DIABETES/BILIARY
MCC NURSING
Diana Blum MSN
DEFINITION
 Disorder of carbohydrate, protein, and fat metabolism resulting
from an imbalance between insulin availability and need.
 Group of metabolic diseases characterized by increased levels of
glucose in the blood (hyperglycemia) resulting from defects in insulin
secretion, insulin action, or both
STATISTICS
•
Third leading cause of death
•
Becoming more common
•
285 million people globally currently have
– 1/3 of which are undiagnosed
•
By 2030 it will exceed 438 million
•
More elderly have (ages 65-74)
•
Prevalent in Caucasians, African Americans, Native Americans, and Hispanics
•
Leading cause of :
– Non traumatic amputations, blindness, and ESRD
WHY IS THIS HAPPENING?
 _________
 _________
 __________
 __________
W H AT A R E T H E R I S K
FAC T O R S ?
INSULINHORMONE
• Anabolic Hormone produced by beta cells in the islets of Langerhans in the
pancreas
• Transports and metabolizes glucose for energy
• Signals the liver to stop the release of glucose
• Prevents fat and glycogen breakdown
– Enhances dietary fat storage in adipose
• Increases protein synthesis
• Controls level of glucose in blood
– Regulates production of
– Regulates storage of glucagon
DIABETES
 Cells stop responding to insulin
 Pancreas may stop producing
Both lead to Hyperglycemia and complications like DKA and HHNS
DIABETES
PREDIABETES
 Normal glucose metabolism
 Obesity
 Previous personal history of hyperglycemia
TYPE 1: JUVENILE
 Insulin dependent(natural level low
or absent)
 Autoimmune process that destroys
beta cells of the pancreas
 Genetics play role
 May be triggered by virus or toxins
TYPE 2
 Non insulin dependent Diabetes
 Pancreas retains some function
but resistance to insulin is a major
cause
 Insulin becomes less
effective at stimulating
glucose uptake by tissues
and regulating glucose
release by liver
 Genetics may play role
 Obesity also plays a role
 Usually onset after 30
 Can take oral nasal or sq insulin
GESTATIONAL
 Glucose intolerance associated
with pregnancy
2-10% women annually
 Related to secretion of placental
hormones which cause insulin
resistance
 At risk: obese, history of
gestational diabetes, glycosuria,
stillbirth or abortion, and fam
history
 TX: diet modifications, insulin
W H AT I S T H E OV E R A L L G OA L ?
C H R O N I C C O M P L I C AT I O N S TO
DIABETES
15
NEPHROPATHY
16
SIGNS AND SYMPTOMS
•
3 P’s} polyuria, polydipsia, polyphagia
•
Fatigue
•
Weakness
•
Sudden vision changes
•
Tingling/numbness of hands or feet
•
Dry skin
•
Slow to heal wounds
•
Recurrent infections
DIAGNOSIS CRITERIA
AMERICAN DIABETES
A S S O C I AT I O N G LYC E M I C G OA L S :
 HbA1C goal: <7 % (6% is upper limit for normal) without
signif. Hypoglycemia
 Preprandial glucose: 90-130 mg/dL
 Postprandial (peak 11/2 hour) 180 mg/dL
 50% of the blood glucose values within target (70 to 140 mg/dL)
 No more than 30% of readings above 200
 No more than 1 or 2 mild hypoglycemic episodes per 1 to 2
weeks
23
A DA G LYC EMI C G OA L S
( C O N T I N U ED) :
 LDL <100 mg/dL
 Triglycerides <150 mg/dL
 HDL >40 for males, >50 for females
 Blood pressure: <130/80 with no signs of orthostatic
hypotension
 Minimal to no peripheral edema
 Urinary albumin excretion <30
 Retention of recognition of hypoglycemia
24
MEDS
 Insulin
• What is it’s most serious side
effect?_______
• What can affect the
absorption of Insulin?
a. _____________
b.______________
c.______________
d.______________
 Insulin is inactivated by,
insulinase, an enzyme in the liver.
NEEDS FOR INSULIN
Increases Needs





