antidiabetic medications & the nursing process karen ruffin rn, msn ed

Antidiabetic Medications

&The Nursing

Process

Karen Ruffin RN, MSN Ed.

IS THERE A DIFFERENCE AND

IF SO WHAT IS IT??

Is it Diabetes or is it Is it Diabetes or is it Hyperglycemia???????????????Hyperglycemia???????????????

What is ???????

HyperglycemiaHyperglycemia

InsulinInsulin

The primary source of energy for The primary source of energy for our bodiesour bodies

What is the difference between

Basel InsulinBasel Insulin

Prandial InsulinPrandial Insulin

Optimal Levels of Blood Sugars

Preprandial-110 mg/dlPreprandial-110 mg/dl

Postprandial-180 mg/dlPostprandial-180 mg/dl

What happens to our bodies when we are

hyperglycemic?

hypertensionVascular smoothmuscle cell growth

Release of chemokinesRelease of cytokinesExpression of cellular adhesion molecules

Hyper coagulationPlatelet ActivationDecreased Fibrinolysis

So what disease states are you at risk for???

MIMI DVTDVT PEPE StrokeStroke AAAAAA RetinopathyRetinopathy

What happens to our bodies when we are

hyperglycemic?

Increased Glucose Decreased Insulin

Increased Glucose Decreased Insulin

STUNS YOUR ???????? FOR 2WEEK

DID YOU KNOW ANY BLOOD DID YOU KNOW ANY BLOOD SUGAR >200 SUGAR >200

Criteria for Diagnosis of DM

DM Screening Symptoms of diabetes + casual plasma glucose level Symptoms of diabetes + casual plasma glucose level

less than or equal to 200 mg/dLless than or equal to 200 mg/dLOROR Fasting plasma glucose higher than or equal to Fasting plasma glucose higher than or equal to

126 mg/dL126 mg/dLOROR 2-hour postload glucose level higher than or equal to 2-hour postload glucose level higher than or equal to

200 mg/dL during an oral glucose tolerance test200 mg/dL during an oral glucose tolerance test Impaired glucose tolerance (IGT)Impaired glucose tolerance (IGT)

◦ FPG <110 mg/dL: normal fasting glucoseFPG <110 mg/dL: normal fasting glucose◦ FPG ≥110 mg/dL but <126 mg/dL: impaired fasting FPG ≥110 mg/dL but <126 mg/dL: impaired fasting

glucose (IFG)glucose (IFG)◦ FPG ≥126 mg/dL: provisional diagnosis of diabetes FPG ≥126 mg/dL: provisional diagnosis of diabetes

mellitusmellitus

What is a HbA1c?

It is a test that allows healthcare It is a test that allows healthcare providers to see how diabetics providers to see how diabetics have managed their blood glucose have managed their blood glucose level over the last 2-3 months….level over the last 2-3 months….

Why do you think this is Why do you think this is important????important????

At what blood glucose level do we At what blood glucose level do we start treating with sliding scale?start treating with sliding scale?

??????????????

So, what do you think So, what do you think we are doing to our we are doing to our

patients???patients???

What is the Difference??

Type 1 diabetesType 1 diabetes

Type 2 diabetesType 2 diabetes

Type 1 Diabetes

Lack of insulin production Lack of insulin production OROR

Production of defective insulinProduction of defective insulin

Affected patients need exogenous insulinAffected patients need exogenous insulin

ComplicationsComplications Diabetic ketoacidosis (DKA)Diabetic ketoacidosis (DKA) Hyperosmolar nonketotic syndromeHyperosmolar nonketotic syndrome

Oral antidiabetic drugs not effectiveOral antidiabetic drugs not effective

SymptomsSymptoms

PolyuriaPolyuria PolydipsiaPolydipsia PolyphagiaPolyphagia GlycosuriaGlycosuria Unexplained weight lossUnexplained weight loss FatigueFatigue HyperglycemiaHyperglycemia

Diabetes Mellitus

Type 2 Diabetes

Most common typeMost common type

Caused by insulin deficiency and insulin Caused by insulin deficiency and insulin resistanceresistance

