Diabetes

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Diabetes

• NUR 105

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DIABETES MELLITUS

• Statistics approximately 21 million in the US
  7 of population. Includes 6 million
  undiagnosed.
• Definition Diabetes mellitus is a chronic
  disorder characterized by impaired metabolism and
  by vascular and neurologic complications. A key
  feature of diabetes is elevated blood glucose or
  hyperglycemia.

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DIABETES MELLITUS

• Pathophysiology
• the blood glucose level is normally regulated by
  insulin, a hormone produced by the beta cells in
  the islets of Langerhans located in the pancreas.
• In health small amounts of insulin are secreted
  continuously into the bloodstream.
• The ingestion of carbohydrates triggers the
  secretion of a large volume of insulin. Insulin
  that is produced in ones own body is called
  endogenous, meaning it is internally produced.
• Insulin that is obtained from other sources and
  administered to a person is called exogenous

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DIABETES MELLITUS

• Pathophysiology
• Glucagon (another hormone produced by the alpha
  cells of the pancreas) allows the liver and
  muscles to release stored glucose if the body is
  hypoglycemic (low blood glucose)
• Insulin and glucagon work together to keep the
  blood glucose at a constant level
• The amount of glucose in the blood regulates the
  rate of insulin secreted

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DIABETES MELLITUS

• Pathophysiology
• Diabetes is caused by an inability of the
  pancreas to produce insulin, or because the cells
  of the body cannot accept and use the insulin\
• Hyperglycemia (elevated blood glucose) is the
  result and cells do not get the energy they need

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DIABETES MELLITUS

• Classifications
• Type I Insulin Dependent Diabetes Mellitus
  (IDDM)
• Previously called insulin-dependent
• Cause the pancreas does not produce insulin at
  all or no endogenous insulin.
• Triggered by an autoimmune destruction of cells
  in the pancreas cause may be idiopathic
  (unknown) usually occurs in children and young
  adults
• Onset usually includes acute development of
  weight loss
• Ketones may build up in the urine and blood
  (Ketosis)
• Exogenous Insulin must be administered for the
  body to use for energy

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Insulin

• Increases the transport of glucose into the
  resting muscle cell.
• Regulates the rate at which carbohydrates are
  used
• Prevents the conversion of glycogen to glucose
• Inhibits the conversion of glycogen to glucose
• Promotes fatty acid synthesis
• Spares fat
• Inhibits the conversion of fats to glucose
• Stimulates protein synthesis in the tissues
• Inhibits the conversion of protein into glucose.

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Lack of Insulin

• Stimulates the conversion of glycogen to glucose
  Higher blood glucose
• Permits fat stores to break down
• Increases triglyceride storage in the e liver
• Halts the storage of proteins
• Causes protein to be dumped into the bloodstream.

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DIABETES MELLITUS

• Classifications
• Type 2 Non-Insulin Dependent Diabetes Mellitus
  (NIDDM)
• AKA Adult-onset Diabetes Mellitus
• Inadequate endogenous insulin and the body's
  ability to properly use insulin. Initially ,
  beta cells respond inadequately to hyperglycemia,
  resulting in chronically elevated blood glucose.
  The continuous high glucose level in the blood
  desensitizes the beta cells so that they become
  less responsive to the elevated glucose. The
  specific resistor sites become insensitive to
  insulin.
• Usually gradual onset and with several risk
  factors
• Obese children now showing greater incidence
• Rarely have DKA

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DIABETES MELLITUS

• Other Classifications
• Gestational Diabetes Mellitus (GDM)
• Triggered by extra metabolic demands during
  pregnancy
• May require insulin or may be diet controlled
• Usually resolved with birth of baby
• Predisposes mother to develop type-2 DM in the
  future

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Diabetes

• Risk Factors for Type 1
• Other than genetic ones, none known.

