Diabetes Mellitus
Chapter 48
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetes Mellitus
• A chronic multisystem disease
characterized by hyperglycemia related
to abnormal insulin production,
impaired insulin utilization, or both
• Affects 29.1 million people
• Seventh leading cause of death
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetes Mellitus
• Leading cause of
• Adult blindness
• End-stage renal disease
• Non-traumatic lower limb amputations
• Major contributing factor
• Heart disease
• Stroke
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Etiology and Pathophysiology
• Combination of causative factors
• Genetic
• Autoimmune
• Environmental
• Absent/insufficient insulin and/or poor
utilization of insulin
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Etiology and Pathophysiology
• Normal glucose and insulin metabolism
• Produced by -cells in islets of Langerhans
• Released continuously into bloodstream
in small increments with larger amounts
released after food
• Stabilizes glucose level in range of 70 to
110 mg/dL
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Normal Insulin Secretion
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Etiology and Pathophysiology
• Insulin
• Promotes glucose transport from the
bloodstream across the cell membrane to
the cytoplasm of the cell
• Cells break down glucose to make energy
• Liver and muscle cells store excess glucose as
glycogen
• Skeletal muscle and adipose tissue are
considered insulin-dependent tissues
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Normal Glucose and Insulin
Metabolism
Normal glucose and insulin metabolism. Insulin binds to receptors along the cell walls of muscle,
adipose, and liver cells. Glucose transport proteins (GLUT 4) then attach to the cell wall and allow
glucose to enter the cell, where it is either stored or used to make energy.
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Etiology and Pathophysiology
• Counterregulatory hormones
• Glucagon, epinephrine, growth hormone,
•
•
•
•
cortisol
Oppose effects of insulin
Stimulate glucose production and release
by the liver
Decrease movement of glucose into cell
Help maintain normal blood glucose levels
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Classes of Diabetes
•
•
•
•
•
Type 1
Type 2
Gestational
Other specific types
Prediabetes
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Type 1 Diabetes Mellitus
• Formerly known as juvenile-onset or
insulin-dependent diabetes
• Accounts for about 5% to 10% of all
people with diabetes
• Generally affects people under age 40
• Can occur at any age
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Type 1 Diabetes Mellitus
Etiology and Pathophysiology
• Autoimmune disorder
• Body develops antibodies against insulin
and/or pancreatic β cells that produce
insulin
• Results in not enough insulin to survive
• Genetic link
• Idiopathic diabetes
• Latent autoimmune diabetes in adults
(LADA)
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Type 1 Diabetes Mellitus
Onset of Disease
• Autoantibodies are present for months
to years before symptoms occur
• Manifestations develop when pancreas
can no longer produce insulin—then
rapid onset with ketoacidosis
• Necessitates insulin
• Patient may have temporary remission
after initial treatment
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Type 2 Diabetes Mellitus
• Formerly known as adult-onset diabetes
(AODM) or non–insulin-dependent
diabetes (NIDDM)
• Most prevalent type (90% to 95%)
• Many risk factors: overweight, obesity,
advanced age, family history
• Increasing prevalence in children
• Greater prevalence in ethnic groups
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Type 2 Diabetes Mellitus
Etiology and Pathophysiology
• Pancreas continues to produce some
endogenous insulin but
• Not enough insulin is produced
OR
• Body does not use insulin effectively
• Major distinction
• In type 1 diabetes there is an absence of
endogenous insulin
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Type 2 Diabetes Mellitus
Etiology and Pathophysiology
• Genetic link
1. Insulin resistance
2. Decreased insulin production by pancreas
3. Inappropriate hepatic glucose production
4. Altered production of hormones and
cytokines by adipose tissue (adipokines)
5. Research continues on role of brain,
kidneys, and gut in type 2 diabetes
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Type 2 Diabetes Mellitus
Etiology and Pathophysiology
• Metabolic syndrome increases risk for
type 2 diabetes
• Elevated glucose levels
• Abdominal obesity
• Elevated BP
• High levels of triglycerides
• Decreased levels of HDLs
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Type 2 Diabetes Mellitus
Onset of Disease
• Gradual onset
• Hyperglycemia may go many years
without being detected
• Often discovered with routine
laboratory testing
• At time of diagnosis
• About 50% to 80% of β cells are no longer
secreting insulin
• Average person has had diabetes for 6.5 years
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Altered Mechanisms in
Type 1 and Type 2 Diabetes
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Prediabetes
• ↑ Risk for developing type 2 diabetes
• Impaired glucose tolerance (IGT)
• OGTT - 140-199 mg/dL
• Impaired fasting glucose (IFG)
• Fasting glucose of 100-125 mg/dL
• Intermediate stage between normal
glucose homeostasis and diabetes
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Prediabetes
• Asymptomatic but long-term damage
already occurring
• Patient teaching important
• Undergo screening
• Manage risk factors
• Monitor for symptoms of diabetes
• Maintain healthy weight, exercise, make
healthy food choices
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Gestational Diabetes
• Develops during pregnancy
• Increases risk of need for cesarean
delivery and of perinatal complications
• Screen high-risk patients first visit;
others at 24 to 28 weeks of gestation
• Usually glucose levels normal
6 weeks post partum
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Other Specific Types of Diabetes
• Results from injury to, interference
with, or destruction of β-cell function in
the pancreas
• From medical conditions and/or
medications
• Resolves when underlying condition is
treated or medication is discontinued
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Clinical Manifestations
Type 1 Diabetes Mellitus
• Classic symptoms
• Polyuria (frequent urination)
• Polydipsia (excessive thirst)
• Polyphagia (excessive hunger)
• Weight loss
• Weakness
• Fatigue
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Clinical Manifestations
Type 2 Diabetes Mellitus
• Nonspecific symptoms
• Classic symptoms of type 1 may manifest
• Fatigue
• Recurrent infection
• Recurrent vaginal yeast or candidal
infection
• Prolonged wound healing
• Visual changes
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Case Study
(©RyanMcVay/Digital Vision/Thinkstock)
• R.H. is a 62-year-old woman who comes
to the clinic for a routine physical
examination.
