n rv 51 diabetes mellitus

7/29/2019 n Rv 51 Diabetes Mellitus

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NRV 51 Diabetes MellitusNRV 51 Diabetes Mellitus

Iclicker QuestionIclicker QuestionDiabetes mellitus occurs when either the body becomes resistant to insulin or this organ does not

make enough insulin:*Pituitary*Pancreas*Spleen

Iclicker QuestionIclicker QuestionThe human body requires which of the following to metabolize glucose?

*Pancrease*Gastrin* Lipase* Insulin

Review of Anatomy & Physiology of the PancreasReview of Anatomy & Physiology of the Pancreas*MS page 873 & 875 877 & 878

Pancreatic SecretionsPancreatic Secretions*Acini digestive enzymes*Islets Insulin & Glucagon*Duct Bicarbonate

Actions of Insulin to Control Glucose LevelsActions of Insulin to Control Glucose Levels*Major stimulus for synthesis and secretion of insulin is elevated BG.*Insulin increases cell membranes permeability to glucose. After it is in the cell, glucose is used

in cellular respiration to produce energy.*Insulin stimulates the liver to convert extra glucose into glycogen (glycogenesis), and helps the

liver and muscles to store glycogen. Glycogen is stored as body sugar, commonly referredto as animal starch.

*Insulin increases the transfer of amino acids across muscle membranes for synthesis intoproteins.

*Insulin speed fatty acid synthesis (lipogenesis) for fat storage.*Insulin slowsglycogenolysis (glycogen breakdown) andgluconeogenesis (formation of glucose

from non-carbohydrate sources).

InsulinInsulin*MS page 876 877 & 878

Blood glucose regulationBlood glucose regulation* BG insulin secretion glucose into cells

Effects of Aging on PancreasEffects of Aging on Pancreas*MS page 876


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Diabetes MellitusDiabetes Mellitus*American Diabetes Association (ADA) Definition:*A group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin

secretion, insulin action, or both. The chronic hyperglycemia of diabetes is associated with

long-term damage, dysfunction, and failure of various organs, especially the eyes, kidneys,

nerves, heart and blood vessels.

*Malfunction of beta cells of pancreas.

Hyperglycemia results from Defects in:Hyperglycemia results from Defects in:*Insulin secretion or*Insulin action or*Both

Incidence of DMIncidence of DM*7 % of population in US*21 million known cases of DM in US*6 million do not know have Diabetes Mellitus in US*No age group exempt*90 95% of known cases are adults*6th leading cause of death in US*Big cost to health care system no cure for DM*Major reason for hospitalization, surgery and community health care*Dialysis Centers DM leading Dx along with HTN

TermsTerms*Family Practice Doctor MD*Internist (Internal Medicine) MD*Endocrinologist - MD*Diabetologist - MD*Certified Diabetic Educator (CDE) - RN*Hyperglycemia*Hypoglycemia

Factors Affecting Blood SugarFactors Affecting Blood Sugar*Raises Hyperglycemia

*Food*Stress*Growth*Medications

*Thiazide Diuretics*Furosemide (Lasix)*Prednisone*BCP*Phenytoin (Dilantin)

*Menstrual Cycle*Lowers Hypoglycemia

*Insulin*Oral Diabetic Agents*Exercise*Alcohol


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Risk Factors for DMRisk Factors for DM*Diet*Obesity*Lack of exercise*Heredity - genetics*Age*Stress emotional or physical*Race MS page 910*Pregnancy

*Recent Infection mumps or coxsackie virus*Autoimmune reaction

AHA Metabolic Syndrome Risk for CV DiseaseAHA Metabolic Syndrome Risk for CV Disease*3 or more risk factors present*MS page 410 Box 17-1 & pages 930 931 & ____

Types of DMTypes of DM*MS page 910*Type 1*Type 2*Pre-Diabetes or Impaired glucose tolerance*Gestational Diabetes*Statistical Risk of Diabetes

Type 1 Diabetes MellitusType 1 Diabetes Mellitus*Formerly known as Insulin Dependent DM IDDM and Juvenile Diabetes or Juvenile-Onset*Bodys immune system destroys beta cells*5 - 10% of all DM cases*More likely to appear early in life*Hereditary*Virus & Environment*Nick Jonas Type 1 Diabetic -

http://www.zimbio.com/pictures/Mu6wvxGVFZy/Nick+Jonas+Discusses+Juvenile+Diabetes+National/4g6iXLaji88/Nick+Jonas

Type 1 Diabetes MellitusType 1 Diabetes Mellitus*Autoimmune*Must take insulin for rest of life*Prone to Ketosis and Diabetic Ketoacidosis (DKA)*Developmental issues may complicate self-care