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DIABETES MELLITUS

• Risk factors Type II
• Sedentary Lifestyle
• Family Hx
• Age 40 years or older
• History of Gestational DM
• History of delivering infant weighing more than
  10lbs
• African American (33 higher risk for type 2 DM)
• Latin American/Hispanic (greater than 300 higher
  risk for type 2 DM)
• Obesity
• American Indians (33 to 50 higher risk for type
  2 DM)

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DIABETES MELLITUS

• S/S
• Polydipsia (excessive thirst)
• Polyuria (excessive urination
• Polyphagia (excessive hunger)
• Dehydration
• Fatigue
• Visual changes like blurred vision
• Elevated blood glucose

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DIABETES MELLITUS

• S/S
• H/A
• Poor wound healing and recurrent infections
• Confusion and changes in mentation
• Occasional muscle cramps
• Weight loss in type 1 DM (glucose is not
  available to the cells, body breaks down fat and
  protein for energy, called ketosis

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Diagnosis of Diabetes

• A patient who meets one or more of the following
  criteria on two separate occasions is considered
  to have DM
• 1. Symptoms of polyuria, polydipsia, polyphagia,
  unexplained weight loss plus random glucose level
  greater than 200mg/dl. A random reading is based
  on a blood sample drawn any time of day without
  regard to mealtimes.

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Diagnoses of Diabetes

• 2. Fasting serum glucose level greater than
  126mg/dl (after at least an 8-hour fast)
• 3. Two-hour posprandial glucose level above
  200mg/dl during an oral glucose tolerance test.
  The test must use a glucose load of 75gm of
  anhydrous glucose dissolved in water. This test
  is often unnecessary.

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Glucose Tolerance Test

• Client consumes diet of 150-300gm of
  carbohydrates for 3 days before the test.
• The patient is then given a Glucola drink with
  75gm of carbs and instructed to remain quiet.
• Glucose can be given IV if patient is unable to
  drink, (not as accurate as oral)
• Blood is drawn then at
• 30 minutes
• 1 hour
• Then hourly for 3 or 5 hours.
• Heparin Lock may be inserted into a vein so
  multiple venipunctures are not needed.

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DIABETES MELLITUS

• Diagnostic Test
• Glycosylated Hemoglobin Test (GHb) or (HbA1c)
  provides an accurate long term index of average
  blood glucose and tells how effective Diabetes
  therapy has been during the preceding 8-12 weeks
  (normal value 3.5-6.2 good control - 7.5
  poor control gt9.0)
• Self Monitoring Blood Glucose or finger stick
  most common method, checked before meals and
  bedtime if BS gt 240 mg/dl test for ketones in
  the urine
• Clinitest and Testape indicate glucose in urine

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DIABETES MELLITUS

• Diagnostic Tests
• Acetest and Ketostix indicate presence of
  ketones in urine
• C-Peptide indicates how much insulin body is
  making, may help determine Type-I or Type-2 DM
• Fasting insulin level
• Other test to be monitored because of effects of
  DM
• Lipid profile, Sr. Cr. And urine microalbumin
  levels to monitor kidney function, urinalysis,
  and ECG

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DIABETES MELLITUS

• Treatment
• The only cure is a pancreas transplant and
  pancreatic cell transplant
• Every patient requires an individual treatment
  plan The goals for the patient with Diabetes
  Mellitus include
• Monitoring and control of blood glucose
• Prevention and early detection of complications
• Lipid level monitoring
• Dietary and weight management
• Participating in an exercise plan
• Maintaining good health, annual physicals,
  attention to self care
• Medications as needed

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DIABETES MELLITUS Tx

• Medical Nutrition Therapy (MNT) Goals
• Attain and maintain optimal metabolic outcomes
  (glucose, lipids, blood pressure).
• Prevent and treat the chronic complications of
  diabetes (obesity, dyslipidemia, cardiovascular
  disease, hypertension, nephropathy).
• Improve health through healthy food choices and
  physical activity.
• Address individual nutritional needs while
  considering lifestyle, personal, and cultural
  preferences.

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Recommended Calorie Distribution for Insulin
Dependent Patients

• Proteins15 to 20 (as long as kidney functions
  are normal)
• Carbohydrates and monosaturated fats 55 -60
• Saturated Fats Less than 10
• Sodium Intake should not exceed 2400mg/day

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Weight Loss

• Weight loss is seldom a goal for the older type 2
  diabetic unless weight is more than 11/2 times
  the normal for height and frame.

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Carbohydrate Counting

• Useful for people who use intensive insulin
  therapy or pumps.
• Insulin doses are based on total grams of Carbs
  to be ingested.
• Well balanced diet within the prescribed
  distribution of proteins, fats, and carbs

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DIABETES MELLITUS

• Treatment (Basic Guidelines)
• The ADA advocates a variety of meal plans based
  on the patients abilities and commitments
• ADA Exchange Diet six exchange lists,
  prescribed as total calories and number of
  exchanges from each group (NOT AS POPULAR NOW)
• CHO Counting a tool to maintain blood glucose
  and lipid levels. Count grams of carbs, and
  measure servings. Offers more flexible food
  choices and may achieve better control

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DIABETES MELLITUS

• Treatment (Basic Guidelines)
• ADA advocates
• Glycemic Index describes how much blood glucose
  level rises with a specific food compared to an
  equivalent amount of glucose. Rarely used in
  clinical practice except with highly motivated ,
  educated patients
• Month-O-Meals booklets with complete and
  interchangeable menus, excellent for patients
  who want to be told what and when to eat.