Infection
Wt gain
Puberty
Inactivity
Hyperthyroidism
Decreases Needs
 Exercise
 Renal Failure
 Weight Loss
 Adrenal Insufficiency
29
O R A L H Y P O G LYC E M I C AG E N TS :
NEVER GIVEN TO TYPE I
 First modify diet, exercise
 Second modify diet, exercise, hypoglycemic

agents
 Third: Insulin added to treatment as B-cells have declined over
time
 HOWEVER, those that respond BEST to oral agents are >40
years and have had diabetes Type II less than 5 years.
33
ORAL HYPOGLYCEMIC AGENTS
NEVER GIVEN TO PREGNANT WOMEN AS CAN
D E P L E T E I N S U L I N F R O M T H E F E T A L PA N C R E A S
 1. Sulfonylureas:

promote insulin release from Bcells

tolbutamide

glyburide

glipizide

gluimepiride
 Adverse effects:
 wt gain, hyperinsulinemia, hypoglycemia
 NOT to be admin. To those with hepatic/renal
insufficiency as causes delayed excretion resulting in
 hypoglycemia
34
 2. Meglitinide “postprandial glucose regulator”

repaglinide

nateglinide
 Work like sulfonylurea but rapid onset and short duration
 Very effective in early release of insulin following a meal
 Very effective with metformin
 Take 1 to 30 minutes AC
 Caution with hepatic impairment
 Causes wt gain
 Hypoglycemia a factor but less than sulfonylureas
37
ORAL HYPOGLYCEMIC AGENTS:
INSULIN SENSITIZERS
 Biguanides

METFORMIN (increases glucose uptake thereby decreasing insulin
resistance)

Does NOT promote Insulin secretion

hypoglycemia is way less than sulfonylureas (only occurs if caloric intake not
enough)
 IT CAN REDUCE HYPERLIPIDEMIA
 THE ONLY ORAL AGENT PROVEN TO DECREASE CV MORTALITY !!
38
 Metformin:

- pt usually loses wt due to loss of appetite

- needs to be discontinued for pt needing IV contrast for
diagnostic study

- should not be used with pts on heart failure meds causes
increased risk of lactic acidosis
39
ORA L HYPOG LYCEMIC AG EN TS:
Α - G LU C O S DA S E I N H I B I T O R S
 - take at beginning of the meal
 - delays digestion of carbohydrates thereby decreasing
glucose absorption
 Acarbose
 Miglitol

- do not stimulate insulin release

- do not cause hypoglycemia
 Major side effects:

- flatulence, diarrhea, abd cramping
 DO NOT USE WITH PT WITH INFLAMMATORY
BOWEL
 DISEASE, COLONIC ULCERATION, INTESTINAL
OBSTUCTION
40
COMPLICATIONS
 DAWN PHENOMENON:

early-morning hyperglycemia
caused by decreased effectiveness of
insulin & increased secretion of growth
hormone & other hormones overnight.
What can be changed in the insulin
dosing to prevent this??
 Somogyi Effect
• Hypoglycemia occurs in the
middle of the nite
• Glucose is released from
liver
• Sugar level increases while
sleeping.
• Pg 1681
ACUTE COMPLICATIONS
Diabetic Ketoacidosis (DKA):
- hyperglycemia induced crisis
- precipitated by stress, infections, MI
trauma, alcohol, dehydration, electrolyte loss
- non-compliance
- S/S: abd pain, vomiting, Kussmaul
respirations, acetone breath,
- severely dehydrated
- may be alert, lethargic, comatose
TREATMENT: fluids, K+, regular Insulin, treatment of
cause, ICU
42
Hyperosmolar Hyperglycemic State (HHS)nonketotic
- less common than DKA
- insulin level is too low to prevent hyperglycemia but high enough to
prevent fat breakdown
- Profound dehydration
- mental status changes, hyperosmolarity,
- extreme hyperglycemia (>600 mg/dL)
- no ketoacidosis
-precipitated by: acute stress (dehydration,
infections) OFTEN FATAL
-hypotension, tachycardia, seizures
DX: BMP, CBC, ABG
COMPLICATIONS OF HHS:
•
Cerebral infarct & MI
•
Mesenteric thrombosis
•
Pulmonary embolism
•
DIC
•
Cerebral edema
•
CHF
•
ARDS
•
rhabdomyolysis
45
TEACHING OPPORTUNITY

Nutrition management

Exercise

Exams
P R O B L E M S WI T H E X E R C I S E
FOR DIABETICS:
 Screen for retinopathy first since strenuous exercise may
precipitate vitreous hemorrhage or retinal detachment
 Pts with eye involvement must avoid physical activity that involves
straining, jarring, valsalva-like maneuvers
 Those with CVD, >35 yrs, autonomic neuropathy, PVD,
microvascular disease need cardiovascular evaluation and stress test
before exercise program
48
EXERCISE (CONTINUED)
 Repetitive exercises on insensitive feet will cause ulcerations
 NO to treadmill, jogging, prolonged walking, step exercise
 Recommend: swimming, bicycling, rowing, chair exercises, arm
exercises, other non-wt-bearing
49
EXERCISE (CONTINUED)
Aerobic activity:
 - swim, walk, run as this promotes utilization
of glucose as the fuel, desirable for CV health,
hypertension, lipid profiles, circulation, wt loss
 Recommended:

- 150 minutes/week of moderate (50 to 70
% of max heart rate)

