Interventions for Clients with Glucose

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					Interventions for Clients with
Diabetes Mellitus

Overview
What is Diabetes?

Why is it a major public health concern?

Pathophysiology
Endocrine Pancreatic Hormones Islets of Langerhans
Alpha cells - glucagon
Beta cells - insulin
Delta cells - somatostatin
Blood Glucose Homeostasis

Classification
Type 1 Diabetes
Type 2 Diabetes
Other Specific Types
Gestational Diabetes


Normal Insulin Production
Physiologic Response to Insufficient Insulin

Hyperglycemia –(F&E imbalances   )
Polyuria
Polydipsia
Polyphagia
Lipolysis
Formation of ketones
Hemoconcentration = hypovolemia
Hyperviscosity of blood

More Effects of Insufficient Insulin
Hypoperfusion
Hypoxia
Hypokalemia
Kussmaul respirations
Metabolic acidosis


Type 1 – Diabetes (IDDM)
Autoimmune Process
     - Beta cells destroyed
    - Insulin deficiency

Idiopathic
    - No known cause
   - Genetic predisposition

Manifestations of Type 1 DM
Hyperglycemia
3 P’s
Polyuria
Polydipsia
Polyphagia
Weight loss
Glycosuria
Fatigue

Type 2 – Diabetes (NIDDM)
Insulin resistance
Obesity
Physical inactivity
Genetic predisposition


Manifestations of Type 2 DM
Hyperglycemia
Polyuria
Polydipsia
Blurred vision
Fatigue
Paresthesias
Skin infections


Other specific types of DM
Genetic defects of beta cells
Genetic defects in insulin action
Diseases of the exocrine pancreas
Endocrine disorders
Drug or chemical induced
Infections

Gestational Diabetes
Glucose intolerance during pregnancy

Diagnostic Tests
Diagnostic criteria recommended by ADA:
Fasting blood glucose test <110 mg/dL
Glucose tolerance test <140 mg/dL
Glycosylated hemoglobin (A1C) 4% to 6%


Lab Assessment
Blood tests
  1. Fasting Blood Glucose Test
  2. Oral Glucose Tolerance Test
  3. Glycosylated Hemoglobin Assays
  4. Glycosylated Serum Proteins and Albumin


Urine Tests
 1. Urine testing for Ketone Bodies
 2. Tests for Renal Function
 3. Urine Testing for Glucose

ADA Treatment Goals
Hgb A1C maintained at 7% or below
Premeal blood glucose level 70 to 110mg/dl
Blood glucose at bedtime 100-140mg/dl

Management
Nonsurgical Management
 1. Dietary interventions
 2. Monitoring of blood glucose levels
 3. Exercise program
 4. Medications to lower blood glucose
Diet Therapy
Meal planning strategies
Exchange System-(Carbohydrates, Protein, and Fat)
Carbohydrate counting-1unit/15g CHO

Exercise Therapy
Increases insulin sensitivity, improves cell uptake of glucose, a   nd promotes weight
loss.

Insulin Therapy
Types of Insulin
Rapid acting (Lispro, Humalog
      - clear
Short acting (Regular)
      - clear
Intermediate (NPH)
      - cloudy
    . Long acting (Lantus/Glargine)
      - clear
      - can’t mix with other insulins

Pre-Mixed Insulin
Humulin or Novolin
 - 70/30
      - 70% NPH / 30% Regular
Novolog
 - 70/30
      - 70% NPL / 30% Novolog
Humalog
 - 75/25 (75% NPL / 25% Humalog
 - 50/50 (50% NPH / 50% Regular
      - Give immediately before meals

Drug Therapy
Sulfonylurea Agents
  - glipizide (Glucotrol) – stimulate insulin production
       - Give 30 min before meals
       - Watch for photosenitivity
Meglitinides Agents
  - repaglinide (Prandin) – stimulate insulin production
                                   Cont.
 - Give 30 min before meals
 - Causes weigh gain
Biguanides Agents
   - glucophage (Metformin – decrease hepatic glucose
   production
        - Take with meals
        - Increase weight loss
        - monitor renal function

Alpha-Glucosidase Inhibitors
   - acarbose (Precose) – block sugar absorption
   - gas forming (rarely prescribed)
   - take with first bite of each of the 3 main meals
   - monitor liver function tests

Thiazolidinedione Agents – sensitize muscle to insulin
   - rosiglitazone (Avandia)
   - pioglitazone (Actos)
       - high incidence pregnancy after menapause
       - use birth control
       - monitor weigh & assess for edema

Surgical Management
Whole-Pancreas Transplantation
 1. Transplant pancreas alone (PTA)
 2. Transplant pancreas after kidney (PAK)
 3. Simultaneous pancreas and kidney(SPK)

Islet Cell Transplantation-(experimental)

Insulin Pump

Common Nursing Diagnosis
Risk for injury R/T hyperglycemia
Risk for injury R/T sensory alterations
Chronic Pain R/T diabetic neuropathy
Ineffective renal tissue perfusion R/T diabetic nephropathy
Potential for Hypoglycemia
Potential for Diabetic Ketoacidosis



Risk for Injury R/T Sensory Alterations
Foot injury is the most common complication of diabetes leading to
hospitalization.
Diabetes is the leading cause of amputation worldwide.