Classic symptoms of Type 1 DMClassic symptoms of Type 1 DM*MS page 910*3 Polys

*Polydipsia*Polyuria*Polyphagia

*Weight loss

Other S/SOther S/S*Fatigue & weakness*Irritability*N/V*Infections

Type 2 Diabetes MellitusType 2 Diabetes Mellitus


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*Formerly known as Non-Insulin Dependent DM NIDDM and Adult-Onset or Maturity-OnsetDiabetes

*Begins with insulin resistance body can not use insulin*90-95% of all known cases of DM*Obesity, Sedentary Lifestyle, Age, Ethnicity, Heredity*Not prone to Diabetic Ketoacidosis (DKA)

Type 2 PrevalenceType 2 Prevalence*Generally develops later in life, but in children due to obesity

*Greater incidence*Native Americans*Hispanic*African Americans*Asian Americans including Pacific Islanders

*Nell Carter ofGive Me a Breakdies at age 54 of CHD complicated by her Type 2 DM -http://images.search.yahoo.com/images/view?back=http%3A%2F%2Fimages.search.yahoo.com%2Fsearch%2Fimages%3Fp%3Dcelebrites%2Bwith%2Btype%2B2%2Bdiabetes%26b%3D43%26ni%3D21%26ei%3Dutf-8%26y%3DSearch%26xargs%3D0%26pstart%3D1%26fr%3Dyfp-t-701-s&w=265&h=400&imgurl=cdn.blisstree.com%2Ffiles%2F2010%2F09%2F1741848-

265x400.jpg&rurl=http%3A%2F%2Fblisstree.com%2Flive%2F5-celebrities-who-died-too-young-and-overweight-yes-a-few-also-used-drugs%2Fgallery-page%2F1%2F&size=27KB&name=...+by+type+2+di...&p=celebrites+with+type+2+diabetes&oid=b7de1bae3e577c493245f8486eae3f26&fr2=&spell_query=celebrities+with+type+2+diabetes&no=62&tt=649&b=43&ni=21&sigr=13jjj83ee&sigi=11jvfbr6f&sigb=14bmm2pn5#FCar=b7de1bae3e577c493245f8486eae3f26

Type 2 Diabetes MellitusType 2 Diabetes Mellitus*Hyperlipidemia is often present*Hypertension is often present

*Weight loss and exercise will improve control of blood sugar, blood pressure, and lipid profile*Oral hypoglycemia agents (OHAs) often effective*May have to take insulin

Comparison of Type 1 vs.. Type 2Comparison of Type 1 vs.. Type 2*MS page 910

Pre-Diabetes or Impaired Glucose TolerancePre-Diabetes or Impaired Glucose Tolerance*MS page 910 & LAB pages ____*Blood glucose > normal, but < criteria for diagnosis of DM*FBS > 110, but < 126 mg/dL*OGTT > 140, but < 200 mg/dL after 2 hours*Risk for developing Type 2 DM, ASHD and CV Diseases.*Weight loss and physical activity can prevent DM

Gestational DiabetesGestational Diabetes*MS page 910*2 - 3rd trimester of pregnancy*Disappears after pregnancy*20 - 50% chance Type 2 DM within 5 10 years
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Iclicker QuestionIclicker QuestionType 1 Diabetes Mellitus is also known as:

*NIDDM*IDDM*Impaired glucose tolerance*Gestational DM

Iclicker QuestionIclicker Question

Type 2 Diabetes Mellitus is also known as:*NIDDM*IDDM*Impaired glucose tolerance*Gestational DM

Iclicker QuestionIclicker QuestionClassic symptoms of Type 1 Diabetes Mellitus include: (Select all that apply.)

*Polyuria*Polydipsia*Polyphagia*Polyphasia

Iclicker QuestionIclicker QuestionOther symptoms of Diabetes Mellitus Type 1 and Type 2 include(s): (Select all that apply.)

