Diabetes Mellitus
Review the pathophysiology of diabetes
- Diabetes is primarily a disorder of glucose metabolism related to absent or insufficient insulin supply and/or poor
utilization of the insulin that is available.
Counter-regulatory hormones:
• Glucagon, epinephrine, growth hormone, and cortisol are counterregulatory hormones that work to oppose
the effects of insulin
• These hormones increase blood glucose levels by stimulating glucose production and output by the liver and
by decreasing the movement of glucose into the cells.
• The counterregulatory hormones and insulin usually maintain blood glucose levels within the normal range by
regulating the release of glucose for energy during food intake and periods of fasting.
Review the pattern of normal insulin secretion
• Insulin is a hormone produced by the β-cells in the islets of Langerhans of the pancreas.
• Under normal conditions, insulin is continuously released into the bloodstream in small pulsatile increments,
with increased release when food is ingested.
• Insulin lowers blood glucose and facilitates a stable, normal glucose range of approximately 70 to 120 mg/dL
(3.9 to 6.66 mmol/L).
• The average amount of insulin secreted daily by an adult is approximately 40 to 50 U, or 0.6 U/kg of body
weight
• Insulin released based on the proportion of glucose in the blood
• The pancreas secretes approximately 20 mcg of insulin each hour into portal vein
• About 50% of insulin is degraded before reaching the systemic circulation
Review what insulin role is in the body
Functions:
- Transports and metabolizes glucose for energy
- Stimulates storage of glucose in the liver and
muscle as glycogen
- Signals the liver to stop the release of glucose
Release Stimulated by:
• Glucose
• Ketone Bodies
• Proteins
• Glucagon
• Gastric Secretions
• Salicylates
• Hyperkalemia
Promotes:
- Movement of K, PO4, and Mg intra & extra cellular
- Transport of amino acids into cells
- Inhibits the breakdown of stored glucose, protein, and fat
- Storage of dietary fat in adipose tissue
Release Inhibited by:
• Hypoglycemia
• Hypokalemia
• Catecholamines
• Beta-Blockers
• Calcium Channel Blockers
• Phenytoin
• Alcohol
Review terminology including Ketoacidosis, satiety, lactic acidosis
Glycogenolysis: Breakdown of hepatic and muscle glycogen to glucose.
Gluconeogenesis: Conversion of fatty acids and protein to glucose. Ketone bodies are created during this process.
Ketoacidosis: Acidosis is accompanied by an accumulation of ketones in the body, resulting from extensive breakdown
of fats because of faulty carbohydrate metabolism.
Lactic acidosis: Accumulation of lactic acid in blood, resulting in a lower pH in muscle & serum. Occurs most
commonly in tissue hypoxia, liver impairment, resp. failure, burn trauma, neoplasms & CV disease.
Satiety: state of being satisfied (feeling full after eating)
Know what lab parameters constitute pre-diabetes
- Individuals with diagnosed prediabetes are at increased risk for the development of type 2 diabetes.
- Prediabetes is defined as impaired glucose intolerance (IGT), impaired fasting glucose (IFG), or both.
- It is an intermediate stage between normal glucose homeostasis and diabetes in which the blood glucose
levels are elevated but not high enough to meet the diagnostic criteria for diabetes.
- IGT is diagnosed if:
2-hour oral glucose tolerance test (OGTT) values are 140 mg/dL [7.8 mmol/L] to 199 mg/dL [11.0
mmol/L]).
- IFG is diagnosed when fasting blood glucose levels are 100 mg/dL [5.56 mmol/L] to 125 mg/dL [6.9
mmol/L]).
Nursing- Patient Education
- It is important to encourage patients to undergo screening and for you to provide education about managing risk
factors for diabetes.
- Patients with prediabetes can take action to prevent or delay the development of type 2 diabetes.
- Those with prediabetes should have their blood glucose and hemoglobin A1C levels tested regularly and should
monitor for symptoms of diabetes, such as polyuria, polyphagia, and polydipsia.
- Maintaining a healthy weight, exercising regularly, and eating a healthy diet have all been found to reduce the risk
of developing overt diabetes in people with prediabetes.