• She works as a banking executive and
gets little exercise.
• She says she is “just tired.”
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Case Study
(©RyanMcVay/Digital Vision/Thinkstock)
• She has gained 18 pounds over the past
year and eats a high-fat diet.
• Her BP is 162/98, heart rate is 92, and
respiration rate is 20.
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Case Study
(©RyanMcVay/Digital Vision/Thinkstock)
• R.H. complains of some weakness in her
right foot that began about a month
ago.
• She says it also feels a little numb.
• A sensory examination reveals
diminished sensations of light touch,
proprioception, and vibration in both
feet.
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Case Study
(©RyanMcVay/Digital Vision/Thinkstock)
• R.H. also complains of increased thirst
and frequent nighttime urination.
• She denies any other weakness,
numbness, or changes in vision.
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Case Study
(©RyanMcVay/Digital Vision/Thinkstock)
• A physical examination reveals an
erythematous scaling rash in both
inguinal areas and in axillae.
• R.H. states the rash has been there on
and off for several years and is worse in
the warm weather.
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Case Study
(©RyanMcVay/Digital Vision/Thinkstock)
• What risk factors for diabetes does R.H.
have?
• Which type of diabetes is R.H. at
highest risk for developing?
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Case Study
(©RyanMcVay/Digital Vision/Thinkstock)
• What clinical manifestations of
diabetes is she displaying?
• What diagnostic tests for diabetes
would you expect the health care
provider to order?
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diagnostic Studies
1. Hemoglobin A1C level: 6.5% or higher
2. Fasting plasma glucose level: higher
than 126 mg/dL
3. Two-hour plasma glucose level during
OGTT: 200 mg/dL (with glucose load
of 75 g)
4. Classic symptoms of hyperglycemia
with random plasma glucose level of
200 mg/dL or higher
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diagnostic Studies
• A1C
• Glycosylated hemoglobin: reflects glucose
levels over past 2 to 3 months
• Used to diagnose, monitor response to
therapy, and screen patients with
prediabetes
• Goal: < 6.5% to 7%
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diagnostic Studies
• Fructosamine
• Reflects glycemia in previous 1-3 weeks
• Autoantibodies
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Case Study
(©RyanMcVay/Digital Vision/Thinkstock)
• R.H.’s diagnostic testing results
• Random glucose test: 253 mg/dL
• A1C: 9.1%
• Urine: positive for glucose and negative
for protein
• Wet preparation of smear from rash:
consistent with Candida albicans
• ECG: evidence of early ventricular
hypertrophy
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Interprofessional Care
• Goals of diabetes management
• Decrease symptoms
• Promote well-being
• Prevent acute complications
• Delay onset and progression of
long-term complications
• Need to maintain blood glucose levels
as near to normal as possible
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Case Study
(©RyanMcVay/Digital Vision/Thinkstock)
• R.H. receives a diagnosis of type 2
diabetes mellitus.
• What 3 treatment modalities will you
expect to teach R.H. about?
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Interprofessional Care
• Patient teaching
• Nutritional therapy
• Drug therapy
• Exercise
• Self-monitoring of blood glucose
• Diet, exercise, and weight loss may be
sufficient for patients with type 2
diabetes
• All patients with type 1 require insulin
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Insulin
• Exogenous insulin
• Insulin from an outside source
• Required for type 1 diabetes
• Prescribed for patients with type 2
diabetes who cannot manage blood
glucose levels by other means
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Insulin
• Human insulin
• Genetically engineered in laboratories
• Categorized according to onset, peak
action, and duration
• Rapid-acting
• Short-acting
• Intermediate-acting
• Long-acting
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Types of Insulin
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Commercially Available Insulin
Preparations
Commercially available insulin preparations showing onset, peak, and duration of action. Individual
patient responses to each type of insulin are different and affected by many different factors.
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Insulin Regimens
• Basal-bolus regimen
• Most closely mimics endogenous insulin
production
• Rapid- or short-acting (bolus) insulin
before meals
• Intermediate- or long-acting (basal)
background insulin once or twice a day
• Less intense regimens can also be used
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Mealtime Insulin (Bolus)
• Insulin preparations
• Rapid-acting (bolus)
• Lispro, aspart, glulisine
• Onset of action 15 minutes
• Injected within 15 minutes of mealtime
• Short-acting (bolus)
• Regular with onset of action 30 to 60 minutes
• Injected 30 to 45 minutes before meal
• Onset of action 30 to 60 minutes
Copyright © 2017, Elsevier Inc. All Rights Reserved.
