Diabetes Mellitus and Hypoglycemia

1
Chapter 46

• Diabetes Mellitus and Hypoglycemia

2
Learning Objectives

• Describe the role of insulin in the body.
• Explain the pathophysiology of diabetes mellitus
  and
• hypoglycemia.
• Describe the signs and symptoms of diabetes
  mellitus
• and hypoglycemia.
• Explain tests and procedures used to diagnose
  diabetes
• mellitus and hypoglycemia.
• Discuss treatment of diabetes mellitus and
• hypoglycemia.
• Explain the difference between type 1 and type 2
  diabetes mellitus.

3
Learning Objectives

• Differentiate between acute hypoglycemia and
  diabetic
• ketoacidosis.
• Describe the treatment of a patient experiencing
  acute
• hypoglycemia or diabetic ketoacidosis.
• Describe the complications of diabetes mellitus.
• Identify nursing interventions for a patient
  diagnosed
• with diabetes mellitus or hypoglycemia.
• Identify nursing interventions for a patient
  diagnosed
• with ketoacidosis.

4
Diabetes Mellitus
5
Pathophysiology

• Chronic disorder of impaired metabolism with
  vascular and neurologic complications
• Key feature is elevated blood glucose, called
  hyperglycemia
• Blood glucose level normally regulated by
  insulin, a hormone produced by beta cells in the
  islets of Langerhans located in the pancreas

6
Type 1

• Absence of endogenous insulin
• Formerly called juvenile-onset diabetes because
  it most commonly occurs in juveniles and young
  adults
• An autoimmune process, possibly triggered by a
  viral infection, destroys beta cells, the
  development of insulin antibodies, and the
  production of islet cell antibodies (ICAs)
• Affected people require exogenous insulin for the
  rest of their lives

7
Type 2

• Inadequate endogenous insulin and bodys
  inability to properly use insulin
• Beta cells respond inadequately to hyperglycemia
  results in chronically elevated blood glucose
• Continuous high glucose level in the blood
  desensitizes the beta cells they become less
  responsive to the elevated glucose
• More common in adults increasing in children
• Controlled by diet and exercise may require oral
  hypoglycemic agents or exogenous insulin

8
Role of Insulin

• Glucose
• Insulin stimulates active transport of glucose
  into cells
• If insulin absent, glucose remains in the
  bloodstream
• Blood becomes thick, which increases its
  osmolality
• Increased osmolality stimulates the thirst center
• Increased fluid does not pass into body tissues
  high serum osmolality retains fluid in the
  bloodstream
• As blood passes through the kidneys, some glucose
  eliminated
• Osmotic force created by glucose draws extra
  fluid and electrolytes with it, causing
  abnormally increased urine volume

9
Role of Insulin

• Fatty acids
• Promotes fatty acid synthesis and conversion of
  fatty acids into fat, which is stored as adipose
  tissue
• Also spares fat by inhibiting breakdown of
  adipose tissue and mobilization of fat and by
  inhibiting the conversion of fats to glucose
• Without adequate insulin, fat stores break down
  and increased triglycerides are stored in the
  liver
• Increased fatty acids in the liver can triple the
  production of lipoproteins promotes
  atherosclerosis

10
Role of Insulin

• Protein
• Enhances protein synthesis in tissues and
  inhibits the conversion of protein into glucose
• Amino acids are admitted into cells enhances
  rate of protein formation while preventing
  protein degradation
• Without adequate insulin, protein storage halts
  large amounts of amino acids dumped into the
  bloodstream
• High levels of plasma amino acids place people
  with diabetes at risk for development of gout
• Changes in protein metabolism lead to extreme
  weakness and poor organ functioning

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Etiology

• An autoimmune malfunction may cause complete
  destruction of the islets of Langerhans in the
  pancreas, creating type 1 diabetes
• Islet cell antibodies are identified in more than
  80 of all people with type 1 diabetes at the
  time of diagnosis

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Figure 46-1
13
Risk Factors

• Obesity
• Sedentary lifestyle
• Family history of diabetes
• Age 40 years and older
• History of gestational DM
• History of delivering infant weighing more than
  10 lb
• African American (33 higher risk for type 2 DM)
• Latin American/Hispanic (gt300 higher risk for
  type 2 DM)
• American Indians (33-50 higher risk for type 2
  DM)