*Weight gain or loss*Fatigue*Blurred vision*Infections

Diagnostic Blood Tests forDiagnostic Blood Tests for DiagnosisDiagnosis of DMof DM

*MS page 882 and LAB page _____*Fasting Blood Sugar/Glucose (FBS)*2 Hour Post-Prandial Blood Sugar/Glucose (2-Hour PPG)*Oral Glucose Tolerance Test (OGTT)

Diagnostic Tests toDiagnostic Tests to MonitorMonitor DMDM*Blood

*Glycosylated Hemoglobin (HbA1C)*Fructosamine Assay

*Urine*Urine for Ketone Bodies*Urine for Microalbumin (MA)

Venous Blood (Serum)Venous Blood (Serum)*Fasting Blood Sugar (FBS)

* MS page 882 & LAB page _____*aka Fasting Plasma Glucose (FPG)*Normal = 70 110 (or 115 mg/dL MS text)


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*Fast for 8 hours before test*Elderly - after age 50

*1 mg per decade of age*Random (Casual) blood glucose

*Normal < 200 mg/dL*Anytime of day

Fingerstick Blood Glucose/SugarFingerstick Blood Glucose/Sugar*FSBS or FSBG

*Normal = 70 110 or 115 mg/dL*DM Pre-diabetic = > 110, but < 126 mg/dL

Two hour Post Prandial (2-Hour PPG)Two hour Post Prandial (2-Hour PPG)*MS page 882 or LAB page _____*Blood sample taken 2 hours after high (75 Grams) CHO meal then nothing else till blood drawn*Usually FBS done before meal

Normally in non-diabetics blood glucose returns to normal level 2 hours after a meal.Diabetics does not return to normal in two hours.

*Normal = < 126 (MS) or < 140 (LAB) mg/dL*MS - Elderly 5 10 mg/dL with age*LAB

* 50 60 y/o = < 150 mg/dL*60 + = 200 mg/dL at 2 hours

*Gestational DM LAB page 277

Diabetes is Diagnosed whenDiabetes is Diagnosed when*MS page 881 and LAB page ____*Any one/two of these:

*Clinical symptoms three polys plus random (casual) FBS 200 mg/dL* FBS of > 126 mg/dL on > one occassion*OGTT > 200 mg/dL after 2 hours of 75 Grams of glucose

Glycosylated Hemoglobin (HbAGlycosylated Hemoglobin (HbA1c1c))*MS page 882 & LAB page ____*Used to monitor DM and determine if client in control & following medical regimen in past 2 -3

months (span of RBC)*Attached to Hemoglobin so cant lie!*No fasting*Test done periodically*Normal = 3.9/4 5.2/5.9 % range*Goal - DM < 7 % (150 mg/dL of glucose)*Control MS page 882


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Fructosamine AssayFructosamine Assay*MS page 882*Used to monitor DM and determine if client in control & following medical regimen in past 2 -3

weeks*Sugar attached to albumin - shorter time frame*Fasting not necessary*Less influenced by age than HbA1c

Urine for KetonesUrine for Ketones

*MS page 882 and LAB page ____*Part of Urinalysis*Also part of Urine for S&A or Keto-Diastix*Check when FSBS is > 240 mg/dL = DKA*Looking for ketones (acetone) = ketonuria*Fresh urine sample

Urine for Microalbumin (MA)Urine for Microalbumin (MA)*Indicator of complications of DM Kidneys, heart, small blood vessels)*First indicator of renal disease*For Diabetic - early indicator of nephropathy, CVD, HTN, retinopathy & end-stage renal

disease

*Recommended all diabetics > 12 y/o yearly microalbumin urine test*Normal = < 2 mg/dL*Calculated with creatinine levels due to hydration status effect LAB page ___

Iclicker QuestionIclicker QuestionThe normal fasting blood sugar (FBS) is:

*70 110 mg/dL*120 200 mg/dL*220 240 mg/dL*300 400 mg/dL

Iclicker QuestionIclicker QuestionWith an Oral Glucose Tolerance Test, it is expected that the blood glucose level would return to a

normal (fasting level) in what time period after the ingestion of an oral glucose solution?

*2 hours*3 hours*4 hours*5 hours

Iclicker QuestionIclicker QuestionWith a diabetic client, a urine for ketones (acetone) test should be done when the blood glucose

level is consistently above:*120*180*210*240


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Iclicker QuestionIclicker QuestionA male client who was recently diagnosed with diabetes mellitus visits his physician for a follow-

up exam. His physician wants to assess how he is adjusting to his new diet and medicationuse. The laboratory study his doctor would order to reflect the patients average bloodglucose level over the past two months is called a(an):

*Fasting Blood Sugar (FBS)*Oral Glucose Tolerance Test (OGTT)* Glycosylated Hemoglobin (HbA1c)

*2 hour Postprandial Blood Glucose (2 Hr PP)

Complications of DiabetesComplications of DiabetesAcute Metabolic ComplicationsAcute Metabolic Complications

*Hyperglycemia*Hypoglycemia

Hyperglycemia CausesHyperglycemia Causes*Too little insulin or diabetes medication*Too much carbohydrate*Illness, especially infection*Stress

