Nursing Management of Clients with Stressors of Endocrine Function DIABETES MELLITUS

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Nursing Management of Clients with Stressors of
Endocrine FunctionDIABETES MELLITUS

• NUR133
• Lectures 1213
• K. Burger, MSEd, MSN, RN, CNE

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Definition Classification

• A group of metabolic diseases characterized by
  elevated levels of blood glucose resulting from
  defects in insulin secretion, insulin action, or
  both
• The disease is further characterized by metabolic
  abnormalities and by long-term complications to
  other body systems
• EVERY BODY SYSTEM IS AFFECTED BY DIABETES

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Classification

• Type 1Diabetes Mellitus
• Lack of insulin or production of defective
  insulin
• Age of onset lt20 yrs
• Often present with DKA
• Always requires exogenous insulin Rx

• Type 2 Diabetes Mellitus
• Reduced ability to respond to insulin and/or
  secrete sufficient amounts
• Age of onset adults
• Obesity co-factor
• Rx variable

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DKA versus HHNS

• Diabetic Ketoacidosis
• Usually preceded by polyuria, polydipsia,
  polyphagia
• BG gt 300
• Ketosis
• Fruity breath
• Lethargy
• Kussmauls Resp

• Hyperglycemic-Hyperosmolar
• Non-ketotic Syndrome
• Gradual Onset
• BG as high as 800
• Hi blood osmolarity
• No ketosis
• Dehydration
• Confusion Coma
• Muscle jerking-seizures

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Interventions for DKA / HHNS

• Restore fluid volume rapidly to maintain
  perfusion to vital organs ( NS IV _at_ 1L/hr)
• Then continue to balance fluids (1/2 NS _at_
  reduced rate )
• Administer IV insulin
• Administer HCO3 in extreme cases
• Monitor K levels
• Monitor for s/s cerebral edema

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Metabolic Acidosis/AlkalosisThe elevator effect
.
 .
Metabolic Acidosis
Metabolic Alkalosis
CO2 H2O H2CO3 H HCO3
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PRIOR to LECTURE

• Students are to complete Winningham Preusser
  CASE STUDYEndocrine Disorders Case Study 4
• BE PREPARED!
• YOU WILL BE CALLED ON IN CLASS TO ANSWER THESE
  QUESTIONS!

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Case Study 4Diabetes MellitusWinningham
Pruesser (2005) Elsevier, Inc.

• The client, Y.L. has been complaining of chronic
  fatigue, increased thirst, constantly being
  hungry, and frequent urination. She denies any
  pain, burning, or low back pain on urination. She
  tells you she has a vaginal yeast infection that
  she has treated numerous times with OTC
  medication. She admits to starting smoking since
  going back to work full time as a clerk in a loan
  company. She also complains of having difficulty
  reading numbers and reports making frequent
  mistakes. She says by the time she gets home and
  makes supper for her family, then puts her child
  to bed, she is too tired to exercise. She reports
  her feet hurt they often burn or feel like
  there are pins in them. She reports that after
  her delivery, she went back to her traditional
  eating pattern, which you know is high in
  carbohydrates Her current weight is 173 lb. Today
  her BP is 152/97 mm Hg and her plasma glucose is
  291 mg/dL.Lab values are as follows
• FBG 184 mg/dL, A1c 10.4, UA glucose, -ketones,
  cholesterol 256 mg/dL, triglycerides 346 mg/dL,
  LDL 32 mg/dL, ratio 8.0. Y.L. is diagnosed with
  type 2 diabetes.
• The PCP decides to start MDI (multiple dose
  injection) insulin therapy and have the patient
  count carbohydrates. Y.L. is scheduled for
  education classes and is to work with the
  diabetes team to get her blood sugar under
  control.

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Case Study 4Diabetes MellitusWinningham
Pruesser (2005) Elsevier, Inc.

• QUESTION 1
• Identify the three methods used to diagnose
• Diabetes mellitus.

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Case Study 4Diabetes MellitusWinningham
Pruesser (2005) Elsevier, Inc.

• QUESTION 9
• What symptoms did YL report that lead you
• to believe she has some form of neuropathy?

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Case Study 4Diabetes MellitusWinningham
Pruesser (2005) Elsevier, Inc.

• QUESTION 10
• What findings in YLs history place her at
• increased risk for the development of other
• forms of neuropathy?

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Case Study 4Diabetes MellitusWinningham
Pruesser (2005) Elsevier, Inc.

• QUESTION 11
• What are some changes that YL can make
• to reduce the risk or slow the progression of
• both macrovascular and microvascular
• disease?

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Case Study 4Diabetes MellitusWinningham
Pruesser (2005) Elsevier, Inc.

• QUESTION 8
• YLs culture prefers foods high in
• carbohydrates. What is carbohydrate counting
• and why would this method work well for YL?

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Case Study 4Diabetes MellitusWinningham
Pruesser (2005) Elsevier, Inc.

• QUESTION12
• YL is enrolled in a smoking cessation class.
• Why is it so important that she stop smoking?

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Case Study 4Diabetes MellitusWinningham
Pruesser (2005) Elsevier, Inc.