Many tissues are resistant to insulinMany tissues are resistant to insulin Reduced number insulin receptorsReduced number insulin receptors Insulin receptors less responsiveInsulin receptors less responsive These people respond to oral These people respond to oral

hypoglycemicshypoglycemics

Type 2 Diabetes

Several comorbid conditionsSeveral comorbid conditions• metabolic syndromemetabolic syndrome OR OR insulin-insulin-

resistance syndromeresistance syndrome OR OR syndrome Xsyndrome X

◦ ObesityObesity◦ Coronary artery diseaseCoronary artery disease◦ DyslipidemiaDyslipidemia◦ HypertensionHypertension◦ Microalbuminemia (protein in the urine)Microalbuminemia (protein in the urine)◦ Enhanced conditions for embolic events Enhanced conditions for embolic events

(blood clots)(blood clots)◦ Insulin ResistanceInsulin Resistance

Coronary Artery Disease

Treatment DIfferences Type 1Type 1

◦ Exogenous insulinExogenous insulin◦ Dietary controlDietary control

Type 2Type 2◦ Lifestyle changesLifestyle changes

Dietary controlDietary control Weight reductionWeight reduction ExerciseExercise

◦ May require oral hypoglycemic therapy or May require oral hypoglycemic therapy or exogenous insulinexogenous insulin

Insulin when oral hypoglycemic medications can Insulin when oral hypoglycemic medications can no longer provide glycemic controlno longer provide glycemic control

Gestational Diabetes

◦ Hyperglycemia that develops during pregnancyHyperglycemia that develops during pregnancy

◦ Insulin must be given to prevent birth defectsInsulin must be given to prevent birth defects

◦ 4% of all pregnancies4% of all pregnancies

◦ Must be reclassified if it persists 6 weeks post-Must be reclassified if it persists 6 weeks post-deliverydelivery

◦ Usually subsides after deliveryUsually subsides after delivery

◦ 30% of patients may develop Type 2 DM within 10 30% of patients may develop Type 2 DM within 10 to 15 yearsto 15 years

Major Long-Term Complications

of DM (Both Types)◦ Macrovascular (atherosclerotic Macrovascular (atherosclerotic

plaque)plaque) Coronary arteriesCoronary arteries Cerebral arteriesCerebral arteries Renal arteriesRenal arteries Peripheral vesselsPeripheral vessels

◦ Microvascular (capillary damage)Microvascular (capillary damage) RetinopathyRetinopathy NeuropathyNeuropathy NephropathyNephropathy

Complications Associated with Diabetes Mellitus

Cardiovascular disease, including Cardiovascular disease, including hypertensionhypertension

Peripheral vascular diseasePeripheral vascular disease Delayed healingDelayed healing

Visual defects, including blindnessVisual defects, including blindness Renal diseaseRenal disease InfectionInfection NeuropathiesNeuropathies ImpotenceImpotence

Oral Hypoglycemics

Sulfonylureas (oldest)Sulfonylureas (oldest)

MeglitinidesMeglitinides

BiguanideBiguanide

ThiazolidinedionesThiazolidinediones

Indications for Oral Hypoglycemics

They are used to lower blood They are used to lower blood sugar levels in patients that diet sugar levels in patients that diet and exercise have failed.and exercise have failed.

The patient must have some The patient must have some pancreatic function left.pancreatic function left.

They can be used as a They can be used as a monotherapy or in conjunction monotherapy or in conjunction with other oral hypoglycemics.with other oral hypoglycemics.

