7349728 diabetes-nursing-care


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7349728 diabetes-nursing-care

  1. 1. Nursing Care: Diabetes Mellitus
  2. 2. Diabetes Normal Pathophysiology Need to consider how insulin works insulin continuously released: during “fasting periods”, the pancreas continuously releases a small amount of insulin along with glucagon. Together a constant level of glucose in the blood is maintained by stimulating the release of glucose from the liver.
  3. 3. Diabetes In diabetes the body’s ability to respond to insulin may decrease the pancreas may stop producing insulin. This in turn leads to hyperglycemia leads to other acute metabolic complications Diabetes is a heterogeneous group of diseases involving disruption of metabolism of carbohydrates, fats, and protein.
  4. 4. Diabetes What population of patients would be at risk for developing diabetes? Classification of diabetes mellitus Type I • may occur at any age • usually thin • abrupt onset • family history?
  5. 5. Diabetes Classification Type II • >age 30 • often obese • few classic symptoms • insulin resistant Impaired glucose tolerance • plasma glucose levels higher than normal, but not diagnostic for diabetes 2 hr plasma glucose >140 mg/dl & < 200 mg/dl
  6. 6. Diabetes Classification Impaired fasting glucose • fasting plasma glucose > 110 mg/dl & < 126 mg/dl Gestational diabetes • has onset or discovery of glucose tolerance during pregnancy
  7. 7. Diabetes Clinical Manifestations Insulin deficiency or decreased insulin activity glucose not used properly osmotic effect on intracellular and interstitial fluid results in frequent urination (polyuria), and thirst (polydipsia) without insulin the patient may experience hunger (polyphagia) • the body will turn to other energy sources besides glucose: first fat and then protein
  8. 8. Diabetes Diagnostic studies diabetes is a multisystem, multiproblem disease, all laboratory studies must be examined with assessment findings normal blood glucose range: 70-110 mg/dl urine tests not sufficient for a dx of diabetes fasting blood glucose of > 126 mg/dl glycosylated hemolobin
  9. 9. Diabetes Nutritional therapy Goals of nutritional therapy • maintenance of as near-normal blood glucose levels • achievement of optimal serum lipid levels • provision of adequate calories for maintaining or attaining reasonable weights, normal growth & development rates • prevention and treatment of acute complications • improvement of overall health through optimal nutrition
  10. 10. Diabetes Nutritional therapy Type I • based on patient’s usual food intake with insulin therapy • eat at consistent times, synchronized with the action of their insulin • monitor blood glucose levels and adjust as needed
  11. 11. Diabetes Nutritional therapy Type II • achieving glucose, lipid, and blood pressure goals • weight loss is desirable • regular exercise • monitor blood glucose level
  12. 12. Nutritional therapy Food composition calorie distribution glycemic index simple sugars and complex carbohydrates Areas of concern alcohol dietetic foods
  13. 13. Diabetes Drug therapy 4 types of insulin; things to consider • how soon the insulin starts working (onset) • when it works the hardest (peak time) • how long it lasts in your body (duration) The nurse may find that different sources list different numbers of hours for onset, peak, duration of action of the main types of insulin, and the patient’s reactions may vary. The nurse should focus on which meals and snacks are being covered by which insulin dose.
