diabetes mellitus maura lindenfeld, rn, msn, cpnp cook children’s medical center
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Diabetes Mellitus Maura Lindenfeld, RN, MSN, CPNP Cook Children’s Medical Center. Diabetes Mellitus:. A group of disorders characterized by hyperglycemia with disturbed carbohydrate, protein, and fat metabolism associated with a relative or absolute deficiency of insulin. Type 1 Diabetes. - PowerPoint PPT PresentationTRANSCRIPT
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Diabetes Mellitus
Maura Lindenfeld, RN, MSN, CPNP
Cook Children’s Medical Center
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Diabetes Mellitus:
A group of disorders characterized by hyperglycemia
with disturbed carbohydrate, protein, and fat metabolism associated with a relative or
absolute deficiency of insulin.
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Type 1 Diabetes
–Insulin Dependent Diabetes Mellitus (IDDM)• autoimmune mediated• insulin deficient
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Type 2 Diabetes
–Type 2 Diabetes–Non-Insulin Dependent Diabetes
Mellitus• insulin resistance• typically family history related• obesity
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Normal Glucose Tolerance
• Fasting BG <100mg/dl • 2-hour post glucose <140
mg/dl
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Impaired Glucose
Impaired Fasting GlucoseImpaired Glucose Tolerance
…a metabolic state intermediate between normal blood glucose and diabetes
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Impaired Fasting Glucose (IFG)
• FBS 100mg/dl but 126 mg/dl
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Impaired Glucose Tolerance (IGT)
• 2 hour post glucose 140mg/dl and 200mg/dl
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Goals of Therapy
• Good blood sugar control• Improved quality of life • Routine• Minimize risk for hypoglycemia• Minimize risk for long-term
complications
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Goals of Therapy
Age Blood Glucose<7yrs 80-200 mg/dl7-11yrs 80 -180 mg/dl>12yrs 80-150 mg/dl
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HbA1C
Not a diagnostic tool• Provides a means to
monitor diabetes therapy• 3 month average blood
glucose • Under 8 is great! (within
1 ½ SD of non-diabetic range)
• At puberty, encourage control in the 7’s.
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Type 2
• Hyperinsulinemia
• Insulin resistance
• Acanthosis Nigricans
• Insulin levels may be low or normal
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Type 2
• Not always insulin-dependent
• Not prone to ketosis-prone under normal circumstances
• Onset may occur at any age, children are being diagnosed earlier and earlier.
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Obesity• 15 – 20% of children and adolescents are
obese
• 62% of total population are obese,childhood obesity has increased by 25% since 2000
• On average, we consume 150 – 250 calories per day more than we did 10 years ago
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Obesity• Decreased physical activity has
contributed to increase in obesity• Increases risks of Type 2 Diabetes,
hypercholesterolemia, hypertriglyceridemia, hypertension, vascular disease
• Prevalence of acanthosis nigricans and insulin resistance increases with the degree of obesity
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Acanthosis Nigricans
“…is a skin lesion characterized by brown, velvety, hyperkeratotic plaques most often found in the axillae, the back of the neck, and other flexural areas.”
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Mild
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Moderate-to-Severe
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Severe
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Type 2 Treatment
• Diet– 45 grams of carbohydrates per meal– Small snacks (if any)– Reduced calorie intake 1500cals/day
• Exercise– 30 minutes of UNINTERRUPTED
exercise daily
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Type 2 -Treatment• Medications
– Actos and Avandia• Taken with meals• Can cause hypoglycemia• Not approved for the use in children
– Glucophage• twice a day with food• Does NOT cause hypoglycemia
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Insulin Regimens
• Conventional - 2 shots/day of short and intermediate insulin
• Intensive - 3 or more shots/day– Lantus or Levamir and Humalog, Novolog or Apidra– NPH and Humalog, Novolog or Apidra– Insulin Pumps
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Insulin Curves
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Insulin Curves
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Insulin Types
Insulin Type Onset (hrs) Peak (hrs) Duration
Humalog 0.25 0.5 – 1.5 3 – 5
Novolog 0.25 0.5 – 1.5 3 - 5
Apidra 0.1 0.25- 1.0 2 - 4
Regular 0.5 – 1 2 – 3 6 – 8
NPH 1 – 1.5 6 – 8 12 – 18
Lantus 0.5 – 1 4-6 24
Levemir 0.5 – 1 4-6 12- 24
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Injection Sites
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Hyperglycemia
• Causes– Incorrect dose or missed dose– Eating more than allowed by meal plan
(incorrect carbohydrate counting)– Not enough exercise– Illness or infection