Contraindications

Know drug allergyKnow drug allergy Active hypoglycemiaActive hypoglycemia Usually not used during pregnancy Usually not used during pregnancy

subq insulin's are used then.subq insulin's are used then. Liver diseaseLiver disease Kidney diseaseKidney disease

Depending on the metabolic Depending on the metabolic pathways of the medicationpathways of the medication

Sulfonylureas

First generationFirst generation: :

chlorpropamide (Diabinese), chlorpropamide (Diabinese), tolazamide (Tolinase)tolazamide (Tolinase) tolbutamide (Orinase)tolbutamide (Orinase)

Second generationSecond generation: :

glimepiride (Amaryl) glimepiride (Amaryl) glipizide (Glucotrol)glipizide (Glucotrol) glyburide (DiaBeta, Micronase)glyburide (DiaBeta, Micronase)

Sulfonylureas Stimulate insulin secretiStimulate insulin secretion from the beta on from the beta

cells of the pancreas, thus increasing insulin cells of the pancreas, thus increasing insulin levelslevels

BetaBeta cell function must be present cell function must be present

Improve sensitivity to insulin in tissuesImprove sensitivity to insulin in tissues

Result: lower blood glucose levelsResult: lower blood glucose levels

First-generation drugs not used as frequently First-generation drugs not used as frequently nownow

Adverse Effects

SulfonylureasSulfonylureas

HypoglycemiaHypoglycemia hematologic effectshematologic effects nauseanausea epigastric fullnessepigastric fullness heartburnheartburn many othersmany others

Interactions SulfonylureasSulfonylureas

Hypoglycemic effect increases when taken with alcohol, Hypoglycemic effect increases when taken with alcohol, anabolic steroids, many other drugsanabolic steroids, many other drugs

Adrenergics (beta blockers) may mask many of the Adrenergics (beta blockers) may mask many of the symptoms of hypoglycemiasymptoms of hypoglycemia

Hyperglycemia: corticosteroids, phenothiazines, Hyperglycemia: corticosteroids, phenothiazines, diuretics, oral contraceptives, thyroid replacement diuretics, oral contraceptives, thyroid replacement hormones, phenytoin, diazoxide and lithium.hormones, phenytoin, diazoxide and lithium.

Allergic cross-sensitivity Allergic cross-sensitivity may occur with loop may occur with loop diuretics and diuretics and sulfonamide antibioticssulfonamide antibiotics

May May interact with alcohol/OTC medication interact with alcohol/OTC medication containing alcohol) - containing alcohol) - causing a disulfiram (Antabuse) -causing a disulfiram (Antabuse) -type reaction (facial flushing, pounding headache, feeling type reaction (facial flushing, pounding headache, feeling of breathlessness, and nausea) of breathlessness, and nausea)

Meglitinides

MeglitinidesMeglitinides repaglinide (Prandin)repaglinide (Prandin) nateglinide (Starlix)nateglinide (Starlix)

MeglitinidesMeglitinides Action similar to sulfonylureasAction similar to sulfonylureas Increase insulin secretion from the Increase insulin secretion from the

pancreaspancreas

Adverse Effects

MeglitinidesMeglitinides

HeadacheHeadache hypoglycemic effectshypoglycemic effects DizzinessDizziness weight gainweight gain joint painjoint pain upper respiratory infection or flu-like upper respiratory infection or flu-like

symptomssymptoms

Biguanides BiguanidesBiguanides

metformin (Glucophage) metformin (Glucophage)

BiguanidesBiguanides Decrease production of glucoseDecrease production of glucose

Increase uptake of glucose by tissuesIncrease uptake of glucose by tissues

Does not increase insulin secretion Does not increase insulin secretion from the pancreas (does not cause from the pancreas (does not cause hypoglycemia)hypoglycemia)

Adverse Effects MetforminMetformin

Primarily affects GI tract: Primarily affects GI tract: abdominal abdominal bloating, nausea, cramping, diarrhea, bloating, nausea, cramping, diarrhea, feeling of fullnessfeeling of fullness

May also cause metallic taste, reduced vitamin May also cause metallic taste, reduced vitamin BB1212 levels levels

Lactic acidosis is rare but lethal if it occursLactic acidosis is rare but lethal if it occurs

Does not cause hypoglycemiaDoes not cause hypoglycemia

Thiazolidinediones ThiazolidinedionesThiazolidinediones

pioglitazone (Actos),pioglitazone (Actos), rosiglitazone (Avandia)rosiglitazone (Avandia) Also known as “glitazones”Also known as “glitazones”