(Basal) Background Insulin
• Used to manage glucose levels in between
meals and overnight
• Long-acting (basal)
• Insulin glargine (Lantus) and detemir
(Levemir)
• Released steadily and continuously with no
peak action for many people
• Administered once or twice a day
• Do not mix with any other insulin or solution
Copyright © 2017, Elsevier Inc. All Rights Reserved.
(Basal) Background Insulin
• Intermediate-acting insulin
• NPH
• Duration 12 to 18 hours
• Peak 4 to 12 hours
• Can mix with short- and rapid-acting insulins
• Cloudy; must agitate to mix
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Combination Insulin Therapy
• Can mix short- or rapid-acting insulin with
intermediate-acting insulin in same
syringe
• Provides mealtime and basal coverage in
one injection
• Commercially premixed or self-mix
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Mixing Insulins
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Insulin
• Storage of insulin
• Do not heat/freeze
• In-use vials may be left at room
temperature up to 4 weeks
• Extra insulin should be refrigerated
• Avoid exposure to direct sunlight,
extreme heat or cold
• Store prefilled syringes upright for 1 week
if 2 insulin types; 30 days for one
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Insulin
• Administration of insulin
• Given by subcutaneous injection
• Regular insulin may be given IV
• Cannot be taken orally
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Insulin
• Administration of insulin
• Absorption is fastest from abdomen,
followed by arm, thigh, and buttock
• Abdomen is often preferred site
• Do not inject in site to be exercised
• Rotate injections within and between sites
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Subcutaneous Injection Sites
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Insulin
• Administration of insulin
• Usually available as U100 insulin (1 mL
•
•
•
•
contains 100 U of insulin)
Syringes marked for units: various sizes
Only user recaps syringe
No alcohol swab for self-injection; wash
with soap and water
Inject at 45- to 90-degree angle
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Insulin Pen
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Insulin
• Insulin pump
• Continuous subcutaneous infusion
• Battery-operated device
• Connected to a catheter inserted into
subcutaneous tissue in abdominal wall
• Program basal and bolus doses that can
vary throughout the day
• Potential for keeping blood glucose levels
in a tighter range
Copyright © 2017, Elsevier Inc. All Rights Reserved.
OmniPad Insulin Management
System
OmniPod Insulin Management System. The Pod holds and delivers insulin. B, The Personal Diabetes
Manager (PDM) wirelessly programs insulin delivery via the Pod. The PDM has a built-in glucose meter.
(Courtesy of Insulet Corporation)
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Insulin
• Problems with insulin therapy
• Hypoglycemia
• Allergic reaction
• Lipodystrophy
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Somogyi Effect
• Somogyi effect
• Rebound effect in which an overdose of
insulin causes hypoglycemia
• Release of counterregulatory hormones
causes rebound hyperglycemia
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Dawn Phenomenon
• Dawn phenomenon
• Morning hyperglycemia present on
awakening
• May be due to release of
counterregulatory hormones in predawn
hours
• Growth hormone and cortisol
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Inhaled Insulin
• Afrezza
• Rapid-acting inhaled insulin
• Administered at beginning of each meal or
within 20 minutes after starting a meal
• Not a substitute for long-acting insulin
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Oral Agents
• Work on 3 defects of type 2 diabetes
• Insulin resistance
• Decreased insulin production
• Increased hepatic glucose production
• Can be used in combination
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Case Study
(©RyanMcVay/Digital Vision/Thinkstock)
• R.H.’s health care provider orders
metformin (Glucophage) 500 mg PO
bid.
• What is the mechanism of action of
metformin?
• What would you teach R.H. about
metformin?
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Mechanisms of Action of Type 2
Diabetes Drugs
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Biguanides
• Metformin (Glucophage)
• Reduces glucose production by liver
• Enhances insulin sensitivity
• Improves glucose transport
• May cause weight loss
• Used in prevention of type 2 diabetes
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Biquanides
• Withhold if patient is undergoing
surgery or radiologic procedure with
contrast medium
• Day or two before and at least 48 hours
after
• Monitor serum creatinine
• Contraindications
• Renal, liver, cardiac disease
• Excessive alcohol intake
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Sulfonylureas
• ↑ Insulin production from pancreas
• Major side effect: hypoglycemia
• Examples
• Glipizide (Glucotrol)
• Glyburide (Glynase)
• Glimepiride (Amaryl)
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Meglitinides
• ↑ Insulin production from pancreas
• Rapid onset: ↓ hypoglycemia
• Taken 30 minutes to just before each
meal
• Should not be taken if meal skipped
• Examples
• Repaglinide (Prandin)
• Nateglinide (Starlix)
Copyright © 2017, Elsevier Inc. All Rights Reserved.
