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Nursing Care and Interventions in Managing Type II Diabetes Mellitus

Keith Rischer, RN, MA, CEN

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Objectives for Today…

Describe the onset, clinical manifestations, laboratory findings and pathologic mechanisms of type 2 diabetes.

Identify clients at risk for type 2 diabetes Differentiate between macro & microvascular complications of

chronic diabetes. Compare the mechanisms of action, side effects and nursing

considerations of the oral antidiabetic medications for type 2 diabetes.

Compare the time action profile, and nursing considerations of insulin to control type 2 diabetes.

Identify nursing care priorities to treat and prevent complications of chronic diabetes.

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Background

90-95% of all diabetes Family history 2-4x risk developing Obesity

Increased resistance to insulin Impaired suppression of glucose production

by liver

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Patho of Type II Diabetes

Pancreas secretes less insulin Beta cells of pancreas

Insulin resistance Initial increase in insulin Leads to beta cell exhaustion & failure

Increased glucose production by liver Metabolic syndrome

Insulin resistance Abd. Obesity HTN-high cholesterol High triglycerides, CRP, low LDL, atherosclerotic

changes

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Those at Highest Risk…

Overweight Abd obesity

>age 40 Inactivity Hypertension High cholesterol Parents with type II DM Gender & Ethnic influences

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Clinical Manifestations

Asymptomatic Same as Type 1

FatiguePolyuriaPolydipsia

Vaginal yeast infections Wounds that do not heal

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Laboratory Diagnosis for Type 2

Symptoms of DM plus casual ^ 200 mg/dLFasting ^ 1262-hr ^ 200

UrineAlbuminKetonesProteinGlucose

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Macrovascular Complications

Cardiovascular disease (most common)2-3 X greater than non-DM, Women moreMI leading cause of death

Cerebrovascular disease^ glucose levels lead to greater brain injury

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Microvascular Complications

Eye and vision complications Retinopathy which is leading cause of new blindness

linked to fasting BG >129 Cataracts, glaucoma, macular degeneration

Diabetic Nephropathy Leading cause of ESRD

Early sign… microalbuminuria Neurontin or Amitriptyline to manage pain

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Diabetic Neuropathy

Clinical ManifestationsLoss of sensation, pain, weaknessLate complication

foot ulcers/deformaties (Charcot’s joints), amputations

CVGI GU

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Male Erectile Dysfunction

Occurs at higher rate and earlier age as compared to general population

Affects 50% of males Treatments

penile implantsmedicationscounseling

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Medications: Sulfonylurea Agents p.1512-1515

Mechanism Require some beta-cell function

Stimulates pancreas to secrete more insulin Increases insulin sensitivity

Hypoglycemia most common SE

Glipizide (Glucatrol)-30” before mealsGlyburide (Diabeta)-with first meal Adverse effects

Hypoglycemia Impaired renal-liver function elevates levels

Onset 15-30”…peak 1-2h…duration 24 hours

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Oral Therapy

Biguanides (Metformin or Glucophage)Decreases liver glucose release and

decreases cellular insulin resistanceShould not cause hypoglycemiaAvoid those with renal disease (causes lactic

acidosis in those with renal, liver, CHF or ETOH)

Withhold 48 hours before using contrast media and surgery requiring anesthesia

Avoid ETOH…causes lactic acidosis

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Oral Therapy

Thiazolidine-diones (Avandia, Actos) Enhance insulin action

Decreasing insulin resistance Can be used with insulin or sulfonylurea Need periodic liver tests to assess for

damage Cause weight gain

Due to fluid retentionElevates HDL as well as LDL & triglycerides

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Oral Therapy

Combination meds Combine with insulinOrals combined with other orals

Drug SelectionBased on cost, age, client’s ability to

manage, response to medsBody’s response to oral DM meds

decreases, so clients may have to go on insulin

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Insulin

Needed for type 1 and often for type 2 Assess elderly’s ability to give insulin Types of insulin

RapidShort IntermediateLong acting

Know the onset, peak, and duration

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Foot Assessment & Care

Do not smoke Inspect feet daily No bare feet Trim toenails Use lotion Report non-healing breaks Complete foot assessment with provider

at least 4 times a year.

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Foot Assessment & Care

Without sensation, risk for injury Peripheral sensation management -

monofilament Footwear - protective shoes Wound Care -

elimination of pressure: contact cast Wound Care clinicsGrowth hormonesDebridement

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Treatment: Chronic Pain

Maintain normal BG levels Anticonvulsants - Neurontin Antidepressants - Amitriptyline Capsaicin cream Pain Clinics and specialty services

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Treatment: Visual Disturbances

Many times loss of central vision Assistive devices

special insulin devices: magnifier on bottle talking glucometers coding objects: wrap rubber band around bottle Fluorescent lighting above object Society for the blind - large print Treatment:

Laser (photocoagulation)Vitrectomy (aspiration of blood, membranes,

fibers)

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Diabetic Glomerulosclerosis (CKD)

Glomeruli changes Capillary basement

thickening Patho

Glucose incorporated into noncellular components

Influenced by high glucose levels

HTN and smoking accelerate progression

Albumin-protein in urine reflect progression of disease

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Treatment: Renal

Tight blood glucose control Random urine test for albumin/creatinine Control of BP - low sodium diet Aggressively treat UTI If nephropathy - restrict protein Avoid dehydration - careful use of diuretics Dialysis Avoid drugs that injure kidney, if IV dye - give

fluids prior

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Exercise Therapy

Essential part of treatment Also increases well-being Can produce hypoglycemia or

hyperglycemia Low intensity aerobic best - walk, swim 20 to 40 minutes performed 4 to 7

days/week Keep logs to note progress

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Exercise Therapy

Complete physical check up before exercise program initiated

Exercise with a friend Always carry a simple sugar Always carry ID Athletes who are diabetic - extra planning

Monitor BG levels to determine effects on their body

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Diet

15 - 20% protein, 80% COH, <10% saturated fat Moderate to high dietary fiber - gradual. If a food has 5 or >

GM/ fiber can deduct from COH Alcohol - 2/day for men, 1 for women Food labels vital Individual meal plans Consistent meals and snacks Type 2 - may be on calorie restriction for wt loss

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Physical & Emotional Needs

Entire family affected - stress of diagnosis Prepare same meals for family - “not special” Group education classes - cooking classes Most is one to one education to tailor to client Assess individual educational needs considering

lifestyle, attitude, goals, ethnic, home, background

Wealth of teaching materials - printed, electronic

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Non-Compliance

Sometimes lack of knowledge, lack of power: Role of nurse to empower

Peer pressure Lack of motivation - unaware of consequences Poor family history of previous members Inadequate finances Unfamiliar with health care system Lack of advocate History of obesity

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Community Resources

Home care for post hospital teaching Out patient diabetic education Contact for emergency Assistance with shopping or cooking Referrals to local resources - Traveling

clinics, senior citizens American Diabetes Association

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Hyperglycemic-Hyperosmolar Nonketotic Syndrome and Coma

Caused by hyperglycemia Increased insulin resistance & CHO intake

Absence of ketones & higher glucose levels (BG >800) than keto-acidosis

High blood osmolarity (>350 mOsm/L) Pulls water out of body cells including brain

Mortality 50% Gradual onset Coma, confusion, decreased Glasgow, Seizures Treatment:

IV fluids 6 to 20 liters in 24 hours IV insulin