Nursing Care of the Patient with Diabetes Mellitus

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DM
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Chronic, multisystem disease $174 billion Adult blindness, ESRD, lower limb amputations Heart disease rates and stroke risk 2-4x’s higher in adults with DM
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Endogenous Insulin
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Increases after meals, then declines Low at night Rises some after dawn
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Type 1
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Islet cell autoantibodies develop months to years before diagnosis Progressive autoimmune destruction of beta cells (80-90% reduction) which leads to hyperglycemia
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Type 2
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Insulin Resistance Impaired glucose tolerance Excessive hepatic glucose production Adipokines have role in altered glucose and fat metabolism
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Secondary DM
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Occurs as a result of another medical condition or as the result of treatment of a medical condition that affects blood glucose levels. Usually resolves as condition resolves Stress, cushings syndrome, TPN, hyperthyroidism, recurrent pancreatitis, meds (steroids, thiazides, Dilantin)
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Diagnostic Criteria for Metabolic Syndrome
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Waist circumference >40(men) >35(women) Triglycerides >150mg/dL or drug treatment for increased triglycerides HDL cholesterol <40(men) 130mmHg systolic or >85mmHg diastolic or drug treatment for hypertension Fasting blood glucose >110 mg/dL or drug treatment for elevated glucose
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Glycosylated Hgb (HbA1C)
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Blood glucose bound to Hgb Indicated glucose control over the last 3-4 months >6.5 on more than one occasion indicates diabetes Goal for diabetic patients is 7% or lower Normal if DM: 4-6% Fasting is not required
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Diagnosis of DM
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A1C >6.5 FPG >126 on more than 1 occasion 2H plasma glucose level >200 during OGTT, using 75g glucose load Classic symptoms of hyperglycemia or hyperglycemia crisis with a random plasma glucose >200
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DM Health Promotion
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Routine screening >45 and repeat at 3 yr intervals At risk: Obesity, relative with DM, physically inactive, ethnicity (NA,AA, hispanics), baby >9lb or GDM, HTN, low HDL/high triglycerides, polycystic ovary syndrome, acanthosis nigricans
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Acanthosis nigricans
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Darker patch of skin on back of neck that might indicate high BG
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Pre-Diabetes
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Impaired fasting glucose/glucose intolerance 100-125 140-199 (OGT) 5.7-6.4 HA1C Prevention needs to be taken Damage to vessels, asymptomatic, educate!
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What should HA1C for a diabetic?
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<7%
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Goals of DM management
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Reduce symptoms Promote well-being Prevent acute complications of hyperglycemia Prevent or delay onset and progression of long term complications (nephropathy, retinopathy, stroke)
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Diabetes Mellitus and NANDA Dx
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Ineffective self-health management Imbalanced Nutrition: More than body requirements Risk for injury (paresthesias)(numbing of feet/LE) Risk for peripheral neurovascular dysfunction DKA or HHNS
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Diagnostics of DM patients
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History and physical exam Labs UA BP, possibly ECG Fundoscopic Exam-dilated eye exam Dental exam Neuro Exam Foot (podiatric) exam Monitoring of weight
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Monofilament Test
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Designed to test the loss of sensation in the feet of diabetic patients. If the person cannot feel the 10g filament, he must be considered at risk to develop a neuropathic ulcer
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Patient Education
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Enable your patient to be the most active participant in their DM care-they must make daily decisions about food intake, blood glucose testing, meds, exercise
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Exercise will…
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Lower blood glucose levels
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DM patients must wear a…
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Medical Alert Bracelet, at all times!