Know what constitutes metabolic syndrome and its importance
- Metabolic syndrome increases risk for type 2 diabetes:
- Elevated glucose levels
- Abdominal obesity
- Elevated blood pressure
- High levels of triglycerides
- Decreased levels of HDLs
- An individual with three of the five = metabolic syndrome.
- Overweight individuals with metabolic syndrome can
prevent or delay the onset of diabetes and stroke through a
program of weight loss and regular physical activity.
- Other risk factors: heart disease, lipid problems, hypertension,
dementia, cancer, Polycystic ovarian syndrome, non-alcoholic fatty
liver disease.
Know the difference between Type 1 and Type 2 diabetes mellitus.
Type 1-The body’s own immune system destroys the insulin-producing cells of the
pancreas (beta cells).
- Classic symptoms: polyuria, polyphagia, and polydipsia
- Dependent on insulin to live
- Usually develops in people < 40 years of age
- Typically has a rapid onset
- Certain genes may predispose individuals
- Is an autoimmune disease
- 5% of all cases of diabetes
Honeymoon period- decreased blood glucose concentrations and markedly decreased
requirements
- Lasts weeks to up to a year
- Increasing exogenous insulin requirements are inevitable and should be anticipated
- Patients should be maintained on insulin even if the dose is very low, interrupted
treatment is associated with a greater incidence of resistance and allergy to insulin
Medical management for Type 1 diabetes
Treatment
- Insulin replacement
• Insulin w/ Rapid onset & short duration used before meals
• All insulins can be given sub-q; only 1 given IV (regular insulin)
• Self-monitor blood glucose (SMBG)
Preventing Complications
• Diet – caloric intake should be spread throughout the day
• Exercise – increase response to insulin & increase glucose tolerance
• Insulin replacement – Since pancreas is basically not working, it produces no insulin, so daily doses of insulin
are imperative to have glycemic control.
• ACEI or ARB – helps prevent diabetic nephropathy & diabetic HTN (goal 140/90 mm/Hg)
• “Statins” – reduce high levels of LDL (prevents CV events) & should be given to all diabetic pts.
Nursing: Care and Teaching
Nutritional Therapy:
• Meal plan is based on individual’s usual food intake and is balanced with insulin and exercise patterns
• Day-to-day consistency important for patients using conventional, fixed insulin regimens
• More flexibility with rapid-acting insulin, multiple daily injections, and insulin pump
Type 2 Diabetes -- Metabolic disorder characterized by elevated glucose due to insulin resistance.
- Clinical manifestations are often nonspecific but common manifestations are fatigue, recurrent infections, recurrent
vaginal yeast or candidal infections, prolonged wound healing, and visual changes.
Some will also experience the classic signs seen with Type 1 DM; polyuria, polydipsia, and polyphagia.
Four major metabolic abnormalities:
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)
- May need additional insulin to maintain normal blood sugar
- NIDDM gradual onset, may go for many years w/ undetected hyperglycemia w/ few, if any, symptoms
- Usually develops after age 40, 80%-90% are overweight, typically has family history of DM
- Type II not prone to ketosis, may develop HHNS
- Many cases are diagnosed on routine laboratory testing or when patients undergo treatment for other conditions,
and an elevated glucose or hemoglobin A1C levels are found.
Know what tests and lab parameters diagnose Type 2 diabetes
The diagnosis through one of four methods. These methods and their criteria for diagnosis are as follows:
1. Hemoglobin A1C level of 6.5% or higher.
2. Fasting plasma glucose (FPG) level of 126 mg/dL (7.0 mmol/L) or higher. Fasting is defined as no caloric
intake for at least 8 hours.
3. 2hr plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher during an OGTT, w/ a glucose load of 75 g.
4. In a patient with classic symptoms of hyperglycemia (polyuria, polydipsia, unexplained weight loss) or
hyperglycemic crisis, a random plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher.
- If a patient presents with a hyperglycemic crisis or clear symptoms of hyperglycemia (polyuria, polydipsia,
polyphagia) with a random plasma glucose level of 200 or higher, repeat testing is not warranted.
- Otherwise, criteria 1 through 3 should be confirmed by repeat testing to rule out laboratory error. It is
preferable for the repeat test to be the same test used initially.