14
Risk Factors

• Metabolic syndrome
• Thought to be a precursor to diabetes
• Impaired glucose tolerance, high serum insulin,
  hypertension, elevated triglycerides, low HDL
  cholesterol, altered size and density of LDL
  cholesterol
• Believed that metabolic syndrome is a chronic
  low-grade inflammatory process affecting
  endothelial tissue
• Long-term effects atherosclerosis, ischemic
  heart disease, left ventricular hypertrophy, type
  2 DM
• Research directed at learning how to detect this
  syndrome early and what interventions might slow
  or arrest the progress

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Long-Term Complications
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Microvascular Complications

• Retinopathy
• Pathological changes in the retina that are
  associated with DM
• Nephropathy
• Kidney damage

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Macrovascular Complications

• Accelerated atherosclerotic changes in the person
  with diabetes
• Associated with coronary artery disease (CAD),
  cerebral vascular accidents (CVA or stroke), and
  peripheral vascular disease (PVD)

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Long-Term Complications
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Neuropathic Complications

• Neuropathy pathologic changes in nerve tissue
• Mononeuropathy affects a single nerve or group of
  nerves
• Polyneuropathy involves both sensory and
  autonomic nerves
• Autonomic neuropathy affects the sympathetic and
  parasympathetic nervous systems

20
Hypoglycemic Unawareness

• The usual symptoms of tachycardia, palpitations,
  tremor, sweating, and nervousness may be absent
• Patient may suddenly have changes in mental
  status as the first sign of hypoglycemia

21
Long-Term Complications

• Foot complications of diabetes
• May have foot problems associated with
  neuropathy, inadequate blood supply, or a
  combination
• Mechanical irritation
• Thermal injury
• Chemical irritation

22
Long-Term Complications Prevention

• Diabetes Control and Complications Trial (DCCT)
  intensive treatment of type 1 DM delayed the
  onset or slowed the progress of diabetic
  retinopathy, nephropathy, and neuropathy
• Outcome of United Kingdom Prospective Diabetes
  Study (UKPDS) similar benefits of tight control
  with type 2 DM

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Long-Term Complications Prevention

• ADA recommends
• Blood pressure lt130 systolic, lt80 diastolic
• Total cholesterol lt200 mg/dL
• LDL lt100 mg/dL
• HDL gt45 mg/dL for men (gt55 mg/dL for women)
• Triglyceride lt150 mg/dL

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Acute Emergency Complications
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Acute Hypoglycemia

• Dangerous drop in blood glucose
• Causes
• Taking too much insulin, not eating enough food
  or not eating at the right time, an inconsistent
  pattern of exercise
• Gastroparesis, renal insufficiency, and certain
  drugs including aspirin and beta-adrenergic
  blockers

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Acute Hypoglycemia

• Signs and symptoms
• Adrenergic shakiness, nervousness, irritability,
  tachycardia, anxiety, lightheadedness, hunger,
  tingling or numbness of the lips or tongue, and
  diaphoresis
• Neuroglucopenia drowsiness, irritability,
  impaired judgment, blurred vision, slurred
  speech, headaches, and mood swings progressing to
  disorientation, seizures, and unconsciousness

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Acute Hypoglycemia

• Treatment
• Give patient 10 to 15 g of quick-acting
  carbohydrates
• Repeat every 15-30 minutes until blood glucose is
  gt70 mg/dL for adults, 80 to 100 mg/dL for older
  adults and children
• If patient is unable to swallow, an IM or
  subcutaneous injection of 1 mg of glucagon or an
  IV dose of 50 mL of 50 dextrose should be given
  as ordered or per protocol

28
Diabetic Ketoacidosis (DKA)

• Life-threatening emergency caused by a relative
  or absolute deficiency of insulin
• Early signs and symptoms
• Anorexia, headache, and fatigue
• As condition progresses, classic symptoms of
  polydipsia, polyuria, and polyphagia develop
• If untreated, patient becomes dehydrated, weak,
  and lethargic with abdominal pain, nausea,
  vomiting, fruity breath, increased respiratory
  rate, tachycardia, blurred vision, and hypothermia