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4 Cornerstones of DM care
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Blood-glucose self monitoring Nutrition Exercise Drug Treatment
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Blood Glucose Self Monitoring
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Wash hands. Alcohol not necessary. Finger dry. Warm water or let arm hang prior to stick Use side of finger pad Follow monitor instructions Record results Test before meals (ac), before & after exercise, illness, if hypoglycemia is expected
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Nutrition
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Timing and amount of food is important Weight reduction as needed (type 2) Minimum of 130g of CHO Monitor GI Fats (saturated <7%, <200mg/day cholesterol and limited trans fats) Protein 15-20% of total calories consumed Limit alcohol b/c it can cause hypoglycemia
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Carb Counting
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Total carbs/day depends on age, weight, activity level, and meds Each serving size of CHO is 15g; 45-60/ meal Include person who will be doing cooking in the teaching
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CC 1
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Consistent carbs; 60gms/meal 1200-1500
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CC 2
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Consistent carbs; 75gms/meal 1800-2000
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CC 3
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Consistent carbs; 90gms/meal 2200-2400
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IM Glucagon
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BG <60 Unconscious Cannot swallow
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Exercise
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Doesn’t have to be vigorous to be effective 150 min/wk of aerobic activity Type 2 should do resistance training 3x/week Properly fitting footwear Warm-up & cool down After meals when glucose is rising Exercise induced hypoglycemia can occur several hours after exercise Make adjustments to insulin dose and food intake to compensate
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If glucose <100mg/dL
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Eat 10-15 CHO snack and retest in 15-30 min Do not exercise if <100 mg/dL
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If glucose >250mg/dL
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If type 1 and ketones present, vigorous activity should be avoided
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Rapid-Acting
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Humalog, Novolog Onset 15 min Peak 60-90 min Duration 3-4 H
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Short-Acting
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Regular Onset 1-2H Peak 2-3H Duration 3-6H
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Intermediate-Acting
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NPH (Humulin N, Novolin N) Onset 2-4H Peak 4-10 H Duration 10-16 H
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Long Acting
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Lantus/Levemir Onset 1-2H Peak No pronounced peak Duration 24+H
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Insulin
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A high alert med!
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Insulin Cautions
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Avoid temp extremes Store extra in refrigerator Gently roll before adminstering Rotate sites Fastest absorption in abdomen, arm, thigh, buttock (slowest) Always have another nurse double check your insulin Only use insulin syringe to administer insulin
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The Ideal Insulin Regimen
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Stimulates the body’s own normal insulin output Combines “basal” insulin with “mealtime” insulin “Basal Bolus” regimen Uses rapid and short acting insulin before meals Use background insulin once a day 4 injections/day
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Very Rapid-Acting Insulin
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Timing is crucial Very rapid-acting insulins have onset of 15 min and should be given 0-15 min before meals Humalog/Novolog
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Short Acting Insulin
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Onset of 30-60 min and should be given 30-45 min before meals Regular Insulin
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Basal Insulin
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Once or twice a day Lantus/Levemir Most physiologic approach, except for pump
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Split-Mixed Dose Regimen
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NPH & regular/rapid taken before breakfast and at dinner 2 injections provide coverage for 24H Must adhere to set meal plan
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When mixing insulins
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Inject air into NPH vial Inject air into regular insulin vial Withdraw regular dose Then withdraw NPH dose adding to the regular insulin already in the syringe
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Complications of Insulin Therapy
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Allergic Reaction Hypoglycemia Lipodystrophy
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Dawn Phenomenon
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Hyperglycemia that is present on awakening in the AM Due to release of counterregulatory hormones in the predawn hours During “growing years” Adjust timing of insulin or increase the dose
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Somogyi Effect
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A rebound effect Too much insulin in the blood during the night BS drops Then hormones release glucose Increase BS Decrease the insulin dose/eat HS snack
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Hypoglycemia
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<70 mg/dl Confusion, irritability, diaphoresis, tremors, hunger, weakness, visual disturbances Check FSBS Rule of 15 IM glucagon D50 IVP
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Rule of 15
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Conscious and able to swallow Give 15g simple CHO, wait 15 min, recheck BS
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5 Steps to Hypoglycemic Rescue
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Identify hypoglycemic event 15g CHO Recheck in 15 min and again in 1H Document the treatment (amt & type of food or med) Notify MD
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Stress of Acute Illness and Surgery
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Emotional and physical stress can result in hyperglycemia Flu, UTI Body requires extra energy to deal with illness-intake and meds are important, don’t skip doses!
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DKA (Diabetic Ketoacidosis)
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Type 1 – insulin, + ketones, acidosis, dehydration Increase fluids & insulin drip; monitor K+ levels
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HHNS (Hyperosmolar hyperglycemia nonketotic syndrome)
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Type 2 + insulin; – ketones Increase fluids, monitor K+ levels
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Macrovascular Problems
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Cardio Cerebrovascular (stroke) Peripheral Vascular
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Microvascular Problems
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Retinopathy Nephropathy Neuropathy
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Diabetic Foot Care
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SO IMPORTANT! Dry feet, esp b/w toes Inspect feet daily Use lanolin Mild foot powder on sweaty feet No commercial remedies Separate overlapping toes with cotton Don’t go barefoot No tight LE clothes No hot water bottles or heating pads on LE Avoid prolonged sitting, crossing legs

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