Medical Surgical Nursing Diabetes Mellitus Endocrine Pancreas • Islets of Langerhans • Beta cells – Insulin Insulin • Produced and secreted by… – Beta cells Insulin • Primary function… – Stimulates the active transport of glucose – from the blood into muscle, liver and adipose tissue – __?__ blood glucose levels • i Glucose Content of Food • Consume food glucose blood stream • *Carbohydrates – Starch • Simple • Complex Secretion of Insulin • Is stimulated by: – What change in homeostasis causes the beta cells to secrete insulin? – Hyperglycemia • Glucose levels in the bloodstream regulate the rate of insulin secretion The major action of insulin • i blood glucose levels • h the permeability of target cell membrane to glucose – Main target cells • Muscle • Liver • Adipose tissue Pathophysiology sumamry • Increased blood glucose levels • Gland – Pancreas • B cells • Insulin • Target cells (muscles) – (insulin pulls glucose from the blood into the muscles) • Decrease blood glucose levels Insulin info • In the absence of insulin, glucose is not able to get into the cells and it is excreted in the urine – Glycouria • Brain cells are not dependent on insulin for glucose intake Function of Insulin • Need insulin for glucose to cross cell membrane • No insulin no glucose into the cell • Glucose stays in the blood • Hyperglycemia Diagnostic tests • Blood glucose / Fasting blood glucose • Glycosylated Hemoglobin Assay Blood Glucose Fasting blood Glucose • Measures blood glucose levels after fasting • Results – – – – Normal – 70-115 mg/dL Diabetic level > 126 mg/dL Critical > 400 mg/dL Critical < 50 mg/dL Fasting Blood Glucose Nursing Responsibility • • • • Fast 6-8 hours Water OK No insulin or anti-diabetic meds Exercise will effect results Glycosylated Hemoglobin Assays (Hgb A1C) • % of glycosylated hemoglobin – RBC lifecycle • @ 120 days (4 months) – Glucose slowly binds with Hgb glycosylated – h serum glucose level h glycosylated Hgb levels Hgb A1C • Provides an average blood glucose levels – Past 2-3 months • Can be taken any time • Normal levels (non-diabetic) – 4-6% • Diabetic level (goal) – <8% Small group questions 1. What are the Islets of Langerhans? 2. What cells of the pancreas secrete insulin? 3. What stimulates insulin to be secreted? What is diabetes mellitus? • Group of disordered characterized by chronic hyperglycemia • Due to faulty insulin production • (Not Diabetes Insipidus) Type 1 – Diabetes Mellitus • Destruction of the Beta cells • Result in – NO insulin production – Insulin dependent S&S of Type 1 DM • Hyperglycemia – ↑ blood glucose levels – No insulin – Glucose stays in the blood stream S&S of Type 1 DM • Glycosuria – Glucose in the urine S&S of type 1 DM • Polyuria • Nocturia S&S of Type 1 DM • Polydipsia – Excessive thirst S&S of Type 1 DM • Polyphagia – Excessive hunger S&S of Type 1 DM • Dehydration – Assessment? • • • • Skin turger Mucus membranes Thirst BUN level Small Group Questions 1. Why would a person with high glucose levels have polyphagia? 2. Explain why polyuria is a common symptom of diabetes Mellitus Type 1. 3. What is hyperglycemia? 4. Why does hyperglycemia happen in Type 1 diabetes mellitus? Small Group Questions 5. What is a normal level for a FBS? 6. Define the following terms: Glucose, Glycosuria. 