*Meds steroids, diuretics, etc.S/S HyperglycemiaS/S Hyperglycemia

*Glycosuria*Polyuria*Anorexia, nausea, vomiting [may be hungry 1st]*Headache, vision changes double vision*Flushed, dry skin*Altered level of consciousness [ALOC]

Treatment of HyperglycemiaTreatment of Hyperglycemia*Type 1 Insulin

*Type 2 Diet & exercise, if necessary OHAs*What to do when traveling MS page 928

Diabetic Ketoacidosis (DKA)Diabetic Ketoacidosis (DKA)*Complication of hyperglycemia*Severe, hard to control diabetics - brittle*Or undiagnosed stress, infection or noncompliance*S & S - MS page 926

*Kussmauls RespirationsKussmauls Respirationshttp://coursewareobjects.elsevier.com/objects/elr/Potter/fundamentals7e/animations/flahttp://coursewareobjects.elsevier.com/objects/elr/Potter/fundamentals7e/animations/flashpage.html?swf=seidel5e_v1/ch12/anim/12-14.swfshpage.html?swf=seidel5e_v1/ch12/anim/12-14.swf

*BS > 240 mg/dL*Glycosuria

*Ketonuria

DKA TreatmentDKA Treatment*Reduce blood glucose

*IV insulin regular RN or MD*Correct fluid & electrolyte imbalance

*IV fluid & IV Potassium
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*Clear urine & blood of ketones*IV glucose, IV potassium

DKA Nursing CareDKA Nursing Care*VS*Monitor IV fluids*I&O* electrolytes*Cardiac monitor arrhythmias

*Monitor blood sugars* Urine for ketones*Teach prevention MS page 926*What to do on Sick Days- MS page 927

HypoglycemiaHypoglycemia*BG < 70 mg. / dL*DM cause = too much insulin for amount of glucose present*Severe hypoglycemia can cause coma, death

Hypoglycemia can also occur whenHypoglycemia can also occur when*Too little food is taken*Insulin or OHA medication is @ its peak of action*Alcohol is taken by persons on OHA meds.*Unusual amounts of exercise are done [exercise increases insulin action]

S/S HypoglycemiaS/S Hypoglycemia*Skin: cool, clammy, moist, pallor, sweating*C-V: inc. HR (palpitations) & inc. BP*Neuro: shaky, nervous, irritable, tremulousness, weakness*GI: Hunger*Eyes: Blurred vision*If untreated can progress to confusion, disorientation, ALOC

HypoglycemiaHypoglycemiaHypoglycemia TreatmentHypoglycemia Treatment

*Prevention is best! If in doubt, treat for hypoglycemia!*Depends upon degree of hypoglycemia and LOC*Fast-acting carbohydrate [CHO] milk, crackers, OJ*15 Grams CHO every 15 minutes*Home Treatment MS page 914*Longer-acting CHO when S/S improved peanut butter, cheese & crackers

Fast-acting CHO for HypoglycemiaFast-acting CHO for Hypoglycemia*120 ml. [4 oz.] orange juice*120 ml. regular soft drink*2 packets sugar or honey*Glucose tablets / gels*Buccal cavity

Recheck blood glucose in 15 min.!Recheck blood glucose in 15 min.!

Hypoglycemia Treatment whenHypoglycemia Treatment when unableunable to give oral sugarto give oral sugar*Intravenous dextrose [D50]*Glucagon [IV, IM, SQ]


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After hypoglycemia is resolvedAfter hypoglycemia is resolved*Pt. should eat a balanced meal*Situation should be analyzed, cause discovered.*Physician needs to be notified.

Hypoglycemia vs. HyperglycemiaHypoglycemia vs. Hyperglycemia*PHARM page ____

Service Dogs for Diabetes (D4D)Service Dogs for Diabetes (D4D)

*http://dogs4diabetics.com/*Can detect hypo and hyperglycemia*Signals owner minutes before*Can help avoid the peaks and valleys of glucose control*Prevent organ damage*A service dog dog gets trained, owner receives training also

*Girl with dog & history of DM -http://images.search.yahoo.com/images/view?back=http%3A%2F%2Fimages.search.yahoo.com%2Fsearch%2Fimages%3Fp%3Ddogs%2B4%2Bdiabetes%26ei%3DUTF-8%26fr%3Dyfp-t-701-s%26fr2%3Dtab-web&w=928&h=960&imgurl=www.childrenwithdiabetes.com%2Fpeople%2Fimages%2FGillian2009crop.jpg&rurl=http%3A%2F%2Fwww.childrenwithdiabetes.com

%2Fkids%2Fd_02_1ul.htm&size=1MB&name=have+been+to+dia...&p=dogs+4+diabetes&oid=3317fe1de68ef9da7dac3e18c7dc3a5b&fr2=tab-web&no=9&tt=7440&sigr=11l0fno1b&sigi=11u0c3nkh&sigb=132ode14m

Iclicker QuestionIclicker QuestionHypoglycemia can be caused by: (Select all that apply.)