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Hyperglycemia
• Onset– Symptoms present more slowly than
hypoglycemia– May progress to ketoacidosis and coma
if undetected
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Symptoms of Hyperglycemia
• Polyuria, polydipsia, polyphagia• Hunger• Blurred vision• Headache• Emotional lability• Flushing• Yeast infections
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Treatment of Hyperglycemia
• Insulin– Extra short acting insulin to correct
for highs– Adjust long acting insulin dose
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Treatment of Hyperglycemia
• Hydration– Depending on the duration of
hyperglycemia May have mild to moderate volume loss• replace fluids orally if tolerated
• Exercise (as long as ketones are negative)
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Correction Factor
• Typical format – For blood glucoses >150 mg/dl give:
150 – 199 1 unit Humalog200 – 249 2 unit Humalog250 – 299 3 units Humalog300 – 349 4 units Humalog350 – 399 5 units Humalog400 – 449 6 units Humalog>450 call endocrinologist on-call
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Hypoglycemia
• Causes– Incorrect dose (too much insulin)– Missed meal or snack– Incomplete meal or snack– Unplanned or excess exercise– Illness– Alcohol consumption
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Hypoglycemia
• Onset– Sudden– May progress to loss of consciousness or
seizure if untreated
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Symptoms of Hypoglycemia
• Autonomic or adrenergic• Shakiness, trembling• Anxiety, nervousness• Weakness• Hunger• Sweating• Nausea, vomiting
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Symptoms of Hypoglycemia
• CNS – Headache– Visual changes– Lethargy– Irritability, restlessness– Confusion– Somnolence, protracted sleep, stupor
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Symptoms of Hypoglycemia
– Hypothermia– Seizures– Bizarre neurologic signs
• Motor• Sensory• Loss of intellectual ability• Personality changes
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Treatment of Hypoglycemia
• Blood Glucose <70 mg/dl• Give 15g carbohydrates: 4 oz of juice,
6 oz of regular soda, 8 oz of milk,3–4 glucose tablets,6 life savers
• Recheck blood glucose in 15 minutes and retreat if blood glucose remains <70 mg/dl, if>70mg/dl give a 15g snack of complex carbohydrates
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Treatment of Hypoglycemia
• If unable to take oral treatment– Glucagon
• <20 kg give 0.5 mg IM or SQ• >20 kg give 1 mg IM or SQ
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Disposable Needles
Why to use a needle once, only once
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Why shot site rotation matters
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KetonesPathophysiology
• Relative or absolute insulin deficiency (diabetes) causes glucose (starvation) and results in the metabolism of fat for energy
• Ketones are a result of fat metabolism– Acetoacetate and -hydroxybutyrate
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Causes of Ketosis
• New diagnosis• Not enough insulin• Illness or infection• Stress
–Emotional or physical• Starvation ketosis
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Symptoms of Ketosis
• Fruity odor of breath or urine (acetone/nail polish odor)
• Abdominal pain• Nausea/vomiting• Kussmaul respirations• Drowsiness• Coma
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Treatment of Ketosis
• Assess blood sugars and urine ketones every 2-4h until ketones cleared
• Extra rapid acting insulin (Humalog/Novolog) every 2-4h
• Extra fluids–Oral fluids initially glucose free
• NO EXCERCISE
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Ketone Monitoring
• Urine–ketostix, multistick, ketodiastick–ketones are pink to purple–negative ketones on the ketone pad
are tan.
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Ketone Monitoring
• Blood–lab - our current method gives ratio
expressed as 1:16, 1:32• the higher the number the more ketones
–bedside serum monitoring• available for home use
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Monitoring
• Four times daily is recommended, always at bedtime (>100)
• Occasional nocturnal readings are required
• Pre-driving blood sugars (>100)
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Monitoring• Honeymoon phase affects insulin regimen
– Partial remission of insulin deficiency after diagnosis
– Meals may trigger insulin release and a dose reduction may be indicated
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Pump Therapy
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Insulin Pump
• Site preparation
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Transfusion Tubing
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Pump Insulin Therapy
• Basal – Takes the place
of the long actinginsulin
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Insulin Pump Therapy
•Bolus•“On Demand” insulin for food and corrections•Types: Normal•Square•Dual•Radio Frequency
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Insulin Pump
• Troubleshooting– Always have a
back up plan– Check pump,
tubing and site
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Questions
• Any Questions?