7. What does an Hgb A1c measure? What are normal values for a diabetic and nondiabetic? Type 2 DM • Pathophysiology – The pancreas cannot produce enough insulin for body’s needs – Impaired insulin secretion Type 2 DM • Weakened Beta cells Due to over use Insulin and Type 2 DM • Not all clients require insulin –1/3 will at some time • Stress • Illness Risk Factors for Type 2 DM • Family history • Obesity • Gestational diabetes or large baby Type 1 vs. Type 2 • Age of onset • Age of onset – Usually < 30 – Usually > 40 Type 1 vs. Type 2 • Body wt at onset – Normal to thin • Insulin production – None • Insulin injections – Always • Body wt at onset – 80% overweight • Insulin production – Not enough • Insulin injections – Sometimes Type 1 vs. Type 2 • Management – Insulin – Diet – Exercise • Management – Diet (wt. Loss) – Exercise – Possibly oral hypoglycemic meds – Possibly insulin Other specific types of Diabetes Mellitus • Gestational • Pancreatitis • Drug or chemical induces diabetes (steroids) S&S of Diabetes Mellitus • Definition: – A group of disorders characterized by chronic Hyperglycemia • 3 P’s – Polydipsia – Polyuria – Polyphagia S&S of Hyperglycemia • Neurological – C/O headache – Dull senses – Stupor – Drowsy – Blurred Vision S&S of Hyperglycemia • Cardiovascular – Tachycardia – Decreased BP – (Dehydration) • Respiratory – Kussmaul's respirations – Sweet and fruity breath – Acetone breath S&S of Hyperglycemia • Gastro-intestinal – Polyphagia – N/V – Polydipsia S&S of Hyperglycemia • Genital-urinary – Polyuria – Glycosuria • Skeletal-muscular – Weak S&S of Hyperglycemia • Integumentary – Dry skin – Flushed face Small Group Questions Mr. McMillan is a 50 year old client brough into the ER with extreme fatigue and dehydration. After the MD sees him the nurses asks Mr. McMillan some additional questions. Based on the clients answers the nurse requests that the MD add a glucose level to the lab work. The results are 800mg/dL. Small group questions 1. What question did the nurse most likely ask? 2. Why was Mr. McMillan fatigued? 3. Why was he dehydrated? Medical Management of DM • No cure • Goal is Control! And prevent complications • Individualized treatment plans – Diet – Exercise – Meds Dietary management of DM Foundation of Diabetic control • Goals – Maintain near-normal blood glucose levels – Achieve optimal serum lipid levels – Provide adequate calories for reasonable weight – Prevent & treat acute complications of insulintreated diabetes – Improve overall health through optimal nutrition The exchange system • Six categories – – – – – – Starch Meat Milk Vegetable Fruit Fat General guidelines of Dietary Management • Protein – 20% • Fat – 20% • Carbohydrates – 60% • ADA: American Diabetic Association Diabetic Meal • Small frequent meals – CONSISTENCY! • • • • Amount of calories Amount of carbohydrates Time Snacks Plan Diabetic Meal Plan • If the client is obese, the key to treatment is… – Weight loss! Meal Plan considerations • • • • Food preferences Lifestyle Schedule Ethnic / Cultural background Alcohol and Diabetes • Increase risk of… – Hypoglycemia – Moderation Exercise and Diabetes • i blood glucose levels More Benefits of exercise • Increases circulation • Improve serum lipid levels • Improves cardiovascular status • Assist with wt control • Decreases stress Rules for the exercising diabetic • Talk to MD first • Regular vs. sporadic • Correlate exercise and glucose levels • Don’t exercise when hypoglycemic • Don’t exercise when hyperglycemic >250 Rules for the exercising diabetic • Do not exercise when insulin is peaking • Carry a quick source of sugar • Best time = 60-90 minutes after a meal Rules for the exercising diabetic • Proper footwear • May need a preexercise snack • Consistency! Monitoring Glucose • Glucometers • FSBS • 2-4 times a day Small Group Questions 1. Give signs & symptoms of hyperglycemia by body system (Why do they manifest these symptoms?) 