Chapter 41

Assessment and Management of Patients With Diabetes Mellitus

Chapter 41

Assessment and Management of Patients With Diabetes Mellitus

Diabetes Mellitus

• A group of diseases characterized by hyperglycemia due to defects in insulin secretion, insulin action, or both

• Affects nearly 21 million people in the United States • Almost 1/3 of cases are undiagnosed • Prevalence is increasing• Minority populations and the elderly are

disproportionately affected

Functions of Insulin

• Transports and metabolizes glucose for energy• Stimulates storage of glucose in the liver and muscle as

glycogen• Signals the liver to stop the release of glucose• Enhances the storage of dietary fat in adipose tissue• Accelerates transport of amino acids into cells• Inhibits the breakdown of stored glucose, protein, and

fat

Classifications of Diabetes

• Type 1 diabetes• Type 2 diabetes• Gestational diabetes• Diabetes mellitus associated with other

conditions or syndromes• See Table 41-1

Type 1 Diabetes

• Insulin producing beta cells in the pancreas are destroyed by an autoimmune process

• Requires insulin, as little or no insulin is produced• Onset is acute and usually before 30 years of age• 5–10% of persons with diabetes

Type 2 Diabetes

• Decreased sensitivity to insulin (insulin resistance) and impaired beta cell function results in decreased insulin production

• 90–95% of person with diabetes• More common in persons over age 30 and in the obese• Slow, progressive glucose intolerance• Treated initially with diet and exercise• Oral hypoglycemic agents and insulin may be used

Pathogenesis of Type 2 Diabetes

Risk Factors

• Type 1: not inherited but a genetic predisposition combined with immunologic and possibly environmental (viral) factors

• Type 2: family history of diabetes, obesity, race/ethnicity, age greater than 45 years, previous identified impaired fasting glucose or impaired glucose tolerance, hypertension ≥ 140/90, HDL ≤ 35 and/or triglycerides ≥ 250, history of gestational diabetes or babies over 9 pounds

• See Chart 41-1

Clinical Manifestations

• “Three Ps”– Polyuria– Polydypsia– Polyphagia

• Fatigue, weakness, vision changes, tingling or numbness in hands or feet, dry skin, skin lesions or wounds that are slow to heal, recurrent infections

• Type 1 may have sudden weight loss, nausea, vomiting, and abdominal pain if DKA has developed

Diagnostic Findings

• Fasting blood glucose 126 mg/dL or more• Random glucose exceeding 200 mg/dL• See Chart 41-3• Gerontologic considerations: age-related

elevation of blood glucose

Treatment goal is to normalize blood glucose levels

• Intensive control dramatically decreases vascular and neuropathic complications

Dietary Management—Goals

• Provide optimal nutrition; all essential food constituents

• Meet energy needs• Achieve and maintain a reasonable weight• Prevent wide fluctuations of blood glucose levels• Decrease serum lipids, if elevated

Role of the Nurse

• Be knowledgeable about dietary management• Communicate important information to the

dietician or other management specialists• Reinforce patient understanding• Support dietary and lifestyle changes

Meal Planning

• Consider food preferences, lifestyle, usual eating times, and cultural/ethnic background

• Review diet history and need for weight loss, gain, or maintenance

• Caloric requirements and calorie distribution throughout the day

• Carbohydrates: 50–60% carbohydrates, emphasize whole grains

• Fat: 20–30%, with >10% from saturated fat and < 300 mg cholesterol

• Fiber• Exchange lists

Glycemic Index

• Describes how much a food increases blood glucose • Combine starchy food with protein and fat containing food

slows absorption, and glycemic response• Raw or whole foods tend to have lower response than cooked,

chopped, or pureed foods• Eat whole fruits rather than juices; decreases glycemic response

due to fiber-slowing absorption• Adding food with sugars may produce lower response if eaten

with foods that are more slowly absorbed

Other Dietary Concerns

• Alcohol• Nutritive and nonnutritive sweeteners• Reading labels

Exercise

• Lowers blood sugar • Aids in weight loss• Lowers cardiovascular risk

Exercise Precautions

• Exercise with elevated blood sugar levels (above 250 mg/dL) and ketones in urine should be avoided

• Insulin normally decreases with exercise; patients on exogenous insulin should eat a 15g carbohydrate snack before moderate exercise to prevent hypoglycemia

• If exercising to control or reduce weight, insulin must be adjusted

• Potential post-exercise hypoglycemia• Need to monitor blood glucose levels

Exercise Recommendations

• Encourage regular daily exercise• Gradual, slow increase in exercise period is encouraged• Modify exercise regimen to patient needs and presence of

diabetic complications or potential cardiovascular problems• Exercise stress test for patients older than age 30 who have

2 or more risk factors is recommended• Gerontologic considerations• See Chart 41-5

Monitoring:

1. Self-Monitoring of blood glucose( SMBG): Enables people with DM to adjust the treatment regimen to obtain optimal blood glucose control. Allow early detection of hypo and hyperglycemia and normalizing blood glucose levels.