*Administration of too much insulin*Excessive or too much exercise*Poor dietary intake

*AlcoholIclicker QuestionIclicker Question

Which of the following statements is true of hyperglycemia? (Select all that apply.)

*It can be caused by exercising more than usual by a person with Type 2 diabetics.*Symptoms include flushed, hot, dry skin along with altered LOC.*Giving too much insulin can lead to ketoacidosis in the hyperglycemic client.*An infection such as a urinary tract infection can cause hyperglycemia.

Iclicker QuestionIclicker QuestionAfter administering treatment for hypoglycemia, the SVN should recheck the blood glucose:

*After 15 minutes*After 30 minutes*After 1 hour*Before the next meal or at HS
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Case Study # 1 HypoglycemiaCase Study # 1 HypoglycemiaA young female with no history of diabetes, but has a history of hypoglycemia went to school

without eating breakfast. At 10 am during a difficult test, she became dizzy, light headed,shaky, weak and diaphoretic.

*What lead to this hypoglycemic event?*What should this student do to treat this event?*What recommendations would you give this student to prevent this episode from recurring?*SBAR this situation.

*Develop a concept map.

Case Study # 2 HyperglycemiaCase Study # 2 HyperglycemiaA young female who is busy preparing for her wedding noticed that she has been losing weight.

She is always hungry and thirsty. She drinks a lot of fluid and has to urinate frequently.She attributes all of these symptoms to stress.

*Do you agree?*What could this person be experiencing?*What assessments are significant?*What nursing diagnoses apply to this person?*SBAR this situation.*Develop a concept map.

Other Diabetes ComplicationsOther Diabetes Complications*Macrovascular*Microvascular

Macrovascular Complications Arterial Occlusive DiseasesMacrovascular Complications Arterial Occlusive Diseases*Coronary artery disease [CAD]*Cerebrovascular Disease [CVA]*Peripheral Vascular Disease [Arteries = PAD]*Orthostatic hypotension rise slowly

Microvascular DiseasesMicrovascular Diseases*Retinopathy*Nephropathy*Neuropathies*Foot and Leg Problems

NeuropathiesNeuropathies*Sensorimotor*Autonomic

Sensorimotor NeuorpathySensorimotor Neuorpathy*Most common in feet*Paresthesias*Burning*Decreased sensation*Gabapentin [NEURONTIN] = analgesic


13/21

Autonomic NeuropathyAutonomic Neuropathy*Delayed gastric emptying

*Metoclopramide [REGLAN] AC*Increases peristalsis

*hypoglycemia unawareness*Impotence

NephropathyNephropathy*UTIs

*Urinary retention* End Stage Renal Disease (ESRD)* BUN & Creatinine and BP* Albuminuria*ACE inhibitors slow progression

Diabetic Retinopathy blindnessDiabetic Retinopathy blindness*Blood vessels rupture & leak scar tissues distorted vision blurred vision & visual acuity*ACE inhibitors dilate blood vessels - progression

InfectionsInfections*Glycosuria UTI*Poor wound healing

Iclicker QuestionIclicker QuestionComplications that can occur with Diabetic who do not achieve tight control would include:

(Select all that apply.)

*Blindness due to diabetic retinopathy.*Edema due to kidney failure due to nephropathy.*Skin breakdown due to neuropathy and paresthesias.*Delayed gastric emptying requiring Reglan for treatment.*Hypertension due to ASHD as a result of hyperglycemia.

Health Deviation Self-Care Requisites in DiabetesHealth Deviation Self-Care Requisites in DiabetesGoals of careGoals of care

*Promote optimal wellness*Support normalcy

*development*lifestyle

*Prevent complications

Goals are best achieved when THE PATIENT is the one in chargeGoals are best achieved when THE PATIENT is the one in chargeM.D., Nurse, dietician, etc. are helpers!

