Alteration in Glucose metabolism
Diabetes- statistics
 25.8 million in U.S. have diabetes- some left undiagnosed
 In the year 2000- 171 million worldwide
 By 2030 will increase to 360 million worldwide
 Overview
 https://www.youtube.com/watch?v=X9ivR4y03DE
Risks and Economic Consequences
 Risks:
o Increased age
o African Americans
o Native Americans
o Hispanics
 Economic Consequences:
o Leading cause of non-traumatic amputations
o Leading cause of death from disease
o Hospitalization rates 2.4 times greater than general population
Classification
 Types:
o Type 1 Diabetes- Insulin dependent, earlier onset
o Type 2 Diabetes- Non-insulin dependent, later onset
 Prediabetes
 Gestational Diabetes- during pregnancy
Pathophysiology
 Insulin secreted by beta cells located in pancreas. when a person eats a meal, insulin is released and helps to move glucose from
the blood into cells, muscle, and liver.
 Insulin:
o Transports & metabolizes glucose for energy
o Stimulates storage of glucose in liver & muscle- glycogen
o Stops release of glucose from liver
o Enhances storage of fat
o Accelerates transport of amino acids
o Inhibits breakdown of protein & fat
Type 1 Diabetes
 5 – 10% of people with Diabetes have Type 1 Diabetes
Pathophysiology:
 characterized as a destruction of beta cells in the pancreas by an autoimmune process which leads to decreased insulin production
 Glucose unable to be stored in liver and remains in blood stream
 If glucose 180-200, kidneys cannot reabsorb all of it and it spills over in urine- glycosuria
 Because glucose is not moved into cells it cannot be used for energy and your body starts breaking down fat- ketones
Type 2 Diabetes
 90 -95% of people with diabetes have type 2 Diabetes
 Risks
o Greater than 30 years old
o Obese
o Increased over the years in obese children, adolescents, and young adults
o Genetics- Parents or siblings with DM
o Race
o Previously impaired glucose intolerance
o Hypertension
o HDL less than or equal to 35 and triglycerides greater than or equal to 250mg
o H/O gestational diabetes or delivery of baby > 9lbs
Pathophysiology
 Due to insulin resistance, decreased sensitivity to insulin,or impaired insulin secretion
 Normally insulin binds to receptors on cell’s surface and sets off a series of reactions. With type 2 Diabetes these reactions are
diminished- beta cells cannot keep up with demand and glucose increases
Prevention of Type 2 Diabetes
 In persons identified as High Risk
 Lifestyle changes
o Weight reduction
o Exercise
o Proper nutrition
 Medications- Glucophage
Gestational Diabetes
 Glucose intolerance onset during pregnancy
 Family History
 Obesity
 High risk ethnicity group- Hispanic, Native American, African American, and pacific islanders
Diabetes- Clinical Manifestations
 Can depend on level of hyperglycemia
 Three Ps
o Polyuria
o Polydipsia
o Polyphagia
 Fatigue
 Weakness
 Vision changes
 Tingling in hands or feet
 Dry skin
 Wounds- slow healing
 Recurrent infection
Diagnostic findings and Assessment
 Fasting plasma glucose- fingerstick
 Random Plasma glucose
 Post-prandial glucose
 Oral glucose tolerance test
 Assess for complications
 Gerontologic considerations
Monitoring Glucose levels and Ketones
 SMBG
 A1C
 Urine for ketones
 Continuous glucose monitor
Assessment of Patients with DM
 S & S of hyper, hypoglycemia
 Blood glucose monitoring results
 Assessment of complications
 Lifestyle
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Risk factors
Management
 Strict glucose control
 Decrease complications
 Monitor sugar
 Pharmacology
 Education
 Proper nutrition and exercise
o Weight loss
o Meal planning
o My Plate Food Guide
o Glycemic index
o Decrease alcohol consumption
o Exercise
Dietary Management
 Consider food preferences, lifestyle, usual eating habits, and culture
 Review diet history and need for weight loss, gain, or maintenance
 Caloric requirements and calorie distribution throughout the day
Dietary Recommendations
 Carbohydrates: 50 - 60% of caloric intake, emphasize whole grains
 Protein- 10 - 20% of caloric intake
 Fat: <30% of caloric intake
 Limit saturated fat to less than 10%
 <300mg cholesterol/day
 Fiber: 25g soluble and insoluble
Dietary Considerations
 Exchange Lists
 Glycemic Index
 Alcohol Consumption
 Sweeteners
Exercise Recommendations
 Encourage exercise 3 times/week
 Resistance training 2 times a week (type 2)
 Exercise at same time of day and for same amount of time
 Use proper footwear and protective equipment
 Avoid trauma to lower extremities
 Avoid exercise in extremes of heat or cold
 Avoid exercise in times of poor metabolic control
Insulin
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Insulin release normally occurs when blood glucose levels rise and continues at a low steady rate between meals- table 51-4
Conventional vs. Intensive approach
Conventional
o One or two Injections per day
o Simple regimen
Intensive
o 3-4 injections a day
Pharmacology- methods
 Injection pens
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Jet injections
Insulin pumps
Insulin Pump
Complications of Insulin Therapy
 Allergic reaction
 Insulin Lipodystrophy
 Morning hyperglycemia
Oral Antidiabetic Agents
 Type 2 patients who cannot be treated with diet and exercise alone
 Combinations of oral drugs may be used
 Major side effects: hypoglycemia; LFTs
 Nursing interventions: monitor blood glucose and assess for potential s/e
 Patient teaching
Sites of Action of Oral Antidiabetic Agents
 Nursing Management
 Diabetic Education Plan
 Tips for managing diabetes
 Healthy eating
 Being active
 Monitoring
 Taking medication
 Problem solving
 Healthy coping
 Reducing risks
 Survival plan
 Pragmatic information
 Teaching
 Assess readiness to learn
 Educate patients on how to self-administer insulin
 Storage
 Selecting syringe/needle
 Mixing insulins
 Withdrawing insulin
 Select and rotate injection sites
 Administration
 Glucometer use
 Food, stress, illness, and exercise affect on blood sugar
 Normal blood glucose ranges
Complications- Hypoglycemia
 Blood sugar less than 70
 S&S
o Sweating
o Tremors, shakiness
o Tachycardia
o Palpitations,
o Light headiness, Inability to concentrate, headache, confusion memory lapse
o Numbness of lips and tongue, slurred speech
o Impaired coordination
o Emotional changes, irrational behavior
o Nervousness
o
Hunger,
Management of Hypoglycemia
 If conscious- Give 15 g of fast-acting, concentrated carbohydrate – Immediately!!!!
