Diabetes nursing, medical, surgical managements

1. Diabetes Mellitus
MEDICAL AND SURGICAL MANAGEMENTS
Diagnostic Evaluation
o FBS ≥ 126 mg/dL
o Random blood glucose ≥ 200 mg/dL with classic symptoms (polyuria, polydipsia, polyphagia, weight loss)
o OGTT ≥ 200 mg/dL on the 2-hour sample
 Tests for glucose control over time are glycated hemoglobin and fructosamine assay.
Management
Diet
 Dietary control with caloric restriction of carbohydrates and saturated fats to maintain ideal body weight.
 The goal of meal planning is to control blood glucose and lipid levels.
Meal Planning Guidelines
PRINCIPLE ACTION
Each meal should consist of a balance of carbohydrates, proteins, and Carbohydrates should be varied to include fruits, starches, and vegetables.
fats. Protein selections that are lean will help reduce fat and cholesterol intake.
Fats should be used sparingly with <10% of total calories derived from saturated fats. High in
calories, fats contribute to weight gain in type 2 diabetes mellitus (DM).
Consistency in timing of meals and amounts of food eaten on a day-to- Avoid skipping or delaying meals.
day basis help regulate blood glucose levels. Measure portion sizes using a scale or measuring cups.
Know the equivalent amounts of commonly used foods within a food group, eg, 1 slice of bread = ½
cup cooked pasta.
Increase the intake of soluble and insoluble fiber. Substitute foods high in fiber for processed foods when possible, eg, whole-grain bread in place of
white bread.
Eat fresh fruit and vegetables in place of juices.
Avoid salt whenever possible. Do not season foods with salt or salt-containing spices.
Limit use of foods with “hidden”• sodium content (eg, crackers, pickled foods, cheese, processed
meats).
Use salt-containing condiments sparingly (ketchup, soy sauce, gravies, bouillon).
Prepare foods to retain vitamins and minerals and reduce fats. Do not fry foods.
Bake, broil, or boil foods and discard fat.
Eat raw fruits and vegetables or steam vegetables to retain fiber.
Avoid adding calories with butter or cream sauces, fat back, and bacon.
Trim all visible fat from meat; skim off fat from stews or other prepared dishes.
Distribute snacks in the meal plan depending on insulin/medication Smaller, more frequent meals may enhance glucose control in type 2 DM.
regimens, physical activity, and lifestyle. Unplanned activity may call for an additional snack to avoid hypoglycemia.
Use alcohol only in moderation. Always consume alcohol with food to avoid hypoglycemia.
1

2. Do not omit food from meal plan in exchange for alcohol.
Limit intake to 1-2 drinks per week (4 oz dry wine, 12 oz beer, or 1.5 oz distilled liquor = 1 alcohol
serving).
Use alternative nonnutritive, noncaloric sweeteners in moderation. Limit “diet” soda intake to 2 L/day.
Avoid frequent use of foods and beverages with concentrated sucrose.
 Weight reduction is a primary treatment for type 2 diabetes.
Exercise
Regularly scheduled, moderate exercise performed for at least 30 minutes most days of the week promotes the utilization of carbohydrates, assists with weight control,
enhances the action of insulin, and improves cardiovascular fitness.
Medication
 Oral antidiabetic agents for patients with type 2 diabetes who do not achieve glucose control with diet and exercise only.
Oral Antidiabetic Agents
AGENT HOW GIVEN
Second-Generation Sulfonylureas
Glyburide (Micronase, DiaBeta) 1.25-20 mg in single or divided dose with meals
Glyburide, micronized (Glynase) 0.75-12 mg in single or divided dose
Glipizide (Glucotrol) 2.5-40 mg in single dose or divided dose with meals
Glipizide (Glucotrol XL) 5-20 mg in single dose before breakfast
Glimepiride (Amaryl) 1-8 mg in single dose with first main meal
Biguanides
Metformin (Glucophage) 500-2,550 mg in 2-3 divided doses with meals
Metformin (Glucophage XR) 500-2,000 mg daily with evening meal
Alpha-Glucosidase Inhibitors
Acarbose (Precose) 150-300 mg in 3 doses with meals; if < 60 kg, maximum dose 50 mg tid
Miglitol (Glyset) 150-300 mg in 3 divided doses with meals
Meglitinide Analogue
Repaglinide (Prandin) 0.5-16 mg in 2-4 divided doses within 30 minutes of starting meal; if meal is skipped, do not take
dose
Amino Acid Derivative
Nateglinide (Starlix) 120-360 mg in 3 divided doses within 30 minutes of starting meal; if meal is skipped, do not take
dose
Thiazolidinediones
Rosiglitazone (Avandia) 4-8 mg in a single dose or 2 divided doses
Pioglitazone (Actos) 15-45 mg in single dose
Combination Agents
Glyburide/metformin (Glucovance) Up to 20/2,000 mg/day in single dose or divided doses
Glipizide/metformin (Metaglip) Up to 20/2,000 mg/day in single dose or divided doses