- Falsely elevated values include recent severe restrictions of dietary carbohydrate, acute illness, medications
(e.g., contraceptives, corticosteroids), and restricted activity such as bed rest.
Know who is at risk for Type 2 diabetes
• Ethnic populations at risk for DM:
• African Americans
• Hispanic/Latino Americans
• American Indians
• Some Asian Americans
• Some native Hawaiians
• Pacific Islanders
• Others at risk:
• Overweight/obese children & adolescents, older individuals, patients with family history of type 2 diabetes
Medical management for Type 2 diabetes
Lifestyle Changes:
Achieve & maintain healthy weight (BMI 19-24.9)
Exercise 30 minutes (minimum) of exercise 5 out of 7 days per week
* Weight loss – combined with exercise – is the single most important factor that will stop the progression toward
type 2 diabetes in overweight individuals.
Diabetes Treatment Goal
• Maintain Glycemic Control
• Avoid long-term complications, including death
• Complications: Hypertension (HTN), heart disease, stroke, blindness, renal failure, neuropathy, lower limb
amputations, ED, gastroparesis
- Oral Anti-diabetic Meds and/or insulin if not controlled sufficiently with oral meds & ALWAYS diet modification and
exercise. Patients benefit from tight glycemic control-can decrease microvascular complications but NOT
macrovascular complications
- Microvascular complications: Diabetic retinopathy, Diabetic nephropathy, Diabetic neuropathy
- Macrovascular disease: atherosclerosis, cardiovascular disease (CVD)
• Downside to tight glycemic control – more episodes of hypoglycemia
Review insulin and know onset, peak, and duration for the following insulin: rapid acting, short acting, and Lantus
Rapid acting/Short duration: lispro (Humalog), aspart (NovoLog), glulisine (Apidra). Are clear solutions
- given with meals to control postprandial glucose rise. All 3 rapid acting insulins REQUIRE a prescription!
Slower acting/Short duration: Regular (Humulin R) Also a clear solution
- Regular (Humulin R) is unmodified human insulin. Can be given SQ before meals or infused SQ to provide
basal glucose control
Intermediate duration: NPH insulin (Humulin N, Novolin N). NPH-can be mixed with short-acting insulin.
Long duration: Glargine (Lantus). Lasts 24 hrs
Insulin adverse effects: Hypoglycemia, edema & weight gain
Know the most commonly used insulin treatment plan – essentially following the release of insulin as the body
naturally does
Basal-bolus regimen:
• Most closely mimics endogenous insulin production
• Intensive insulin therapy, consisting of multiple daily insulin injections together with frequent selfmonitoring of blood glucose
• Goal: to achieve a near-normal glucose level of 70 to 130 mg/dL before meals
• Rapid- or short-acting (bolus) insulin before meals
• Rapid-acting
• Lispro, aspart, glulisine
• Onset of action 15 minutes
• Injected within 15 minutes of mealtime
• Short-acting
• Regular with onset of action 30 to 60 minutes
• Injected 30 to 45 minutes before meal
• Onset of action 30 to 60 minutes
• Note: more likely to cause hypoglycemia because of a longer duration of action
• Intermediate- or long-acting (basal) background insulin once or twice a day
• Long-acting insulin
• glargine (Lantus) and detemir (Levemir)
• Released steadily and continuously with no peak action
• Administered once or twice a day
• Do not mix with any other insulin or solution
• Intermediate-acting insulin
• NPH
• Duration 12 to 18 hours
• Peak 4 to 12 hours (can result in hypoglycemia)
• Can mix with short- and rapid-acting insulins
• Cloudy; must agitate to mix
What does a patient need to be taught to administer their own insulin? Why are sites of injection rotated and
which areas of the body can be used?
- Rotate injection sites to avoid lipodystrophy
• Administration of insulin
• Typically given by subcutaneous injection
• Regular insulin may be given IV
• Cannot be taken orally
• The fastest subcutaneous absorption is from the abdomen, followed by
the arm, thigh, and buttock.
• Caution the patient about injecting into a site that is to be exercised.
• A patient should not inject insulin into the thigh and then go
jogging.
• Exercise of the area containing the injection site, together with the increased body heat and
circulation generated by the exercise, may increase the rate of absorption and speed the onset of
insulin action.
