Nursing Management for Diabetes Mellitus


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  • Nursing Management for Diabetes Mellitus

    1. 1. DIABETES MELLITUS Nelia S. Bañaga – Perez RN, MSN, MAEd Northeastern College Nursing Department Santiago City, Philippines
    2. 2. DIABETES MELLITUS <ul><li>An endocrine disorder in which there is insufficient amount or lack of insulin secretion to metabolize carbohydrates. </li></ul><ul><li>It is characterized by hyperglycemia, glycosuria and ketonuria. </li></ul>
    3. 5. Diabetes Mellitus Pathophysiology <ul><li>The beta cells of the Islets of Langerhan of the Pancreas gland are responsible for secreting the hormone insulin for the carbohydrate metabolism. </li></ul><ul><li>Remember the concept - sugar into the cells. </li></ul>
    4. 6. Diabetes Mellitus Types <ul><li>Type 1 - IDDM </li></ul><ul><ul><li>little to no insulin produced </li></ul></ul><ul><ul><li>20-30% hereditary </li></ul></ul><ul><ul><li>Ketoacidosis </li></ul></ul><ul><li>Gestational </li></ul><ul><ul><li>overweight; risk for Type 2 </li></ul></ul><ul><li>Type 2 - NIDDM </li></ul><ul><ul><li>some insulin produced </li></ul></ul><ul><ul><li>90% hereditary </li></ul></ul><ul><li>Other types include Secondary Diabetes : </li></ul><ul><ul><li>Genetic defect beta cell or insulin </li></ul></ul><ul><ul><li>Disease of exocrine pancreas </li></ul></ul><ul><ul><li>Drug or chemical induced </li></ul></ul><ul><ul><li>Infections- pancreatitits </li></ul></ul><ul><ul><li>Others- steroids, </li></ul></ul>
    5. 7. INSULIN <ul><li>Insulin is a protein made of 2 chains- alpha and beta </li></ul><ul><li>Preproinsulin is produced initially </li></ul><ul><ul><li>Precursor molecule that is inactive </li></ul></ul><ul><ul><li>Must be made smaller before becoming active </li></ul></ul><ul><li>Proinsulin </li></ul><ul><ul><li>Precursor that includes alpha and beta chains </li></ul></ul><ul><ul><li>Also has a C-peptide chain </li></ul></ul><ul><ul><li>C-peptide levels are used to measure rate that beta cells secrete insulin </li></ul></ul>
    6. 8. INSULIN <ul><li>Insulin allows glucose to move into cells to make energy </li></ul><ul><li>Liver is first major organ to be reached </li></ul><ul><ul><li>Promotes production and storage of glycogen (glycogenisis) </li></ul></ul><ul><ul><li>Inhibits glycogen breakdown into glucose (glycogenolysis) </li></ul></ul><ul><ul><li>Increases protein and lipid synthesis </li></ul></ul><ul><ul><li>Inhibits tissue breakdown by inhibiting liver glycogenolysis (ketogenesis- converts fats to acids) & gluconeogenisis (conversion of proteins to glucose) </li></ul></ul><ul><ul><li>In muscle, promotes protein and glycogen synthesis </li></ul></ul><ul><ul><li>In fat cells, promotes triglyceride storage </li></ul></ul>
    7. 9. INSULIN <ul><li>Pancreas secretes 40-50 units of insulin daily in two steps: </li></ul><ul><ul><li>Secreted at low levels during fasting ( basal insulin secretion </li></ul></ul><ul><ul><li>Increased levels after eating (prandial) </li></ul></ul><ul><ul><li>An early burst of insulin occurs within 10 minutes of eating </li></ul></ul><ul><ul><li>Then proceeds with increasing release as long as hyperglycemia is present </li></ul></ul>
    8. 10. GLUCOSE HOMEOSTASIS <ul><li>Glucose is main fuel for CNS </li></ul><ul><li>Brain cannot make or store, therefore needs continuous supply </li></ul><ul><li>Fatty acids can be used when glucose is not available ( triglycerides) </li></ul><ul><li>Need 68-105 mg/dL to support brain </li></ul><ul><li>Decreased levels of glucose, insulin release is stopped with glucagon released </li></ul>
