2. Diabetes
Normal Pathophysiology
Need to consider how insulin works
insulin continuously released: during “fasting
periods”, the pancreas continuously releases a
small amount of insulin along with glucagon.
Together a constant level of glucose in the
blood is maintained by stimulating the release
of glucose from the liver.
3. Diabetes
In diabetes
the body’s ability to respond to insulin may
decrease
the pancreas may stop producing insulin. This
in turn leads to hyperglycemia leads to other
acute metabolic complications
Diabetes is a heterogeneous group of diseases
involving disruption of metabolism of
carbohydrates, fats, and protein.
4. Diabetes
What population of patients would be at
risk for developing diabetes?
Classification of diabetes mellitus
Type I
• may occur at any age
• usually thin
• abrupt onset
• family history?
5. Diabetes
Classification
Type II
• >age 30
• often obese
• few classic symptoms
• insulin resistant
Impaired glucose tolerance
• plasma glucose levels higher than normal, but not
diagnostic for diabetes 2 hr plasma glucose >140
mg/dl & < 200 mg/dl
7. Diabetes
Clinical Manifestations
Insulin deficiency or decreased insulin activity glucose not used
properly
osmotic effect on intracellular and interstitial fluid
results in frequent urination (polyuria), and thirst (polydipsia)
without insulin the patient may experience hunger (polyphagia)
• the body will turn to other energy sources besides glucose:
first fat and then protein
8. Diabetes
Diagnostic studies
diabetes is a multisystem, multiproblem
disease, all laboratory studies must be
examined with assessment findings
normal blood glucose range: 70-110 mg/dl
urine tests not sufficient for a dx of diabetes
fasting blood glucose of > 126 mg/dl
glycosylated hemolobin
9. Diabetes
Nutritional therapy
Goals of nutritional therapy
• maintenance of as near-normal blood glucose levels
• achievement of optimal serum lipid levels
• provision of adequate calories for maintaining or
attaining reasonable weights, normal growth &
development rates
• prevention and treatment of acute complications
• improvement of overall health through optimal
nutrition
10. Diabetes
Nutritional therapy
Type I
• based on patient’s usual food intake with insulin
therapy
• eat at consistent times, synchronized with the action
of their insulin
• monitor blood glucose levels and adjust as needed
11. Diabetes
Nutritional therapy
Type II
• achieving glucose, lipid, and blood pressure goals
• weight loss is desirable
• regular exercise
• monitor blood glucose level
13. Diabetes
Drug therapy
4 types of insulin; things to consider
• how soon the insulin starts working (onset)
• when it works the hardest (peak time)
• how long it lasts in your body (duration)
The nurse may find that different sources list different
numbers of hours for onset, peak, duration of action
of the main types of insulin, and the patient’s
reactions may vary. The nurse should focus on which
meals and snacks are being covered by which insulin
dose.
14. Insulin
Rapid-acting insulin:
onset: 15 minutes after injection
peak: 30-90 minutes later
duration: may last as long as 5 hours
Short-acting:
onset: 30 minutes after injection
peak:2 to 4 hours
duration: 4 to 8 hours
15. Insulin
Intermediate-acting
onset: 2 to 6 hours
peak: 4 to 14 hours
duration: 14 to 20 hours
Long-acting
onset: 6 to 14 hours
peak: 10 to 16 hours
duration: 20 to 24 hours
17. Insulin and Oral Agents
Problems with insulin therapy
allergic reactions
lipodystrophy
Somogyi effect and dawn phenomenon
Oral medications
Other drugs affecting blood glucose levels
Things to consider…
exercise, self-monitoring
18. Nursing Management: Diabetes
Assessment:
Subjective data
• past health information
• family history
• medications
• surgery and other treatments
Health-perception-health management
• + family history, malaise
23. Nursing Management: Diabetes
Insulin therapy
assessment of patient’s use of and response to
insulin therapy
education of the patient regarding
administration, adjustment to, and side effects
of insulin
The “new” diabetic
Stress of acute illness and surgery
24. Nursing Management: Diabetes
Oral agents
nursing responsibilities similar to those taking
insulin
Personal hygiene
dental
skin care
Medical identification and travel
Follow-up nursing management
26. Complications of Diabetes
Diabetic Ketoacidosis
Etiology
• undiagnosed diabetes
• inadequate treatment of existing diabetes
• insulin not taken as prescribed
• change in diet, insulin, or exercise regimen
28. Complications of Diabetes
Diabetic Ketoacidosis
Nursing interventions
• initial
– ensure patent airway
– O2
– establish IV access and begin fluid resuscitation
– begin continuous IV insulin
– identify history of diabetes, time of last food, and
time/amount of last insulin injection
29. Complications of Diabetes
Diabetic Ketoacidosis
Nursing interventions
• ongoing monitoring
– monitor VS, LOC, cardiac rhythm, O2 saturation, and
urine output
– assess breath sounds
– monitor serum glucose and serum potassium
– anticipate possible administration of sodium bicarb with
severe acidosis (pH < 7.0)
30. Complications of Diabetes
Hyperglycemic Hyperosmolar Nonketosis
occurs in a patient who has some insulin to
prevent DKA but not enough to prevent severe
hyperglycemia, osmotic diuresis, and
extracellular fluid depletion
usually is a history of inadequate fluid intake,
increasing mental depression and polyuria
HHNK constitutes a medical emergency
31. Complications of Diabetes
Hyperglycemic Hyperosmolar Nonketosis
nursing management
• administration of a rapid-acting insulin
• administration of IV fluid
• assessment of mental status
• I & O
• assessment of blood glucose levels
• assessment of blood and urine for ketones
• electrocardiogram monitoring
33. Complications of Diabetes
Hypoglycemia
causes
• alcohol intake with food
• too little food - delayed, omitted, inadequate intake
• diabetic medication or food taken at wrong time
• loss of weight with change of medication
• use of B-blockers
34. Complications of Diabetes
Hypoglycemia
nursing management
• immediate ingestion of 5-20 g of simple
carbohydrates
• ingestion of another 5-20 g of simple carbohydrates
in 15 min if no relief obtained
• contact physician if no relief obtained
• collaborate with physician
• prevention is the key
35. Complications of Diabetes
Hyperglycemia
clinical manifestations
• elevated blood sugar
• increase urination
• increase in appetite followed by lack of appetite
• weakness, fatigue
• blurred vision, HA
• nausea and vomiting, abdominal cramps
• glycosuria
• progression to DKA or HHNK
37. Complications of Diabetes
Hyperglycemia
nursing management
• notify physician
• continuance of diabetes medication as ordered
• frequent checking of blood and urine specimens and
recording of results
• prevention is key
39. Question
A diabetic patient has a serum glucose level of 824 m/dl
and is sleepy and unresponsive. Following assessment of
the patient the nurse suspects DKA rather than HHNK
based on the finding of
a) polyuria
b) severe dehydration
c) rapid, deep respirations
d) decreased serum potassium