2. A diabetic meal plan’s main goal is to maintain near normal glucose levels. How is this done? 3. The exchange diabetic meal plan is divided into six categories, what are they? Small Group Questions 4. What affect does alcohol have on a diabetic? 5. What affect does exercise have on a diabetic? 6. What council would you give a diabetic regarding exercise? Onset – Peak - Duration • Onset – The time period from injection to when it begins to take effect • Peak – When insulin is working its hardest and therefore blood glucose levels are at their lowest Onset – Peak - Duration • Duration – Length of time the insulin works or lasts Types of Insulin – Very short acting/ rapid acting • Lispro (Humalog) • Aspart (Novolog) Appearance Onset Peak ¼ hour Clear 1 hour • Insulin pumps • Rapid reduction of glucose level Duration 3 hours Types of Insulin – Short-acting / regular • Humalog R; Novolin R; Iletin II Regular Appearance Onset Peak Duration Types of Insulin – Short-acting / regular • Humalog R; Novolin R; Iletin II Regular Appearance Clear Onset Peak Duration Types of Insulin – Short-acting / regular • Humalog R; Novolin R; Iletin II Regular Appearance Onset Clear ½ - 1 hr (1 hour) Peak Duration Types of Insulin – Short-acting / regular • Humalog R; Novolin R; Iletin II Regular Appearance Onset Peak Clear ½ - 1 hr (1 hour) 2-3 hrs (3 hour) Duration Types of Insulin – Short-acting / regular • Humalog R; Novolin R; Iletin II Regular Appearance Onset Peak Duration Clear ½ - 1 hr (1 hour) 2-3 hrs (3 hour) 4-6 hrs (5 hours) • Administered 20-30 minutes before meals • IV • Usually given 4 x a day Types of Insulin – Intermediate-acting • NPH; Humulin N; Lente: Novolin L; Novolin N Appearance Onset Peak Duration Types of Insulin – Intermediate-acting • NPH; Humulin N; Lente: Novolin L; Novolin N Appearance Cloudy Onset Peak Duration Types of Insulin – Intermediate-acting • NPH; Humulin N; Lente: Novolin L; Novolin N Appearance Onset Cloudy 2-4 hrs (2 hrs) Peak Duration Types of Insulin – Intermediate-acting • NPH; Humulin N; Lente: Novolin L; Novolin N Appearance Onset Peak Cloudy 2-4 hrs (2 hrs) 6-12 hrs (12 hrs) Duration Types of Insulin – Intermediate-acting • NPH; Humulin N; Lente: Novolin L; Novolin N Appearance Onset Peak Duration Cloudy 2-4 hrs (2 hrs) 6-12 hrs (12 hrs) 16-20 hrs (24 hrs) • Administer after meals • Usually given 2x a day • Eat at onset! Learning Tip: Even and Odd • Short-acting think odd – (1-3-5) • Intermediate-acting think even – (2-12-24) Regular vs. Intermediate (NPH) When should insulin be administered • Short-acting / regular – 30 min before meals (ac) – Do not allow more than 30 min to pass by without eating • hypoglycemia • Intermediate acting – After meals (pc) • If mixed (regular & intermediate) – 30 min before meals What route is insulin administered • IV – Regular • Sub-cutaneous Syringe Types • Insulin syringe • 27-29 gauge Route (Self Administration) • Subcutaneous tissue – If you can “pinch an inch” • 90 degree angle – If you can’t “pinch an inch” • 45 degree angle Area’s of injection • • • • Abdomen Arm Thigh Hips Factors affecting absorption rates • Quickest – Abdomen What would you do? Which of the following is frequently best to teach / do first when doing initial diabetic training? A. How & where to purchase insulin B. Preparation & storage of insulin C. Mixing insulin with return demonstration D. Self-injection of insulin E. Learning O-P-D of insulin types Insulin Pumps • • • • • Portable infusion pump Subcutaneous needle Continuous/basal rate Additional bolus if needed Change site q24-48 hours Insulin Pumps • S/E - risks – Hypoglycemia – Infection – Hyperglycemia Small Group Question Mrs. Evans is 60 year old women with type 2 DM. She is on Intermediate Acting Insulin [Novolin L (Lente)] every morning. She normally eats her meals at 8:00 AM, 12:00 PM, and 6:00 PM. 1. What time should she take her morning insulin? 