- 90 min/week of vigorous (70% of max
heart rate)
EXERCISE 3 days/week with no more than 2
consecutive days without exercise
50
 Anaerobic activity:

- wt lifting (avoided) unless approved by cardiologist and
ophthalmologist
 - if approved:

- 3x/week, targeting all major muscle groups
51
ELECTROLYTE
MANAGEMENT
 Phosphate is not recommended to be replaced
 Calcium and Magnesium may be
 Potassium shifts from intracellular to extracellular placing them at
risk for ____?
 _HYPOKALEMIA_.
 Bicarb is only replaced in life threatening situations( acidosis <6.9)
• HYPOGLYCEMIA/INSULIN SHOCK
• 1) The person will be sweating, clammy, pale,
trembling and feel weak.
• 2) Ask the person what he needs and get it for
him or her.
• 3) Feed the person a quickly absorbed sugar such
as fruit juice, honey or a soft drink. Do not attempt
to feed a person who has lost consciousness.
W H AT D O YO U D O I F T H E Y
BECOME UNCONSCIOUS BEFORE ABLE TO
FEED A CARB/JUICE, ETC.?
• Dextrose 50%
• (D 50)
• 25gm/50ml - 1 ampule
•
Usual Dose: 1 amp Action: Provides glucose
calories for metabolic needs
Indications: Hypoglycemia, Use with insulin for
hyperkalemia Precautions: Monitor blood glucose,
can cause thrombosis in small veins.
BILIARY TRACT
ASSESSMENT
 Present illness: digestive disturbance, pain, meals, aggravating and
relieving factors
 PMH: GB dx, pregnancy, surgery, meds
 Fam Hx: GB dx
 System: pruritis, indigestion, fat intolerance, dyspepsia, n/v, light
colored stools, dark urine
HEPATITIS
JAUNDICE
Hepatitis A
(HAV)
Hepatitis
B
(HBV)
Hepatitis C
(HCV)
Hepatitis D
(HDV)
Hepatitis E
(HEV)
What is it?
HAV is a virus that
causes inflammation
of the liver. It does
not lead to chronic
disease.
HBV is a
HCV is a virus HDV is a virus that causes HEV is a virus that causes
virus that
that causes
inflammation of the liver. inflammation of the liver. It is
causes
inflammation of It only infects people with rare in the United States. There is
inflammationthe liver. This
HBV.
no chronic state.
of the liver. infection can lead
The virus
to cirrhosis and
can cause
cancer.
liver cell
damage,
leading to
cirrhosis
(scarring of
the liver) and
cancer.
Incubation period
15 to 50 days.
45 to 2 to 25 2 to 8 2 to 9 weeks. Average 40 days.
Average 30 days. 160
weeks. weeks.
days. Average
Average 7 to 9
120
weeks.
days.
Hepatitis A
Hepatitis B Hepatitis C
Hepatitis D
(HAV)
(HBV)
(HCV)
(HDV)
How is it spread?
Transmitted by
Contact with Contact with Contact with infected
fecal/oral route,
infected
infected
blood, contaminated
through close
blood, seminal blood,
needles. Sexual contact
person-to-person fluid, vaginal contaminated with HDV-infected
contact or ingestion secretions,
IV needles, person.
of contaminated contaminated razors and
food and water.
needles,
tattoo/body
including
piercing
tattoo/body tools.
piercing tools. Infected
Infected
mother to
mother to
newborn.
newborn.
NOT easily
Human bite. spread
Sexual
through sex.
contact.
Hepatitis E
(HEV)
Transmitted through
fecal/oral route. Outbreaks
associated with
contaminated water supply
in other countries.
Hepatitis A
(HAV)
Symptoms
May have none.
Adults may have
light stools, dark
urine, fatigue, fever
and jaundice
(yellowing of the
skin).
Hepatitis
B
(HBV)
Hepatitis C
(HCV)
Hepatitis D
(HDV)
May have none.
Even fewer acute Same as HBV.
Some people have cases seen than any
mild flu-like
other hepatitis.
symptoms, dark
Otherwise same as
urine, light stools, HBV.
jaundice, fatigue and
fever.
Hepatitis E
(HEV)
Same as HBV.
Treatment of chronic disease
No specific
treatment.
Interferon and anti- Interferon
Interferon.
virals.
(peginteferon) along
with the antiviral
ribavirin.
Supportive.
Hepatitis A
(HAV)
Hepatitis B
(HBV)
Hepatitis C
(HCV)
Hepatitis D
(HDV)
Hepatitis E
(HEV)
Who is at risk?
Household or sexual
contact with an
nfected person or
iving in an area with
HAV outbreak.
Travelers to
developing countries,
men who have sex
with men and IV and
non-IV drug users.
Infant born to Anyone who had a blood
IV drug users, men
Travelers to
infected mother,transfusion or organ transplantwho have sex with
developing countries,