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Diabetic Ketoacidosis (DKA)

• Late signs
• Air hunger (Kussmauls respirations), coma, and
  shock
• Death can result without prompt medical care

30
Diabetic Ketoacidosis (DKA)

• Treatment aimed at correction of three main
  problems
• Dehydration
• Electrolyte imbalance
• Acidosis

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Hyperglycemic Hyperosmolar Nonketotic Syndrome

• Patient goes into a coma from extremely high
  glucose levels (gt600 mg/dL)
• There is no evidence of elevated ketones
• Pancreas produces enough insulin to prevent
  breakdown of fatty acids and formation of
  ketones, but not enough to prevent hyperglycemia
• Persistent hyperglycemia causes osmotic diuresis,
  resulting in loss of fluid and electrolytes
• Dehydration and hypernatremia develop
• May be caused by the same factors that trigger
  ketoacidosis

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Medical Diagnosis

• One or more of the following criteria on two
  separate occasions is considered DM
• Polyuria, polydipsia, polyphagia, unexplained
  weight loss plus random glucose level gt200 mg/dL
  
• Fasting serum glucose level gt126 mg/dL (after at
  least an 8-hour fast)
• Two-hour postprandial glucose level gt200 mg/dL
  during oral glucose tolerance test (OGTT) under
  specific guidelines. Test must use a glucose load
  of 75 g of anhydrous glucose dissolved in water

33
Medical Diagnosis

• Prediabetes
• Individuals with impaired fasting glucose (IFG)
  and/or impaired glucose tolerance (IGT)
• Individuals should receive education on weight
  reduction and increasing physical activity

34
Medical Diagnosis

• Oral glucose tolerance test
• Diet of 150 to 300 g carbohydrate for 3 days
  before test
• Night before test, patient fasts after midnight
• Morning of test, blood drawn for fasting serum
  glucose
• Patient then given a drink (Glucola) containing
  75 g of carbohydrates and instructed to remain
  quiet
• Blood drawn at 30 minutes and 1 hour after the
  ingestion of glucose. After these two samples,
  blood is drawn at hourly intervals until the test
  is completed

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Medical Treatment

• Nutritional management
• Medical nutrition therapy (MNT) is an important
  part of diabetes management should be included
  in diabetes self-management education
• Because of complexity of nutritional management,
  a registered dietitian should be part of the
  diabetes management team, and the individual with
  diabetes should be included in decision making

36
Medical Treatment

• Exercise
• Effective adjunct for people with diabetes
• Aids in weight loss, improves cardiovascular
  conditioning, improves insulin sensitivity, and
  promotes a sense of well-being
• Exercising muscle uses glucose at 20 times the
  rate of a muscle at rest and does not require
  insulin

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Insulin Therapy

• All patients with type 1 disease need insulin
  injections some patients with type 2 disease may
  eventually need insulin
• Insulins classified by source and course of
  action
• Source human, pork, or beef (beef is being
  phased out)
• Course of action rapid acting, short acting,
  intermediate acting, and long acting
• All rapid-acting and short-acting insulins are
  clear
• The other insulins are cloudy

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Figure 46-2
39
Insulin Therapy

• Route
• Oral insulin cannot be given orally because it
  is rendered useless in the gastrointestinal tract
  
• Subcutaneously all insulins can be given
  subcutaneously
• Intravenously ONLY regular insulin can be given
  intravenously
• Inhalation a form of insulin that can be taken
  by inhalation has recently been approved, but it
  is not yet widely used

40
Insulin Therapy

• Concentrations
• U-100 insulin has 100 units/mL
• Most commonly used
• U-500 insulin has 500 units/mL
• Used only in emergencies and for patients who are
  extremely insulin resistant
• U-40 insulin has 40 units/mL
• Not available in the United States

41
Insulin Therapy

• Premixed insulin products
• Contain both Regular and NPH insulin
• 70 NPH and 30 Regular insulin
• 50 NPH and 50 Regular insulin
• 75 NPH and 25 Lispro

42
Insulin Therapy

• Dosing schedules
• Conventional therapy
• Typically uses a combination of a short-acting
  and an intermediate- or long-acting insulin
• Intensive therapy
• To achieve tight control may require 3 or 4
  injections daily
• Continuous subcutaneous insulin infusion
• Patient has indwelling subcutaneous catheter
  connected to an external portable infusion pump
  pump delivers Regular insulin continuously