2. When will this dose onset? 3. When will this does peak? 4. What does this insulin look like? Mrs. Sweet Peas takes 13 units of Short-Acting Insulin [Humalog R] q ac. Her meals are B-8:00 AM, L-12:00 PM, D-7:00PM 1. What time should Mrs. Peas take her mid-day (lunch)dose of insulin? 2. When this dose onset? 3. When will this dose peak? 4. What does this insulin look like? Mrs. Gumdrop takes 6 units of Intermediate Acting Insulin [NPH] at HS (10PM). She eats her meals at: B-7AM, L-11AM, D-5PM. • When will this dose onset? A. 9 AM B. 7:30 AM C. 7 PM D. 10:30 PM E. 12 AM Mrs. Gumdrop takes 6 units of Intermediate Acting Insulin [NPH] at HS (10PM). She eats her meals at: B-7AM, L-11AM, D-5PM. • When will this dose peak? A. 1 AM B. 10 PM C. 10 AM D. 9 PM E. None of the above Mrs. Gumdrop takes 6 units of Intermediate Acting Insulin [NPH] at HS (10PM). She eats her meals at: B-7AM, L-11AM, D-5PM. • What does this insulin look like? A. Clear B. Cloudy Mr. Chocolate Chip Cookie takes 10 units of Regular Insulin [Novolin R] q AM. His meals are at : B-7AM, L-11AM, D-5PM. • When should he take his morning does of insulin? A. 6 AM B. 6:30 AM C. 7 AM D. 7:30 AM E. None of the above Mr. Chocolate Chip Cookie takes 10 units of Regular Insulin [Novolin R] q AM. His meals are at : B-7AM, L-11AM, D-5PM. • When will this does peak? A. 7:30 AM B. 8:30 AM C. 9:30 AM D. 10:30 AM E. None of the above Mr. Chocolate Chip Cookie takes 10 units of Regular Insulin [Novolin R] q AM. His meals are at : B-7AM, L-11AM, D-5PM. • What does this insulin look like? A. Clear B. Cloudy Ms. Eng Ewe takes 10 units of Short-Acting Insulin [Iletin II Lente] and 5 units of Intermediate Acting Insulin [NPH] q AM. Her meals are B-8AM, L-12PM, D-7PM • When should she take her insulin injection? A. 7:00 AM B. 8:00 AM C. 9:00 AM D. 10:00 AM E. None of the above Ms. Eng Ewe takes 10 units of Short-Acting Insulin [Iletin II Lente] and 5 units of Intermediate Acting Insulin [NPH] q AM. Her meals are B-8AM, L-12PM, D-7PM 1. When will her insulin onset 2. When will her insulin peak Mixing Insulin – How to #1 Assemble equipment • Insulin • Syringe • Alcohol swab • MD order Mixing insulin – How to #2 Check MD order for dose and types Mixing insulin – How it #3 Roll the bottle of intermediate acting insulin (DO NOT SHAKE) Mixing insulin – How it #4 Wipe the top of both vials with alcohol swab Mixing insulin – How it #5 Draw up and inject an amount of air equal to the dose of intermediate acting insulin into the cloudy vial. Then remove syringe from the vial Mixing insulin – How it #6 Draw up and inject an amount of air equal to the amount of short-acting insulin into the clear vial. *Leave syringe in the vial Mixing insulin – How it #7 Draw up the correct amount of clear/regular insulin. Mixing insulin – How it #8 Double check with another nurse if this is the institutions policy. Mixing insulin – How it #9 Remove the syringe and insert into the cloudy vial. Carefully draw up the correct amount of insulin. Mixing insulin – How it #10 Double check with another nurse before removing the syringe from the vial What do you do if you draw up too much intermediate acting insulin with mixing? A. Push it back into the vial and re-draw up the correct amount. B. Waste the med and start over with the same syringe. C. Waste the med and start over with a clean syringe. D. Who cares, a little extra never hurt anyone! Just give it to the patient. What do you do if you draw up too much Regular/clear insulin when mixing? A. Push it back into the vial