6685869 diabetes mellitus
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Nur 105Adult Health I
DIABETES MELLITUSJackie C. Williams, RN-C, MSN
Shelton State Community College
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DEFINITIONDIABETES MELLITUS
An endocrine disorder in which there is insufficient amount or lack of insulin secretion to metabolize carbohydrates.
It is characterized by hyperglycemia, glycosuria and ketonuria.
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Diabetes MellitusPathophysiology
The beta cells of the Islets of Langerhan of the Pancreas gland are responsible for secreting the hormone insulin for the carbohydrate metabolism.
Remember the concept - sugar into the cells.
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Diabetes MellitusTypes
Type 1 - IDDM little to no insulin
produced 20-30% hereditary Ketoacidosis
Gestational overweight; risk for
Type 2
Type 2 - NIDDM some insulin
produced 90% hereditary
Other types include Secondary Diabetes : Genetic defect beta cell
or insulin Disease of exocrine
pancreas Drug or chemical
induced Infections-pancreatitits Others-steroids,
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Absence of Insulin Hyperglycemia Polyuria Polydipsia Polyphagia Hemoconcentration, hypervolemia,
hyperviscosity, hypoperfusion, and hypoxia
Acidosis, Kussmaul respiration Hypokalemia, hyperkalemia, or normal
serum potassium levels
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Assessment History Blood tests
Fasting blood glucose test: two tests > 126 mg/dL
Oral glucose tolerance test: blood glucose > 200 mg/dL at 120 minutes
Glycosylated hemoglobin (Glycohemoglobin test) assays
Glucosylated serum proteins and albumin FSBS – (finger stick) monitoring blood sugar
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Urine Tests
Urine testing for ketones Urine testing for renal function Urine testing for glucose
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Diabetes MellitusClinical Manifestation
Hyperglycemia Three P’s -
Polyuria
Polyphagia
Polydispsia
Gradual Onset
Hypoglycemia Weak, diaphoretic,
sweat, pallor, tremors, nervous, hungry, diplopia, confusion, aphasia, vertigo, convulsions
Treatment - OJ with sugar, or IV glucose
Sudden onset
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Hyperglycemia - Clinical Manifestations
Three P’s – polyuria, polydypsia,
polyphagia Glycosuria Dehydration Hypotension Mental Changes
Fever Hypokalemia Hyponatremia Seizure Coma
Life Threatening!!!
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Risk for Injury Related to Hyperglycemia
Interventions include: Dietary interventions, blood glucose
monitoring, medications Oral Drugs Therapy
(Continued)
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Risk for Injury Related to Hyperglycemia (Continued)
Oral therapy Sulfonylurea agents Meglitinide analogues Biguanides Alpha-glucosidase inhibitors Thiazolinedione antidiabetic agents
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Oral HypoglcemiasKey Points
Monitor serum glucose levels Teach patient signs and symptoms of
hyper/hypoglycemia Altered liver, renal function will affect
medication action Avoid OTC meds without MD approval Assess for GI distress and sensitivity Know appropriate time to administer med
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Diet Therapy Goals of diet therapy Principles of nutrition in diabetes
Protein, fats and carbohydrates, fiber, sweeteners, fat replacers
Alcohol Food labeling Exchange system, carbohydrate
counting Special considerations for type 1 and
type 2 diabetes
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Diabetes MellitusDiet
American Diabetic Association
Food groups/ exchanges
Carbohydrates - 60%
Fats - 30% Protein - 12-20%
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Diabetes - Monitoring Glucose Levels
Urine - Ketones
FSBS
Wear ID Bracelet
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Diabetes - TreatmentExercise
Purpose - controls blood glucose and lowers blood glucose
Purpose - reduce the amount of insulin needed
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Exercise Therapy
Benefits of exercise Risks related to exercise Screening before starting exercise
program Guidelines for exercise Exercise promotion
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Drug Therapy Drug administration Drug selection Insulin therapy:
Insulin analogue Short-acting insulin Concentrated insulin Intermediate
(Continued)
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Drug Therapy (Continued)
Fixed-combination Long-acting Buffered insulins
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Insulin Regimens
Single daily injection protocol Two-dose protocol Three-dose protocol Four-dose protocol Combination therapy Intensified therapy regimens
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Pharmacokinetics of Insulin
Injection site Absorption rate Injection depth Time of injection Mixing insulins
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Complications of Insulin Therapy
Hypoglycemia Lipoatrophy Dawn phenomenon Somagyi's phenomenon
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Alternative Methods of Insulin Administration
Continuous subcutaneous infusion of insulin
Implanted insulin pumps Injection devices New technology includes:
Inhaled insulin Transdermal patch (being tested)
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Client Education
Storage and dose preparation Syringes Blood glucose monitoring Interpretation of results Frequency of testing Blood glucose therapy goals