• Disadvantages of SMBG are in the need for good visual acuity, fine motor coordination, cognitive ability, comfort with technology, willingness and cost

• Candidates for SMBG: - Unstable DM - A tendency for sever ketosis and hypoglycemia - Hypoglycemia without warning symptoms - Abnormal renal glucose threshold• Frequency: 2-4 times per day is recommended (before meals and

bedtime)

Cont….

2. Glucosylated Hemoglobin: HgbA1c (2-3 month) 3. Urine testing for glucose4. Urine testing for Ketones (Ketonuria): should be performed

whenever patients with type 1 have glucosuria or persistently elevated blood glucose levels ( more than 240mg/dl for two testing periods), and during illness and pregnancy.

Insulin Therapy

• Blood glucose monitoring • Categories of insulin

(see Table 41-3)– Rapid-acting– Short-acting– Intermediate-acting– Very long-acting

• Inhaled insulin

4. Pharmacological therapy:

I. Insulin therapy: taken one or two times per day( or even more often) to control blood glucose. Accurate monitoring of blood glucose levels is essential

• Insulin preparations: - Time course: onset, peak, and duration of action ( rapid acting

(lispro), short acting (HR), intermediat-acting (NPH or Lent), Long acting (Ultralent), and Mixed (70% NPH and 30% R) (table 41-3)

• Source: beef, pork, and Human insulin which is now widly used

Insulin regimens:

1. Conventional regimen: is to simplify the insulin regimen ( 1-2 injections/day). May be appropriate for the terminally ill, unwilling or unable to engage in the self-management activities that are part of amore complex insulin regimen

2. Intensive regimen: 3-4 injection/day to achieve as much control over blood glucose levels as is safe and practical and to decrease complications

Normal Pancreatic Insulin Release

One Injection Per Day

Two Injections Per Day-Mixed

Three or Four Injections Per Day

Insulin Pump

Insulin Pump

Insulin regimens:

1. Conventional regimen: is to simplify the insulin regimen ( 1-2 injections/day). May be appropriate for the terminally ill, unwilling or unable to engage in the self-management activities that are part of amore complex insulin regimen

2. Intensive regimen: 3-4 injection/day to achieve as much control over blood glucose levels as is safe and practical and to decrease complications

Teaching Patients Insulin Self-Management

• Use and action of insulin

• Symptoms of hypoglycemia and hyperglycemia

– Required actions

• Blood glucose monitoring

• Self-injection of insulin: see Charts 41-7 and 41-8

• Insulin pump use

Teaching Patients Insulin Self-Management

• Use and action of insulin• Symptoms of hypoglycemia and

hyperglycemia– Required actions

• Blood glucose monitoring• Self-injection of insulin• Insulin pump use

Complications of insulin therapy:

• The most common complication of insulin therapy is hypoglycemia.

• Local allergic reaction: swelling, redness, tenderness and induration… 2-4 cm wheal may appear in the sight of injection 1-2 hours after injection administered. (occur at the beginning stage of therapy).

• Systemic allergic reactions: Are rare. Can treated with giving small doses of insulin which gradually increased.

• Insulin lipodystrophy: local reaction cause either lipoatrophy or lipohypertrophy (fibrofatty masses) at the site of injection.

Cont…

• Insulin resistance: due to obesity or immune antibodies.

• Morning Hyperglycemia: insufficient level of insulin due to dawn phenomena (normal glucose level up to 3 am when Bld glucose start to rise) and Somogyi effect (nocturnal hypoglycemia followed by rebound hyperglycemia)

- Insulin waning: the progressive increase in blood glucose from bed time to morning and is prevented by moving the evening dose of NPH insulin to bed time

Alternative Methods of insulin therapy:

• Insulin pens• Jet injection: deliver insulin through skin under pressure( absorbed faster)• Insulin pumps: continuous s/c insulin infusion• Implantable and inhalant insulin Delivery.• Transplantation.

Oral Antidiabetic Agents

• Used for patients with type 2 diabetes who cannot be treated with diet and exercise alone.