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DIABETES MELLITUS

• Treatment (Exercise)
• Regularity and amount of exercise is important
• Muscles use glucose and lower circulating blood
  glucose
• Promotes utilization of CHO, improves
  circulation, lipid levels, cardiovascular status,
  weight loss and decreases stress
• Should be individualized
• Medic Alert Bracelet

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Exercise and Diabetes

• Have a complete medical examination before
  starting a program.
• Because circulating insulin may be inadequate to
  ensure glucose uptake, avoid exercise when your
  serum glucose is greater than 250mg/dl and
  ketosis is present.
• Exercise with caution if your serum glucose is
  greater than 300mg/dl and no ketosis is present.
• 5G of simple carb should be consumed at the end
  of 30 minutes and at 30 minute intervals
• Wear comfortable shoes.

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Exercise Diabetes

• Warm up with 5-10 minutes of aerobic
• Discuss with physician whether to alter food or
  insulin intake before exercise.
• Avoid exercise during the peak action of insulin
  and oral hypoglycemic agents when hypoglycemia is
  more likely to occur.
• Carbohydrates snacking may be necessary with
  prolonged or intense exercise.
• If you take insulin, inject it in the abdomen
  rather than an extremity before a workout because
  the drug is absorbed much more quickly from the
  abdomen.
• Some people experience hypoglycemia several hours
  after exercise, have food available for these
  situations.
• Wear medic alert bracelet.

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DIABETES MELLITUS

• Pharmacologic Management
• Insulin key regulator for passage of glucose
  into the cells for energy
• Produced by beta cells of pancreas
• Plays a significant role in protein and lipid
  metabolism
• Pancreas secretes insulin at a steady rate of
  0.5-1 unit per hour

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DIABETES MELLITUS

• Pharmacological Management
• Insulin
• Hyperglycemia is caused by three abnormalities
• Liver produces excess glucose
• Absent or impaired insulin production and
  secretion by the pancreas
• Insulin resistance peripherally
• Historically insulin obtained from beef or pork
  pancreas
• Today biosynthetic human insulin is used almost
  exclusively
• Human insulin is purer
• More effect
• Lower incidence of causing allergies/resistance

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DIABETES MELLITUS

• Pharmacological Management
• Insulin
• The nurse must be aware of the onset, peak, and
  duration of insulin, so that decisions can be
  made, as to when to give the insulin and when to
  be alert for symptoms of low blood glucose as
  when patients go for test and procedures
• Onset time required for medication to have an
  initial effect or action
• Peak when the agent will have the maximum
  effect
• Duration length of time that the agent remains
  active in the body

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Rapid Acting Insulin

• Insulin lispro (Humalog)
• Clear
• Onset 15 minutes
• Peak 0.5-1 hour
• Duration 3-4 hours
• Administer 15 minutes before eating.

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Rapid Acting Insulin

• Insulin aspart (Novolog)
• Clear
• Onset 15 minutes
• Peak 1-3 hours
• Duration 3-5 hours

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Short Acting Insulin

• Regular Insulin (Humulin R, Novolon R)
• Color Clear
• Onset- 30 minutes to 1 hour
• Peak- 2-5 hours
• Duration- 6-8 hours
• ONLY INSULIN GIVEN IV Humlin R

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Intermediate Acting

• NPH insulin
• Cloudy
• Onset- 1.5 hours
• Peak- 4-12 hours
• Duration- 10-24 hours

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Long-Acting

• Insulin Glargine (Lantus)
• Onset- 1-2 hours
• DOES NOT PEAK
• Duration- 20-24 hours
• CANNOT MIX WITH OTHER INSULINS

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Inhaled Rapid-Acting , Short Acting

• Insulin human rDNA orgin (Exubera)
• Powder in blister packs
• Onset- 9-18 minutes
• Peak- 27 minutes