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Diabetic Education - Preventive Medicine
Proper skin and foot care
Proper Eye Exam
Proper diet and fluids
Diabetic Neuropathy
Diabetic Retinopathy
Diabetic Nephropathy
Diabetic gastroparesis
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Diabetes MellitusComplications
Hyperglycemia
Hypoglycemia
Diabetic Ketoacidosis
Hyperosmolar Hyperglycemic
Nonketotic Syndrome
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Acute Complications of Diabetes
Diabetic ketoacidosis Hyperglycemic-hyperosmolar-
nonketotic syndrome Hypoglycemia from too much
insulin or too little glucose
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Diabetic Ketoacidosis
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Potential for Diabetic Ketoacidosis
Interventions include: Monitoring for manifestations Assessment of airway, level of
consciousness, hydration status, blood glucose level
Management of fluid and electrolytes(Continued)
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Potential for Diabetic Ketoacidosis (Continued)
Drug therapy goal: to lower serum glucose by 75 to 150 mg/dL/hr
Management of acidosis Client education and prevention
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Complication – KetoacidosisTreatment
Patent airway Suctioning Cardiac monitoring Vital Signs Central venous
pressure Blood work – ABG,
BS, chemistry panel
Administration of Na Bicarb
Foley – monitor urinary output
I & O Frequent
Repositioning
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Complication – HHNCHyperosmolar Hyperglycemic
Non-Ketotic Coma Fluid moves from
inside to outside cell vausing diuresis and loss of Na+ and K+
Treatment - Give insulin and correct fluid and electrolytes imbalance
Signs and Symptoms Hypotension Mental changes Dehydration Hypokalemia Hyponatremia
Life Threatening!!!
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Chronic Complications of Diabetes
Cardiovascular disease Cerebrovascular disease Retinopathy (vision) problems Diabetic neuropathy Diabetic nephropathy Male erectile dysfunction
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Diabetes MellitusNursing Process
Assessment – Medicines, Allergies, Symptoms, Family Hx
Nursing Diagnosis- Anxiety and Fear, Altered
Nutrition, Pain, Fluid Volume Deficit
Planning – Address the nursing diagnosis
Implementation – Prevent complications, monitor
blood sugars, administer meds and diet, teach diet
and meds, Asess , Assess, Assess
Evaluation- Goals, EOC’s
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Whole-Pancreas Transplantation
Operative procedure Rejection management Long-term effects Complications Islet cell transplantation hindered by
limited supply of beta cells and problems caused by antirejection drugs
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Risk for Delayed Surgical Recovery
Interventions include: Preoperative care Intraoperative care Postoperative care and monitoring
includes care of: Cardiovascular Renal Nutritional
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Risk for Injury Related to Sensory Alterations
Interventions and foot care practices: Cleanse and inspect the feet daily. Wear properly fitting shoes. Avoid walking barefoot. Trim toenails properly. Report nonhealing breaks in the skin.
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Wound Care
Wound environment Debridement Elimination of pressure on infected
area Growth factors applied to wounds
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Chronic Pain
Interventions include: Maintenance of normal blood glucose
levels Anticonvulsants Antidepressants Capsaicin cream
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Risk for Injury Related to Disturbed Sensory Perception: Visual
Interventions include: Blood glucose control Environmental management
Incandescent lamp Coding objects Syringes with magnifiers Use of adaptive devices
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Ineffective Tissue Perfusion: Renal
Interventions include: Control of blood glucose levels Yearly evaluation of kidney function Control of blood pressure levels Prompt treatment of UTIs Avoidance of nephrotoxic drugs Diet therapy Fluid and electrolyte management
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Potential for Hypoglycemia Blood glucose level < 70 mg/dL Diet therapy: carbohydrate
replacement Drug therapy: glucagon, 50%
dextrose, diazoxide, octreotide Prevention strategies for:
Insulin excess Deficient food intake Exercise Alcohol
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Potential for Hyperglycemic-Hyperosmolar Nonketotic Syndrome and Coma
Interventions include:MonitoringFluid therapy: to rehydrate the client and restore normal blood glucose levels within 36 to 72 hrContinuing therapy with IV regular insulin at 10 units/hr often needed to reduce blood glucose levels
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Health Teaching Assessing learning needs Assessing physical, cognitive, and
emotional limitations Explaining survival skills Counseling Psychosocial preparation Home care management Health care resources
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Diabetes MellitusSummary
Treatable, but not curable. Preventable in obesity, adult client. Diagnostic Tests Signs and symptoms of hypoglycemia and
hyperglycemia. Treatment of hypoglycemia and
hyperglycemia – diet and oral hypoglycemics. Nursing implications – monitoring, teaching
and assessing for complications.