1/3/2008. Karen Burke Priscilla LeMone Elaine Mohn-Brown. Medical-Surgical Nursing Care, 2e Karen Burke, Priscilla LeMone, and Elaine Mohn-Brown

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1 Medical-Surgical Nursing Care Second Edition Karen Burke Priscilla LeMone Elaine Mohn-Brown Chapter 17 Caring for Clients with Diabetes Mellitus Diabetes Mellitus Chronic disease Not a single disorder Group of metabolic disorders Characterized by hyperglycemia Overview Large number of individuals are not diagnosed Cannot be cured Can be controlled in efforts to control complications 1

2 Affects: Eyes Kidneys Nervous system Cardiovascular system Complications Type 1 DM Usually occurs in children and adolescents Results from an autoimmune disorder that destroys the beta cells of islets of Langerhans Type 1 DM Insulin no longer produced Leads to hyperglycemia and breakdown of body fat and protein Cells starve Burning of fat leads to ketosis Ketone bodies accumulate 2

3 Type 1 DM - Pathophysiology Elevated blood glucose Excess spills into the urine leading to glycosuria Once hyperglycemia and glycosuria occur, three manifestations of diabetes are seen: Polyuria Polydipsia Polyphagia Type 2 DM Characterized by hyperglycemia due to insufficient insulin production and insulin resistance Not enough insulin to lower blood glucose levels Enough insulin to prevent the breakdown of fats; ketosis does not develop Risk factors: Heredity Obesity Increasing age High-risk ethnic group Type 2 DM Role of Obsesity Reduces available insulin receptor sites, leading to insulin resistance Three-quarters of older adults with type 2 are overweight All older adults develop insulin resistance Weight loss through diet and exercise can reduce insulin resistance With enough weight loss, may not need oral medications 3

4 Type 2 DM - Diagnosis Often undiagnosed for years Less severe hyperglycemia Only polyuria and polydipsia are present Breeding ground for bacterial infections Cloudiness of eye lens leading to blurred vision Destruction of peripheral nerves leading to paresthesias Fatigue due to tissue starvation BOX 17-1 Manifestations of Type 1 and Type 2 Diabetes Mellitus. Laboratory Tests Plasma glucose (PG) level Fasting blood glucose level (FBG) Oral glucose tolerance test (OGTT) 4

5 Routine Screening Should Be Done If: Obese First-degree relative with DM High-risk ethnic population Delivered baby > 9 lb or gestational diabetes history Hypertensive HDL < 35 mg/dl Triglycerides > 250 mg/dl Impaired glucose tolerance or fasting glucose in the past Self-Monitoring Blood Glucose Monitor and achieve metabolic control Useful if ill or pregnant Useful if symptomatic with hypo- or hyperglycemia On insulin: three or more times per day Not on insulin: two to three times per week Equipment Lancet Blood glucose monitoring machine Test strips Follow manufacturer s instructions for use 5

6 Noninvasive Blood Glucose Monitoring GlucoWatch Biographer: worn as a watch Measures glucose value in perspiration Urine Testing for Ketones and Glucose Has unpredictable results Should be done with type 1 diabetes Either Acidtest or Ketostix Normal result is no glucose in urine Insulin Pork or synthetic Strengths: rapid-acting, acting, short-acting, intermediate- acting, long-acting 6

7 TABLE 17-2 Action of Insulin Preparations. Insulin Strengths Insulin Strengths 100 U per ml or 500 U per ml Administered in a sterile, single-use, disposable syringe All insulin given parenterally Regular insulin: either subcutaneous or intravenous Alternative Delivery Methods Insulin pen Jet injector Continuous subcutaneous infusion pump 7

8 Figure Sites of insulin injection. Injection Sites Process: pinch skin, inject needle at 90-degree angle Do not inject into muscle; do not massage after injecting Rotate injection sites Minimize painful injections BOX 17-2 Procedure Checklist: Techniques to Minimize Painful Injections. 8

9 Problems with Insulin Injections Lipodystrophy Lipoatrophy TABLE 17-3 Nursing Implications for Administering Insulin and Client Teaching. Insulin Regimen Individualized Mix short and longer acting Timing depends on feed, exercise, glucose level, type of insulin Tight glucose control results in fewer long-term complications Oral Antidiabetic Agents 9

10 Hypoglycemia Type 1 or type 2 diabetes Causes Too much insulin Overdose of oral antidiabetic agents Too little food Excess physical activity Sudden onset; blood glucose < 50 mg/dl BOX 17-6 Manifestations of Hypoglycemia. Hypoglycemia Unawareness May develop in some people with long-standing type 1 diabetes No symptoms of hypoglycemia in the presence of a low blood glucose level 10