• Teach patients to rotate the injection within one anatomic site, such as the abdomen, for at least 1 week
before using a different site, such as the right thigh. This allows for better insulin absorption.
• For example, it may be helpful to think of the abdomen as a checkerboard, with each half-inch square
representing an injection site. Injections are rotated systematically across the board, with each
injection site at least ½ to 1 inch away from the previous injection site.
Problems with Insulin Therapy
- Somogyi effect: (more info later)
- Allergic reaction: Local inflammatory reactions to insulin may occur, such as itching, erythema, and burning
sensation around the injection site. Local reactions may be self-limiting within 1 to 3 months or may improve with a
low dose of antihistamine. A true insulin allergy is rare.
- Lipodystrophy: atrophy of subcutaneous tissue may occur if the same injection sites are used frequently.
- Hypoglycemia
Know how to recognize signs and symptoms of hypoglycemia
- Imperative to check within 15-30 minutes after giving fastacting insulin for hypoglycemia
- Beta Blockers can mask the s/s of hypoglycemia
Know how metformin works and side effects
- Oral Anti-diabetic Drugs for type 2 DM only
- Metformin (Glucophage) a biguanide:
- Decreases glucose production by liver, increases glucose uptake by muscle & adipose tissue.
- 1st line drug of choice for the treatment of Type 2, particularly overweight & obese people and those with
normal kidney function.
- Aim: Decrease insulin resistance and increase insulin sensitization
- Take w/food
- Only antidiabetic drug that has been conclusively shown to prevent the cardiovascular complications of
diabetes. Helps reduce LDL and triglyceride levels
- Adverse Effects: N/D, decreased appetite
- Increased risk for lactic acidosis in patients w/ renal impairment due to decreased excretion which increases
drug level. Alcohol also increases the risk of lactic acidosis
Know guidelines for diet and exercise in Type 2 DM
Glycemic control (diet & exercise) – In type 2 DM, diet & exercise can normalize insulin release & decrease insulin
resistance
Glycemic control with Medication – PO, insulin & other agents
• Initiate diet, exercise (TLC) & one drug therapy (metformin HCl)
• TLC & add second drug (metformin plus sulfonylurea or basal insulin)
• TLC & metformin & switch from sulfonylurea or basal insulin to intensive insulin therapy
Know signs and symptoms of diabetes (hyperglycemia)
• Extreme thirst.
• Frequent urination.
• Lethargy / drowsiness.
• Breath odor (fruity, sweet or wine-like)
• Sudden vision changes, blurred vision.
• Increased appetite, constant hunger.
• Unexplained weight loss.
• Sugar in urine
Know the following DM care and teaching
Nutritional Therapy:
• Emphasis on achieving glucose, lipid, and blood pressure goals
• Weight loss- 5% to 7% of body weight often improves glycemic control
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A nutritionally adequate meal plan with appropriate serving sizes, a reduction of saturated and trans
fats, and low carbohydrates can bring about decreased calorie consumption.
• Spacing meals- spreads nutrients throughout the day
• Regular exercise and learning new behaviors and attitudes can help facilitate long-term lifestyle
changes
Fiber: 25 to 30 g/day
Nutritive and nonnutritive sweeteners- in moderation
Alcohol
• Limit to moderate amount, one drink per day for women and two drinks per day for men
• Alcohol inhibits gluconeogenesis (breakdown of glycogen to glucose) by the liver -- can cause severe
hypoglycemia
• Consume with food to reduce risk of nocturnal hypoglycemia if using insulin
• Consume with carbs to reduce hypoglycemia, but then watch for hyperglycemia from carbs
Diet Education
• Dietitian initially provides instruction
Carbohydrate counting
• Serving size is 15 g of carbs
• Typically 45 to 60 g per meal
• Insulin dose based on number of carbs consumed
• Patient teaching essential
Exchange lists
• The patient will choose foods from the various exchanges on the basis of the prescribed meal plan.
