Nursing Management of Clients
with Stressors of Endocrine
Function
DIABETES MELLITUS
NUR133
Lectures # 12&13
K. Burger, MSEd, MSN, RN, CNE
Definition & Classification
• A group of metabolic diseases characterized by
elevated levels of blood glucose resulting from
defects in insulin secretion, insulin action, or
both
• The disease is further characterized by
metabolic abnormalities and by long-term
complications to other body systems
• EVERY BODY SYSTEM IS AFFECTED BY
DIABETES
Classification
Type 1Diabetes Mellitus
 Lack of insulin or
production of defective
insulin
 Age of onset: <20 yrs
 Often present with DKA
 Always requires
exogenous insulin Rx
Type 2 Diabetes Mellitus
 Reduced ability to
respond to insulin
and/or secrete
sufficient amounts
 Age of onset: adults*
 Obesity = co-factor
 Rx: variable
DKA versus HHNS
Diabetic Ketoacidosis
 Usually preceded by
polyuria, polydipsia,
polyphagia
 BG > 300
 Ketosis
 Fruity breath
 Lethargy
 Kussmaul’s Resp
HyperglycemicHyperosmolar
Non-ketotic Syndrome


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
Gradual Onset
BG as high as 800
Hi blood osmolarity
No ketosis
Dehydration
Confusion – Coma
Muscle jerking-seizures
Interventions for
DKA / HHNS
• Restore fluid volume rapidly to maintain
perfusion to vital organs ( NS IV @ 1L/hr)*
• Then continue to balance fluids
(1/2 NS @ reduced rate )
• Administer IV insulin
• Administer HCO3 in extreme cases
• Monitor K levels
• Monitor for s/s cerebral edema*
Metabolic Acidosis/Alkalosis
The elevator effect
Metabolic
Acidosis
CO2 + H2O =
Metabolic
Alkalosis
H2CO3 =
H + HCO3
PRIOR to LECTURE
• Students are to complete:
Winningham & Preusser CASE STUDY
Endocrine Disorders – Case Study #4
• BE PREPARED!
• YOU WILL BE CALLED ON IN CLASS TO
ANSWER THESE QUESTIONS!
Case Study 4
Diabetes Mellitus
Winningham & Pruesser (2005) Elsevier, Inc.
The client, Y.L. has been complaining of chronic fatigue, increased thirst,
constantly being hungry, and frequent urination. She denies any pain,
burning, or low back pain on urination. She tells you she has a vaginal yeast
infection that she has treated numerous times with OTC medication. She
admits to starting smoking since going back to work full time as a clerk in a
loan company. She also complains of having difficulty reading numbers and
reports making frequent mistakes. She says by the time she gets home and
makes supper for her family, then puts her child to bed, she is too tired to
exercise. She reports her feet hurt; they often “burn or feel like there are pins
in them.” She reports that after her delivery, she went back to her traditional
eating pattern, which you know is high in carbohydrates Her current weight
is 173 lb. Today her BP is 152/97 mm Hg and her plasma glucose is 291
mg/dL.Lab values are as follows:
FBG 184 mg/dL, A1c 10.4, UA +glucose, -ketones, cholesterol 256 mg/dL,
triglycerides 346 mg/dL, LDL 32 mg/dL, ratio 8.0. Y.L. is diagnosed with type
2 diabetes.
The PCP decides to start MDI (multiple dose injection) insulin therapy and
have the patient count carbohydrates. Y.L. is scheduled for education
classes and is to work with the diabetes team to get her blood sugar under
control.
Case Study 4
Diabetes Mellitus
Winningham & Pruesser (2005) Elsevier, Inc.
QUESTION #1
Identify the three methods used to diagnose
Diabetes mellitus.
Case Study 4
Diabetes Mellitus
Winningham & Pruesser (2005) Elsevier, Inc.
QUESTION #9
What symptoms did YL report that lead you
to believe she has some form of neuropathy?
Case Study 4
Diabetes Mellitus
Winningham & Pruesser (2005) Elsevier, Inc.
QUESTION #10
What findings in YLs history place her at
increased risk for the development of other
forms of neuropathy?
Case Study 4
Diabetes Mellitus
Winningham & Pruesser (2005) Elsevier, Inc.
QUESTION #11
What are some changes that YL can make
to reduce the risk or slow the progression of
both macrovascular and microvascular
disease?
Case Study 4
Diabetes Mellitus
Winningham & Pruesser (2005) Elsevier, Inc.
QUESTION # 8
YLs culture prefers foods high in
carbohydrates. What is carbohydrate counting
and why would this method work well for YL?
Case Study 4
Diabetes Mellitus
Winningham & Pruesser (2005) Elsevier, Inc.
QUESTION#12
YL is enrolled in a smoking cessation class.
Why is it so important that she stop smoking?
Case Study 4
Diabetes Mellitus
Winningham & Pruesser (2005) Elsevier, Inc.
QUESTION # 2
Identify (3) functions of insulin
Case Study 4
Diabetes Mellitus
Winningham & Pruesser (2005) Elsevier, Inc.