5 Aspects of Diabetes Management5 Aspects of Diabetes Management*Education*Diet*Activity*Medication*Monitoring


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Blood Sugar ControlBlood Sugar Control*Keeping blood sugar near normal [tight control] prevents or delays microvascular

complications*Tight control requires excellent self-care*Tight control may not be appropriate where risk of hypoglycemia is high

Tight Control GoalsTight Control Goals*Fasting Blood Glucose - 80-130*Glycosylated Hemoglobin [HbA1C] - < 7%

Diet GoalsDiet Goals*Maintain blood sugars as near-normal as possible*Achieve optimal serum lipid levels*Provide needed calories & nutrients

Special Goals - Type 2Special Goals - Type 2*Keep BP WNL*Achieve desired lipid levels*Weight loss if appropriate

Food Intake - Type 1Food Intake - Type 1* Must be synchronized w/ insulin intake and exercise.*ADA diet 1800 cal ADA, 2400 cal ADA, etc.

Food composition recommendedFood composition recommended*10 - 20 % calories from protein*< 10% calories from saturated fat*Insulin need determined by amount of CHO consumed*Complex CHOs preferred over simple*Alcohol in moderation

DietDiet*Glycemic Index*CHO counting*Exchange List*Eat at same time each day*Eat foods from all food groups*Limit fat and sugar foods

*Eat about the same amount each day*Use snacks to prevent low blood sugar*Plate Method

*1/3 protein*1/3 starch*1/3 vegetable*plus fruit & beverage

Exercise-BenefitsExercise-Benefits*Improves insulin utilization*Improves blood lipids*Promotes weight loss*Increases sense of well-being


15/21

Exercise - RisksExercise - Risks*Persons on insulin, sulfonylurea drugs*May cause hypoglycemia*May worsen hyperglycemia if insulin deficient

Minimizing Exercise RisksMinimizing Exercise Risks*Type 1 - dont exercise if BG > 240, ketones in urine*Snack before, after if prolonged exercise*Insulin dose may be decreased

*Check blood glucose before, during, after exerciseSelf-Monitoring of Blood Glucose [SMBG]Self-Monitoring of Blood Glucose [SMBG]

*Monitors effectiveness of diet-exercise-medication program*Guides insulin administration*Recommended for most diabetics*Frequency QID or daily or weekly

SMBG TimingSMBG Timing*AC & HS most common, esp. if hospitalized, or on insulin or tight control*BID or daily for some*After meals to assess adequacy of insulin dose*Before, during & after exercise if on insulin or previous hypoglycemia occurrence w/ exercise*Any time S/S of hypo or hyperglycemia occur

Hospitalized DiabeticsHospitalized Diabetics*Often have higher than their usual blood sugars [stress of illness]*Pts. controlled on oral meds @ home may require insulin*Need for insulin may be temporary

Diabetic Foot Problems-CausesDiabetic Foot Problems-Causes*Neuropathy - loss of pain and pressure sensation*Poor circulation - impairs wound healing

*Smoking much more dangerous to diabetics*Immunocompromised

Diabetic Foot Problems-PreventionDiabetic Foot Problems-Prevention*MS page 927*Inspection*Thorough drying after bathing*Lubrication*Podiatry for problems*Well-fitting closed-toes shoes*Dont go barefoot*Trim nails*Lambs wool for pressure relief*Exercise

Recommended Health ScreeningRecommended Health Screening*Dilated eye exam yearly*Test for microalbuminuria yearly*Blood lipid panel yearly*HbA1C every 3 months


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Patient EducationPatient Education*Infection Control*Fluids*Eye Exams*Medications travel MS page 928*Blood Glucose Monitoring*Medic Alert tags*Working with Elder Clients MS page 928

Patient Education - continuedPatient Education - continued*American Diabetes Association*Diabetic Educator*Home Care Visits*Website

*American Diabetic Association -http://www.diabetes.org/

*Dogs 4 Diabetes - http://dogs4diabetics.com/

Diabetic Nursing Care PlanDiabetic Nursing Care Plan*MS page 923 - 925

Iclicker QuestionIclicker Question

You are preparing to give a male client his insulins - Regular and NPH - one morning. Hisglucose level is 57mg/dL. He just drank some water. You would:

*Administer both of his insulins, his breakfast tray is available.*Administer both of his insulins and bring him orange juice with extra sugar.*Hold his both of his insulins, give him orange juice and recheck his blood glucose.*Hold his NPH insulin, give him orange juice and recheck his blood glucose.*Give him an injection of Glucagon.

Iclicker QuestionIclicker QuestionPatient teaching for a Diabetic client would include: (Select all that apply.)

*Encouragement to get yearly eye exams.*Purchasing properly-fitted closed toes shoes.*Getting his/her blood pressure checked monthly.*Seeing a podiatrist for any foot problems.*Exercising at least 30 minutes daily.

Case Study # 3 Diabetic ComplicationsCase Study # 3 Diabetic ComplicationsA young male who has had Type 1 DM since his teens presents with a microalbumin level of 10,

an elevated BUN and creatinine, edema of the lower extremities and dyspnea on exertion(DOE).