ThiazolidinedionesThiazolidinediones Decrease insulin resistance Decrease insulin resistance ““Insulin sensitizing drugs”Insulin sensitizing drugs” Increase glucose uptake and use in Increase glucose uptake and use in

skeletal muscleskeletal muscle Inhibit glucose and triglyceride production in Inhibit glucose and triglyceride production in

the liverthe liver

Adverse Effects

ThiazolidinedionesThiazolidinediones

Moderate weight gainModerate weight gain Edema Edema Mild anemia Mild anemia Hepatic toxicityHepatic toxicity—monitor liver —monitor liver

function testsfunction tests

Alpha-glucosidase Inhibitors

Alpha-glucosidase inhibitorsAlpha-glucosidase inhibitors acarbose (Precose)acarbose (Precose) miglitol (Glysetmiglitol (Glyset))

Alpha-glucosidase inhibitorsAlpha-glucosidase inhibitors Reversibly inhibit the enzyme alpha-Reversibly inhibit the enzyme alpha-

glucosidase in the glucosidase in the small intestinesmall intestine Result: Result: delayed absorption of glucosedelayed absorption of glucose Must be taken with meMust be taken with meals to prevent als to prevent

excessive postprandial blood glucose excessive postprandial blood glucose elevations (with the “first bite” of a meal)elevations (with the “first bite” of a meal)

Adverse Effects

α-glucosidase inhibitorsα-glucosidase inhibitors

FlatulenceFlatulence diarrheadiarrhea abdominal painabdominal pain

Do not cause hypoglycemia, Do not cause hypoglycemia, hyperinsulinemia, or weight gainhyperinsulinemia, or weight gain

Insulins Mechanism of ActionMechanism of Action SubstituteSubstitute for & for & same effects same effects as as endogenous insulinendogenous insulin

Restores the diabetic Restores the diabetic patient’s ability patient’s ability to: to: Metabolize carbohydrates, fats, and proteinsMetabolize carbohydrates, fats, and proteins Store glucose Store glucose in the liverin the liver Convert glycogen Convert glycogen to fat storesto fat stores

Some derived from porcine sourcesSome derived from porcine sources

Most now human-derivedMost now human-derived, using recombinant DNA , using recombinant DNA technologiestechnologies

Goal: tight glucose control Goal: tight glucose control

To To reduce the incidence of long-term complicationsreduce the incidence of long-term complications

Indications

To treat both types of diabetesTo treat both types of diabetes

Each patient requires careful Each patient requires careful customization of the dosing customization of the dosing regimen for optimal glycemic regimen for optimal glycemic controlcontrol

Contraindications

Anyone who is hypoglycemic?????Anyone who is hypoglycemic?????

Adverse Effects

Are all signs and symptoms of Are all signs and symptoms of hypoglycemia including shock and hypoglycemia including shock and death.death.

Human-Based Insulins

Rapid-ActingRapid-Acting Most rapid onset of actionMost rapid onset of action Shorter durationShorter duration

May be given SC or via continuous SC May be given SC or via continuous SC infusioninfusionpump (but not IV)pump (but not IV)

Insulin Onset (mins)

Peak (hrs) Duration (hrs)

aspart (Novolog) 2-33 1-3 3-5

lispro (Humalog) 2-33 30mins – 2.5 3-6.5

glulisine (Apidra) 2-33 30mins – 1.5 1.-25


Short-ActingShort-Acting regular insulin (regular insulin (Humulin R, Novolin R)Humulin R, Novolin R)

Onset 30 – 60 minutesOnset 30 – 60 minutes The only insulin product that can be The only insulin product that can be

given by IV bolus, IV infusion, or even IMgiven by IV bolus, IV infusion, or even IM

Insulin Onset (mins) Peak (hrs)

Duration (hrs)

Humulin R 30 mins to 4 hrs 2.5-5 5-10

Novolin R 30 2.5-5 8

Sliding-Scale Insulin Dosing

SC rapid or short-acting SC rapid or short-acting doses adjusted doses adjusted according to blood glucose test resultsaccording to blood glucose test results

