Diabetes Part 2


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Diabetes Part 2

  1. 1. Care of Clients with Diabetes Mellitus <br />1<br />Part2 - Complications<br />
  2. 2. Somogyi effect<br />Periods of hypoglycemia followed by rebound hyperglycemia<br />Hypoglycemia causes some diabetics to release epinephrine <br />Decrease evening dose or move to bedtime<br /> or increase bedtime snack<br />Diagnose with a 2 or 3 am blood sugar<br />2<br />
  3. 3. Dawn phenomenon<br />Nocturnal release of growth hormone- leads to an increase in glucose around 4-8 am; normal for everyone<br />Treat with increase of evening insulin or move supper insulin to bedtime<br />More severe in adolescence<br />3<br />
  4. 4. Acute complications<br />Hypoglycemia<br />Diabetic ketoacidosis: DKA<br />Hyperosmolar hyperglycemic syndrome: HHS<br />4<br />
  5. 5. Hypoglycemia-causes<br />Too little food- or delayed<br />Too much diabetic medicine<br />Too much exercise without compensation<br />Alcohol intake without food<br />5<br />
  6. 6. Hypoglycemia- symptoms<br />Tremors, Nervousness<br />Irritability, personality changes, abnormal behavior<br />Cool, clammy skin with diaphoresis<br />Increased heart rate<br />Hunger, Headache<br />Unsteady gait, slurred or incoherent speech<br />Vision changes: double or blurred vision<br />Seizures, coma<br />6<br />
  7. 7. Hypoglycemia- management<br />Immediate ingestion of 15 g. of simple CHO<br />4 oz of juice<br />4 oz of regular soda<br />1 tablespoon of honey or syrup<br />2 tablespoons of raisins<br />3-4 hard candy<br />Commercial dextrose product: 3-4 tablets<br />7<br />
  8. 8. Hypoglycemia- management <br />Repeat tx if no improvement in 15 min.<br />If not eating a regular meal within the next <br /> 1-2 hours follow with additional food that contains protein & CHO<br />4 oz milk, slice of bread, peanut butter & crackers<br />8<br />
  9. 9. Hypoglycemia- severe reaction<br />50% Dextrose: IV<br />20-50 ml<br />Followed by infusion of D5W<br />Glucagon: subcutaneous or IM<br />.5- 1 mg<br />Raises the blood glucose level by 20-30 within a few minutes<br />Person should eat as soon as regain consciousness<br />Causes N/V<br />9<br />
  10. 10. Glucagon<br />Glucagon can cause vomiting, so be sure to place the person on his or her side prior to injecting so they do not choke. After injecting glucagon, follow with food once the person regains consciousness and is able to swallow. <br />10<br />
  11. 11. Hypoglycemia: severe<br />Glucose gel or cake icing gel can be put on the cheek inside the mouth<br />Honey rubbed into gums also has worked<br />Inform patients to always wear medical alert identification<br />11<br />
  12. 12. Hypoglycemia: severe<br />15 grams of fast acting CHO will raise blood glucose by approximately 45 points in 10-15 minutes<br />Do not treat with high-fat foods: chocolate, ice cream<br />Over treatment is common<br />12<br />
  13. 13. Diabetic ketoacidosis (DKA)- etiology<br />Too little insulin with increased caloric intake<br />Physical or emotional stress<br />Undiagnosed DM<br />13<br />
  14. 14. DKA: Too little insulin<br />Glucose cannot enter cells & be used for cellular energy<br />Body releases & breaks down stored fats & proteins to provide needed energy<br />Free fatty acids from stored triglycerides are released & metabolized in the liver in such large amounts that ketones are formed. <br />Excess ketones- Acidosis<br />14<br />
  15. 15. DKA-Pathophysiology<br />Hyperosmolarity: hyperglycemia (glucose &gt; 250) dehydration (serum osmolarity normal or just above normal)<br />Fluid & electrolyte imbalance: osmotic diuresis<br />Metabolic Acidosis<br />PH &lt; 7.30 Norm: 7.35- 7.45<br />HCO3 &lt; 15 Norm: 22-26<br />Urinary ketones &gt;3+ Norm: 0<br />15<br />
  16. 16. DKA- symptoms<br />Develops rapidly over 24 hours<br />Increased blood glucose- &gt; 250 mg/dl<br />Abdominal pain, N/V<br />Kussmaul’s respiration<br />Acetone noted on breath- fruity <br />Hypotension<br />16<br />
  17. 17. DKA- treatment<br />Insulin: IV infusion of regular insulin<br />Replacement of fluids to correct hypovolemia<br />NS 10-20 ml/kg of body weight over first 1-2 hours<br />17<br />
  18. 18. DKA- treatment<br />Correct electrolyte imbalance<br />Changes in serum potassium, calcium, magnesium, & phosphate can occur<br />Hyperkalemic: potassium can’t get into the cells without insulin. When administer insulin the potassium reenters the cell & patient runs a risk for hypokalemia<br />18<br />
  19. 19. DKA: Nursing Interventions<br />Take hourly glucose levels<br />Obtain ABG’s<br />Monitor electrolytes every 1-4 hours<br />Cardiac monitor to watch for dysrhythmias <br />Assess every 1-4 hours<br />VS<br />Urine output<br />Neurologic status<br />19<br />
  20. 20. DKA: complication<br />Cerebral edema<br />Can occur 6-10 hours within start of treatment<br />Occurs when blood glucose falls too rapidly: causing fluid to shift into the brain cells<br />Can also occur with sodium levels dropping too rapidly. Fluid replacement must be monitored carefully<br />20<br />
  21. 21. DKA<br />Once the patient’s blood glucose is stable and the patient can have food by mouth or through a feeding tube, subcutaneous insulin can begin<br />Give first subcutaneous insulin 1-2 hours before you discontinue the insulin infusion<br />21<br />
  22. 22. Sick Day Management<br />When sick:<br />Always take diabetes medicine<br />Test glucose at least every 4 hours <br />Call the doctor if:<br />Blood glucose consistently &gt; 250 mg/dl<br />Ketone test is moderate to high<br />Feel sick & vomit<br />Think you might have an infection<br />Keep well hydrated<br />Replace foods with liquids that contain CHO <br />22<br />
  23. 23. Hyperosmolar hyperglycemic syndrome- HHS<br />Severe hyperglycemia &gt; 600 mg/dl<br />Takes days or weeks to fully develop<br /> Type 2 diabetes with diminished renal function &/or cardiac disease<br />23<br />
  24. 24. HHS<br />Causes:<br /> infection: UTI, pneumonia, sepsis<br /> inadequate adherence with insulin regimen<br /> new diagnosis of diabetes<br />Triggers: <br /> MI & CVA<br /> Surgery<br /> Pancreatitis<br />Medications<br /> Pregnancy<br />24<br />
  25. 25. HHS- symptoms<br />Reflect dehydration & altered CHO, fat, & protein metabolism<br />Thirst<br />Tachycardia<br />Polyuria<br />Fatigue<br />Weight loss<br />Blurred vision<br />Altered mental status<br />Coma<br />25<br />