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1 Wk 9. Management of Clients with Diabetes Mellitus 1. Diabetes Mellitus body s inability to metabolize carbohydrates, fats, proteins hyperglycemia associated with serious complications, but reduce occurrences with preventive measures 1) Classification Type 1 autoimmune beta-cell destruction absolute insulin deficiency Type 2 progressive insulin secretory defect with insulin resistance usually associated with obesity Gestational during pregnancy Other types genetic defects in beta-cell function, diseases of the pancreas (e.g., cystic fibrosis) disease induced by drugs 1) Etiology and Risk Factors (1) Type 1 DM previously called IDDM, juvenile-onset DM destruction of pancreatic beta cells absolute insulin deficiency 10% of all people in US, usually diagnosed before 30 Incidence : 12 ~14 cases per 100,000, <age 20 years one of the most common childhood diseases (2) Type 2 Diabetes Mellitus previously called NIDDM or adult-onset DM both genetic and environmental factors. most common type not associated with HLA tissue types, circulating ICAs Heredity plays a major role: more common in identical twins Obesity is a major risk factor cardiovascular and total mortality rates: 2~3times in non-diabetic 2) Pathophysiology (1) Type 1 Diabetes Mellitus No develop in genetic predisposition Diminishing beta-cell mass : no produce enough insulin to sustain life becomes dependent on exogenous insulin (2) Type 2 Diabetes Mellitus Limited beta-cell response to hyperglycemia

2 Desensitization: Beta cells become progressively less efficient reversible by normalizing glucose levels ratio of proinsulin to insulin increases Decreased Glucose Utilization Cells need insulin as a carrier for glucose adipose tissue, skeletal, cardiac muscle requires insulin Increased Fat Mobilization When glucose is unavailable when glucose is unavailable: use fat stored Fat metabolism form ketones Increased Protein Utilization Lack insulin protein wasting lack insulin stimulate protein synthesis increased catabolism (destruction) Amino acids change to glucose in liver increase glucose 3) Clinical Manifestation hyperglycemia Type 1: diabetic ketoacidosis possibility of life-threatening situations Type 2: gradual symptom deveoplment for years polyuria, polydipsia, polyphagia 4) Diagnosis (1) Fasting Blood Glucose Level Fasting blood glucose: blood sample not ingested except water for at least 8 hours reflect glucose level from hepatic production FBS >126 mg/dl IFG: 110 ~125 mg/dl (2) Casual Blood Glucose Level Casual (random) blood glucose > 200 mg/dl (3) Postload Blood Glucose Level Postload or postprandial (after a meal) glucose level> 2-hour postload glucose level > 200 mg/dl during an oral glucose tolerance test (OGTT) 5) Laboratory Tests Related to Diabetes Mellitus (1) Glycosylated Hemoglobin Level higher blood glucose, higher glycosylated hemoglobin (HbA1C) (2) Glycosylated Albumin Level Glycosylated albumin (fructosamine)

3 (3) Connecting Peptide (C-Peptide) Level When proinsulin broken apart, 2 products (insulin, connecting peptide) formed (4) Ketonuria presence of ketones in urine : body using fat as major source of energy ketoacidosis (5) Proteinuria Microalbuminuria: amout of protein in urine early manifestation of kidney disease: early nephropathy 6) Self-Monitoring of Blood Glucose (SMBG) immediate feedback, data on blood glucose levels body responds to food, insulin, activity, and stress Type 1 and pregnant taking insulin: recommended more than 3 times daily before each meal, bedtime, middle of night (3:00 AM) Type 2 : frequency and timing of SMBG mutually agreed 7) Medical Management (1) Promote Proper Nutrition Specific goals include improving blood glucose and lipid Alcohol alcohol consumption, use of artificial sweeteners No need to give up alcoholic beverages entirely Artificial Sweeteners Physical activity: lowers blood glucose by increasing carbohydrate metabolism fosters weight reduction, maintenance, increases insulin sensitivity side effect: hypoglycemia Occasionally, hyperglycemia and ketosis taking insulin or oral hypoglycemic: adjustments needed Pts with meal planning and physical activity alone (type 2) not risk for hypoglycemia when exercising (3) Administer Medications Oral Antidiabetes Drugs Insulin Therapy Insulin Sources Rapid-Acting Insulin approved in 1996 to minimize absorption limitations of regular human insulin lispro (Humalog), insulin aspart (NovoLog) available as premixed insulins: both rapid-acting and intermedi- ate-acting component should be injected within 15 minutes before a meal Insulin Dosage starting dose: 0.5 unit/kg/day 2/3 commonly given in morning, 1/3 given in evening