• Starches, fruits, milk, meat, sweets, fats, free foods
USDA ‘My Plate’ method
• Helps patient visualize the amounts of non-starchy vegetable (1/2), starch (1/4), and protein (1/4) that
should fill a 9-inch plate
Consistent carbohydrate diet
Self-monitoring of blood glucose – who should and when should checking blood glucose occur
People that may benefit from checking blood glucose include those:
• taking insulin
• that are pregnant
• having a hard time controlling blood glucose levels
• having low blood glucose levels
• having low blood glucose levels without the usual warning signs
• have ketones from high blood glucose levels
Need to know from HCP when to check blood glucose
• Before breakfast, lunch, & dinner, and before bedtime snack
• 1-2 hours after a meal
• Periods of stress, illness, or surgery
• Pregnancy; changes in treatment plan
• When suspect low blood sugar
Know dawn phenomenon and Somogyi effect
The Dawn phenomenon is characterized by hyperglycemia that is present on awakening.
• It has been suggested that two counterregulatory hormones, growth hormone and cortisol, excreted in increased
amounts in the early morning hours are responsible.
• The Dawn phenomenon affects a majority of people with diabetes and tends to be most severe when growth
hormone is at its peak in adolescence and young adulthood.
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Careful assessment is required to document the Somogyi effect or Dawn phenomenon because the treatment for
each differs.
o The treatment for Somogyi effect is less insulin.
o The treatment for Dawn phenomenon is an increase in insulin or an adjustment in administration time.
▪ Ask the patient to measure and document bedtime, nighttime (between 2:00 and 4:00 AM), and
morning fasting blood glucose levels on several occasions.
▪ If the predawn levels are less than 60 mg/dL (3.3 mmol/L) and signs and symptoms of
hypoglycemia are present, the insulin dosage should be reduced.
▪ If the 2:00 to 4:00 AM blood glucose level is high, the insulin dosage should be increased. In
addition, counsel the patient on appropriate bedtime snacks
Hyperglycemia in the morning may be due to the Somogyi effect.
• A high dose of insulin produces a decline in blood glucose levels during the night.
o As a result, counterregulatory hormones (e.g., glucagon, epinephrine, growth hormone, cortisol) are
released, stimulating lipolysis, gluconeogenesis, and glycogenolysis, which in turn produce rebound
hyperglycemia.
o The danger of this effect is that
when blood glucose levels are
measured in the morning,
hyperglycemia is apparent and the
patient (or the health care
professional) may increase the
insulin dose.
▪ If a patient is experiencing
morning hyperglycemia,
checking blood glucose
levels between 2:00 AM
and 4:00 AM for
hypoglycemia to determine
if the Somogyi effect is the
cause.
▪ The patient may report
headaches on awakening
and may recall having night sweats or nightmares.
▪ A bedtime snack, a reduction in the dose of insulin, or both can help to prevent the Somogyi effect.
Exercise Benefits:
• Can lower blood sugar & improve body’s ability to use glucose.
• Can decrease the amount of insulin used
• Reverse the resistance to insulin that occurs with being overweight
• Improves risk factors for heart disease and decreases the risk of heart problems
• Combined with a meal plan, can control Type II DM without the need for other medications
• Regular physical exercise & activity provides an effective way for all persons with DM to manage their blood
sugars
Exercise: Getting Started
Program should be individually tailored for patient
• Requires proper adjustment of insulin & extra food (snack) consumption
• Time of day, type of exercise, and duration of exercise will determine whether adjustments to insulin or
meal plan should be made
• Consult MD before starting any exercise program
• If patient over 35, need a stress test
• Test blood sugar before & after exercise
• Do not exercise if blood glucose 100 < or > 240 and there are ketones in urine
• If blood glucose > 240 and no ketones:
• Type I DM - no exercise glucose > 300
• Type II DM - no exercise glucose > 400
To Prevent Low Blood Sugar
• Exercise 1 - 1 1/2 hours after eating
• Check blood glucose before & after exercise and follow snack guidelines
• Always carry a carbohydrate snack with you
• Drink plenty of fluids
• Wear shoes and equipment that fits well
• Include strength training at least 2x weekly
• Also helps with managing glucose
• If blood glucose is < 100 mg/dL prior to starting exercise – eat 15 g of carbohydrate before starting
• Don’t start exercise if glucose < 90 or > 250.
• For every 30 minutes of exercise, need 15-20g of carbohydrates
Sick day management
- Any condition that causes vomiting or diarrhea can cause blood glucose to elevate.