  14. 14. Insulin Rapid-acting insulin: onset: 15 minutes after injection peak: 30-90 minutes later duration: may last as long as 5 hours Short-acting: onset: 30 minutes after injection peak:2 to 4 hours duration: 4 to 8 hours
  15. 15. Insulin Intermediate-acting onset: 2 to 6 hours peak: 4 to 14 hours duration: 14 to 20 hours Long-acting onset: 6 to 14 hours peak: 10 to 16 hours duration: 20 to 24 hours
  16. 16. Insulin Strength Additives Storage and safety Administration Insulin therapy Insulin delivery
  17. 17. Insulin and Oral Agents Problems with insulin therapy allergic reactions lipodystrophy Somogyi effect and dawn phenomenon Oral medications Other drugs affecting blood glucose levels Things to consider… exercise, self-monitoring
  18. 18. Nursing Management: Diabetes Assessment: Subjective data • past health information • family history • medications • surgery and other treatments Health-perception-health management • + family history, malaise
  19. 19. Nursing Management: Diabetes Nutritional-metabolic weight thirst and hunger Nausea and vomiting poor healing compliance with diet Elimination constipation or diarrhea frequent urination, incontinence, nocturia skin infections
  20. 20. Nursing Management: Diabetes Activity-exercise muscle weakness, fatigue cognitive-perceptual abdominal pain, headache, blurred vision, numbness or tingling of extremities, pruritis Sexuality-reproductive impotence, frequent vaginal infections, decreased libido
  21. 21. Nursing Management: Diabetes Coping-stress depression apathy irritability Value-belief commitment to lifestyle changes involving diet, medication, and activity patterns
  22. 22. Nursing Management: Diabetes Objective data eyes integumentary respiratory cardiovascular gastrointestinal neurologic musculoskeletal diagnostic findings
  23. 23. Nursing Management: Diabetes Insulin therapy assessment of patient’s use of and response to insulin therapy education of the patient regarding administration, adjustment to, and side effects of insulin The “new” diabetic Stress of acute illness and surgery
  24. 24. Nursing Management: Diabetes Oral agents nursing responsibilities similar to those taking insulin Personal hygiene dental skin care Medical identification and travel Follow-up nursing management
  25. 25. Intermission
  26. 26. Complications of Diabetes Diabetic Ketoacidosis Etiology • undiagnosed diabetes • inadequate treatment of existing diabetes • insulin not taken as prescribed • change in diet, insulin, or exercise regimen
  27. 27. Complications of Diabetes Diabetic Ketoacidosis Assessment • dry mouth, thirst, abdominal pain, N & V, confusion, lethargy, flushed dry skin, eyes appear sunken, breath odor of ketones, rapid, weak pulse, labored breathing, fever, urinary frequency, serum glucose > 300 mg/dl, glucosuria and ketonuria
  28. 28. Complications of Diabetes Diabetic Ketoacidosis Nursing interventions • initial – ensure patent airway – O2 – establish IV access and begin fluid resuscitation – begin continuous IV insulin – identify history of diabetes, time of last food, and time/amount of last insulin injection
  29. 29. Complications of Diabetes Diabetic Ketoacidosis Nursing interventions • ongoing monitoring – monitor VS, LOC, cardiac rhythm, O2 saturation, and urine output – assess breath sounds – monitor serum glucose and serum potassium – anticipate possible administration of sodium bicarb with severe acidosis (pH < 7.0)
  30. 30. Complications of Diabetes Hyperglycemic Hyperosmolar Nonketosis occurs in a patient who has some insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion usually is a history of inadequate fluid intake, increasing mental depression and polyuria HHNK constitutes a medical emergency
  31. 31. Complications of Diabetes Hyperglycemic Hyperosmolar Nonketosis nursing management • administration of a rapid-acting insulin • administration of IV fluid • assessment of mental status • I & O • assessment of blood glucose levels • assessment of blood and urine for ketones • electrocardiogram monitoring
  32. 32. Complications of Diabetes Hypoglycemia clinical manifestations • blood glucose <50 mg/dl • cold, clammy skin • numbness of fingers , toes, mouth • emotional changes, HA, nervousness, seizures, coma, faintness, dizziness • changes in vision • hunger • unsteady gait, slurred speech
  33. 33. Complications of Diabetes Hypoglycemia causes • alcohol intake with food • too little food - delayed, omitted, inadequate intake • diabetic medication or food taken at wrong time • loss of weight with change of medication • use of B-blockers
  34. 34. Complications of Diabetes Hypoglycemia nursing management • immediate ingestion of 5-20 g of simple carbohydrates • ingestion of another 5-20 g of simple carbohydrates in 15 min if no relief obtained • contact physician if no relief obtained • collaborate with physician • prevention is the key
  35. 35. Complications of Diabetes Hyperglycemia clinical manifestations • elevated blood sugar • increase urination • increase in appetite followed by lack of appetite • weakness, fatigue • blurred vision, HA • nausea and vomiting, abdominal cramps • glycosuria • progression to DKA or HHNK
  36. 36. Complications of Diabetes Hyperglycemia causes • too much food • too little or no diabetes medication • inactivity • emotional, physical stress • poor absorption of insulin
  37. 37. Complications of Diabetes Hyperglycemia nursing management • notify physician • continuance of diabetes medication as ordered • frequent checking of blood and urine specimens and recording of results • prevention is key
  38. 38. Chronic Complications Macroangiopathy Microangiopathy Peripheral Vascular Disease Diabetic Retinopathy Nephropathy Neuropathy Skin changes
  39. 39. Question A diabetic patient has a serum glucose level of 824 m/dl and is sleepy and unresponsive. Following assessment of the patient the nurse suspects DKA rather than HHNK based on the finding of a) polyuria b) severe dehydration c) rapid, deep respirations d) decreased serum potassium