Typically Typically used in hospitalized diabetic used in hospitalized diabetic patientspatients Or in Or in patients on TPN /patients on TPN / enteral enteral tube feedings tube feedings or or

receiving receiving steroidssteroids

Subcutaneous insulin is Subcutaneous insulin is ordered in an ordered in an amount that increases as the blood amount that increases as the blood glucose increasesglucose increases


Intermediate-ActingIntermediate-Acting isophane insulin suspension (isophane insulin suspension (also called NPH) also called NPH) (Humulin N, (Humulin N,

Novolin N)Novolin N)

isophane insulin suspension & insulin injectionisophane insulin suspension & insulin injection

(Humulin 50/50 , (Humulin 50/50 , Humulin 70/30, Novolin 70-30)Humulin 70/30, Novolin 70-30)

Lispro protamine suspension (Lispro protamine suspension (Humalog 75/25Humalog 75/25, Novolog Mix , Novolog Mix 70/30)70/30)

insulin zinc suspension (insulin zinc suspension (LenteLente, Novolin L), Novolin L)

CloudyCloudy appearance appearance Slower in onset and more prolonged duration than Slower in onset and more prolonged duration than

endogenous insulinendogenous insulin

Human-Based Insulins Intermediate-Acting

Insulin Onset (hrs)


Isophane (NPH):

Humulin N 1-4 4-12 16-28

Novolin N 1-5 4-12 24

Isophane & Insulin:

Humulin 50/50 0.5 4-8 24

Humulin 70/30 0.5 4-12 24

Novolin70/30 0.5 2-12 24

Human-Based Insulins Intermediate-Acting

Insulin Onset (hrs)


lispro protamine & lispro:

Humalog Mix 75/25 0.25-0.5 0.5-1.5 12-24

Novolog Mix 70/30 0.2-0.33 2.4 24

Insulin Zinc Suspension:

Lente Iletin II 1-1.5 8-12 24

Novolin L 1-4 7-15 20-28

Human-Based Insulins Combination Insulin ProductsCombination Insulin Products

NPH 70% and regular insulin 30% NPH 70% and regular insulin 30% (Humulin 70/30, (Humulin 70/30, Novolin 70/30)Novolin 70/30)

NPH 50% and regular insulin 50% NPH 50% and regular insulin 50% (Humulin 50/50)(Humulin 50/50)

insulin lispro protamine suspension 75% insulin lispro protamine suspension 75% and insulin lispro 25% (and insulin lispro 25% (Humalog Mix Humalog Mix 75/25)75/25)

Human-Based InsulinsLong-Acting

Insulin Onset Peak Duration

glargine (Lantus 1 No peak activity

24 (when administered at hs)

detemir (Levemir) 1 6-8 6-28

DM Monitoring – Daily AC & HS

Ante CibumAnte Cibum: before meals: before meals

HSHS: Hour of Sleep: prior to taking any HS snack: Hour of Sleep: prior to taking any HS snack

Rapid or short acting insulin used to cover any blood Rapid or short acting insulin used to cover any blood sugar (accucheck, chemstrip) sugar (accucheck, chemstrip) Dose by Dose by protocolprotocol (protocols are usually hospital- (protocols are usually hospital-

based)based)

for any result greater than 150mg/dL for any result greater than 150mg/dL Usually 1-2U for every 50mg/dL >150 with special Usually 1-2U for every 50mg/dL >150 with special

instructions to notify physician if >300 mg/dLinstructions to notify physician if >300 mg/dL

Injection Sites

Insulin PumpsExternal Internal

HypoglycemiaAdverse Effect of Insulin

EarlyEarly◦ Confusion, irritability, tremor, sweatingConfusion, irritability, tremor, sweating

LaterLater◦ Hypothermia, seizuresHypothermia, seizures◦ Coma and death will occur if not treatedComa and death will occur if not treated

Abnormally low blood glucose levelAbnormally low blood glucose level (<50 mg/dL(<50 mg/dL))

Mild cases Mild cases can be treated with diet—higher intake can be treated with diet—higher intake of protein and lower intake of carbs—to prevent a of protein and lower intake of carbs—to prevent a rebound postprandial hypoglycemiarebound postprandial hypoglycemia

Good way to remember!!!