o 3 or 4 glucose tablets
o 4 to 6 ounces of juice or regular soda (not diet soda)
o 6 to 10 hard candies
o 2 to 3 teaspoons of honey
 Retest blood glucose in 15 minutes,
 Retreat if < 70 mg/dL or if symptoms persist more than 10 to 15 minutes and testing is not possible
 Management- Hypoglycemia (cont.)
 Provide a snack with protein and carbohydrate unless the patient plans to eat a meal in 30-60 minutes
 If the patient cannot swallow or is unconscious:
o Subcutaneous or intramuscular glucagon 1 mg
o 25 to 50 mL 50% dextrose solution (D50W) IV
 (After injection of glucagon, the patient may take as long as 20 minutes to regain consciousness.)
Diabetic Ketoacidosis
 S & So Polyuria, Polydipsia
o Blurred vision, weakness, headache
o Hypotension
o Anorexia, abdominal pain
o Nausea/Vomiting
o Fatigue
o Fruity breath (due to ketones)
o Kussmaul’s respirations, mental status change
o Glycosuria
o Dehydration
o Orthostatic hyptension due to intravascular depletion
Prevention of DKA
 “Sick day rules” (Chart 51-9)
 Assess for underlying causes
 Don’t’ skip insulin doses
 Hydrate and consume small, frequent carbs!
 Diabetic Ketoacidosis (cont.)
 Diagnostic findings
 Management:
o Rehydrate- IVF
o Restore electrolytes
o Reverse acidosis
Hyperglycemic Hyperosmolar Syndrome
 S&S
o Fatigue, hypotension
o Polyuria, dehydration
o Irritability, tachycardia
o Polydipsia
o Poor hearing, variable neurologic signs
o Skin wounds
o Vaginal infections
o Blurred vision
 Management
o Fluid replacement
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Correction of electrolytes imbalances
Insulin administration- low rate
Long-term complications
 Can be seen in both type1 diabetes and type 2 diabetes, usually do not occur until 5-10 years after diagnosis
 Macrovascular complications:
o Changes in medium to large blood vessels, atherosclerosis causes blood vessels to thicken, sclerose and occlude due to
plaque
 CAD
 CVD
 PVD- atherosclerotic changes in large blood vessels in lower extremities
 MI- more common in elderly and type 2
 Microvascular-Due to capillary basement membrane thickening
o Diabetic retinopathy
o S&S
 Blurred vision due to macular edema, floaters
 Diagnostic findings- ophthalmoscope examination
 Management
o Diabetic Retinopathy
 Microvascular-Nephropathy- Kidney disease
o S&S
 Hypoglycemia
 Elevated electrolyte values
o Diagnostics albumin in urine is an early sign
 BUN & Creatinine
o Management
 Neuropathy
o Peripheral
o Autonomic
o Sudomotor
o Sexual dysfunction
Foot and Leg Problems
 Important to teach clients the importance of foot care
 Sensory neuropathy
 Motor neuropathy
 PVD
 Immunocompromised
 Neuropathic Ulcers
Management of Foot & Leg Problems
 Pt. needs to see podiatrist once a year
 Educate Patient on:
 Proper bathing and drying of feet
 Wear closed toe shoes that fit well
 Trimming of toe nails
 Smoking cessation
 Avoiding self-medicating foot problems
Hyperglycemia in Hospital
 Illness = increase sugar
 Changes in usual routine
 Medications
 IV dextrose
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Vigorous treatment of hypoglycemia
Inappropriate use of sliding scale
Mismatched timing of insulin and meals
Overuse of sliding scale
Lack of change in insulin despite decreased dietary intake
Vigorous treatment of hyperglycemia
Delayed meal after insulin administration
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