*What are your concerns re this client?*What questions would you ask this young man?*What other data would you like to know?*What recommendations do you have for this young man?*What patient teaching would be helpful?
http://www.diabetes.org/http://www.diabetes.org/http://dogs4diabetics.com/http://www.diabetes.org/http://dogs4diabetics.com/


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DIABETIC DRUGS -DIABETIC DRUGS - Pharm Chapter ___

InsulinInsulin*Function

*Allows glucose into cells*Allows glucose to enter liver*Prevents fat breakdown*Stores excess calories as fat

InsulinInsulin*Must be taken daily*Cannot be taken orally

*Inactivated by digestive enzymes*Must be given by injection*Someone must give injection

*Abdomen*Rotate Sites MS page 917

*All Human insulin now*Used to have Beef or Pork

*U100 (100 Units per 1 ml)*Syringe must match insulin U100

InsulinInsulin*Class : hormone*Actions : promotes cellular uptake of glucose thereby lowering BG*Indications : Type 1 DM, Type 2 DM where BG control cant be achieved w/ oral meds*Nursing : comes in different types, w/ different kinetics; exercise increases effect

InsulinInsulin nursingnursing: contd: contd* BG before giving; S/S hypoglycemia; higher dose may be needed when pt. is ill or otherwise

stressed; abdomen is preferred SQ injection site; rotate injection sites

Insulin routesInsulin routes*Subcutaneous [SQ]-usually*Intranasal*Intravenous - when faster action is needed

*RN or MD, not LVN

Subcutaneous SitesSubcutaneous Sites*Abdomen - most consistent absorption*Arms*Legs*Rotation recommended to avoid lipoatrophy

*Uncommon with human insulin

Insulin ConcentrationsInsulin Concentrations*U100 - 100 units / ml. usually

*Use U-100 syringe*U 500 - 500 units / ml.

*very insulin-resistant clients*use U-500 syringes


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Insulin SyringesInsulin Syringes*Orange cap*Marked in units*Flat top*1/2 ml most common size*Also comes in 1 ml, 1/3 ml, 1/4 ml

INSULIN TYPES - KINETICSINSULIN TYPES - KINETICS* Different insulins have different onsets, peaks, durations of action

* MS page 915*Bottles good for 30 days after opening*Room temperature unless used infrequently*Lantus no mix with other insulins in same syringe*Lantus once at day at night/bedtime

Insulin / Meal TimingInsulin / Meal Timing*Regular - 30 min. AC*Humalog - 5-10 min. AC

Insulin & Sliding ScaleInsulin & Sliding Scale*SMBG AC & HS*Dose based on blood sugar*Dose to cover hyperglycemia AND*Provide insulin for meal or snack to follow*Combining Insulins MS page 916

*Clear to cloudy

Sliding ScaleSliding Scale*Syllabus page*U100 Regular Insulin

*Humalog some cases*Given AC & HS

MS page 915 & SyllabusMS page 915 & Syllabus

Insulin MixturesInsulin Mixtures*70/30 = 70% NPH, 30% Regular*50/50 = 50% NPH, 50% Regular*75/25 = 75% insulin lispro protamine suspension, 25% insulin lispro injection (rDNA origin)*Advantage - avoids errors from mixing

Exenatide [Byetta]Exenatide [Byetta]*MS page 919*Incretin mimetic

*Increases glucose-dependant insulin production*Suppresses elevated glucagon*Slows gastric emptying

*Type 2 [w/ oral med]*Injectable*Supplied in prefilled pen*Fixed dosing for all pts.*Within 1 hr. before morning & evening meals*Nausea, vomiting most frequent SEs

Exubera - Inhalable InsulinExubera - Inhalable Insulin


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*Within 10 min. before meals*Smoking is a contraindication

*Increased hypoglycemia risk*Severe chronic lung disease is a contraindication

*Causes small decline in pulmonary function*Hypoglycemia is most frequent adverse effect

*? Still being produced - reported that Pfizer stopped production January 2008 dt low demandfor drug

Type[s] of insulin used depends onType[s] of insulin used depends on*Goals of treatment*Self care agency

Insulin PumpsInsulin Pumps*MS page 919*Closest to normal pancreatic function*Continuous SQ infusion @ basal rate[s]*Bolus dose for meals*Regular or Humalog

Insulin - Pen or Jet InjectorInsulin - Pen or Jet Injector

Drugs That Increase or Decrease Hypoglycemia Effect of InsulinDrugs That Increase or Decrease Hypoglycemia Effect of Insulin

Iclicker QuestionIclicker QuestionA female client is on a sliding scale to control her diabetes. At lunchtime, her blood glucose is 200.