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Insulin Pump

• Pharmacological Management
• Insulin Pump
• Battery operated device, worn on a belt with a
  needle inserted in SC tissue
• Provides a continuous low-dose insulin infusion
• Patient can add a bolus prior to meals and snacks
  based on blood sugar
• Allows for tighter control of blood glucose and
  more flexible lifestyle patient needs to be
  conscientious, intensive self-monitoring of
  blood glucose is essential
• Site is changed every 24-48 hours
• Used with all types of insulin

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DIABETES MELLITUS

• Pharmacological Management
• Insulin Pens
• Pre-filled insulin cartridge loaded into a
  pen-like holder
• Two types
• Disposable pre-filled with set amounts of
  insulin, once used, it is thrown away
• Non-disposable insulin cartridge is replaced
  when empty
• Both require a pen needle, which is screwed onto
  the tip of the pen
• Easy to use, no need to draw up insulin from a
  vial
• Dose can be set for patients with visual and
  dexterity issues
• More expensive that vials, not all types insulin
  available for use in pens
• Cannot mix insulin so two injections required

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DIABETES MELLITUS SLIDING SCALE
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Insulin

• Storage of Insulin
• Store insulin in a cool place, refrigeration
  preferred, away from direct sunlight
• Unopened shelf life 1 year
• Once opened, shelf life 30 days must be dated
  and initialed when opened
• Do not freeze pre-filled syringes should be kept
  in a vertical position with needles up roll
  syringe to remix solution before giving

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DIABETES MELLITUS

• Pharmacological Management
• Administration of Insulin
• Administered subcutaneously (Regular insulin is
  the only insulin given IM or IV)
• Roll the vial of cloudy insulin, do not shake, to
  avoid bubbles, causing an inaccurate dose to be
  drawn
• When mixing insulin, inject an amount of air
  equal to the insulin dose into the cloudy vial
  first, remove syringe, draw up air equal to dose
  of clear, then draw up clear insulin, remove
  syringe, now draw up cloudy
• Be careful not to inject any cloudy insulin into
  the clear bottle. Regular insulin is always
  drawn up first

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DIABETES MELLITUS

• Pharmacological Management
• Administration of Insulin
• Before giving the insulin dose, Must Always Be
  Checked by Another Nurse
• Administer 30 minutes before meals
• Inject a mixed dose of insulin within 5 minutes
  of preparation, because after this time the
  regular insulin binds to the NPH insulin and its
  action is reduced
• During stress, illness, or surgery, the patient
  maybe managed with sliding scale insulin (Regular
  only) where the dose is dependent on the
  finger-stick blood glucose level

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DIABETES MELLITUS

• Pharmacological Management
• Administration sites
• Rotation of sites is essential to prevent
  lipodystrophy, a spongy swelling at or around
  site which can interfere with absorption
• Careful records must be maintained
• Aspiration before and massaging after injection
  on longer recommended
• Abdominal injection sites preferred for rapid,
  consistent absorption
• Injection site should be 1 inch from previous site

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Complications of Insulin Therapy

• Complications of Insulin Therapy
• Hypoglycemia blood glucose drops below 50 and
  most often occurs before meals or when insulin
  action is peaking
• Somogyi Phenomenon Patients blood glucose
  rises in spite of increasing insulin dose
• Insulin causes hypoglycemia at night, generating
  a release of glucose-elevating hormones
  (epinephrine, cortisol, and glucagon) which then
  REBOUNDS to manifest as hyperglycemia in early
  morning

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Somogyi Phenomenon

• Diagnoses- Measure blood glucose between 2 and 4
  am and again at 7am.
• The 2 and 4 am levels below 60mg/dl and a 7am
  level above 180mg/dl support the diagnosis.

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Complications of Insulin Therapy

• Somogyi Phenomenon
• May be inadvertently treated with an increase
  insulin dosage making problems worse
• Symptoms night sweats, restlessness, early
  morning nausea, H/A and confusion
• Treatment Decreasing evening dose of exogenous
  insulin by 2-3 units every 3 or 4 days until the
  rebound hyperglycemia is brought under control.
  Bedtime snack may also be helpful

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Complications of Insulin Therapy

• Dawn Phenomenon
• Caused by natural release of growth hormone and
  cortisol during the early morning hours causing
  hyperglycemia
• Treatment adjust evening insulin dose by 1 or 2
  units and give at a later time

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DIABETES MELLITUS

• Pharmacological Management
• Oral Hypoglycemic Medications
• Usually given to DM Type-2 patients who are not
  controlled with exercise and diet alone
• Remember they are not insulin pills because
  insulin is a protein and would be digested.
  These drugs improve the bodys sensitivity to
  insulin
• The pancreas must be partially functioning