QUESTION #3
Insulin’s main action is to lower blood sugar
levels. Several hormones produced in the
body inhibit the effects of insulin. Identify (3)
ANTIDIABETIC AGENTS
ORAL
 Sulfonylurea Agents
 Biguanides
 Alpha-glucosidase
Inhibitors
 Thiazolidinediones
• Meglitinides
INSULINS
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Rapid Acting
Short Acting
Intermediate Acting
Long Acting
Combination
ORAL ANTIDIABETICS
Sulfonylureas
• Chlorpropamide ( Diabinese ) 1st generation
• Glipizide ( Glucotrol ) 2nd generation
• Glyburide ( Micronase ) 2nd generation
• Work best in early stages of disease
• Stimulate beta cells to secrete insulin
• Also have some effect on glucose
absorption & storage in tissues
• Most commonly prescribed type oral rx
Sulfonylurea Drugs
Nursing Implications
• Hypoglycemia is most common side-effect
• Can also cause blood dyscrasias
• Geriatric clients and anyone with decreased organ function more susceptible
to above
• Cross allergies to loop diuretics and sulfonamides
• Diabinase and other 1st generation sulfonylureas should not be taken with
alcohol; potential severe reaction
• Glucotrol has most rapid onset and shorter duration
• Usually taken 30 minutes before meals
Biguanides
• Metformin ( Glucophage )
•
•
•
•
•
Reduces the production of glucose
Decreases intestinal absorption of glucose
Increases the uptake of glucose
Does NOT produce hypoglycemia
Often given in combination with other orals
Biguanides
Nursing Implications
• Onset within 1 hr, duration 24 hrs
• Hold med temporarily if pt going for diagnostic
studies involving iodinated contrast materials
• Should not be used in renal impaired client
• Side effects are mostly GI related but usually
transient:
– Abdominal bloating
– Nausea
– Diarrhea
Alpha –glucosidase Inhibitors
• Miglitol ( Glyset )
• Delays glucose absorption after a meal
• Taken with first bite of each meal
• GI side effects: abd pain, diarrhea, flatus
usually lessen over time
• Contraindicated for persons with
inflammatory bowel disease
Thiazolidinediones
• Rosiglitazone ( Avandia )
•
•
•
•
•
Decrease insulin resistance
Stimulate peripheral glucose uptake
Inhibit glucose production in the liver
Side effects: weight gain, edema, anemia
Potential for hepatic toxicity; liver enzymes
need to be monitored
Meglitinides
• Repaglinide ( Prandin )
• Nateglinide ( Starlix )
• Rapidly increases release of insulin from
pancreas
• Must be taken with meals 0-30min ac
• Meal must have adequate CHO
Insulin Therapy
•
•
•
•
Rapid - Lispro
Short - Regular
Intermediate -NPH
Long - Lantus
Case Study 4
Diabetes Mellitus
Winningham & Pruesser (2005) Elsevier, Inc.
QUESTION #4
YL was started on lispro (Humalog) and
glargine (Lantus) insulin. What is the most
important point to make when teaching the
patient about glargine?
Case Study 4
Diabetes Mellitus
Winningham & Pruesser (2005) Elsevier, Inc.
QUESTION #5
Because YL has been on regular insulin in the
past, you want to make sure she understands the
difference between regular and lispro. What is the
most significant difference between these two
insulins?
Case Study 4
Diabetes Mellitus
Winningham & Pruesser (2005) Elsevier, Inc.
QUESTION #6
What is the peak time and duration for lispro
insulin?
Case Study 4
Diabetes Mellitus
Winningham & Pruesser (2005) Elsevier, Inc.
QUESTION #7
YL wants to know why she can’t take NPH and
regular insulin. She is more familiar with them
and has taken them in the past. Explain why the
MD chose lispro and glargine insulin over NPH
and regular insulin.
Insulin Rx Considerations
• Rotation within one anatomic site is
preferred to moving from site to site.
• Abdomen provides best absorption
• Be alert to Dawn and/or Somagyi
Phenomena
• Refrigerate unused insulin
• Insulin in use can be left out up to 28 days
• Do not re-use needles. Dispose properly
Alternative Methods of Insulin
Administration
•
•
•
•
External pumps
Internal pumps
Injection devices
Inhaled ( under development )
Common Nursing Implications for
Antidiabetic Medications
• Monitor for hypo/hyperglycemia
• Many drug interactions; both agonist and
antagonist
• Use cautiously in geriatric clients and
those with organ impairment
• Monitor A1c levels q2-3months
• Monitor BG levels daily
• Patient teaching is KEY!!!
Self-Study
Hypoglycemia versus Hyperglycemia
Signs & Symptoms
Hypoglycemia
 _______________
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 _______________
Hyperglycemia
 _______________
 _______________
 _______________
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 _______________
 _______________
 _______________
Self-Study
Insulin Comparison
Action / Onset / Duration
Agent
LISPRO
REGULAR
NPH
LANTUS
Onset
Peak
Duration