Managing Diabetes Mellitus

Review

• What is the chief characteristic of diabetes mellitus?

• What is the cause of the chief characteristic?• What are the primary pancreatic hormones

and their function? • What is the primary goal of treatment? • Differentiate between the pathophysiology of

type 1 and type 2 diabetes mellitus.

Osmotic Diuresis

• When there is not enough insulin glucose can not enter cells. The liver will increase production and release of glucose. Excess blood glucose increases serum osmolality. The kidney’s respond by increasing glucose excretion; water and electrolytes follow. Polyuria results in dehydration and marked electrolyte loss.

More Questions

• Glucose from food can not be stored in the liver. What is the implication of this?

• What is considered the target blood sugar value?

• What is a renal threshold?• When is the renal glucose threshold reached? • Why should the presence of glucose in the

urine not be used to guide treatment?

And More Questions

• What is the body’s source of energy when glucose is not available?

• What is the implication of this?

• Differentiate between the primary treatment for type 1 and type 2 diabetes mellitus.

• What does the treatment regimen depend upon?

And Even More Questions

• What are clinical manifestations dependent upon?

• What are the classical symptoms?• What are additional symptoms?

Manifestations

Diagnostic Findings Indicating Diabetes Mellitus

• Fasting Blood Glucose > 126 mg/dL• Random plasma glucose > 200 mg/dL on more

than one occasion• Hgb A1C (glycated hemoglobin) – Normal 4-6%

Nutritional Therapy

• Cornerstone of treatment• Includes: nutrition, meal planning, and weight

control• Distribution of nutrients – 50-60% CHO (majority whole grains)– 20-30% Fat– 10-20% Protein – 25 g fiber/day

Exercise

• Another cornerstone of treatment• Lowers glucose and decreases cardiovascular

risks• Should not be initiated until glucose levels are <

250 mg/dL• Recommendations:– Exercise same time each day– Start slow, gradually increase duration– If > 30 y/o with 2 CV risks, exercise stress test– Elderly- realistic and consistent

Measures to Aid Self-Management

• Blood glucose monitoring – Intermittent– continuous

• Urine glucose testing no longer standard of care

• Ketone testing – If consistently ↑ serum glucose or glycosuria,

during illness, in pregnant diabetic, and in gestational diabetes

Pharmacologic Therapy

• Compare and contrast the pharmacologic treatment of type 1 and type 2 diabetes mellitus.

• Insulin regimens– Variable– Goal: mimic normal pattern of insulin secretion in

response to food intake and activity patterns

• Two approaches– Conventional– Intensive

Sliding Scale Insulin • Mrs. J has an order for

insulin to be given at 0730. The order reads NPH insulin 24 units and Regular insulin 8 units subcutaneously.

• She is also on sliding scale insulin coverage. Her 0700 blood sugar is 351.

• How will you proceed. • What must you

ensure? • When would you

expect a hypoglycemic reaction?

• Fingerstick (BSBS) • Blood Sugar mg/dL:

• < 70 call MD• 201-250 4 units subcutaneously • 251-300 6 units subcutaneously• 301-350 8 units subcutaneously• 351- 400 10 units subcutaneously• 401-450 12 units subcutaneously• 451-500 14 units subcutaneously• > 500 call MD

Nursing Management

What is one of the most essential aspects of nursing management of diabetes mellitus? What must be done before initiating this activity? What should be included in this activity?

Hypoglycemia

• Immediate treatment:– 15 g of fast acting CHO– Retreat in 15 min if

glucose < 70-75 mg/dL– Follow with

protein/starch snack

• Emergency measures:– 1 mg Glucagon – 25-50 mL Dextrose in

water IV

Diabetic Ketoacidosis

• ↓ serum HCO3, pH• ↑ creatinine, BUN• ↓, normal, or ↑ Na+, K+• + Urine and blood ketones

• Sick Day rules– Don’t eliminate insulin– Contact MD if can’t take

fluids without vomiting or if ketones are present

DKA: Nursing Management

• Monitor fluid, electrolyte and hydration status• Monitor blood glucose, VS, ABGs• Prevent fluid overload– VS and lung assessments • I&O• Monitor urine output before staring K+ • Documentation: lab values, frequent changes in

fluids and meds, patient response to treatment

Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)

• Characterized by alterations in awareness• Minimal to absent ketosis• Lack of effective insulin• Persistent hyperglycemia → osmotic diuresis→

loss of water and electrolytes. Water shifts from intracellular to extracellular space→ hypernatrimia and ↑ osmolality.

• Polyuria • Precipitating event

Management HHNSMedical:

• Fluid replacement– 0.9 or 0.45% saline– Change to D5W when glucose

< 250-300 mg/dL

• Correct electrolytes– K+ if adequate urine

• Insulin – Continuous

Nursing:

• Closely monitor VS, fluids, labs

• Maintain safety• Monitor I&O and hydration

status• Care for underlying

condition• Careful cardiovascular,

pulmonary and renal assessments

Complications of Diabetes Mellitus• Macrovascular– Cardiovascular disease– Cerebrovascular disease – Peripheral vascular disease

• Microvascular– Retinopathy– Nephropathy

• Neuropathy – Peripheral – Autonomic– Spinal

Diabetic Nephropathy

• Renal disease secondary to microvascular changes

• Filtration mechanism damaged→ proteinuria and ↑ pressure in kidney vessels

• Manifestations: – Same as other renal disease;– Progressive renal failure

• Assessments and diagnostics– Albumin in urine is earliest sign

Diabetic Nephropathy Medical Management• Control HTN (ACEI)• Prevention or vigorous UTI

Rx• Avoid nephrotoxic

substances• Adjust meds as renal

function decreases• ↓ Na+ and protein diet

Nursing Management• Orthostatic Hypotension

– ↑ Na diet, d/c meds that impede ANS response, sympathomimetics, mineralcorticoids, lower body elastic garments

• Decreased GI motility– Low fat diet, freq. sm. meals,

close glucose monitoring; Reglan

• Diarrhea– Bulk forming lax, antidiarrheals

• Constipation – Fiber, fluids, meds, laxatives,

enemas

Hypoglycemia Unawareness

• Autonomic nephropathy that affects the adrenal medulla is responsible for diminished or absent adrenergic symptoms of hypoglycemia. – Shakiness, sweating, nervousness, palpitations

• Frequent blood sugar monitoring needed.• Risk for developing extreme hypoglycemia.• Goals for blood sugar levels may need to be

changed.

Foot and Leg Problems

• Neuropathy, PVD, and immunocompromise are contributing factors.

• Diabetic ulcer development begins with a soft tissue injury.

• Risk of developing these problems increases with age, duration of diabetes, and development of complications

Management

• Teaching proper foot care• Good hygiene and skin care– So not put lotions between toes

• Shoes must fit well• Trim nails straight across– Do not trim toenails of a diabetic patient

• Reduce risk factors• Avoid home remedies, OTC agents, and self-

medicating to treat foot problems.