and re-draw up the correct amount. B. Waste the med and start over with the same syringe. C. Waste the med and start over with a clean syringe. D. Who cares, a little extra never hurt anyone! Just give it to the patient. How would you do it? Give 8u Humulin R and 12u NPH sub-q, qAM. Sliding Scale • Used during – Surgery – Illness – Stress • Determines insulin dose based on FSBG • FSBS check usually every 4-6 hrs • Usually regular insulin is used Sample Sliding Scale • • • • • • Check FSBS before meals and at HS (2200) 4u Humulin R insulin for glucose 151-200 mg/dL 6u Humulin R insulin for glucose 201-250 mg/dL 8u Humulin R insulin for glucose 251-300 mg/dL 10u Humulin R insulin for glucose 301-350 mg/dL Call MD for glucose >350 mg/dL Questions for sliding scale • • Check FSBS before meals and • • • • • at HS (2200) 4u Humulin R insulin for glucose 151-200 mg/dL 6u Humulin R insulin for glucose 201-250 mg/dL 8u Humulin R insulin for glucose 251-300 mg/dL 10u Humulin R insulin for glucose 301-350 mg/dL Call MD for glucose >350 mg/dL A. B. C. D. E. If FSBS 189 how much insulin would you give? None 4 units 6 units 8 units 10 units Questions for sliding scale • • Check FSBS before meals and • • • • • at HS (2200) 4u Humulin R insulin for glucose 151-200 mg/dL 6u Humulin R insulin for glucose 201-250 mg/dL 8u Humulin R insulin for glucose 251-300 mg/dL 10u Humulin R insulin for glucose 301-350 mg/dL Call MD for glucose >350 mg/dL A. B. C. D. E. If FSBS 309 how much insulin would you give? None 4 units 6 units 8 units 10 units Questions for sliding scale • • Check FSBS before meals and • • • • • at HS (2200) 4u Humulin R insulin for glucose 151-200 mg/dL 6u Humulin R insulin for glucose 201-250 mg/dL 8u Humulin R insulin for glucose 251-300 mg/dL 10u Humulin R insulin for glucose 301-350 mg/dL Call MD for glucose >350 mg/dL A. B. C. D. E. If FSBS 120 how much insulin would you give? None 4 units 6 units 8 units 10 units Questions for sliding scale • • Check FSBS before meals and • • • • • at HS (2200) 4u Humulin R insulin for glucose 151-200 mg/dL 6u Humulin R insulin for glucose 201-250 mg/dL 8u Humulin R insulin for glucose 251-300 mg/dL 10u Humulin R insulin for glucose 301-350 mg/dL Call MD for glucose >350 mg/dL A. B. C. D. E. If FSBS 60 how much insulin would you give? None 4 units 6 units 8 units 10 units Pre-mixed insulin • NPH + Regular • Novolin 70/30 – 70% NPH – 30% regular Insulin Storage • Vial NOT being used refrigerate • Vial in use room temperature • Storage life un-refrigerated = 1 month Insulin Therapy Complications • Hypoglycemia • Causes – Too much insulin – Too little food – Extreme exercise S&S of Hypoglycemia • Neuro – – – – Dizzy / faint Nervous / Irritability Blurred vision Numb tongue or lips S&S of Hypoglycemia • Cardiovascular – Full bounding pulse • Respiratory – Shallow breathing • Gastro-intestinal – Polyphagia S&S of Hypoglycemia • Genital-urinary – No polydipsia – No polyuria • Skeletal/muscular – Weak – Trembling / tremor • Integumentary – Perspiring/ Moist – Pale Small group Questions 1. When is a sliding scale commonly used? 2. A tuberculin syringe is also calibrated in units. Is it OK to use a TB syringe to draw up insulin? 3. What route is insulin administered? 