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DIABETES MELLITUS

• Pharmacological Management
• Classifications Insulin Stimulators
• Stimulates beta cells to increase insulin
  secretion and increases insulin receptor
  sensitivity
• May be given with other classes of oral agents
• Should be administered 15-30 minutes before
  meals, except for Diabinese which is given with
  breakfast
• Avoid alcoholic beverages may cause
  Antabuse-lke reactions (facial flushing, pounding
  H/A, breathlessness, and nausea
• Alcohol can potentiate the hypoglycemic effects,
  so if taken, should be taken with meals
• Drugs come from same family as sulfonamide
  antibiotics, must watch for allergies to sulfa
  drugs
• Side effects weight gain, skin rash, GI upset,
  hemolytic anemia, cholestasis , sulfa allergies.

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PRAMLINTIDE (Symlin)

• The medication pramlintide (Symlin) carries with
  it an FDA BLACK BOX WARNING!!!
• This medication has the potential to cause severe
  hypoglycemia within 3 hours of administration.
  It is critically important that the nurse observe
  the patient closely for any signs or symptoms of
  hypoglycemia.

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Sulfonylureas (Stimulator)

• Lowers blood sugar by stimulating the beta cells
  of the pancreas to secrete more insulin and
  increasing the sensitivity of insulin receptors.
• A significant adverse effect of the sulfonyureas
  is the risk of hypoglycemia.

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Biguanides

• Metaformin (Glucophage, Fortamet)
• Action- Inhibits hepatic glucose production,
  increases insulin sensitivity.
• Side Effects- Lactic Acidosis, hypoglycemia when
  used with sulfonylurea or meglitnide.
• Advantage Does not cause insulin release

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Meglitinides

• Prandin
• Starlix
• Secrete pancreatic secretion of insulin
• Side Effects- Hypoglycemia, weight gain.
• Stimulate Pancreas for Insulin secretion but
  shorter acting than sulfonylurea

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Thizolidnediones

• Actos (Pioglitzaone) GIVE WITH MEALS
• Avandia (Rosiglitzaone)
• Increases insulin sensitivity in the tissues
• Side Effects- Hypoglycemia when used with
  sulfonylurea or meglitinide, weight gain,
  decreased effectiveness of oral contraceptives,
  possible liver dysfunction.
• Notify doctor of weight gain an edema.

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Alpha Glucosidase Inhibitors

• Absorption Delayers inhibit enzymes in the
  small intestine and pancreas
• Reduces rate of CHO digestion and absorption
• Results in a reduced glucose absorption
• May be given with other oral agents
• Give at start of meals
• Side effects diarrhea, flatulence, abdominal
  pain
• Acarbose (Precose)
• Miglitol (Glyset)

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Complications of Diabetes Mellitus

• Hyperglycemia occurs when patient is unable to
  compensate for the increased blood glucose
• Caused by over eating, stress, not enough
  insulin, or other medications, and/or illness
• S/S similar to when 1st diagnosed polyuria,
  lethargy, polydipsia, H/A, polyphagia, blurred
  vision, coma, BG gt 300 mg/dl, n/v
• Treatment assess cause, notify MD if vomiting,
  and monitor blood glucose closely
• Call MD if BG gt 200 mg/dl for changes in
  medication
• If BG gt 300 mg/dl, call MD, check urine for
  ketones and increase fluid intake