State of hyperglycemia State of hyperglycemia with with ketosisketosis Usually results from infection, environment, or emotional Usually results from infection, environment, or emotional

stressorstressor As a result of Lack of Insulin, Breakdown:As a result of Lack of Insulin, Breakdown:

Fat – free fatty acids in liver – ketone bodies – Fat – free fatty acids in liver – ketone bodies – ketones in urineketones in urine

Protein – to form new glucose / increased BUNProtein – to form new glucose / increased BUN Glycogen to glucose (decrease use of glucose Glycogen to glucose (decrease use of glucose

because of decreased insulin)because of decreased insulin) Osmotic diuresisOsmotic diuresis Dehydration / Electrolyte ImbalanceDehydration / Electrolyte Imbalance Hyperosmolality HemoconcentrationHyperosmolality Hemoconcentration AcidosisAcidosis DeathDeath

Diabetic Ketoacidosis

Sudden onsetSudden onset Factors: infection, stressors, inadequate insulinFactors: infection, stressors, inadequate insulin Kussmaul respiration / fruity odor to breath, nausea, Kussmaul respiration / fruity odor to breath, nausea,

abdominal painabdominal pain Dehydration, electrolyte imbalance, polyuria, polydipsia, Dehydration, electrolyte imbalance, polyuria, polydipsia,

weight loss, dry skin, sunken eyes, soft eyeballs, lethargy, weight loss, dry skin, sunken eyes, soft eyeballs, lethargy, comacoma

Glucose >300 mg/dLGlucose >300 mg/dL pH <7.35 / Bicarbonate < 15 mEq/LpH <7.35 / Bicarbonate < 15 mEq/L

Na – low / K+ </> / Na – low / K+ </> / Cr >1.5 mg/dLCr >1.5 mg/dL Blood & Urine Ketones - PositiveBlood & Urine Ketones - Positive

Diabetic Ketoacidosis

State of hyperglycemia State of hyperglycemia without without ketosisketosis Little breakdown of fat (little or no ketone Little breakdown of fat (little or no ketone

bodies)bodies) Breakdown Breakdown

Glycogen– formation of new glucose – Glycogen– formation of new glucose – hyperglycemiahyperglycemia Very high levels of glucose >800mg dLVery high levels of glucose >800mg dL

Osmotic diuresis – extracellular dehydrationOsmotic diuresis – extracellular dehydration Renal insufficiency – hyperosmolality – Renal insufficiency – hyperosmolality –

intracellular dehydrationintracellular dehydration Hypokalemia – shock – tissue hypoxia - ComaHypokalemia – shock – tissue hypoxia - Coma

Hyperglycemic-hyperosmolar nonketotic syndrome (HHNS)

Gradual onsetGradual onset Factors: infection, other stressors, poor fluid intakeFactors: infection, other stressors, poor fluid intake Altered CNS function – neurologic symptomsAltered CNS function – neurologic symptoms Dehydration / electrolyte lossDehydration / electrolyte loss Glucose > 800 mg/dLGlucose > 800 mg/dL pH >7.4 / Bicarbonate >20 mEq/LpH >7.4 / Bicarbonate >20 mEq/L Na & K+ normal or lowNa & K+ normal or low Bun & Cr – elevatedBun & Cr – elevated Blood & Urine Ketones - negativeBlood & Urine Ketones - negative

Hyperglycemic-hyperosmolar nonketotic syndrome (HHNS)

TreatmentTreatment Rehydrate with NS (if severe) or ½ NSRehydrate with NS (if severe) or ½ NS

Use CVP or PCWP / UO / blood pressure monitoringUse CVP or PCWP / UO / blood pressure monitoring

IV insulin According to Sliding ScaleIV insulin According to Sliding Scale Never Reduce hyperglycemia by 10% /hrNever Reduce hyperglycemia by 10% /hr

Replace Potassium (will not be as severe as Replace Potassium (will not be as severe as DKA)DKA)