4. Compare the signs and symptoms of hyper and hypoglycemia – How come they are not all opposite signs and symptoms? – Why are some so similar? – Which symptoms can you look for to tell the difference between hyper and hypoglycemia? (*) – What is the biggest risk factor in using an insulin pump? Oral Hypoglycemic Agents Sulfonylurea Cholpropamide (Diabanese) Glipizide (Glucotrol) Glimepride (Amaryl) Glyburide (Diabeta, Micronase) Oral Hypoglycemic Agents Biguanides Metformin (Glucophage) Glucovance Sulfonyurea+Biguanide Oral Hypoglycemic Agents • Oral hypoglycemic meds are not Insulin • Oral hypoglycemic meds require some production of insulin • Oral hypoglycemic agents are used in the treatment of type ___DM – Type 2 • Oral hypoglycemic meds are meant to supplement diet and exercise, not replace them Oral Hypoglycemic Agents • Oral hypoglycemic meds cannot be used during pregnancy • Oral hypoglycemic meds may need to be held temporarily and insulin prescribed if BS levels rise due to stress or illness etc. • Action varies so effect may be enhanced by use of multiple meds Sulfonylureas • Sulfonylurea’s work primarily by h the secretion of insulin by directly stimulating the pancreas Sulfonylurea • Side-effects of Sulfonylurea – Hypoglycemia – GI upset Biguanides • Biguanides work primarily by aiding insulin’s action on peripheral receptor sites (target cells) • Biguanides are NOT associated with episodes of hypoglycemia • Biguanides + sulfonylurea may h the glucose lowering effect Biguanides • Major side effects of Metformin are: – Anorexia/ wt. Loss • Metformin is contraindicated in patients with Renal impairment Can diabetes pills help me? • • • • • Only Type 2 DM Results vary Effectiveness wears off Insulin may still need to be taken occasionally Pregnant… Small Group Questions It’s your turn! Small Group Questions 1. A type 1 DM asks you “Why do I have to have insulin injections, why can’t I just take the Insulin pills?” How would you answer him? 2. Mrs. Murdock is a Type 2 DM. She was taking Glucatrol 20 mg BID. The MD changed her meds today to Micronase 5 mg PO BID and Glucophage 500 mg PO BID. Mrs. Murdock asks you why she is taking two medications now, instead of just increasing the dose of Glucatrol? Hypoglycemia • Definition: When blood glucose levels fall below 70mg/dL • < 50mg/dL = severe Hypoglycemia: Etiology • Any time – Usually: Before meals or a night • Too much insulin or oral hypoglycemic meds • Too little food • Excessive exercise Hypoglycemia: Dx & Assessment • Signs & Symptoms • Can occur suddenly! • If pt is a long time diabetic • No early S&S Hypoglycemia: Dx & Assessment • #1 Dx tool – Lab Values • FSBS Hypoglycemia can result: • When a patients baseline blood glucose level is 100mg/dL • When a patients baseline blood glucose level is 200mg/dL – Drops to 60 mg/dL – Drops to 120 mg/dL Hypoglycemia: Medical Management • Assess for S&S • P blood sugar level • Admin. fast sugar Hypoglycemic Protocol: Sample • For BG <60 mg/dL – If patient can take PO, give 15g of fast acting carbohydrate. – Check FSBG q 15 minutes and repeat above if BG<80. Glucose Fast! • 15 g fast acting carbohydrate – 4-6 oz. Juice/soda Rules to remember • • • • • • Do not add sugar to OJ Recheck FSBS q 15 min until WNL Avoid high fat slows absorption of glucose Instruct: carry fast sugar NPO if “unconscious” or confused If meal is >1 hr away, follow with a protein and complex carbohydrate Hypoglycemia treatment Unconscious • Position: side lying Hypoglycemia Gerontological Consideration • Cognitive deficits – not recognize S&S • Decreased renal function – oral hypoglycemic meds stay in body longer • More likely to _________a meal – Skip • Vision problems – inaccurate insulin draws Hypoglycemia Nursing measures • Follow protocol • Teach – Carry simple sugar at all times – S&S or hypoglycemia – How to prevent Hypoglycemia – Check FSBS if you suspect NOW! Treating Hyperglycemia • Assess for – S&S • Check – FSBS • Administer – insulin per MD order Medical Management/treatment • Monitor Fluid and electrolytes – Especially K+ – Push fluids