43
Insulin Therapy

• Insulin mixing
• Two types can be mixed in one syringe to avoid
  two injections
• Insulin injection
• Site rotation helps prevent lipohypertrophy or
  lipoatrophy
• Absorption rate varies with different body sites
• American Diabetes Association recommends rotating
  sites within one anatomic area rather than moving
  among all areas
• See Figure 46-3

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Figure 46-3
45
Insulin Therapy

• Insulin pump
• Needle is inserted subcutaneously in an
  appropriate part of the anatomy
• Pump is programmed to deliver a steady trickle of
  insulin throughout the day and can provide a
  bolus of insulin at mealtimes

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Figure 46-4
47
Insulin Therapy

• Intranasal route
• Only 10 of the drug is absorbed through the
  nasal mucosa, making it relatively expensive to
  use
• Nasal irritation is a frequent side effect
• Only Regular insulin is given intranasally
• Insulin catheter
• Indwelling subcutaneous catheters may be placed
  in the abdomen to permit repeated insulin
  injections without repeated needlesticks

48
Oral Hypoglycemic Agents

• If patients with type 2 DM unable to control
  blood glucose with nutrition and exercise,
  physician may prescribe oral hypoglycemics
• Sulfonylureas (three generations),
  alpha-glucosidase inhibitors, biguanides,
  thiazolidinediones, D-phenylalanines,
  meglitinides
• Combination oral medications
• ACTOplus met (pioglitazone and metformin),
  Avandamet (rosiglitazone and metformin),
  Avandaryl (rosiglitazone and glimepiride),
  Glucovance (glyburide and metformin), Metaglip
  (glipizide and metformin)

49
Self-Monitoring of Blood Glucose

• Allows patients to monitor blood glucose levels
  to regulate their diet, exercise, and medication
  regimens to remain euglycemic
• Portable electronic glucose meters have largely
  replaced other methods of self-monitoring

50
Glycosylated Glucose Levels

• Glycosylated hemoglobin (HbA1c) reflects glucose
  levels over the past few months
• Fructosamine levels reflect those over several
  weeks

51
Complications of Therapy

• Hypoglycemia
• A person injects too much insulin, does not eat
  enough, eats at the wrong time, or exercises
  inconsistently glucose levels may suddenly drop
• Somogyi phenomenon
• Rebound hyperglycemia in response to hypoglycemia
  
• Dawn phenomenon
• An increase in fasting blood glucose levels
  between 5 and 9 AM that is not related to
  hypoglycemia

52
Assessment

• Ketoacidosis ketonuria, Kussmauls respirations,
  orthostatic hypotension, hypertension, nausea,
  vomiting, lethargy, or change in level of
  consciousness
• Hypoglycemic patient expect to find tachycardia,
  anxiety, trembling, and decreasing level of
  consciousness
• Be alert for indications of hyperosmolar
  nonketotic coma

53
Assessment

• Attempt to determine the following
• Type of diabetes
• Hypoglycemic agents name, dosage, when last dose
  was taken
• Food and fluid intake for the past 3 days
• Relevant laboratory values blood glucose, blood
  pH, bicarbonate levels, electrolytes, and
  osmolality and urine osmolality

54
Health History

• Chief complaint and history of present illness
• Signs/symptoms that prompted patient to seek
  medical care
• Past medical history
• Type and duration of DM
• Name and dosage of prescribed medications and
  when they were last taken
• If patient monitors blood glucose, record type of
  equipment used, testing schedule, recent test
  results
• Family history
• Diabetes, heart disease, stroke, hypertension,
  hyperlipidemia

55
Health History

• Review of systems
• Description of the patients general health
• Changes in skin moisture or turgor
• Inquire whether the patient has had floaters,
  diplopia (double vision), or blurred vision, or
  has seen white halos around objects
• Abdominal symptoms diarrhea, abdominal bloating,
  and gas
• Problems passing or holding urine
• If any pain in the legs, note when it occurs
• Numbness, tingling, or burning in the extremities
  