4 Insulin Pump Therapy Small portable pumps: continuous administration of regular insulin Inhaled Insulin Inhaled insulin (Exubera) approved by FDA in January 2006 Intensive Diabetes Mellitus Therapy adjust insulin doses to keep glucose levels as close to normal as possible Combination Therapy use of two or more oral antidiabetes agents or oral agent combined with insulin sulfonylurea agents: enhance effect of endogenous insulin by reducing insulin resistance 4) Nursing Management team approach is recommended Crucial members: nurse, dietitian, physician, psychologist, social worker, (1) Readiness for Enhanced Self-Care Explain the Pathophysiology of Diabetes Mellitus Prevent Complications from Physical Activity adequately hydrated before starting exercise eat 15 to 30 g of carbohydrate before exercise if blood glucose < 100 mg/dl DM identification glucose level > 250 mg/dl, check ketone levels Avoid alcohol, beta-blockers : may increase risk of hypoglycemia or hyperglycemia Plan Nutrition Therapy to Achieve Target Blood Glucose Level balanced nutritional plan Calories Moderate caloric reduction : reduction of 250 to 500 calories per day Reduction of fat calories : good initial modification Regular exercise (3~5 times weekly) Protein High protein intake: increases renal workload, glomerular filtration rate lower end of recommended scale for protein intake: about 10% of daily calories restricted Fat decrease total dietary fat to 30% or less of total calories with saturated fat decreased to less than 10% Carbohydrates sucrose : produces glycemic response Clinical guidelines: 50%~60% carbohydrates in either simple or complex form (2) Risk for Unstable Blood Glucose Provide Instruction on Blood Glucose Monitoring Use blood glucose strips if they are unable or unwilling to purchase a meter With some meters and strips, a 15% difference between capillary blood and venous blood glucose Provide Instruction on Urine Testing: urine testing for glucose is rare

5 Provide Instruction on Insulin Administration insulin concentrations: prescribed in units, U-100 insulin: 100 units of insulin per milliliter Insulin Syringes: 0.25, 0.30, 0.50, 1 ml syringe; short (8 mm) and long (12.7 mm) needles Insulin Pens: pen-like holders with prefilled cartridges holding 150 to 300 units of insulin disposable needle, insulin dose dialed or entered into pen, priming each new needle Prefilled Syringes: chemically stable for up to 3 wks, stored in frig Mixing regular and NPH insulins in one syringe: acceptable and convenient Site Selection and Rotation: absorption varies from site to site: injections about an inch apart : to avoid sites above muscles exercise heavily: exercise increases absorption two injections daily: one site for morning, another site for evening Rotate injection sites: to decrease variability of absorption 5) Modifications for Older Clients common among older adults normal aging affect glucose levels blood glucose increase with age, fasting levels increase by 1 mg/dl per decade postprandial values by 6 to 13mg/dl per decade 6) Surgical Management (1) Pancreas Transplant 80% of pancreas transplantation procedures with kidney transplantation renal function check side effects of cyclosporine (hyperglycemia, nephrotoxicity) own pancreas left intact (98% of exocrine function) Complications vessel thrombosis, rejection, infection Thrombosis symptoms: sudden urine amylase decrease, rapid increases in blood glucose gross hematuria, pain in iliac fossa, and tenderness in graft area Prevention: blood flowing through pancreas should be kept at high rate for 72 hrs Outcomes discharge 7 to 10 days without need for insulin Within 3 to 4 months, resumes normal life Successful transplantation: blood glucose (between 60 and 110 mg/dl), C-peptide levels (2) Islet Cell Transplant as treatment for type 1 7) Nursing Management of the Surgical Client focus of care: monitor for rejection, adverse effects of immunosuppressants, infection, occlusion of vessels

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