,flushing,and dry mucus membrances. Observe for cardiac changes reflecting dehydration,metabolic and electrolyte imbalance,tachycardia,hypotension,weak pulse,ECG changes including elevated P wave flattendT wave or inverted and prolonged QT intervals Assess respiratory status kussmual breathing,acctone breaths characteritic of metabolic acidosis Assess gastro intestinal symptoms like nausea vomiting extreme thirst,abdominal bloating,cramping,and diarrhoea Genito urinary symptoms-nocturia and polyuria Neurologic signs- crying,restlessness,twitching,tremers,drowsiness,lethargy,hea dache.
NURSING MANAGEMENT Stabilize the patient’s airway,breathing,circulation Obtain 16 gauge iv line on both site and assess cardiac monitoring and pulse oxymetry. Monitor serum glucose hourly and urine ketone Monitor basic electrolyte,osmolarity and venousPHevery 4 hourly until pt is stable. Determine and treat any underlyingcausesof DKAeg;; pneumonia,UTIand MI
1.FLUID REPLACEMENT[ADULT] Give 1 litre of normal saline[0.9%]rapidly via No I8 gauge cannula if cardiac function is normal. Then one litre of normal saline/ hour, for 1st3 hrs for those individuals who are in shock . Then 250-500ml /hr of normal saline depending on hydration status until blood sugar is 14 mmol/L[250 mg/L]. blood sugar level<14 mmol/L 0.9%should be switched toD51/2NS or DNS at 125 to 250ml/hour. Assess blood pressure & heart rate frequently. Monitor intake and out put for signs of fluid overload. Monitor urine specific gravity to assess fluid changes.
INSULIN TREATMENT Regular insulin 0.1 units/kg. as an IV bolus. Then regular insulin infusion IV 0.14 units /kg./hour until blood sugar reaches 14mmol/litre ( 250mg/dl) & follow IV infusion protocol 1ml regular insulin = 100units Start insulin infusion 6units/hr. Doctor’s order x solution in volume 6units x 50 ____________________________ = ____________ Strength of solution 100 units 300_____ = 3ml/hr. ( 6units/hr.)100
RATE OF INFUSION ACCORDING TO SLIDING SCALE OF REGULAR INSULINCAPILLARY BLOOD GLUCOSE IN UNITS OF INSULIN / HOURMG/DL <99 0.5ml/hr. 100______ 149 (5.6—8.2mmol) 1ml/hr. 150 ______ 199 ( 8.3_____11 ) 2ml/hr. 200 ______ 249 ( 11.1 ____13.8 ) 3ml/hr. 250_______299 (13.9____ 16.6) 4ml/hr. 300_______349 ( 16.7____19.4) 5ml/hr. 350_______399 ( 19.5_____22.2) 6ml/hr. 400_______450 ( 22.3_____24.9) 8ml/hr. >450 ( > 24.9) 10ml/hr.
ANION GAP- Substract the major measured anion fromthe major measured Cations (Cl +Hco3- Na) • IV insulin infusion can be switched to subcutaneous insulin according to sliding scale. • Arterial bicarbonate rises 18. • Anion gap 10 up to 12 + or- 2 • Urine aceton 3times negative • Oral intake has resumed • It is important to give the first subcutaneous insulin approximately two hours before stopping the infusion • Flush the entire IV infusion set with solution containing insulin & dicard the solution ,then refill it again • Keep separate IV line for insulin infusion and electrolyte replacement
POTASSIUM REPLACEMENT Aims to keep serum k+ between 4 to 5meq/ L to prevent hyper or hypokalemea. If initial potassium is <3.3 Hold insulin & replace K+ Do not give K+ direct IV, must be added to IV fluids If K+ is >5 do not give Kcl recheck within hour If k+ is 4__ 5 give Inj.kcl 20meq in each liter of fluid If K+ is 3__4 give Inj.kcl 30meq in each liter of fluid If K+ is <3 give Inj.kcl40meq in two hour & recheck Follow sliding scale of K+ every 6th hourly until stable
BICARBONATE REPLACEMENT If arterial PH <7 give 50ml of bicarbonate in 250ml of 0.45% NSS over one hour Bicarbonate infusion to correct acidosis is avoided,during the treatment of DKA because it precipitates further sudden decrease in serum potassium . INVESTIGATION AND OUTCOME BASED EVALUATION Serum glucose initially and hrly until acctone disappear Serum potassium initially and hrly if K+ < 3 or > 5 Electrolyte and renal function initially and then 6 hrly .. Serum osmolarity , VBG,cardiac enzymes ,CBC Urine analysis and urine culture if needed
COMPLICATION Premature discontinuation of Ivinsulin can result in prolonged DKA Too rapid infusion of IVF in case of severe dehydration can cause cerebral edema and death If blood glucose level falls too fast or too slow,before the brain has time to equilibrate,the water is pulled from the cerebrospinal fluid and the brain causing cerebraloedema and death Hypoxiaand leads to ARDS Hypoglycemia,venous and arterial thrombosis
PATIENT EDUCATION Instruct to take insulin or oral diabetic agent as usual Check blood sugar and urine sugar every 4 hrly Report elevated glucose and urine acctone to physician Usual meal plan cannot be followed substitute soft foods 6- 8 times /day If any symptoms like vomiting and diarrhoe or fever consume liquid diet every half to one hour to prevent dehydration and provide calories Inform physician about extreme fluid loss maybe dangerous. For type 1 diabetic, iniability to retain oral fluid needs hospitallization to avoid DKA and possible coma