    9. 11. GLUCOSE <ul><li>Glucagon causes release of glucose from liver </li></ul><ul><ul><li>Liver glucose is made thru glycogenolysis (glucogen to glucose) & </li></ul></ul><ul><ul><li>Gluconeogenesis </li></ul></ul><ul><li>When liver glucose is not available, lypolysis occures ( breakdown of fat) OR </li></ul><ul><li>Proteinlysis (breakdown of amino acids) </li></ul>
    10. 12. ABSENCE OF INSULIN <ul><li>Insulin needed to move glucose into cells </li></ul><ul><li>Without insulin, body enters a state of breaking down fats and proteins </li></ul><ul><li>Glucose levels increase (hyperglycemia) </li></ul>
    11. 13. Absence of Insulin <ul><li>Hyperglycemia </li></ul><ul><li>Polyuria </li></ul><ul><li>Polydipsia </li></ul><ul><li>Polyphagia </li></ul><ul><li>Hemoconcentration, hypervolemia, hyperviscosity, hypoperfusion, and hypoxia </li></ul><ul><li>Acidosis, Kussmaul respiration </li></ul><ul><li>Hypokalemia, hyperkalemia, or normal serum potassium levels </li></ul>
    12. 14. Assessment <ul><li>History </li></ul><ul><li>Blood tests </li></ul><ul><ul><li>Fasting blood glucose test: two tests > 126 mg/dL </li></ul></ul><ul><ul><li>Oral glucose tolerance test: blood glucose > 200 mg/dL at 120 minutes </li></ul></ul><ul><ul><li>Glycosylated hemoglobin ( Glycohemoglobin test) assays </li></ul></ul><ul><ul><li>Glucosylated serum proteins and albumin </li></ul></ul><ul><li>FSBS – (finger stick) monitoring blood sugar </li></ul>
    13. 15. Urine Tests <ul><li>Urine testing for ketones </li></ul><ul><li>Urine testing for renal function </li></ul><ul><li>Urine testing for glucose </li></ul>
    14. 16. Diabetes Mellitus Clinical Manifestation <ul><li>Hyperglycemia </li></ul><ul><ul><li>Three P’s - </li></ul></ul><ul><ul><ul><li>Polyuria </li></ul></ul></ul><ul><ul><ul><li>Polyphagia </li></ul></ul></ul><ul><ul><ul><li>Polydispsia </li></ul></ul></ul><ul><li>Gradual Onset </li></ul><ul><li>Hypoglycemia </li></ul><ul><ul><li>Weak, diaphoretic, sweat, pallor, tremors, nervous, hungry, diplopia, confusion, aphasia, vertigo, convulsions </li></ul></ul><ul><ul><li>Treatment - OJ with sugar, or IV glucose </li></ul></ul><ul><li>Sudden onset </li></ul>
    15. 23. Hyperglycemia - Clinical Manifestations <ul><li>Three P’s – polyuria, polydypsia, </li></ul><ul><li>polyphagia </li></ul><ul><li>Glycosuria </li></ul><ul><li>Dehydration </li></ul><ul><li>Hypotension </li></ul><ul><li>Mental Changes </li></ul><ul><li>Fever </li></ul><ul><li>Hypokalemia </li></ul><ul><li>Hyponatremia </li></ul><ul><li>Seizure </li></ul><ul><li>Coma </li></ul><ul><li>Life Threatening!!! </li></ul>
    16. 27. Risk for Injury Related to Hyperglycemia <ul><li>Interventions include: </li></ul><ul><ul><li>Dietary interventions, blood glucose monitoring, medications </li></ul></ul><ul><ul><li>Oral Drugs Therapy </li></ul></ul><ul><ul><ul><li>(Continued) </li></ul></ul></ul>
    17. 28. Risk for Injury Related to Hyperglycemia (Continued) <ul><ul><li>Oral therapy </li></ul></ul><ul><ul><ul><li>Sulfonylurea agents </li></ul></ul></ul><ul><ul><ul><li>Meglitinide analogues </li></ul></ul></ul><ul><ul><ul><li>Biguanides </li></ul></ul></ul><ul><ul><ul><li>Alpha-glucosidase inhibitors </li></ul></ul></ul><ul><ul><ul><li>Thiazolinedione antidiabetic agents </li></ul></ul></ul>