having sex with before 1992, health care
men, dialysis patients, especially pregnant
infected person workers, IV drug users, dialysis healthcare workers,
women.
or multiple
patients, infants born to
infants born to
partners, IV
infected mother and having infected mothers and
drug users,
multiple sex partners.
those having sex with a
emergency
HDV infected person.
responders,
health care
workers, men
who have sex
with men,
household
contacts of
chronically
infected persons
and dialysis
patients.
Hepatitis A
(HAV)
Hepatitis B
(HBV)
Hepatitis C
(HCV)
Hepatitis D
(HDV)
Hepatitis E
(HEV)
Prevention
Get a hepatitis A vaccine. Get a hepatitis B
vaccine.
Take immune globulin
within two weeks of
Take immune
exposure.
globulin within two
weeks of exposure.
Wash hands with soap and
water after going to the
Practice safe sex.
toilet.
Clean up infected
Use household bleach to blood with bleach
clean surfaces
and wear protective
contaminated with feces, gloves.
such as changing tables.
Don't share razors,
Practice safe sex.
toothbrushes or
needles.
Don't inject street
drugs.
Don't get a tattoo or
body piercing.
Practice safe sex.
Clean up spilled blood with
bleach. Wear gloves when
touching blood.
Don't share razors or
toothbrushes.
Don't inject street drugs.
Don't get a tattoo or body
piercing.
Get a hepatitis B vaccine Avoid drinking or using
to prevent HBV infection. potentially contaminated
water.
Practice safe sex.
Wash your hands with
soap and water after going
to the toilet.
CIRRHOSIS
 12th leading cause of death
 Irreversible
 Causes: hepatitis, rt heart failure, ETOH
 Alcohol is most common in USA
 S/S: gradual, fatigue, weakness, anorexia, wt loss, VIT D
deficiency
PORTAL HTN
 Result of scarring of liver
 Normal is 3mmHG increases to 10mmHG
 Portal veins carry blood from GI tract
 Causes varices or thin walled veins being prone to rupture and
ascites
CHOLELITHIASIS
 Gallstones in biliary tract
 If stone can’t pass it causes
obstruction
 2 stone types: cholesterol and pigmented
 s/s: fever, N/V, abd pain, right shoulder pain, back pain, restlessness after
meals, jaundice, pruritis, clay colored stools, dark urine, deficiencies in vitamin
A, E, D, K
 Diagnostics: abd x-ray, US, MRI, FLP, ERCP,
 TX: LAP- Chole, provide rest, IVF, NG Sxn, Antibx, low fat liquid diet
immediately after episode avoiding eggs, cream, pork, fried foods, cheese, rich
dressings, gas forming veggies, and alcohol.
BILIARY DYSKINESIA
• Motility disorder of the GB
• Uncommon
• S/S: episodic epigastric or
RUQ pain, N/V
• Pain occurs after fatty meal
• Dx: serum bilirubin amylase,
lipase, AST, ALT,CBC
• Tx: surgery, low fat diet, meds
(ursodial or chenodiol), lithotripsy,
herbal goldenseal
ASSESSMENT
Present illness: general well being, digestive problems,
pain
PMH: abd trauma, abd disorders, surgery, metabolic
disorders, meds
FAM HX: pancreatic disorders
System: pruritis, resp distress, n/v, abd pain
Functional: diet, ETOH use
Exam: restlessness, flushing, diaphoresis, low grade
fever, tachycardia, tachypnea, hypotension, jaundice,
dryness, scratches, abd distention, tenderness, hypoactive
bowel tones, abd discoloration
PANCREATITIS
• Inflamed pancreas from activation of potent pancreatic enzymes within the
pancreas, mainly trypsin
– Acute or chronic
• Causes: ETOH, viral infections, peptic ulcer dx, cysts, renal fx,
hyperparathyroidism, trauma, surgery, etc
• S/S: abd pain, severe vomiting, flushing, cyanosis, dyspnea, low grade fever,
tachycardia and tachypnea, hypotension, distended abd, absent bowel tones = ileus,
shock
PANCREATIC CANCER
 Spreads quickly
• 75% are adenocarcinomas at head of
pancreas
 43920 new cases each yr in USA
• Many cases are men in 60s
 Risk factors: smoking, pancreatitis, high fat diet
 Dx: Spiral CT is the most accurate tool
 S/S:pain, jaundice, liver enlargement, wt loss, glucose
intolerance, anorexia, vomiting, weakness, diarrhea
• The most common sign is painless progressive
jaundice
 Tx: surgery, pain meds, tube feedings, post op radiation,
chemo
 NSG DX: pain, fear, skin integrity, disturbed body
image
THE END
Questions