α-Glucosidase Inhibitors
• “Starch blockers”
• Slow down absorption of carbohydrate in
small intestine
• Take with first bite of each meal
• Example
• Acarbose (Precose)
• Miglitol (Glyset)
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Thiazolidinediones
• Most effective in those with insulin
resistance
• Improve insulin sensitivity, transport,
and utilization at target tissues
• Examples
• Pioglitazone (Actos)
• Rosiglitazone (Avandia)
• Rarely used because of adverse effects
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Dipeptidyl Peptidase–4 (DDP-4) Inhibitor
• Blocks inactivation of incretin hormones
• ↑ Insulin release
• ↓ Glucagon secretion
• ↓ Hepatic glucose production
• Examples (gliptins)
• Sitagliptin (Januvia)
• Saxagliptin (Onglyza)
• Linagliptin (Tradjenta)
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Sodium-Glucose Co-Transporter 2
(SGLT2) Inhibitors
• SGLT2 inhibitors work by
• Blocking reabsorption of glucose by
kidney
• Increasing glucose excretion
• Lowering blood glucose levels
• Canagliflozin (Invokana)
• Dapagliflozin (Farxiga)
• Empagliflozin (Jardiance)
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Dopamine Receptor Agonist
• Bromocriptine (Cycloset)
• Mechanism of action unknown
• Thought that patients with type 2
diabetes have low levels of dopamine
• Increases dopamine receptor activity
• Alone or in combination
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Glucagonlike Peptide-1 Receptor Agonists
• Simulate glucagonlike peptide–1 (GLP-1)
• Increase insulin synthesis and release
• Inhibit glucagon secretion
• Slow gastric emptying
• Increases satiety
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Drug Therapy
Amylin Analog
• Pramlintide (Symlin)
• Slows gastric emptying, reduces
postprandial glucagon secretion,
increases satiety
• Used concurrently with insulin
• Subcutaneously in thigh or abdomen
before meals
• Watch for hypoglycemia
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Drug Therapy
• Combination oral therapy
• Blend two different classes of medications
to treat diabetes
• Improves adherence because patient
takes fewer pills
• Other drugs affecting blood glucose
levels
• Drug interactions can potentiate
hypoglycemia and hyperglycemia effects
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetes
Nutritional Therapy
•
•
•
•
Counseling
Education
Ongoing monitoring
Interprofessional team
• Registered dietitian with expertise in
diabetes management
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetes
Nutritional Therapy Goals
• ADA healthy food choices
• Maintain blood glucose levels to as close to
•
•
•
•
normal as safely possible
Normal lipid profiles and blood pressure
Prevent or slow complications
Individual needs; personal, cultural
preferences
Maintain pleasure of eating
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetes
Nutritional Therapy: Type 1 DM
• Meal planning
• Based on usual food intake and preferences
• Balanced with insulin and exercise patterns
• Day-to-day consistency makes it easier to
manage blood glucose levels
• More flexibility with rapid-acting insulin,
multiple daily injections, and insulin pump
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Case Study
(©RyanMcVay/Digital Vision/Thinkstock)
• What would you teach R.H. about her
dietary needs in relation to her type 2
diabetes?
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetes
Nutritional Therapy: Type 2 DM
• Emphasis on achieving glucose, lipid,
and BP goals
• Weight loss
• Nutritionally adequate meal plan with ↓
fat and CHO
• Spacing meals
• Regular exercise
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetes
Nutritional Therapy
• Food composition
• Healthy balance of nutrients is essential to
maintain blood glucose levels and overall
health
• Energy from food intake can be balanced
with energy output
• Individualized to lifestyle and health goals
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetes
Nutritional Therapy
• Carbohydrates
• Minimum of 130 g/day
• Fruits, vegetables, whole grains, legumes,
low-fat dairy
• All benefit from including dietary fiber
• Nutritive and nonnutritive sweeteners
may be used in moderation
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetes
Nutritional Therapy
• Fats
• Limit saturated fats to < 7% of total
calories
• Limit cholesterol to < 200 mg/day
• Minimize trans fat
• Healthy fats come from plants
• Olives, nuts, avocados
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetes
Nutritional Therapy
• Protein
• Should make up 15% to 20% of total
calories
• High-protein diets not recommended
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetes
Nutritional Therapy
• Alcohol
• Limit to moderate amount
• 1 drink/day for women; 2 drinks/day for men
• Inhibits gluconeogenesis by liver
• Can cause severe hypoglycemia
• Blood glucose levels must be monitored
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetes
Nutritional Therapy
• Diet teaching
• Dietitian initially provides instruction
• Carbohydrate counting
• Serving size is 15 g of CHO
• Typically 45 to 60 g per meal
• Insulin dose based on number of CHOs
consumed
• Patient teaching essential
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetes
Nutritional Therapy
• Exchange lists
• Starches, fruits, milk, meat, vegetables,
fats, free foods
• Consistent CHO diet
• USDA MyPlate method
Copyright © 2017, Elsevier Inc. All Rights Reserved.
MyPlate for People With Diabetes
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Case Study
(©RyanMcVay/Digital Vision/Thinkstock)
• R.H. realizes that she needs to start
exercising in order to gain her health
back.
• She asks you what she should be doing.
• How would you respond?