• Combinations of oral drugs may be used• Major side effect: hypoglycemia • Nursing interventions: monitor blood glucose,

and for hypoglycemia and other potential side effects

• Patient teaching

Sites of Action of Oral Antidiabetic Agents

II- Oral Antidiabetic Agents:

• Used for the treatment for type II Diabetic patients who can’t treated by diet and exercise alone

• Cant be used during pregnancy• Are Five groups:1. Sulfonylureas:• Action: - Stimulating the pancreas to secret insulin. Cant be used with Type I DM - also improve insulin action at the cellular level. - May directly decrease glucose production by the liver.• Side effects: GI symptoms, dermatology reactions and hypoglycemia (most one)

specially with delayed food intake or exercise is increased.• 2nd generation of this group have shorter half- life than 1st generation which make

them safer to use in elderly and even in adults in regards to hypoglycemia

2. Biguanides:

• Metphormin (glucophage).• Action: Facilitating insulin’s action on peripheral receptors sites.• Used in combination with Sulfonylureas agent• Side effects: Hypoglycemia, Lactic acidosis is a potential serious side effect• Contraindicated in patient with renal impairment or at risk for renal

impairment• Nursing measures: renal function should be monitored, should not be

administered 2 days before any diagnostic test requires use of contrast agent.

3. Oral Alpha Glucosidase inhibitors:

• Acarbose (Precose)• Action: Delaying absorption of glucose from the intestinal system resulting in a lower

postprandial blood glucose level. Should be taken immediately before meals.• They are not systemically absorbed. • Side effect: diarrhea and flatulence

4. Thiazolidinedions:• Troglitazone (Rezulin)• First line agent to treat type II DM, in conjunction of diet• Action: enhance insulin action at the receptor site without increasing insulin secretion.• Side effect: can affect liver function, LFT showed be taken as base line and monthly for

12 months• Can cause resumption of ovulation in perimenopausal women putting them at risk for

pregnancy.

Meglitinides:

• Repaglinides (Prandin)• Action: stimulate the release of insulin from the pancreas• Has fast action and short duration and should be taken before each meal.• Side effect: Hypoglycemia

5. Education:• the diabetic patient should be knowledgeable about nutrition, medication

effects and side effects, exercise, disease progression, prevention strategies, monitoring techniques, and medication adjustment.

Acute Complications of Diabetes• Hypoglycemia• Diabetic ketoacidosis (DKA)• Hyperglycemic hyperosmolar nonketotic

syndrome (HHNS), aka hyperosmolar nonketotic coma or hyperglycemia hyperosmolar syndrome (HHS)

Hypoglycemia• Abnormally low blood glucose level (below 50–60

mg/dL)• Causes include too much insulin or oral hypoglycemic

agents, too little food, and excessive physical activity• Manifestations– Adrenergic symptoms: sweating, tremors, tachycardia,

palpitations, nervousness, hunger– Central nervous system symptoms: inability to concentrate,

headache, confusion, memory lapses, slurred speech, numbness of lips and tongue, irrational or combative behavior, double vision, drowsiness

– Severe hypoglycemia may cause disorientation, seizures, and loss of consciousness

Assessment• Onset is abrupt and may be unexpected• Symptoms vary from person to person• Symptoms also vary related to the rapidly of

decrease in blood glucose and usual blood glucose range

• Decreased adrenergic response may affect symptoms in persons who have had diabetes for many years probably related to autonomic neuropathy

Management of Hypoglycemia

• Treatment must be immediate• Give 15 g of fast-acting, concentrated carbohydrate– 3 or 4 glucose tablets– 4–6 ounces of juice or regular soda (not diet soda)– 6–10 hard candies– 2–3 teaspoons of honey

• Retest blood glucose in 15 minutes, retreat if >70 mg/dL or if symptoms persist more than 10–15 minutes and testing is not possible.

• Provide a snack with protein and carbohydrate unless the patient plans to eat a meal within 30–60 minutes.