    18. 29. Oral Hypoglcemias Key Points <ul><li>Monitor serum glucose levels </li></ul><ul><li>Teach patient signs and symptoms of hyper/hypoglycemia </li></ul><ul><li>Altered liver, renal function will affect medication action </li></ul><ul><li>Avoid OTC meds without MD approval </li></ul><ul><li>Assess for GI distress and sensitivity </li></ul><ul><li>Know appropriate time to administer med </li></ul>
    19. 31. Diet Therapy <ul><li>Goals of diet therapy </li></ul><ul><li>Principles of nutrition in diabetes </li></ul><ul><ul><li>Protein, fats and carbohydrates, fiber, sweeteners, fat replacers </li></ul></ul><ul><ul><li>Alcohol </li></ul></ul><ul><ul><li>Food labeling </li></ul></ul><ul><ul><li>Exchange system, carbohydrate counting </li></ul></ul><ul><ul><li>Special considerations for type 1 and type 2 diabetes </li></ul></ul>
    20. 32. Diabetes Mellitus Diet <ul><li>American Diabetic Association </li></ul><ul><li>Food groups/ exchanges </li></ul><ul><li>Carbohydrates - 60% </li></ul><ul><li>Fats - 30% </li></ul><ul><li>Protein - 12-20% </li></ul>
    21. 33. Diabetes - Monitoring Glucose Levels <ul><li>Urine - Ketones </li></ul><ul><li>FSBS </li></ul><ul><li>Wear ID Bracelet </li></ul>
    22. 34. Diabetes - Treatment Exercise <ul><li>Purpose - controls blood glucose and lowers blood glucose </li></ul><ul><li>Purpose - reduce the amount of insulin needed </li></ul>
    23. 35. Exercise Therapy <ul><li>Benefits of exercise </li></ul><ul><li>Risks related to exercise </li></ul><ul><li>Screening before starting exercise program </li></ul><ul><li>Guidelines for exercise </li></ul><ul><li>Exercise promotion </li></ul>
    24. 37. Drug Therapy <ul><li>Drug administration </li></ul><ul><li>Drug selection </li></ul><ul><li>Insulin therapy: </li></ul><ul><ul><li>Insulin analogue </li></ul></ul><ul><ul><li>Short-acting insulin </li></ul></ul><ul><ul><li>Concentrated insulin </li></ul></ul><ul><ul><li>Intermediate </li></ul></ul><ul><ul><li>(Continued) </li></ul></ul>
    25. 38. Drug Therapy (Continued) <ul><ul><li>Fixed-combination </li></ul></ul><ul><ul><li>Long-acting </li></ul></ul><ul><ul><li>Buffered insulins </li></ul></ul>
    26. 40. Insulin Regimens <ul><li>Single daily injection protocol </li></ul><ul><li>Two-dose protocol </li></ul><ul><li>Three-dose protocol </li></ul><ul><li>Four-dose protocol </li></ul><ul><li>Combination therapy </li></ul><ul><li>Intensified therapy regimens </li></ul>
    27. 42. Pharmacokinetics of Insulin <ul><li>Injection site </li></ul><ul><li>Absorption rate </li></ul><ul><li>Injection depth </li></ul><ul><li>Time of injection </li></ul><ul><li>Mixing insulins </li></ul>
    28. 44. Complications of Insulin Therapy <ul><li>Hypoglycemia </li></ul><ul><li>Lipoatrophy </li></ul><ul><li>Dawn phenomenon </li></ul><ul><li>Somagyi's phenomenon </li></ul>
    29. 46. Alternative Methods of Insulin Administration <ul><li>Continuous subcutaneous infusion of insulin </li></ul><ul><li>Implanted insulin pumps </li></ul><ul><li>Injection devices </li></ul><ul><li>New technology includes: </li></ul><ul><ul><li>Inhaled insulin </li></ul></ul><ul><ul><li>Transdermal patch (being tested) </li></ul></ul>
    30. 47. Client Education <ul><li>Storage and dose preparation </li></ul><ul><li>Syringes </li></ul><ul><li>Blood glucose monitoring </li></ul><ul><li>Interpretation of results </li></ul><ul><li>Frequency of testing </li></ul><ul><li>Blood glucose therapy goals </li></ul>
    31. 50. Diabetic Education - Preventive Medicine <ul><li>Proper skin and foot care </li></ul><ul><li>Proper Eye Exam </li></ul><ul><li>Proper diet and fluids </li></ul><ul><li>Diabetic Neuropathy </li></ul><ul><li>Diabetic Retinopathy </li></ul><ul><li>Diabetic Nephropathy </li></ul><ul><li>Diabetic gastroparesis </li></ul>