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetes
Exercise
• Type/amount
• Minimum 150 minutes/week aerobic
• Resistance training three times/week
• Benefits
• ↓ Insulin resistance and blood glucose
• Weight loss
• ↓ Triglycerides and LDL , ↑ HDL
• Improve BP and circulation
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetes
Exercise
• Start slowly after medical clearance
• Monitor blood glucose
• Glucose-lowering effect up to 48 hours after
exercise
• Exercise 1 hour after a meal
• Snack to prevent hypoglycemia
• Do not exercise if blood glucose level > 300
mg/dL and if ketones are present in urine
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Self-Monitoring of Blood Glucose
(SMBG)
• Enables decisions regarding diet, exercise,
and medication
• Accurate record of glucose fluctuations
• Helps identify hyperglycemia and
hypoglycemia
• Helps maintain glycemic goals
• A must for insulin users
• Frequency of testing varies
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Blood Glucose Monitors
Blood glucose monitors are used to measure blood glucose levels. Bayer Contour Link glucose meter. (Courtesy of Bayer Diabetes)
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Self-Monitoring of Blood Glucose
(SMBG)
• Alternative blood sampling sites
• Data uploaded to computer
• Continuous glucose monitoring
• Displays glucose values with updating
every 1 to 5 minutes
• Helps identify trends and track patterns
• Alerts to hypoglycemia or hyperglycemia
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Self-Monitoring of Blood Glucose
(SMBG)
The MiniMed® 530730G with Enlite (A) delivers insulin through a thin plastic tubing to an infusion set, which has
a cannula (B) that sits under the skin. Continuous glucose monitoring occurs through a tiny sensor (C) inserted
under the skin. Sensor data are sent continuously to the insulin pump through wireless technology giving a
more complete picture of glucose levels, which can lead to better treatment decisions and improved health.
(MiniMed® 530G with Enlite® manufactured by the diabetes division of Medtronic, Inc)
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Self-Monitoring of Blood Glucose
(SMBG)
• Patient teaching
• How to use, calibrate
• When to test
• Before meals
• Two hours after meals
• When hypoglycemia is suspected
• During illness
• Before, during, and after exercise
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Bariatric Surgery
• Bariatric surgery
• Patients with type 2 diabetes
• When lifestyle and drug therapy management
is difficult
• BMI >35 kg/m2
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Pancreas Transplantation
• For type 1 diabetes with kidney transplant
• Eliminates need for exogenous insulin,
SMBG, dietary restrictions
• Can also eliminate acute complications
• Long-term complications may persist
• Lifelong immunosuppression
• Islet cell transplantation experimental
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Culturally Competent Care
• Culture can have a strong influence on
dietary preferences and meal preparation
• High incidence of diabetes
• Hispanics
• Native Americans
• African Americans
• Asians and Pacific Islanders
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Assessment
• Subjective Data
• Past health history
• Viral infections, trauma, infection, stress,
pregnancy, chronic pancreatitis, Cushing
syndrome, acromegaly, family history of
diabetes
• Medications
• Insulin, OAs, corticosteroids, diuretics,
phenytoin
• Recent surgery
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Assessment
• Subjective Data
• Malaise
• Obesity, weight loss or gain
• Thirst, hunger, nausea/vomiting
• Poor healing
• Dietary compliance
• Constipation/diarrhea
• Frequent urination, bladder infections
• Nocturia, urinary incontinence
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Assessment
• Subjective Data
• Muscle weakness, fatigue
• Abdominal pain, headache, blurred vision
• Numbness/tingling, pruritus
• Impotence, frequent vaginal infections
• Decreased libido
• Depression, irritability, apathy
• Commitment to lifestyle changes
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Assessment
• Objective Data
• Sunken eyeballs, history of vitreal
•
•
•
•
•
hemorrhages, cataracts
Dry, warm, inelastic skin
Pigmented skin lesions, ulcers, loss of hair
on toes, acanthosis nigricans
Kussmaul respirations
Hypotension
Weak, rapid pulse
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Assessment
• Objective Data
• Dry mouth
• Vomiting
• Fruity breath
• Altered reflexes, restlessness
• Confusion, stupor, coma
• Muscle wasting
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Assessment
• Objective Data
• Serum electrolyte abnormalities
• Fasting blood glucose level of 126 mg/dL
or higher
• Oral glucose tolerance test and/or random
glucose level exceeding 200 mg/dL
• Leukocytosis
• ↑ Blood urea nitrogen, creatinine
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Assessment
• Objective Data
• ↑ Triglycerides, cholesterol, LDL, VLDL
• ↓ HDL
• Hemoglobin A1C value > 6.0%
• Glycosuria
• Ketonuria
• Albuminuria
• Acidosis
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Diagnoses
•
•
•
•
Ineffective health management
Risk for unstable blood glucose levels
Risk for injury
Risk for peripheral neurovascular
dysfunction
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Planning
• Overall Goals
• Active patient participation
• Few or no hyperglycemia or hypoglycemia
emergencies
• Maintain normal blood glucose levels
• Prevent or minimize chronic complications
• Adjust lifestyle to accommodate diabetes
plan with a minimum of stress
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Implementation
• Health Promotion
• Identify, monitor, and teach patients at
risk
• Obesity: primary risk factor
• Routine screening for all overweight
adults and those older than 45
• Diabetes risk test