• QUESTION 2
• Identify (3) functions of insulin

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Case Study 4Diabetes MellitusWinningham
Pruesser (2005) Elsevier, Inc.

• QUESTION 3
• Insulins main action is to lower blood sugar
• levels. Several hormones produced in the
• body inhibit the effects of insulin. Identify (3)

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ANTIDIABETIC AGENTS

• ORAL
• Sulfonylurea Agents
• Biguanides
• Alpha-glucosidaseInhibitors
• Thiazolidinediones
• Meglitinides

• INSULINS
• Rapid Acting
• Short Acting
• Intermediate Acting
• Long Acting
• Combination

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ORAL ANTIDIABETICSSulfonylureas

• Chlorpropamide ( Diabinese ) 1st generation
• Glipizide ( Glucotrol ) 2nd generation
• Glyburide ( Micronase ) 2nd generation
• Work best in early stages of disease
• Stimulate beta cells to secrete insulin
• Also have some effect on glucose absorption
  storage in tissues
• Most commonly prescribed type oral rx

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Sulfonylurea DrugsNursing Implications

• Hypoglycemia is most common side-effect
• Can also cause blood dyscrasias
• Geriatric clients and anyone with decreased organ
  function more susceptible to above
• Cross allergies to loop diuretics and
  sulfonamides
• Diabinase and other 1st generation sulfonylureas
  should not be taken with alcohol potential
  severe reaction
• Glucotrol has most rapid onset and shorter
  duration
• Usually taken 30 minutes before meals

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Biguanides

• Metformin ( Glucophage )
• Reduces the production of glucose
• Decreases intestinal absorption of glucose
• Increases the uptake of glucose
• Does NOT produce hypoglycemia
• Often given in combination with other orals

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BiguanidesNursing Implications

• Onset within 1 hr, duration 24 hrs
• Hold med temporarily if pt going for diagnostic
  studies involving iodinated contrast materials
• Should not be used in renal impaired client
• Side effects are mostly GI related but usually
  transient
• Abdominal bloating
• Nausea
• Diarrhea

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Alpha glucosidase Inhibitors

• Miglitol ( Glyset )
• Delays glucose absorption after a meal
• Taken with first bite of each meal
• GI side effects abd pain, diarrhea,
  flatususually lessen over time
• Contraindicated for persons with inflammatory
  bowel disease

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Thiazolidinediones

• Rosiglitazone ( Avandia )
• Decrease insulin resistance
• Stimulate peripheral glucose uptake
• Inhibit glucose production in the liver
• Side effects weight gain, edema, anemia
• Potential for hepatic toxicity liver enzymes
  need to be monitored

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Meglitinides

• Repaglinide ( Prandin )
• Nateglinide ( Starlix )
• Rapidly increases release of insulin from
  pancreas
• Must be taken with meals 0-30min ac
• Meal must have adequate CHO

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Insulin Therapy

• Rapid - Lispro
• Short - Regular
• Intermediate -NPH
• Long - Lantus

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Case Study 4Diabetes MellitusWinningham
Pruesser (2005) Elsevier, Inc.

• QUESTION 4
• YL was started on lispro (Humalog) and
• glargine (Lantus) insulin. What is the most
• important point to make when teaching the
• patient about glargine?

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Case Study 4Diabetes MellitusWinningham
Pruesser (2005) Elsevier, Inc.

• QUESTION 5
• Because YL has been on regular insulin in the
• past, you want to make sure she understands the
• difference between regular and lispro. What is
  the
• most significant difference between these two
• insulins?

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Case Study 4Diabetes MellitusWinningham
Pruesser (2005) Elsevier, Inc.

• QUESTION 6
• What is the peak time and duration for lispro
• insulin?

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Case Study 4Diabetes MellitusWinningham
Pruesser (2005) Elsevier, Inc.

• QUESTION 7
• YL wants to know why she cant take NPH and
  regular insulin. She is more familiar with them
  and has taken them in the past. Explain why the
  MD chose lispro and glargine insulin over NPH and
  regular insulin.

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Insulin Rx Considerations

• Rotation within one anatomic site is preferred to
  moving from site to site.
• Abdomen provides best absorption
• Be alert to Dawn and/or Somagyi Phenomena
• Refrigerate unused insulin
• Insulin in use can be left out up to 28 days
• Do not re-use needles. Dispose properly

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Alternative Methods of Insulin Administration

• External pumps
• Internal pumps
• Injection devices
• Inhaled ( under development )

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Common Nursing Implications for Antidiabetic
Medications

• Monitor for hypo/hyperglycemia
• Many drug interactions both agonist and
  antagonist
• Use cautiously in geriatric clients and those
  with organ impairment
• Monitor A1c levels q2-3months
• Monitor BG levels daily
• Patient teaching is KEY!!!

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Self-StudyHypoglycemia versus HyperglycemiaSigns
Symptoms

• Hypoglycemia
• _______________
• _______________
• _______________
• _______________
• _______________
• _______________
• _______________
• _______________

• Hyperglycemia
• _______________
• _______________
• _______________
• _______________
• _______________
• _______________
• _______________
• _______________

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Self-StudyInsulin ComparisonAction / Onset /
Duration