    32. 52. Diabetes Mellitus Complications <ul><li>Hyperglycemia </li></ul><ul><li>Hypoglycemia </li></ul><ul><li>Diabetic Ketoacidosis </li></ul><ul><li>Hyperosmolar Hyperglycemic Nonketotic Syndrome </li></ul>
    33. 53. Acute Complications of Diabetes <ul><li>Diabetic ketoacidosis </li></ul><ul><li>Hyperglycemic-hyperosmolar-nonketotic syndrome </li></ul><ul><li>Hypoglycemia from too much insulin or too little glucose </li></ul>
    34. 54. Diabetic Ketoacidosis
    35. 55. Potential for Diabetic Ketoacidosis <ul><li>Interventions include: </li></ul><ul><ul><li>Monitoring for manifestations </li></ul></ul><ul><ul><li>Assessment of airway, level of consciousness, hydration status, blood glucose level </li></ul></ul><ul><ul><li>Management of fluid and electrolytes </li></ul></ul><ul><ul><li>(Continued) </li></ul></ul>
    36. 56. Potential for Diabetic Ketoacidosis (Continued) <ul><ul><li>Drug therapy goal: to lower serum glucose by 75 to 150 mg/dL/hr </li></ul></ul><ul><ul><li>Management of acidosis </li></ul></ul><ul><ul><li>Client education and prevention </li></ul></ul>
    37. 57. Complication – Ketoacidosis Treatment <ul><li>Patent airway </li></ul><ul><li>Suctioning </li></ul><ul><li>Cardiac monitoring </li></ul><ul><li>Vital Signs </li></ul><ul><li>Central venous pressure </li></ul><ul><li>Blood work – ABG, BS, chemistry panel </li></ul><ul><li>Administration of Na Bicarb </li></ul><ul><li>Foley – monitor urinary output </li></ul><ul><li>I & O </li></ul><ul><li>Frequent Repositioning </li></ul>
    38. 59. Complication – HHNC Hyperosmolar Hyperglycemic Non-Ketotic Coma <ul><li>Fluid moves from inside to outside cell vausing diuresis and loss of Na+ and K+ </li></ul><ul><li>Treatment - Give insulin and correct fluid and electrolytes imbalance </li></ul><ul><li>Signs and Symptoms </li></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Mental changes </li></ul></ul><ul><ul><li>Dehydration </li></ul></ul><ul><ul><li>Hypokalemia </li></ul></ul><ul><ul><li>Hyponatremia </li></ul></ul><ul><ul><li>Life Threatening!!! </li></ul></ul>
    39. 60. Chronic Complications of Diabetes <ul><li>Cardiovascular disease </li></ul><ul><li>Cerebrovascular disease </li></ul><ul><li>Retinopathy (vision) problems </li></ul><ul><li>Diabetic neuropathy </li></ul><ul><li>Diabetic nephropathy </li></ul><ul><li>Male erectile dysfunction </li></ul>
    40. 64. Diabetes Mellitus Nursing Process <ul><li>Assessment – Medicines, Allergies, Symptoms, Family Hx </li></ul><ul><li>Nursing Diagnosis- Anxiety and Fear, Altered Nutrition, Pain, Fluid Volume Deficit </li></ul><ul><li>Planning – Address the nursing diagnosis </li></ul><ul><li>Implementation – Prevent complications, monitor blood sugars, administer meds and diet, teach diet and meds, Asess , Assess, Assess </li></ul><ul><li>Evaluation- Goals, EOC’s </li></ul>
    41. 65. Whole-Pancreas Transplantation <ul><li>Operative procedure </li></ul><ul><li>Rejection management </li></ul><ul><li>Long-term effects </li></ul><ul><li>Complications </li></ul><ul><li>Islet cell transplantation hindered by limited supply of beta cells and problems caused by antirejection drugs </li></ul>
    42. 66. Risk for Delayed Surgical Recovery <ul><li>Interventions include: </li></ul><ul><ul><li>Preoperative care </li></ul></ul><ul><ul><li>Intraoperative care </li></ul></ul><ul><ul><li>Postoperative care and monitoring includes care of: </li></ul></ul><ul><ul><ul><li>Cardiovascular </li></ul></ul></ul><ul><ul><ul><li>Renal </li></ul></ul></ul><ul><ul><ul><li>Nutritional </li></ul></ul></ul>