- Increased stress or infection can instigate hyperglycemia.
- Recommend serum glucose check q 4 hours
- Eat or drink 30 to 50 grams of carbohydrates every 3 to 4 hours to keep body nourished.
- Should stop patient from making ketones and prevent hypoglycemia.
- If having trouble eating, encourage bland foods like the ones listed below.
Each equal one carbohydrate choice:
- 1 cup clear soup or broth
- 1/2 cup regular gelatin
- 1/2 cup regular soft drink, like 7-up or Sprite
- 1/2 Popsicle, 1/2 cup unsweetened applesauce
- 1/3 cup apple juice
- 1/2 cup sports drink, like Gatorade
Patients with Type 1 Diabetes:
- If glucose level > 240mg/dL, important to check
urine for ketones.
If ketonuria, call provider.
- Check temperature regularly.
- If unable to keep solid food down, instruct patient
to drink one cup of liquid every hour while awake to
prevent dehydration. If unable to maintain liquid
intake, should go to emergency room.
Patient should contact provider if:
• Blood sugar stays higher than **180 mg/dL or lower than 70 mg/dL.
• Can’t keep liquids or solids down.
• Temperature over 101 F.
• Diarrhea and / or vomiting.
Patients with Type 2 diabetes:
- May need to stop taking oral antidiabetic meds during illness.
- Recommend sugar-free OTC cough medication.
• Instruct patient to continue insulin, even if unable to maintain food intake. May need dose adjustment.
- Recommend fluids with sugar so blood sugar doesn't drop too low.
Foot care
How to examine feet by health care provider and by the patient
Clinician:
What to look for:
- Neuro exam for sensory changes
• Bruises
Clinician and Patient:
• Cracks/breaks in skin
- Skin exam for
• soggy skin, dry skin
Temperature
• Swelling
Color
• corns & calluses
Ulcers
• Ingrown toenails
Erythema
• Blisters
CV Exam:
• Sharp toenails
Pulses, Color, Temperature
• Hot/cold spots
Claudication, Ankle-Brachial index
• Discoloration
How to care for feet; what to avoid
- Wash feet every day using warm water and soap
Dry between toes well!
Rub cream on feet
DO NOT put between TOES
May need a tinea cream
- Nail care
Do not cut nails too short.
Cut nails straight across.
Use nail file to smooth sharp edges of nails.
See a podiatrist if problems arise.
- Soaking feet is not recommended.
- Do not walk around barefooted.
- Wear thick socks and change when needed during the day.
- Wear well cushioned, closed shoes large enough for foot and socks.
Shoes, socks recommendations
• To enhance diabetic foot health, the Joslin Diabetes Center offers these tips for buying new shoes and tossing old
ones:
• Buy shoes made of soft, stretchable leather.
• When possible, choose laced shoes over loafers because they fit better and offer more support.
• For better shock absorption, look for a cushioned sole instead of a thin leather sole.
• Shop for shoes later in the day because feet swell as the day progresses.
• The distance between your longest toe and the shoe tip should be half of your thumb's width.
• To ensure proper fit, try on shoes while wearing the socks that you'll be using.
• Wear new shoes for 1-2 hours for the first time, then check feet for cuts or blisters. The next day, wear them
3-4 hours and gradually build up time to make sure they aren't injuring your feet.
• A diabetic-style shoe is characterized by being made of soft leather, has a deep toe box, has a rounder, wider
toe box that can accommodate things like hammertoes and bunions.
• More safety a step further by wearing protective water shoes during swimming. Going barefoot exposes
feet to injury, so wearing slippers in the house is recommended
• wear new shoes for 1-2 hours then take off and exam feet.
• Most foot complications occur after a patient has had diabetes for 10-15 years, says John Giurini, DPM, chief
of podiatry at Beth Israel Deaconess Medical Center. But, he adds, "For individuals who are under very poor
control, the complications may occur sooner."