Diabetic Neuropathy
About 60-70% of people with diabetes have mild to severe forms of nervous
system damage, including:
Impaired sensation or pain in the feet or hands
Slowed digestion of food in the stomach
Carpal tunnel syndrome
Other nerve problems
More than 60% of nontraumatic lower-limb amputations in the United States
occur among people with diabetes.

Foot Care Instructions
Inspect your feet daily
Do not wear the same pair of shoes 2 days in a row
Wear clean cotton socks daily
Do not go barefooted
Trim your toenails straight across with a nail clipper
Do not treat blisters, see your physician

Chronic Pain
Neuropathic pain
  1. Anticonvulsant drugs (Neurontin)
  2. Tricyclic antidepressants – (Elavil,Pamelor)
  3. Capsaicin cream, Zostrix-HP - burning

Ineffective Renal Tissue Perfusion
ADA recommends yearly evaluation of kidney function
 1. Spot urine collection – (albumin-creatinine ratio)
 2. 24-hour urine collection (creatinine)
 3. Timed urine collection
Acute Complications of Diabetes

HYPOGLYCEMIA
Potential for Hypoglycemia
Four common causes:
 1. Excess insulin
 2. Deficient intake or absorption of food
 3. Exercise
  4. Alcohol




Symptoms of Hypoglycemia
Responses of the ANS
Hunger
Irritability
Shakiness
Pale, cool skin
Rapid pulse
Hypotension
Impaired Cerebral Function
Headache
Inability to concentrate
Slurred speech
Blurred vision
Decrease in LOC
Seizures/Coma


Management of Hypoglycemia
Hypoglycemic protocol
Mild hypoglycemia (BG < 60 and symptomatic)
         - 10 to 15g of carbohydrate
         - Recheck BG in 15minutes
Moderate (BG < 40 and symptomatic)
          -15 to 30g of rapidly absorbed CHO
Severe (BG < 20 and unable to swallow)
          - 1mg of glucagon IM/SQ or amp of D50 IVP

Diabetic Ketoacidosis (DKA)
Pathophysiology
Four Metabolic Problems
Hyperosmolarity from hyperglycemia and dehydration
Metabolic acidosis from an accumulation of ketoacids
Extracellular volume depletion from osmotic diuresis
Electrolyte imbalances




Laboratory Findings for DKA
BG >250mg/dl
Plasma pH < 7.3
Plasma HCO3 < 15meq/L
Presence of serum ketones
Presence of urine ketones and glucose
Abnormal levels of serum Na, K, Cl-


Clinical Manifestations DKA
Dehydration: polyuria, polydipsia, weight loss, dry skin, sunken eyes,
lethargy, coma, rapid weak pulse, hypotension
Metabolic Acidosis (ketosis): N/V, “fruity” breath, Kussmaul
respirations, abdominal pain


Treatment for DKA
Frequent assessment of client: LOC, V/S, blood glucose levels, fluid
and electrolyte status
Correct fluid volume deficit
1 liter of isotonic saline over 1 hour
1 liter of hypotonic saline over 6 to 8 hrs
1 liter of hypertonic solution (D51/2NS) over 8 to 12 hrs.




Drug therapy for DKA
Insulin therapy: lower BG by 75-150mg/dl/hr
Regular insulin IV bolus dose of .1u/kg followed by IV drip of .1u/kg/hr.
SQ insulin when client can eat and ketosis has ended.
Electrolyte replacement
Potassium
Bicarbonate



Patho for HHS
Metabolic Problems

Laboratory Findings

Clinical Manifestations

Treatment


Chronic Complications of Diabetes Mellitus
Alterations in the CV System
Macrovascular
Cardiovascular Disease
Cerebrovascular Disease
Peripheral Vascular Disease
Microvascular
Nephropathy

Retinopathy


Diabetic Retinopathy

Diabetic Nephropathy

    Alterations in the Peripheral and Autonomic
                  Nervous Systems
Diabetic Neuropathies
Peripheral Neuropathies – Polyneuropathy and Mononeuropathy
Visceral Neuropathies – Autonomic Neuropathies



Client and Family Teaching



Sick-Day Rules
Notify your health care provider that you are ill.
Monitor your blood glucose at least every 4 hours.
Test your urine for ketones if BG>240.
Continue to take your insulin or oral antidiabetic agents.
Drink 8 to 12 ounces of sugarfree liquids every hour that you are
awake.
Continue to eat meals at regular times.

				
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Description: Interventions for Clients with Glucose