• www.diabetes.org/risk-test.jsp
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Implementation
• Acute Care
• Hypoglycemia
• Diabetic ketoacidosis
• Hyperosmolar hyperglycemic nonketotic
syndrome
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Implementation
• Acute illness and surgery
• ↑ Blood glucose level secondary to
counterregulatory hormones
• Frequent monitoring of blood glucose
• Ketone testing if glucose level exceeds 240
mg/dL
• Report glucose levels exceeding 300 mg/dL
twice or moderate to high ketone levels
• Increase insulin for type 1 diabetes
• Type 2 diabetes may necessitate insulin
therapy
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Implementation
• Acute illness
• Maintain normal diet if able
• Increase noncaloric fluids
• Continue taking antidiabetic medications
• If normal diet not possible, supplement
with CHO-containing fluids while
continuing medications
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Implementation
• Intraoperative period
• IV fluids and insulin
• Frequent monitoring of blood glucose
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Implementation
• Ambulatory Care
• Overall goal is to enable patient or
caregiver to reach an optimal level of
independence in self-care activities
• Increased risk for other chronic conditions
• Successful interaction with interprofessional
team
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Implementation
• Ambulatory Care
• Assess patient’s ability to perform SMBG
and insulin injection
• Use assistive devices as needed
• Assess patient/caregiver knowledge and
ability to manage diet, medication, and
exercise
• Teach manifestations and how to treat
hypoglycemia and hyperglycemia
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Implementation
• Ambulatory Care
• Frequent oral care
• Foot care
• Inspect daily
• Avoid going barefoot
• Proper footwear
• How to treat cuts
• Travel needs
• Medication, supplies, food, activity
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Medical Alert
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Management
Evaluation
• Expected Outcomes
• Knowledge
• Self-care measures
• Balanced diet and activity
• Stable, safe, and healthy blood glucose
levels
• No injuries
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Acute Complications
of Diabetes Mellitus
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Acute Complications
• Diabetic ketoacidosis (DKA)
• Hyperosmolar hyperglycemic syndrome
(HHS)
• Hypoglycemia
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetic Ketoacidosis (DKA)
• Caused by profound deficiency of
insulin
• Characterized by
• Hyperglycemia
• Ketosis
• Acidosis
• Dehydration
• Most likely to occur in type 1 diabetes
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetic Ketoacidosis (DKA)
• Precipitating factors
• Illness
• Infection
• Inadequate insulin dosage
• Undiagnosed type 1 diabetes
• Poor self-management
• Neglect
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetic Ketoacidosis (DKA)
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetic Ketoacidosis (DKA)
• Clinical manifestations
• Dehydration
• Poor skin turgor
• Dry mucous membranes
• Tachycardia
• Orthostatic hypotension
• Lethargy and weakness early
• Skin dry and loose; eyes soft and sunken
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetic Ketoacidosis (DKA)
• Clinical manifestations
• Abdominal pain, anorexia, nausea/vomiting
• Kussmaul respirations
• Sweet, fruity breath odor
• Blood glucose level of ≥ 250 mg/dL
• Blood pH lower than 7.30
• Serum bicarbonate level < 16 mEq/L
• Moderate to high ketone levels in urine or
serum
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetic Ketoacidosis (DKA)
• Less severe form may be treated on
outpatient basis
• Hospitalize for severe fluid and
electrolyte imbalance, fever,
nausea/vomiting, diarrhea, altered
mental state
• Also if communication with health care
provider is lacking
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Diabetic Ketoacidosis (DKA)
• Ensure patent airway; administer O2
• Establish IV access; begin fluid
resuscitation
• NaCl 0.45% or 0.9%
• Add 5% to 10% dextrose when blood
glucose level approaches 250 mg/dL
• Continuous regular insulin drip 0.1
U/kg/hr
• Potassium replacement as needed
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Case Study
(©RyanMcVay/Digital Vision/Thinkstock)
• What would you teach R.H. about
hyperglycemia associated with type 2
diabetes?
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Hyperosmolar Hyperglycemic
Syndrome (HHS)
• Life-threatening syndrome
• Occurs with type 2 diabetes
• Precipitating factors
• UTIs, pneumonia, sepsis
• Acute illness
• Newly diagnosed type 2 diabetes
• Impaired thirst sensation and/or inability
to replace fluids
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Hyperosmolar Hyperglycemic
Syndrome (HHS)
Pathophysiology of hyperosmolar hyperglycemic syndrome. (Modified from Urden LD, Stacy KM, Lough ME: Critical care nursing: diagnosis
and management, ed 6, St Louis, 2010, Mosby)
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Hyperosmolar Hyperglycemic
Syndrome (HHS)
• Enough circulating insulin to prevent
ketoacidosis
• Fewer symptoms lead to higher glucose
levels (>600 mg/dL)
• More severe neurologic manifestations
because of ↑ serum osmolality
• Ketones absent or minimal in blood and
urine
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Hyperosmolar Hyperglycemic
Syndrome (HHS)
• Medical emergency
• High mortality rate
• Therapy similar to that for DKA
• IV insulin and NaCl infusions
• More fluid replacement needed
• Monitor serum potassium and replace as
needed
• Correct underlying precipitating cause
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Case Study
(©RyanMcVay/Digital Vision/Thinkstock)
• Despite intense patient teaching, R.H.
presents to the ED with hyperglycemic
hyperosmolar syndrome.