Health promotion and prevention of complications
What needs to be checked annually including lipids, kidney function, examining feet, blood pressure:
- Glycohemoglobin (2 -4 times/year)—HbA1c, A1c
For elderly, A1c of 8 is acceptable
- Kidney function
Check creatinine, urinalysis (protein, ketones)
- Cholesterol & triglycerides
- Foot exam: Monofilament exam
- Eye exam: Fundoscopic exam
- Blood pressure
- Flu immunization annually
- Pneumovax when dx with DM then again at 65
What parameters are acceptable for a DM patient – indicating the patient is managing their DM well; Know
parameters for elderly patients – why are they different?
Surgery and DM – pre and post-operative care regarding medications
• Why important to continue to control DM closely in the hospital:
• want to maintain as close as possible a euglycemia
• sliding scales do not allow this
• Effects of hyperglycemia
• poor wound healing
• hypercoagulability
• promotes DM related diseases
Morning of Surgery
• NPO status (However, stress of surgery, hospitalization causes release of glucocorticoids & catecholamines)
• Night before surgery if on insulin – take half dose
• Day of surgery – stop all oral anti-diabetic drugs
• May give short acting insulin on sliding scale or continuously if needed
• Check FBS during operation and give dextrose PRN
• Insulin dependent DM – may receive insulin during surgery depending on glucose level
Type of Patient
Blood Sugar
General Medical-surgical
Fasting 90 -126 mg/dL
Random 200 mg/dL
Cardiac surgery
< 150 mg/dL
Critically ill
< 150 mg/dL
Acute neurological disorders
80-140 mg/dL
Preoperative Period
• DM Type II patient on Metformin
• Stop drug 48-72 hours before elective surgery
• After surgery, check blood glucose and urine ketones every 4-6 hours.
• If hyperglycemic - insulin may be given.
Postoperatively
• Continue IV fluids with glucose while NPO
• Insulin is given either by dividing the normal daily dose equally over 24-hr. period and giving SQ or IV.
• All DM patients need 125-150 g of carbohydrates per day until normal diet resumed.
Chronic Complications of DM
 Long term problems usually occur because of
blood flow
 Macrovascular damage – heart disease, HTN & stroke
usually due to atherosclerosis (hyperglycemia & lipid
metabolism)
 Microvascular damage – damage to small blood
vessels & capillaries
• Retinopathy (blindness)
• Nephropathy
• Sensory & motor neuropathy (tingling in
finger, toes)
• Autonomic Neuropathy (Gastroparesis)
• Amputations r/t infections
• Erectile dysfunction
Diabetes emergencies
Hypoglycemia
• Defined according to the following serum glucose levels:
• < 50 mg/dL in men
• < 45 mg/dL in women
• < 40 mg/dL in infants and children
• Onset: epinephrine is released
• Slow onset: allows body to adapt to low blood sugar
• Requires urgent intervention
Mild Hypoglycemia
Moderate Hypoglycemia
- Dizziness
- Confusion
- Paleness (mouth & nose)
- slurred speech
- Tachycardia
- somnolence
- Palpitations
- Decreased ability to
- Diaphoresis
concentrate
- Numbness (mouth, tongue,
- extreme fatigue
fingers)
- blurred vision
- Hunger
- double vision
- Shakiness
- irrational behavior
- Pounding heart
- decreased response
- Nervousness
time
- Headache
- Uncontrolled, erratic
- Dilated pupils
behavior
- Weakness
- Drowsiness
Severe Hypoglycemia
- seizures
- disoriented behavior
- coma
- loss of consciousness
- staggering
- inability to arouse
- slurred speech
- anger
- Uncontrolled behavior
- “Drunk appearance”
- Loss of coordination
- Inability to awaken
- Death
What to do: The Rule of 15
Take your blood sugar. If your blood sugar is 70 mg/dl or less, and with symptoms, treat with 15 grams of simple
carbohydrate.
15 Gram Emergency Foods:
4 oz. fruit juice
OR
1 small serving of chewy candy such as gummy bears
8 oz. skim milk
OR
1 small tube of cake decorating gel
6-8 Lifesavers (chew)
OR
1 small box of raisins (2 Tbsp.)
4 oz. of regular soda
OR
1 tube of glucose gel
OR 3-4 glucose tabs (15 grams worth)
• Wait 15 minutes and retest the blood glucose. If not up to 70 mg/dl, re-treat with a second dose of 15 grams
emergency food.