Hyperglycemic-hyperosmolar nonketotic syndrome (HHNS

Antidiabetic Drugs:Nursing Implications

Before giving any drugs that alter Before giving any drugs that alter glucose levels, obtain and glucose levels, obtain and document:document:

A thorough historyA thorough history Vital signsVital signs Blood glucose levelBlood glucose level, HbA1c level, HbA1c level Potential complications and drug Potential complications and drug

interactionsinteractions


Before giving any drugs that alter glucose levels:Before giving any drugs that alter glucose levels:

Assess the patient’s ability to consume foodAssess the patient’s ability to consume food

Assess blood glucose levelAssess blood glucose level

Assess for nausea or vomitingAssess for nausea or vomiting

Hypoglycemia may be a problem if antidiabetic drugs are Hypoglycemia may be a problem if antidiabetic drugs are given and the patient does not eatgiven and the patient does not eat

If a patient is NPO for a test or procedure, consult physician to If a patient is NPO for a test or procedure, consult physician to clarify orders for antidiabetic drug therapyclarify orders for antidiabetic drug therapy


Keep in mind that overall concerns for any Keep in mind that overall concerns for any diabetic patient increase when the patient:diabetic patient increase when the patient:

Is under stressIs under stress

Has an infectionHas an infection

Has an illness or traumaHas an illness or trauma

Is pregnant or lactatingIs pregnant or lactating

Antidiabetic Drugs:Patient Education

Thorough patient education is essential regarding:Thorough patient education is essential regarding:◦ Disease processDisease process◦ Other Risk Factors:Other Risk Factors:

SmokingSmoking HTNHTN CADCAD

◦ Self-Care:Self-Care: MedicationMedication Psychological adjustmentPsychological adjustment NutritionNutrition Activity and ExerciseActivity and Exercise Blood-glucose testingBlood-glucose testing Self-administration of insulin or oral drugsSelf-administration of insulin or oral drugs

◦ Potential complicationsPotential complications How to recognize and treat hypoglycemia and hyperglycemiaHow to recognize and treat hypoglycemia and hyperglycemia

FIGURE 36-3 Diabetes health care plan.

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing ImplicationsInsulin

When insulin is ordered, ensure:When insulin is ordered, ensure:◦ Correct routeCorrect route◦ Correct type of insulinCorrect type of insulin◦ Timing of the doseTiming of the dose◦ Correct dosageCorrect dosage

Insulin order and prepared dosages are Insulin order and prepared dosages are second-checked with another nursesecond-checked with another nurse◦ Check blood glucose level before giving insulinCheck blood glucose level before giving insulin◦ Roll vials between hands them to mix suspensions – no shaking!Roll vials between hands them to mix suspensions – no shaking!◦ Ensure correct storage of insulin vialsEnsure correct storage of insulin vials◦ ONLY insulin syringes, calibrated in units, to administer insulinONLY insulin syringes, calibrated in units, to administer insulin◦ Ensure correct timing of insulin dose with mealsEnsure correct timing of insulin dose with meals

Nursing ImplicationsInsulin

InsulinInsulin

When drawing up two types of insulin in one syringe:When drawing up two types of insulin in one syringe: Always Always withdraw the regular or rapid-acting insulin withdraw the regular or rapid-acting insulin

firstfirst

Provide Provide thorough patient education thorough patient education regarding regarding self-administration of insulin injections, including self-administration of insulin injections, including timing of doses, monitoring blood glucoses, and timing of doses, monitoring blood glucoses, and injection site rotationsinjection site rotations

Nursing Implications Oral Antidiabetic drugs

Always check blood glucose levels before givingAlways check blood glucose levels before giving

Usually given 30 minutes before mealsUsually given 30 minutes before meals Administer the medication at exact time – Administer the medication at exact time –

with meal or when food is in sight*with meal or when food is in sight*

AlphaAlpha-glucosidase inhibitors are given with the first -glucosidase inhibitors are given with the first bite of each main mealbite of each main meal

Metformin is taken with meals to reduce GI effectsMetformin is taken with meals to reduce GI effects