Emergency Measures

• If the patient cannot swallow or is unconscious:– Subcutaneous or intramuscular glucagon 1 mg– 25–50 mL 50% dextrose solution IV

Diabetic Ketoacidosis (DKA)

• Caused by an absence of or inadequate amount of insulin resulting in abnormal metabolism of carbohydrate, protein, and fat

• Clinical features– Hyperglycemia– Dehydration– Acidosis

• Manifestations include polyuria, polydipsia, blurred vision, weakness, headache, anorexia, abdominal pain, nausea vomiting, acetone breath, hyperventilation with Kussmaul respirations, and mental status changes

Pathophysiology of DKACauses:• 1. Decreased or missed dose of insulin. • 2. illness (stress………> which stimulate the

secretion of certain hormones such as glucagon, epinephrine and norepinephrine, cortisol, and growth hormone….. Promote production of glucose from liver and interfere glucose utilization

3. Undiagnosed and untreated diabetes

Assessment of DKA• Blood glucose levels vary from 300–800 mg/dL• Severity of DKA is not related to blood glucose

level• Ketoacidosis is reflected in low serum bicarbonate

and low pH; low PCO2 reflects respiratory compensation

• Ketone bodies in blood and urine• Electrolytes vary according to water loss and level

of hydration

Prevention• “Sick day rules”• Assess for underlying causes• Diagnosis and proper management of

diabetes

Treatment of DKA

• Rehydration with IV fluid• IV continuous infusion of regular insulin• Reverse acidosis and restore electrolyte balance• Note: rehydration leads to increased plasma

volume and decreased K+, insulin enhances the movement of K+ from extracellular fluid into the cells

• Monitor – Blood glucose and renal function/UO – EKG and electrolyte levels—Potassium– VS, lung assessments, signs of fluid overload

Hyperglycemic Hyperosmolar Nonketotic Syndrome

• Hyperosmolality and hyperglycemia occur due to lack of effective insulin. Ketosis is minimal or absent.

• Hyperglycemia causes osmotic diuresis with loss of water and electrolytes; hypernatremia, and increased osmolality occur.

• Manifestations include hypotension, profound dehydration, tachycardia, and variable neurologic signs due to cerebral dehydration.

• High mortality.

Treatment of HHNS• Rehydration • Insulin administration• Monitor fluid volume and electrolyte status• Prevention– BGSM– Diagnosis and management of diabetes– Assess and promote self-care management skills

Long-Term Complications of Diabetes• Macrovascular complications– Accelerated atherosclerotic changes– Coronary artery disease, cerebrovascular disease,

and peripheral vascular disease • Microvascular complications– Diabetic retinopathy, nephropathy

• Neuropathic changes– Peripheral neuropathy, autonomic neuropathies,

hypoglycemic unawareness, neuropathy, sexual dysfunction

sensorimotor polyneuropathy

• : parasthesias, burning sensations, feet become numb, decrease awareness of position and WT of objects, decrease sensation of light touch lead to an unsteady gait, decrease sensation of pain and temperature

Clinical manifestation:

1. Cardiovascular: Slight tachycardia, orthostatic hypotension, silent or painless myocardial ischemia and infarction

2. Gastrointestinal: Delayed gastric emptying, bloating ,nausea, and vomiting, Diabetic constipation or diarrhea may occur.

3. Urinary: Urinary retention, decreased sensation of bladder fullness, increase risk of UTI.

4. Adrenal gland (Hypoglycemic Unawareness): Diminished or absent of adrenegic symptoms of hypoglycemia

5. Sudomotor neuropathy: decrease or absence of sweating of the extremities, with a compensatory increase in upper body sweating. Dryness of feet increase the risk of foot ulcer

6. Sexual dysfunction: impotence in men ( This complication makes the patients to seek health and mainly DM discovered after that).

Diabetic RetinopathyRefer to fig. 41-8

Neuropathic Ulcers

Diabetic foot:

• Three diabetic complications increase risk of foot infection:1. Neuropathy: sensory neuropathy leads to loss of pain and pressure

sensation, autonomic neuropathy lead to increase dryness and fissuring of the skin

2. Peripheral vascular disease: poor circulation…. Poor wound healing3. Immunocompramise DM impairs the ability of specialized WBC’s to

destroy bacteria.

Medical management: Control of Glucose level, bed rest, antibiotic, debridement.

Nursing management:

Nursing Process: The Care of the Patient with Diabetes—Assessment

• Assess the primary presenting problem• In addition, assess needs related to diabetes• Patient knowledge of diabetes and diabetes

care skills• Blood glucose levels• Skin assessment• Preventative health measures• See Chart 41-4

Teaching Patients Self-Care• Assess knowledge and adherence to plan of care.• Provide basic information about diabetes, its cause

and symptoms, and acute and chronic complications and their treatment.

• Teach self-care activities to prevent long-term complications including foot care, eye care, and risk-factor management.

• Include family in plan of care.• Provide information, encourage health promotion

activities, and recommended health screenings.