•
Repeat in small increments. When blood glucose is above 100 mg/dl, have a substantial snack or meal, such as a
sandwich or cheese and crackers; make it a meal with protein.
•
If after two treatments the low remains, call your physician, or if you feel faint, call 911.
Treatment of Unconscious Hypoglycemic Patient
• When venous access is unavailable or at home
• Administer glucagon 0.5 to 2 mg (IM)
• Turn patient to their left side (Recovery position)
• Glucagon can make some patients vomit, also may not be protecting their airway
• After 15 minutes, if no response, repeat glucagon administration
• When aroused – carbohydrate to replace glycogen stores. Once blood sugar stable, give protein snack.
• Glucagon lasts for 1 ½ hours. Need to check blood sugar hourly for 3-4 hours to ensure glucose remains
normal range
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•
When venous access is available
• Obtain glucose level
• Administer one ampule of 50% glucose (IV) without waiting for labs
• Administer a continuous 50% glucose drip until either blood glucose is over 200 mg/dL or consciousness
returns.
• If necessary, maintain blood glucose of 100-200 mg/dL using 10% dextrose and H2O until patient can
consume oral nutrients.
Should recover within a minute.
Diabetes ketoacidosis (DKA)- Type 1 DM
DKA is a serious condition that can lead to diabetic coma & even death. (mortality higher in nonwhites and females)
May be caused by hyperglycemia (high blood glucose) or hypoglycemia (low blood glucose) in people with
diabetes.
- When cells don't get the glucose they need for energy, the body
begins to burn fat for energy, which produces ketones. The body does
this when it doesn’t have enough insulin & the body cannot utilize the
glucose in the body
• IDDM - feel sick - thirst, polyuria, weakness, altered
mental status, air hunger, abdominal pain, vomiting
• Blood glucose elevation (> 300 mg/Dl); can lead to
renal insufficiency or dehydration.
• Acidosis - due to ketoacidosis, increase respirations to
decrease CO2 and acid
Decompensation
• Rapid deterioration in LOC progressing to coma.
• Peripheral vasodilatation - skin warm, dry, & flushed.
• Shock symptoms.
Electrolyte Changes
• K+ level - dependent on duration of DKA
• High-initial, H ions intracellular = K+ to serum
• Low - lost in osmotic diuresis due to elevated glucose levels.
• Pt. needs K+ replacement
Management
• Requires frequent glucose monitoring, frequent electrolyte
checks, ABGs and EKG and meticulous intake & output
observation & documentation.
• IV rehydration & continuous IV insulin
• Electrolyte repletion
Hyperglycemic, Hyperosmolar Syndrome (HHS)
• Hyperglycemic, Hyperosmolar Syndrome (HHS) is a complication of DM that results from insulin deficiency.
• High mortality rate (> 50%) partially due to the severe degree of fluid and electrolyte derangements.
• HHS usually presents in older patients with type 2 DM and carries a higher mortality than DKA, estimated at
approximately 10-20%
Presentation
• Hyperglycemia (Glucose > 800 mg/dL),
• Hyperosmolarity (Serum osmolality > 350 mOsmo/L)
• Dehydration
• No significant ketoacidosis-No KETONES !
• NIDDM; don’t feel sick
• EKG may show hypokalemia, altered CNS
Other common s/s
• Few early symptoms, so glucose can climb high
before problem recognized.
• Polyuria, polydipsia, thirst, weakness, altered
mental status, no acetone breath
• Glucose > 600, increase diuresis, increase
osmolality
Treatment
• Similar to DKA
• Fluid Replacement:
- 9-12 liter loss of fluids can occur - isotonic NS
given to prevent vascular collapse.
Dextrose is added when serum glucose is 250-300 mg/dL
Take Home Message
• Fluids, fluids, & fluids!
• Start IV of 0.9% NS
• Will replace volume in the intravascular
space
• Decrease the counterregulatory hormones
• Lower blood glucose
• After blood sugar reaches 250
• IV changed to D5 ½ NS
Management
• First check potassium level
• If low, may hold insulin until K+ corrected
• If normal, then start regular insulin IV drip
• HHNS – will usually have other electrolyte abnormalities as well
- Also may need thiamine to be administered