Nursing ImplicationsInsulin & hypoglycemic

medications Assess for signs of hypoglycemiaAssess for signs of hypoglycemia If hypoglycemia occurs:If hypoglycemia occurs:

Give glucagon orGive glucagon or Have the patient eat glucose tablets Have the patient eat glucose tablets

or gel, corn syrup, honey, fruit juice, or gel, corn syrup, honey, fruit juice, or nondiet soft drink oror nondiet soft drink or

Have the patient eat a small Have the patient eat a small snack such as crackers or half a snack such as crackers or half a sandwichsandwich

Monitor blood glucose levelsMonitor blood glucose levels

Nursing Implications Monitor for therapeutic responseMonitor for therapeutic response

Decrease in blood glucose levels to the Decrease in blood glucose levels to the level prescribed by physicianlevel prescribed by physician

Measure hemoglobin A1c to monitor long-Measure hemoglobin A1c to monitor long-term compliance to diet and drug therapyterm compliance to diet and drug therapy

Watch for hypoglycemia and hyperglycemiaWatch for hypoglycemia and hyperglycemia

Review

When administering insulin, the nurse When administering insulin, the nurse must keep in mind that the most must keep in mind that the most immediate and serious adverse effect of immediate and serious adverse effect of insulin therapy is which of the following?insulin therapy is which of the following? A: HyperglycemiaA: Hyperglycemia B: HypoglycemiaB: Hypoglycemia C: BradycardiaC: Bradycardia D: Orthostatic HypotensionD: Orthostatic Hypotension

Review

A dose of long acting insulin has been A dose of long acting insulin has been ordered for bedtime for a diabetic ordered for bedtime for a diabetic patient. The nurse expects to give which patient. The nurse expects to give which type of insulin?type of insulin? A: RegularA: Regular B: LenteB: Lente C: NPHC: NPH D: Glargine (Lantus)D: Glargine (Lantus)

Review

A Patient is to be placed on an insulin drip A Patient is to be placed on an insulin drip to control his high blood glucose levels. to control his high blood glucose levels. The nurse knows that which of the The nurse knows that which of the following is the only type of insulin that following is the only type of insulin that can be given IV?can be given IV? A: RegularA: Regular B: LenteB: Lente C: NPHC: NPH D: UltralenteD: Ultralente

Review

While monitoring a patient who is While monitoring a patient who is receiving insulin therapy, the nurse receiving insulin therapy, the nurse observes for signs of hypoglycemia, such observes for signs of hypoglycemia, such as which of the following?as which of the following? A: Decreased pulse and respiratory rate and A: Decreased pulse and respiratory rate and

flush skin.flush skin. B: Increased pulse rate and a fruity, acetone B: Increased pulse rate and a fruity, acetone

breath odor.breath odor. C: Weakness, sweating, and confusion.C: Weakness, sweating, and confusion. D: Increased urine output and edema.D: Increased urine output and edema.

Review

When giving oral acarbose When giving oral acarbose (Precose), the nurse should (Precose), the nurse should administer it at what time?administer it at what time? A: 15 minutes before mealA: 15 minutes before meal B: 30 minutes before mealB: 30 minutes before meal C: with the first bite of a mealC: with the first bite of a meal D: 1 hour after eatingD: 1 hour after eating

Review

A patient taking rosiglitazone (Avandia) A patient taking rosiglitazone (Avandia) tells the nurse, “There’s my insulin pill!” tells the nurse, “There’s my insulin pill!” The nurse describes the mechanism of The nurse describes the mechanism of action of Avandia by explaining that this action of Avandia by explaining that this drug is not insulin but it works by:drug is not insulin but it works by: A: Stimulating the beta cells of the pancreas A: Stimulating the beta cells of the pancreas

to produce insulin.to produce insulin. B: Decreasing insulin production.B: Decreasing insulin production. C: Inhibiting hepatic glucose production.C: Inhibiting hepatic glucose production. D: Decreasing intestinal absorption of glucose.D: Decreasing intestinal absorption of glucose.

antidiabetic medications & the nursing process karen ruffin rn, msn ed

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