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Hypoglycemia CausesExogenous
Causes Predisposing Factors Occurrence
Insulin Intentional or accident OD Inadequate food intake Increased exercise Decrease insulin requirement Other medications MOST FREQUENT CAUSE OF HYPOGLYCEMIA
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Hypoglycemia CausesExogenous
Causes Predisposing Factors Occurrence
Oral hypoglycemic agents Intentional or accident OD Inadequate food intake Other medications Frequent cause of hypoglycemia with sulfonylurea's and meglitinides. PRAMLINITIDE!
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Hypoglycemia CausesExogenous
Causes Predisposing Factors Occurrence
Alcohol Particularly likely in chronically malnourished or acutely food-deprived clients Occurs in 6-36 hr of ingesting moderate to large amounts of alcohol
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Hypoglycemia CausesExogenous
Causes Predisposing Factors Occurrence
Exercise Increased duration and intensity of exercise increases glucose uptake and normally decreases insulin secretion Occurs with both insulin sulfonylurea administration and intense exercise, but may be unpredictable in onset.
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Hypoglycemia CausesEndogenous
Causes Predisposing Factors Occurrence
Organic hypoglycemia Insulinoma (tumor of beta cells of the pancreatic islets of Langerhans Uncommon neoplasm of beta cells
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Hypoglycemia CausesEndogenous
Causes Predisposing Factors Occurrence
Extrapancreatic neoplasm's May be mesenchymal tumors, hepatomas, adrenocortical carcinomas, gastronintestinal tumors, lymphomas, or leukemias Rare most common in adults 40-70 yrs of age.
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Hypoglycemia CausesFunctional
Causes Predisposing Factors Occurrence
Alimentary hypoglycemia (Dumping Syndrome) Rapid dumping of carbohydrates into upper small intestine Postgastrectomy
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Hypoglycemia CausesFunctional
Causes Predisposing Factors Occurrence
Drug Related (ethanol, haloperidol, pentamdine, salicylates) reactive hypoglycemia Syndrome with symptoms such as diaphoresis, tachycardia, tremulousness, headache, fatigue, drowsiness, and irritability Rarely diagnosed throughout the world, May be overdiagnosed in the United States according to statement by ADA
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Hypoglycemia CausesFunctional
Causes Predisposing Factors Occurrence
Rapid discontinuation of TPN Endocrine deficiency states (cortisol, growth hormone, glucagons, epinephrine) Easily Prevented
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Hypoglycemia CausesFunctional
Causes Predisposing Factors Occurrence
Glucocorticoid deficiency Critical illness (cardiac, hepatic, and renal disease) A danger for any person with adrenal insufficiency.
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Hypoglycemia CausesFunctional
Causes Predisposing Factors Occurrence
Severe Liver Deficiency Insufficient glucose ouput by liver Fasting hypoglycemia
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Hypoglycemia CausesFunctional
Causes Predisposing Factors Occurrence
Lack of body stores for protein, fat and carbohydrates Profound Malnutrition Common, also found with relative frequency in kwashiorkor
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Hypoglycemia CausesFunctional
Causes Predisposing Factors Occurrence
Prolonged Muscular exercise Metabolism of energy-producing substances Occurs if exercise is too prolonged or severe or if nutritional intake and carbohydrate stores are insufficient.
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Hypoglycemia

• Hypoglycemia result of excess secretion of
  insulin, leading to blood glucose below 50 mg/dl
• Cause skipping meals, exercise, or medicated
  with too much insulin
• Most often occurs before meals and when insulin
  is peaking
• Repeated or extremely low BG levels may cause
  neurologic damage
• S/S hunger, H/A, diaphoresis, blurred vision,
  irritability, confusion, pallor, tremors,
  seizures, coma
• Treatment assess possible causes, get
  finger-stick BG
• Administer fast sugar immediately if patient is
  alert (15 grams of CHO 4-6 oz. orange juice)
• If unconscious and no IV access,1 mg glucagon
  (SC) or IM per hospital protocol
• IV 50ml of 50 Dextrose.

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Hypoglycemia

• Recheck glucose in 15 minutes and repeat
  procedure until improvement noted
• Call MD if no improvement
• Educate patient to recognize and prevent low
  blood glucose symptoms
• Self Monitoring of Blood Glucose Levels
• Test blood glucose levels two to four times a
  day, ac and hs
• Teach how to use lancets or lasers to obtain
  blood sample
• Teach to use a log or diary to record glucose
  levels

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Diabetic Keto Acidosis (DKA)

• Tissues cannot utilize glucose without insulin,
  resulting in an increase in serum glucose levels.
• The high osmotic pressure created by excess
  glucose leads to osmotic diuresis (polyuria). As
  glucose is eliminated in the kidneys, so are
  large amounts of water and electrolytes
  (electrolyte imbalance)

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DKA

• 3. The patient voids large amounts of dilute
  urine (polyuria)
• 4. To make matters worse, the sympathetic
  nervous system responds to the cellular need for
  fuel by converting glycogen to glucose and
  manufacturing additional glucose.
• 5. As glycogen stores are depleted, the body
  begins to burn fat and protein for energy.

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DKA

• 6. Fat metabolism produces acidic substances
  called ketone bodies that accumulate and lead to
  metabolic acidosis.
• 7. Protein metabolism results in the loss of
  lean muscle mass and a negative nitrogen balance.