• She has been ill with the flu and has not
taken her metformin as prescribed.
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Case Study
(©RyanMcVay/Digital Vision/Thinkstock)
• R.H.’s admitting blood glucose level is
832 mg/dL.
• She is admitted to the ICU for IV
hydration and insulin therapy.
• What will be your priority nursing
assessments/interventions for R.H.?
Copyright © 2017, Elsevier Inc. All Rights Reserved.
DKA/HHS
Nursing Management
• Monitor
• IV fluids
• Insulin therapy
• Electrolytes
• Assess
• Renal status
• Cardiopulmonary status
• Level of consciousness
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Hypoglycemia
• Too much insulin in proportion to
glucose in the blood
• Blood glucose level < 70 mg/dL
• Neuroendocrine hormones released
• Autonomic nervous system activated
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Case Study
(©RyanMcVay/Digital Vision/Thinkstock)
• As you administer IV insulin to R.H., for
which clinical manifestations of
hypoglycemia will you assess R.H.?
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Hypoglycemia
• Common manifestations
• Shakiness
• Palpitations
• Nervousness
• Diaphoresis
• Anxiety
• Hunger
• Pallor
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Hypoglycemia
• Altered mental functioning
• Difficulty speaking
• Visual disturbances
• Stupor
• Confusion
• Coma
• Untreated hypoglycemia can progress
to loss of consciousness, seizures,
coma, and death
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Hypoglycemia
• Hypoglycemia unawareness
• No warning signs/symptoms until glucose
level critically low
• Related to autonomic neuropathy and
lack of counterregulatory hormones
• Patients at risk should keep blood glucose
levels somewhat higher
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Hypoglycemia
• Causes
• Too much insulin or oral hypoglycemic
agents
• Too little food
• Delaying time of eating
• Too much exercise
• Symptoms can also occur when high
glucose level falls too rapidly
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Hypoglycemia
• Check blood glucose level
• If < 70 mg/dL, begin treatment
• If > 70 mg/dL, investigate further for cause
of signs/symptoms
• If monitoring equipment not available,
treatment should be initiated
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Case Study
(©RyanMcVay/Digital Vision/Thinkstock)
• Several days after being admitted for
hyperglycemia, R.H.’s blood glucose
level drops to 56 mg/dL.
• R.H. remains alert and oriented.
• What are your priority nursing
interventions?
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Hypoglycemia
• Treatment: rule of 15
• Consume 15 g of a simple carbohydrate
• Fruit juice or regular soft drink, 4 to 6 oz
• Recheck glucose level in 15 minutes
• Repeat if still < 70 gm/dL
• Avoid foods with fat
• Decrease absorption of sugar
• Avoid overtreatment
• Give complex CHO after recovery
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Hypoglycemia
• Treatment
• In acute care settings
• Fifty percent dextrose 20 to 50 mL IV push
• Patient not alert enough to swallow
• Glucagon 1 mg IM or subcutaneously
• Explore reason why occurred
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications of
Diabetes Mellitus
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Angiopathy
• Damage to blood vessels secondary to
chronic hyperglycemia
• Leading cause of diabetes-related
death
• Macrovascular and microvascular
• Tight glucose levels can prevent or
minimize complications
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Macrovascular Angiopathy
• Diseases of large and medium-sized
blood vessels
• Greater frequency and earlier onset in
patients with diabetes
• Cerebrovascular disease
• Cardiovascular disease
• Peripheral vascular disease
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Macrovascular Angiopathy
• Decrease risk factors (yearly screening)
• Obesity
• Smoking
• Hypertension
• High fat intake
• Sedentary lifestyle
• Screen for and treat hyperlipidemia
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Microvascular Angiopathy
• Thickening of vessel membranes in
capillaries and arterioles
• Specific to diabetes and includes
• Retinopathy
• Nephropathy
• Dermopathy
• Usually appear 10 to 20 years after
diagnosis
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Diabetic Retinopathy
• Microvascular damage to retina
• Most common cause of new cases of
adult blindness
• Nonproliferative: more common
• Proliferative: more severe
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Diabetic Retinopathy
• Nonproliferative
• Partial occlusion of small blood vessels in
retina causes microaneurysms
• Proliferative
• Involves retina and vitreous humor
• New blood vessels formed
(neovascularization): very fragile and
bleed easily
• Can cause retinal detachment
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Diabetic Retinopathy
• Initially no changes in vision
• Annual eye examinations with dilation
to monitor
• Maintain healthy blood glucose levels
and manage hypertension
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Diabetic Retinopathy
• Treatment
• Laser photocoagulation
• Most common
• Laser destroys ischemic areas of retina
• Vitrectomy
• Aspiration of blood, membrane, and fibers
inside the eye
• Drugs to block action of vascular
endothelial growth factor (VEGF)
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Diabetic Nephropathy
• Damage to small blood vessels that supply
the glomeruli of the kidney
• Leading cause of end-stage renal disease
• Risk factors
• Hypertension
• Genetics
• Smoking
• Chronic hyperglycemia
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Diabetic Nephropathy
• Annual screening
• If albuminuria present, drugs to delay