11 Treatment Mild Immediate treatment 15 g rapid-acting acting sugar Severe Hospitalized Intravenous glucose Hypoglycemia Diabetes Ketoacidosis (DKA) Life-threatening illness in type 1 Hyperglycemia, dehydration, coma Excess glucose leads to dehydration, sodium and potassium loss Burning of fat leads to ketosis Kidneys unable to excrete ketones, leads to ketoacidosis DKA Treatment Hospital admission Treatment: fluids, insulin, electrolytes 11

12 Hyperosmolar Hyperglycemic State (HHS) Seen in type 2 diabetes Severely elevated blood glucose Extreme dehydration Altered LOC Develops slowly over hours to days Life-threatening emergency HHS Treatment Correct fluid and electrolyte imbalances; provide insulin BOX 17-5 Manifestations of Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS). 12

13 Macrovascular Complications Macrocirculation Large blood vessels undergo changes due to atherosclerosis Complications Coronary artery disease Stroke Peripheral vascular disease Complication: CAD Risk factor for an MI High cholesterol and high triglycerides Complication: Stroke Two to six times more likely to occur in type 2 Hypertension plays a role 13

14 Complication: Peripheral Vascular Disease Greater in type 2 Diabetes-induced induced arteriosclerosis Can lead to leg ulcers and gangrene Microvascular Complications Microcirculation Eyes Kidneys Nerves Complication: Diabetic Retinopathy Changes in the retinal capillaries; lead to retinal ischemia, retinal hemorrhage, or detachment Retinopathy stages: nonproliferative and proliferative Leading cause of blindness in people ages 20 to 74 Yearly eye exams are recommended 14

15 Complication: Diabetic Nephropathy Disease of the kidneys Characterized by albumin in the urine, hypertension, edema, renal insufficiency Most common cause of renal failure First indication: microalbuminuria Treatment: ACE inhibitors Complication: Diabetic Neuropathy Disorder of the peripheral nerves and autonomic nervous system Results: sensory and motor impairments, postural hypotension, delayed gastric emptying, diarrhea, impaired genitourinary function Result from the thickening of the capillary membrane and destruction of myelin sheath Complication: Diabetic Neuropathy Bilateral sensory disorders Appear first in toes, feet, and progress upward to fingers and hands Treatment None specific Focus on controlling neuropathic pain with tricyclic antidepressants or topical cream capsaicin (Zostrix) 15

16 Complication: Autonomic Neuropathy Involves numerous body systems such as cardiovascular, gastrointestinal, genitourinary Medications Diet Exercise Foot care Teaching Plan Contents Medications Type of medication Oral or insulin Insulin Type, dosage, mixing instructions, times of onset and peak, obtaining and care of equipment, self-injections, locations for injections, timing of injections with meals 16

17 Diet Role of diet with control of blood glucose levels Complex carbohydrates and food high in fiber Limit sugar, fat, sodium, alcohol How to read food labels Personal food preferences Eating away from home Relationship between diet, exercise, medication Exercise Purpose Importance Types Personal exercise choices Foot care Wash feet daily Inspect feet daily 17

18 Figure Ulceration following trauma to the foot of a person with diabetes. (Courtesy of Harry Przekop/Medichrome/The Stock Shop, Inc.) Concerns for Young Adults Assess the young adult s lifestyle including eating habits/patterns, exercise Provide teaching to address the need for scheduled eating gp patterns and exercise regime Concerns for Middle-Aged Adults Assess the client s lifestyle to include eating habits/patterns, exercise Provide teaching to address the need for scheduled eating gp patterns and exercise regime. 18

19 TABLE 17-6 Nutrient Recommendations for Adults with Diabetes. Concerns for Older Adults If obese, might need diet, exercise, and weight reduction program Consider: dietary likes/dislikes, eating habits, meal preparation, p age-related changes in taste and smell, dental health Consider: age-related decline in calorie needs and reduced physical activity Might be on a fixed income Concerns for Older Adults Coexisting illnesses and multiple medications can decrease appetite and reduce energy to plan, cook, or eat Dietary restrictions can lead to avoidance of social gatherings Decreased thirst mechanism can lead to dehydration 19

20 Concerns for Older Adults Exercise should be individualized depending on physical limitations Withdrawal from social situations can lead to depression Visual and fine motor skill deficits can make insulin administration, glucose monitoring, food preparation, exercise and foot care difficult or impossible. The Nursing Process Used to assess, diagnose, plan, implement, and evaluate care for the client with diabetes mellitus. Assessment 20

21 Nursing Diagnoses Imbalanced Nutrition Impaired Skin Integrity Risk for Infection Risk for Injury Ineffective Coping Evaluation Collect data related to chronic complications Identify frequency of DKA, HHNS, hypoglycemia Document VS, LOC, skin integrity, complications Notify MD of client s response to treatment Reinforce teaching related to medications, diet, and self-care Document 21