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DKA Signs and Symptoms

• Early- Anorexia, headache, and fatigue.
• Progresses to-Polydipsia, Polyuria, Polyphagia.
• Dehydration, Weakness, Lethargy, Abdominal Pain,
  Nausea, Emesis, Fruity Breath, Increased
  Respiratory Rate, Tachycardia, blurred Vision,
  Hypothermia.
• Late Air Hunger (due to acidosis) Kussmauls
  Respirations, Coma, Shock and Death

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DKA Treatment

• Diabetic Ketoacidosis
• Treatment
• Maintain patent airway
• IV fluids to maintain fluid and electrolyte
  balance
• Insulin management
• Monitor renal function, especially K levels and
  add IV potassium per orders
• Monitor BG q 1-2 hours
• VS q1-2 hours ABGs q 1hour
• Keep patient warm

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Complications of Diabetes Mellitus

• Hyperglycemia Hyperosmolar Nonketotic Syndrome
  (HHNKS)
• Extreme hyperglycemia without acidosis, because
  some insulin is being produced, cells are not
  starved therefore, ketones are not seen in the
  blood or urine
• Patient may not feel physically ill because there
  is no ketoacidosis
• Usually occurs in NIDDM when diabetes is
  uncontrolled or during stress or infection
• S/S extreme thirst, severe dehydration,
  alterations in LOC confused, shock, coma.
  Blood glucose very high, from 800-2400 mg/dl,
  blood osmolarity (concentration) very high gt 320
  mOsm/kg

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Complications of Diabetes Mellitus

• HHNKS
• Treatment
• IV fluid replacement
• IV insulin
• Monitor electrolytes
• Monitor BG

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Long-term Complications of Diabetes Mellitus

• Seen in Type I and Type II diabetics
• Complications r/t the effects of chronic
  hyperglycemia
• Macrovascular complications involving large
  blood vessels and microvascular involving the
  tiny blood vessels

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Long-term Complications of Diabetes Mellitus

• Macrovascular Circulatory System
• Atherosclerosis
• Hypertension
• Elevated LDL, cholesterol and triglyceride levels
• Increased platelet clotting
• These factors increase the incidence of heart
  attack, stroke, and poor circulation of the feet
  and legs
• Microvascular
• Eyes Retinopathy (damage to the tiny retinal
  blood vessels) leading to blindness
• High incidence of cataracts at an earlier age

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Long-term Complications of Diabetes Mellitus

• Diabetic ulcer and gangrene

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Long-term Complications of Diabetes Mellitus

• Gangrene

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Foot Care

• Inspect Daily
• Wash in warm not hot water
• Dry feet watch between toes
• Cut the nails straight across unless doctors
  order requires podiatrist
• Clean Cotton socks Daily
• Proper Fitting shoes
• Never wear open sandals
• Use socks and blankets to warm feet
• Test H20 temp before stepping into bath or shower
• Elevate Feet whenever possible

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Long-term Complications of Diabetes Mellitus

• Diabetic Retinopathy

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Long-term Complications of Diabetes Mellitus

• Atherosclerosis

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Long-term Complications of Diabetes Mellitus

• Hemodialysis

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Long-term Complications of Diabetes Mellitus

• Microvascular
• Kidneys Nephropathy (damage to the vessels
  within the kidneys)
• DM is the leading cause of end-stage renal
  disease (ESRD), leading to kidney failure
• Native Americans, Hispanics, and
  African-Americans at highest risk
• Hemodialysis or peritoneal dialysis is needed
  when kidneys have lost most of their function
• Keep accurate I/O if ordered
• Urine Testing
• Tests for glucose and ketones
• Urine tested for ketones during illness, stress,
  and pregnancy
• Presence of ketones indicates glucose level gt 300
  and should be reported to MD immediately

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Long-term Complications of Diabetes Mellitus

• Microvascular
• Nerves Neuropathy (nerve damage) is the most
  common chronic complication
• Sensorimotor polyneuropathy aka peripheral
  neuropathy causes numbness (paresthesias) and
  pain or burning sensation in lower extremeties
• Patient at risk for foot injuries
• Avoid tight fitting garments and shoes
• Autonomic neuropathies affect
• GI gastroparesis (delayed gastric emptying),
  constipation, diarrhea
• GU retention, neurogenic bladder
• Reproductive male impotence

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Complications of Diabetes Mellitus