3. Rosiglitazone/metformin (Avandamet) Up to 8/2,000 mg/day in divided doses
o Act by a variety of mechanisms, including stimulation of insulin secretion from functioning beta cells, reduction of hepatic glucose production, enhancement of
peripheral sensitivity to insulin, and reduced absorption of carbohydrates from the intestine.
o Sulfonylureas and meglitinide analogues may cause hypoglycemic reactions.
o Biguanides, alpha-glucosidase inhibitors, and meglitinide analogues may cause significant flatus and GI adverse effects.
 Insulin therapy for patients with type 1 diabetes who require replacement.
Insulin Onset, Peak, and Duration
INSULIN ONSET PEAK DURATION
Immediate-acting
(lispro, aspart) 0.25 hour 0.5-1 hour 5 hours
Short-acting
(regular, semilente) 0.5-1 hour 2-4 hours 5-7 hours
Intermediate-acting
(NPH, lente) 1-3 hours 6-12 hours 18-24 hours
Long-acting
(ultralente) 4-6 hours 10-30 hours 24-36 hours
(insulin glargine) 1 hour none 24+1 hours
Mixed
(Regular 30%, NPH 70%) 0.5 hour 2-12 hours 24 hours
(Regular 50%, NPH 50%) 0.5 hour 3-5 hours 24 hours
(Lispro 25%, NPH 75%) 0.25 hour 0.5-1.5 hours 24 hours
(Aspart 30%, NPH 70%) 0.25 hour 1-4 hours 24 hours
o May also be used for type 2 diabetes when unresponsive to diet, exercise, and oral antidiabetic therapy.
o Hypoglycemia may result as well as rebound hyperglycemia (Somogyi effect).
o Commonly results in increased appetite and weight gain.
General Health
The American Diabetes Association (2003) recommends the following goals of treatment.
 Glycemic control
o HbA1c < 7%
o Preprandial glucose 90 to 130 mg/dL
o Peak postprandial glucose < 180 mg/dL
 BP < 130/80 mm Hg
 Lipid control
o Low-density lipoprotein < 100 mg/dL
o High-density lipoprotein > 40 mg/dL
o Triglycerides < 150 mg/dL
 Microalbumin (spot urine) < 30 mcg/mg creatinine

4. NURSING MANAGEMENT
IDEAL
Nursing Diagnoses
 Imbalanced Nutrition: More than Body Requirements related to intake in excess of activity expenditures
 Fear related to insulin injection
 Risk for Injury (hypoglycemia) related to effects of insulin, inability to eat
 Activity Intolerance related to poor glucose control
 Deficient Knowledge related to use of oral hypoglycemic agents
 Risk for Impaired Skin Integrity related to decreased sensation and circulation to lower extremities
 Ineffective Coping related to chronic disease and complex self-care regimen
 Deficient fluid volume
 Disabled family coping
 Disturbed sensory perception: Visual, tactile
 Imbalanced nutrition: Less than body requirements
 Impaired skin integrity
 Impaired urinary elimination
 Ineffective coping
 Ineffective tissue perfusion: Renal, cardiopulmonary, peripheral
 Risk for infection
 Risk for injury
 Sexual dysfunction
Nursing Interventions
 Keep accurate records of vital signs, weight, fluid intake, urine output, and calorie intake.
 Monitor serum glucose and urine acetone levels.
 Monitor patient for acute complications of diabetes therapy, especially hypoglycemia (vagueness, slow cerebration, dizziness, weakness, pallor, tachycardia,
diaphoresis, seizures, and coma).
 If the patient experiences a hypoglycemic episode, immediately give a carbohydrate in the form of fruit juice, hard candy, honey or, if the patient is unconscious,
glucagon or I.V. dextrose.
 Also, be alert for signs and symptoms of hyperosmolar coma (polyuria, thirst, neurologic abnormalities, and stupor); this hyperglycemic crisis requires I.V. fluids and
insulin replacement.
 Monitor diabetic effects on the cardiovascular system (such as cerebrovascular, coronary artery, and peripheral vascular impairment) and on the peripheral and
autonomic nervous systems.
 Provide meticulous skin care, especially to the feet and legs.
 Treat all injuries, cuts, and blisters.
 Avoid constricting hose, slippers, or bed linens.
 Observe the patient for signs of urinary tract and vaginal infection.

5.  Encourage adequate fluid intake.
 Monitor the patient for signs and symptoms of diabetic neuropathy (numbness or pain in the hands and feet, footdrop, and neurogenic bladder).
 Consult a dietitian to plan a diet with the recommended allowances of calories, protein, carbohydrates, and fats, based on the patient's particular requirements.
 Encourage the patient to verbalize feelings about diabetes and its effects on lifestyle and life expectancy.
 Offer emotional support and a realistic assessment of his condition.
 Stress that with proper treatment he can have a near-normal lifestyle and life expectancy.
 Help the patient develop coping strategies.
 Refer him and his family to a counselor, if necessary. Encourage them to join a support group.