• Changes in mental alertness or seizures

56
Health History

• Functional assessment
• Explore factors that can affect patients ability
  to perform self-care, including literacy,
  financial resources such as health insurance, and
  family support

57
Health History

• Physical examination
• Level of consciousness, posture and gait, and
  apparent well-being
• Vital signs, height, and weight
• Skin color, warmth, turgor, and lesions noted
• Inspect eye grounds for evidence of diabetic
  retinopathy or cataracts
• Be alert for a sweet, fruity odor to the
  patients breath that is common with ketoacidosis
  
• Carefully assess the feet
• Test gait, balance, and motor coordination

58
Interventions

• Ineffective Health Maintenance
• Ineffective Therapeutic Regimen Management
• Risk for Deficient Fluid Volume
• Risk for Injury
• Activity Intolerance
• Chronic Pain
• Disturbed Sensory Perception or Impaired Skin
  Integrity
• Disturbed Thought Processes
• Ineffective Coping

59
Hypoglycemia
60
Pathophysiology

• Develops when the blood glucose level falls to
  less than 45 to 50 mg/dL
• Symptoms occur at different blood levels
  according to individual tolerances and how
  rapidly the level falls

61
Causes

• Exogenous hypoglycemia
• Results from outside factors acting on the body
  to produce a low blood glucose
• Include insulin, oral hypoglycemic agents,
  alcohol, or exercise

62
Causes

• Endogenous hypoglycemia
• Occurs when internal factors cause an excessive
  secretion of insulin or an increase in glucose
  metabolism
• These conditions may be related to tumors or
  genetics

63
Causes

• Functional hypoglycemia
• From a variety of causes, including gastric
  surgery, fasting, or malnutrition

64
Signs and Symptoms

• Glucose level falls rapidly, causes epinephrine,
  cortisol, glucagon, and growth hormone to be
  secreted in an attempt to increase glucose levels
  
• Symptoms weakness, hunger, diaphoresis, tremors,
  anxiety, irritability, headache, pallor, and
  tachycardia
• A blood glucose level that falls over several
  hours symptoms attributed to lack of essential
  glucose to brain tissue
• Symptoms confusion, weakness, dizziness, blurred
  or double vision, seizure, and in severe cases,
  coma

65
Medical Diagnosis

• The diagnosis of hypoglycemia not associated with
  diabetes can be based on fasting blood glucose,
  OGTT, intravenous glucose tolerance test, and
  72-hour inpatient fasting
• Whipples triad
• The presence of symptoms
• Documentation of low blood glucose when symptoms
  occur
• Improvement of symptoms when blood glucose rises

66
Medical Treatment

• In an unconscious patient who has diabetes,
  hypoglycemia should be suspected until it is
  ruled out
• 50 mL of 50 glucose solution should be
  administered immediately
• The patient with a milder form of hypoglycemia
• Treated with 15 g carbohydrate
• If the patients condition does not improve,
  another
• 15 g of carbohydrate should be given after 10
  minutes

67
Medical Treatment

• Prevention of hypoglycemia by proper food intake
  
• The diet is directed by the underlying cause
• If overproduction of insulin after carbohydrate
  ingestion, a low-carbohydrate, high-protein diet
• Restriction of carbohydrates to no more than 100
  g/day is recommended
• Simple sugars avoided complex carbohydrates
  encouraged
• Patients may tolerate smaller, more frequent
  meals. Alcohol should be avoided

68
Assessment

• Present illness shakiness, nervousness,
  irritability, tachycardia, anxiety,
  lightheadedness, hunger, tingling or numbness of
  the lips or tongue, nightmares, and crying out
  during sleep
• Note when episodes occur in relation to meals and
  particular food intake
• The past medical history documents diabetes,
  previous gastric surgery, abdominal cancer, or
  adrenal insufficiency
• Medications, paying particular attention to
  hypoglycemic agents

69
Assessment

• Note hypoglycemic agents, prescribed dose, and
  the time last dose taken
• Functional assessment information about current
  diet, exercise, alcohol intake, and the effects
  of symptoms on daily activities
• Important aspects of the physical examination
  include general behavior, appearance, pulse, and
  blood pressure

70
Interventions

• Deficient Knowledge
• Risk for Injury
• Impaired Adjustment