• Other Complications
• Infections
• Patients with diabetes more prone to infections
  d/t delayed healing from impaired circulation
• Insulin requirements may need to be increased if
  infection present
• WBCs become sluggish and ineffective
• Periodontal disease increased d/t bacteria and
  plaque
• Foot complications with DM leading cause of
  amputation
• Observe for signs of infection, injury or stress
  and teach patient to do the same

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Sick Day Care

• Treatment/Nursing Management
• Medication
• Take insulin as prescribed.
• Adjust dose as directed depending on Glucose
  readings
• It oral hypoglycemia, take your usual dose. Do
  not increase unless doctors order. If your have
  emesis the doctor may order sub q insulin.
• Diet
• Eat normal diet on schedule
• If N V, replace carbohydrate solid foods with
  fruit juice, regular soft drinks, or Jell-O
• Monitoring Blood Sugar and Ketones
• Monitor Q4 and record
• If severely ill Q2 hours
• Dip urine for Ketones if BG over 240mg/dl

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When to Call Physician

• If emesis, abdominal pain or temp above 100.2 F
• If blood glucose is above 200mg/dl
• If Ketones are in urine
• If you cannot reach physician GO TO ER

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Complications of Diabetes Mellitus

• Treatment/Nursing Management
• Priorities in hospital
• A nursing care plan should be formulated with
  complete understanding of cause of admission
• A thorough and ongoing assessment
• Knowledge of the current symptoms, potential
  complications, lab values, and medications
• Discharge planning should be initiated as soon as
  possible

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Diabetes Mellitus

• Treatment/Nursing Management
• Patient Education
• Is the key to effective self management
• Consider knowledge base, ability to learn,
  emotional and physical health, family influence,
  socio-economic status, cultural influences and
  current lifestyle patterns
• Topics to teach
• Glucose monitoring - S/S of complications
• Urine testing - Lifestyle changes
• Medication administration - Foot care
• Dietary management - Sick-day management

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Complications of Diabetes Mellitus

• Treatment/Nursing Management
• Foot Care
• Never use sharp objects to poke or dig under the
  toenail or around the cuticle
• Ingrown toenails or nails that are thick should
  be cared for by a podiatrist
• After washing feet, gently rub any corns and
  callused areas with a pumice stone to control
  buildup
• Use pads on corns to reduce pressure
• Sick-Day
• Teach to continue to take insulin or oral
  hypoglycemic medications
• Monitor BG 4-6 times a day while sick
• Check urine for ketones
• If BG gt300 or presence of ketones, report to MD
• Extreme n/v or diarrhea report to MD risk of
  extreme fluid loss is dangerous

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Diabetes Mellitus

• Treatment/Nursing Management
• Emotional Support
• Encourage family involvement
• Encourage verbalization of feels/fears
• Answer questions
• Assist and follow up with consults as dietary,
  etc.
• Stress importance of frequent primary care
  provider visits

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Deficient Knowledge

• R/T- Lack of Knowledge of Diabetes Management
• Goals- Patient will correctly describe type 1
  diabetes and treatment. Patient will demonstrate
  self medication, meal planning, and understanding
  of management of exercise and drug effects.

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Ineffective Therapeutic Regimen Management

• R/T- Financial, personal, or family pattern
  disruption
• Goal- Client will express intent to adhere to
  prescribed regimen of care.

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Deficient Fluid Volume

• R/T-Altered Urinary Output
• Goals-Client will maintain normal blood volume,
  as evidence by normal tissue turgor, pulse, and
  blood pressure.

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Imbalanced Nutrition

• Less or more
• R/TAlterations in insulin availability or
  utilization.

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Risk for Injury

• R/T- Adverse effects of drugs, increased
  susceptibility to infection
• R/T- Severe decrease in tissue perfusion in feet.
• Goals
• Clients blood glucose will remain within goal
  range established by physician
• Patient will state measures to reduce risk of
  infections and will identify symptoms that should
  be reported.

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Ineffective Health Maintenance

• R/T- Lack of knowledge of dietary management of
  DM, drug therapy, and self-monitoring
• Goal- Client will demonstrate the ability to
  adhere to prescribed diet and drug therapy and to
  monitor blood glucose

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Ineffective Therapeutic Regimen Management

• R/T- financial limitations and difficulties with
  transportation for food, drugs, and medical care
• Goals-Client will manage her prescribed diet and
  drug therapy.

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Risk for Infection

• R/T- Elevated blood Glucose Level
• Goals
• Interventions

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