    43. 67. Risk for Injury Related to Sensory Alterations <ul><li>Interventions and foot care practices: </li></ul><ul><ul><li>Cleanse and inspect the feet daily. </li></ul></ul><ul><ul><li>Wear properly fitting shoes. </li></ul></ul><ul><ul><li>Avoid walking barefoot. </li></ul></ul><ul><ul><li>Trim toenails properly. </li></ul></ul><ul><ul><li>Report nonhealing breaks in the skin. </li></ul></ul>
    44. 68. Wound Care <ul><li>Wound environment </li></ul><ul><li>Debridement </li></ul><ul><li>Elimination of pressure on infected area </li></ul><ul><li>Growth factors applied to wounds </li></ul>
    45. 69. Chronic Pain <ul><li>Interventions include: </li></ul><ul><ul><li>Maintenance of normal blood glucose levels </li></ul></ul><ul><ul><li>Anticonvulsants </li></ul></ul><ul><ul><li>Antidepressants </li></ul></ul><ul><ul><li>Capsaicin cream </li></ul></ul>
    46. 70. Risk for Injury Related to Disturbed Sensory Perception: Visual <ul><li>Interventions include: </li></ul><ul><ul><li>Blood glucose control </li></ul></ul><ul><ul><li>Environmental management </li></ul></ul><ul><ul><ul><li>Incandescent lamp </li></ul></ul></ul><ul><ul><ul><li>Coding objects </li></ul></ul></ul><ul><ul><ul><li>Syringes with magnifiers </li></ul></ul></ul><ul><ul><ul><li>Use of adaptive devices </li></ul></ul></ul>
    47. 71. Ineffective Tissue Perfusion: Renal <ul><li>Interventions include: </li></ul><ul><ul><li>Control of blood glucose levels </li></ul></ul><ul><ul><li>Yearly evaluation of kidney function </li></ul></ul><ul><ul><li>Control of blood pressure levels </li></ul></ul><ul><ul><li>Prompt treatment of UTIs </li></ul></ul><ul><ul><li>Avoidance of nephrotoxic drugs </li></ul></ul><ul><ul><li>Diet therapy </li></ul></ul><ul><ul><li>Fluid and electrolyte management </li></ul></ul>
    48. 72. Potential for Hypoglycemia <ul><li>Blood glucose level < 70 mg/dL </li></ul><ul><li>Diet therapy: carbohydrate replacement </li></ul><ul><li>Drug therapy: glucagon, 50% dextrose, diazoxide, octreotide </li></ul><ul><li>Prevention strategies for: </li></ul><ul><ul><li>Insulin excess </li></ul></ul><ul><ul><li>Deficient food intake </li></ul></ul><ul><ul><li>Exercise </li></ul></ul><ul><ul><li>Alcohol </li></ul></ul>
    49. 73. Potential for Hyperglycemic-Hyperosmolar Nonketotic Syndrome and Coma <ul><li>Interventions include: </li></ul><ul><ul><li>Monitoring </li></ul></ul><ul><ul><li>Fluid therapy: to rehydrate the client and restore normal blood glucose levels within 36 to 72 hr </li></ul></ul><ul><ul><li>Continuing therapy with IV regular insulin at 10 units/hr often needed to reduce blood glucose levels </li></ul></ul>
    50. 74. Health Teaching <ul><li>Assessing learning needs </li></ul><ul><li>Assessing physical, cognitive, and emotional limitations </li></ul><ul><li>Explaining survival skills </li></ul><ul><li>Counseling </li></ul><ul><li>Psychosocial preparation </li></ul><ul><li>Home care management </li></ul><ul><li>Health care resources </li></ul>
    51. 76. Diabetes Mellitus Summary <ul><li>Treatable, but not curable. </li></ul><ul><li>Preventable in obesity, adult client. </li></ul><ul><li>Diagnostic Tests </li></ul><ul><li>Signs and symptoms of hypoglycemia and hyperglycemia. </li></ul><ul><li>Treatment of hypoglycemia and hyperglycemia – diet and oral hypoglycemics. </li></ul><ul><li>Nursing implications – monitoring, teaching and assessing for complications. </li></ul>
    53. 78. Any Questions???