diabetes mellitus maura lindenfeld, rn, msn, cpnp cook children’s medical center
TRANSCRIPT
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
–Insulin Dependent Diabetes Mellitus (IDDM)
• autoimmune mediated
• insulin deficient
Type 2 Diabetes
–Type 2 Diabetes
–Non-Insulin Dependent Diabetes Mellitus
• insulin resistance
• typically family history related
• obesity
Normal Glucose Tolerance
• Fasting BG <100mg/dl • 2-hour post glucose <140
mg/dl
Impaired Glucose
Impaired Fasting GlucoseImpaired Glucose Tolerance
…a metabolic state intermediate between normal blood glucose and diabetes
Impaired Fasting Glucose (IFG)
• FBS 100mg/dl but 126 mg/dl
Impaired Glucose Tolerance (IGT)
• 2 hour post glucose 140mg/dl and 200mg/dl
Goals of Therapy
• Good blood sugar control• Improved quality of life • Routine• Minimize risk for hypoglycemia• Minimize risk for long-term
complications
Goals of Therapy
Age Blood Glucose
<7yrs 80-200 mg/dl
7-11yrs 80 -180 mg/dl
>12yrs 80-150 mg/dl
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.
Type 2
• Hyperinsulinemia
• Insulin resistance
• Acanthosis Nigricans
• Insulin levels may be low or normal
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.
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
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
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.”
Mild
Moderate-to-Severe
Severe
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
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
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
Insulin Curves
Insulin Curves
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
Injection Sites
Hyperglycemia
• Causes
– Incorrect dose or missed dose
– Eating more than allowed by meal plan (incorrect carbohydrate counting)
– Not enough exercise
– Illness or infection
Hyperglycemia
• Onset– Symptoms present more slowly than
hypoglycemia
– May progress to ketoacidosis and coma if undetected
Symptoms of Hyperglycemia
• Polyuria, polydipsia, polyphagia• Hunger• Blurred vision• Headache• Emotional lability• Flushing• Yeast infections
Treatment of Hyperglycemia
• Insulin– Extra short acting insulin to correct
for highs– Adjust long acting insulin dose
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)
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
Hypoglycemia
• Causes– Incorrect dose (too much insulin)– Missed meal or snack– Incomplete meal or snack– Unplanned or excess exercise– Illness– Alcohol consumption
Hypoglycemia
• Onset– Sudden– May progress to loss of consciousness or
seizure if untreated
Symptoms of Hypoglycemia
• Autonomic or adrenergic• Shakiness, trembling
• Anxiety, nervousness
• Weakness
• Hunger
• Sweating
• Nausea, vomiting
Symptoms of Hypoglycemia
• CNS – Headache– Visual changes– Lethargy– Irritability, restlessness– Confusion– Somnolence, protracted sleep, stupor
Symptoms of Hypoglycemia
– Hypothermia
– Seizures
– Bizarre neurologic signs
• Motor
• Sensory
• Loss of intellectual ability
• Personality changes
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
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
Disposable Needles
Why to use a needle once, only once
Why shot site rotation matters
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
Causes of Ketosis
• New diagnosis• Not enough insulin• Illness or infection• Stress
–Emotional or physical• Starvation ketosis
Symptoms of Ketosis
• Fruity odor of breath or urine (acetone/nail polish odor)
• Abdominal pain• Nausea/vomiting• Kussmaul respirations• Drowsiness• Coma
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
Ketone Monitoring
• Urine–ketostix, multistick, ketodiastick
–ketones are pink to purple
–negative ketones on the ketone pad are tan.
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
Monitoring
• Four times daily is recommended, always at bedtime (>100)
• Occasional nocturnal readings are required
• Pre-driving blood sugars (>100)
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
Pump Therapy
Insulin Pump
• Site preparation
Transfusion Tubing
Pump Insulin Therapy
• Basal
– Takes the place of the long acting
insulin
Insulin Pump Therapy
•Bolus•“On Demand” insulin for food and corrections•Types: Normal•Square•Dual•Radio Frequency
Insulin Pump
• Troubleshooting
– Always have a back up plan
– Check pump, tubing and site
Questions
• Any Questions?