progression:
• ACE inhibitors
• Angiotensin II receptor antagonists
• Control of hypertension and blood
glucose levels in a healthy range:
imperative
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Diabetic Neuropathy
• Nerve damage due to metabolic
derangements of diabetes
• 60% to 70% of patients with diabetes
have some degree of neuropathy
• Reduced nerve conduction and
demyelinization
• Sensory or autonomic
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Diabetic Neuropathy
• Sensory neuropathy
• Loss of protective sensation in lower
extremities
• Major risk for amputation
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Diabetic Neuropathy
• Distal symmetric polyneuropathy
• Most common form
• Affects hands and/or feet bilaterally
• Loss of sensation, abnormal sensations,
pain, and paresthesias
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Neuropathy: Neurotrophic
Ulceration
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Diabetic Neuropathy
• Treatment for sensory neuropathy
• Managing blood glucose levels
• Drug therapy
• Topical creams
• Tricyclic antidepressants
• Selective serotonin and norepinephrine
reuptake inhibitors
• Antiseizure medications
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Diabetic Neuropathy
• Autonomic neuropathy
• Can affect nearly all body systems
• Gastroparesis
• Delayed gastric emptying
• Cardiovascular abnormalities
• Postural hypotension, resting tachycardia,
painless myocardial infarction
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Diabetic Neuropathy
• Autonomic neuropathy
• Sexual function
• Erectile dysfunction
• Decreased libido
• Vaginal infections
• Neurogenic bladder → urinary retention
• Empty frequently, use Credé’s maneuver
• Medications
• Self-catheterization
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Foot Complications
• Microvascular and macrovascular diseases
increases risk for injury and infection
• Sensory neuropathy and PAD are major risk
factors for amputation
• Also clotting abnormalities, impaired immune
function, autonomic neuropathy
• Smoking increases risk
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Foot Complications
• Sensory neuropathy → loss of
protective sensation → unawareness of
injury
• Monofilament screening
• Peripheral artery disease
• ↓ Blood flow, ↓ wound healing, ↑ risk for
infection
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Foot Complications
• Patient teaching to prevent foot ulcers
• Proper footwear
• Avoidance of foot injury
• Skin and nail care
• Daily inspection of feet
• Prompt treatment of small problems
• Diligent wound care for foot ulcers
• Neuropathic arthropathy (Charcot’s
foot)
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Necrotic Toe Before and After
Amputation
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Skin Problems
• Diabetic dermopathy
• Most common
• Red-brown, round or oval patches
• Acanthosis nigricans
• Manifestation of insulin resistance
• Velvety light brown to black skin
• Necrobiosis lipoidica diabeticorum
• Red-yellow lesions
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Necrobiosis Lipidoidica Diabeticorum
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chronic Complications
Infection
• Defect in mobilization of inflammatory
cells and impaired phagocytosis
• Recurring or persistent infections
• Treat promptly and vigorously
• Patient teaching for prevention
• Hand hygiene
• Flu and pneumonia vaccine
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Psychologic Considerations
• High rates of
• Depression
• Anxiety
• Eating disorders
• Open communication is critical for early
identification
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Gerontologic Considerations
• Increased prevalence and mortality
• Glycemic control challenging
• Increased hypoglycemic unawareness
• Functional limitations
• Renal insufficiency
• Meal planning and exercise
• Patient teaching must be adapted to
needs
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Audience Response Question
A patient with type 1 diabetes calls the clinic with
complaints of nausea, vomiting, and diarrhea. It is
most important that the nurse advise the patient to
a. Withhold the regular dose of insulin.
b. Drink cool fluids with high glucose content.
c. Check the blood glucose level every 2 to 4 hours.
d. Use a less strenuous form of exercise than usual
until the illness resolves.
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Audience Response Question
The nurse plans a class for patients who have newly
diagnosed type 2 diabetes mellitus. Which goal is
most appropriate?
a. Make all patients responsible for the management
of their disease.
b. Involve the family and significant others in the care
of these patients.
c. Enable the patients to become active participants
in the management of their disease.
d. Provide the patients with as much information as
soon as possible to prevent complications.
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Audience Response Question
A patient screened for diabetes at a clinic has a
fasting plasma glucose level of 120 mg/dL (6.7
mmoL/L). Which statement by the nurse is best?
a. “You will develop type 2 diabetes within 5 years.”
b. “You are at increased risk for developing
diabetes.”
c. “The test is normal, and diabetes is not a problem.”
d. “The laboratory test result is positive for type 2
diabetes.”
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Audience Response Question
The nurse is caring for a patient with type 1 diabetes
mellitus who is admitted for diabetic ketoacidosis.
The nurse would expect which laboratory test result?
a. Hypokalemia
b. Fluid overload
c. Hypoglycemia
d. Hyperphosphatemia
Copyright © 2017, Elsevier Inc. All Rights Reserved.