She requires insulin. Which type of insulin should be given with her sliding scale?

*Regular*NPH*Lente*Ultra Lente

Iclicker QuestionIclicker QuestionAfter giving a female client her insulin per the ordered sliding scale, you would assess her for

symptoms of:

*Hypoglycemia in 2 hours.*Hyperglycemia in 3 hours.*Diabetic ketoacidosis after 4 hours.*Pre-diabetes after 6 hours.

Case Study # 4 Type 1 DiabeticCase Study # 4 Type 1 DiabeticA middle-aged female with Type 1 DM who takes Humalog insulin before each meal per sliding

scale and Lantus insulin every evening is planning a trip to visit her family in Europe.

*What assessments/concerns would be important to discuss with this client?*What travel tips would you give this client?*What concerns would you have for her insulin therapy?*SBAR this situation.*Develop a concept map.

ORAL Hypoglycemic Agents (OHAs)ORAL Hypoglycemic Agents (OHAs)


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*MS page 920*Sulfonylureas*Starch blockers*Insulin sensitizers*Biguanides

ORAL Hypoglycemic AGENTS (OHAs)ORAL Hypoglycemic AGENTS (OHAs)

SulfonylureasSulfonylureas

*Stimulate pancreas to secrete insulin*Risk for hypoglycemia if inadequate food intake*Drugs: glipizide [Glucotrol], glyburide [DiaBeta, Micronase], repaglionide [Prandin]

SulfonylureasSulfonylureas*Drugs = Glipizide (Glucotrol), Glyburide (DiaBeta, Micronase). Chlorpropamide (Diabenase)*Class : oral hypoglycemic & sulfonylureas*Action : stimulates pancreatic insulin production*Indication : Type 2 diabetes*Nursing : BG; give before or w/ meal; hold if pt. not eating; S/S hypoglycemia; for allergy

to sulfa, can cause weight gain

Starch BlockersStarch Blockers

*Drugs = acarbose [Precose], miglitol [Glyset]*Class : alpha-glucosidase inhibitor*Action : inhibits CHO absorption from GI tract*Indication : Type 2 diabetes*Nursing : BG; Give w/ first bite of food; may cause bloating, flatulence

Insulin SensitizersInsulin Sensitizers*Drugs = rosiglitazone [Avandia] & pioglitazone [Actos]*Class : insulin sensitizer*Action : increases tissue sensitivity to insulin*Indication : Type 2 diabetes*Nursing : LFTs, dec. H & H, wt. gain, dose of other oral hypoglycemia agent may need to be

decreased

Liver InhibitorLiver Inhibitor*Drug: Metformin [Glucophage]*Class : biguanide*Action : primary: inhibits liver glycogen breakdown to glucose-also increases cellular uptake of

glucose*Indication : Type 2 diabetes; may be sole agent, or combined w/ other drugs*Nursing : must be dcd 48 hrs. before X-ray studies w/ iodine contrast & when pt. Dehydrated

[possible kidney toxicity]; Cr.

Newer Drugs -Newer Drugs - $25 billion / year worldwide


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Iclicker QuestionIclicker QuestionWhich of the following statement/s about oral hypoglycemic agents is/are true? (Select all that

apply.)

*Most should be given in the morning or AC or with meals.*Some such as glipizide (Glucotrol) or glyburide (DiaBeta, Micronase) contain sulfa so need to

check for sulfa allergy.*Some can cause hypoglycemia if inadequate food intake.*The ingestion of alcohol with some can cause hyperglycemia.

Case Study # 5 Type 2 DM on OHAsCase Study # 5 Type 2 DM on OHAsA middle-aged male who is obese and has Type 2 DM takes Metfomin and Actos daily. His LDL is

200 and his HLD is 45. His HbA1c is 9.

*What are your concerns re this client?*What other assessments would you like to view?*What recommendations do you have for this client?*What patient teaching would you provide?*SBAR this client.*Develop a concept map.

Quiz TimeQuiz Time*Turn off cell phone.*Need one green scantron, pencil, eraser and iclicker.*Please put all your personal belongings in your backpack including cell phones and water bottles.*Please put your backpack in the front of the room.*On your scantron, legibly write your name, todays date, NRV 51, Quiz # ___,Diabetes Mellitus*Turn on your iclicker when the quiz begins.*Take a deep breath and think positive,*Scantrons will be passed forward to instructor before test review begins.*Test review will begin as soon as quiz is finished.

n rv 51 diabetes mellitus

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