Diabetes: Nursing Assessment & Management

1. Diabetes: Nursing Assessment & Management N251: 2012

2. What is Diabetes? • Lack of insulin secreted by beta cells of pancreas (Type I IDDM) • 5-10% of cases, an autoimmune disease • Juvenile diagnosis • Insulin Resistance • Varying amounts produced, body unable to use it effectively (Type II NIDDM) • Most common • Most often affects adults over age 40yrs

3. Normal Process

4. Insulin is the key that opens the door

5. Glycosuria • Glycosuria: glucose present in the urine • Happens when glucose concentration in the blood exceeds renal threshold for glucose (9.9-11.1mmol/L) • When excess glucose is excreted in urine, it is accompanied by excessive loss of fluid and electrolytes (osmotic diuresis)

6. Three ‘P’s of Diabetes • Polyuria: increased urine output • Polydipsia: increased thirst • Polyphagia: increased hunger

7. Management • Primary goal: • normalize blood glucose levels • reduce development of vascular & neuropathic complications • Nutritional management • Exercise • Monitoring of blood glucose • Pharmacologic therapy • Education

8. Management • Self-monitoring of blood glucose (glucometer) • Key component of treatment with insulin regime, **ALWAYS test blood glucose prior to administering insulin** • For those not requiring insulin, it is helpful for monitoring the effectiveness of exercise, diet and oral agents

9. Blood Glucose Testing: • Warm hand/fingers • Wash with soap/water & dry • Try to avoid pad of finger • Discard first drop of blood • Provide guaze/ tissue

10. Normal Blood Glucose: • Adult: 4-6 mmol/L • Child: 3.5-5.5 mmol/L

11. **Need to Know Insulin Info!**

12. Insulin • Roll vial to thoroughly mix • Do not allow to freeze • Once opened, good for 1 month @ room temperature **be sure to date vial** • Rotate injection sites

13. Lab Values • Glycosylated Hemoglobin (Hgb A1C) • Blood test which reflects average blood glucose levels over a period of approx. 2-3 months • When blood glucose is elevated, glucose molecules attach to Hgb in the RBC • The longer the amt of glucose in the blood remains above normal, the more glucose binds to the RBC and the higher the A1C level • The Hgb attached to the RBC is permanent and lasts for lifetime of RBC, approx. 120days

14. Monitor: Urine • Urine testing for glucose • Limited to those who cannot or will not use a self-monitoring system • Urine applied to strip, match color on strip to chart • Does not accurately reflect blood glucose levels at time of test • Renal threshold (9.9-11.1), is far above target levels • Difficult to assess for hypoglycemia

15. Monitor: Ketones • Testing for Ketones • When no insulin available, body starts to breakdown stored fat for energy • Ketones are a by-product of fat breakdown, and they accumulate in the blood and urine • Signals that control of Type 1 is deteriorating

16. Hypoglycemia Sweating Tremor Irrational behavior Lightheadedness Tachycardia Slurred speech Hunger LOC if severe Confusion Hyperglycemia Polyuria Dehydration Weakness Headache Polydipsia Acetone breath Nausea Rapid respirations N/V Signs to Recognize

17. Acute Complications • Hypoglycemia (insulin reaction) • Too much insulin • Too much oral hypoglycemic • Too little food • Excessive physical exercise • Manifestations: sweating, tremor, tachycardia, hunger, nervousness, confusion, impaired coordination, irrational behavior, may lead to seizures, LOC

18. Management of Hypoglycemia: Immediate action required • Give fast acting source of carbohydrate (juice, pop, life savers, sugar/honey) • Do not need to add sugar to fruit juice • Retest within 15 minutes • Once symptoms resolve, give snack with protein & starch

19. Long-term Complications: DM • Macrovascular • Changes in med-lg blood vessels • Vessel walls thicken, sclerose, & become occluded by plaque that adheres to vessel wall: eventually, blood flow is blocked • Tend to occur at an earlier age in those with DM • Microvascular • Unique to diabetes • Capillary basement membrane thickening, due to responses assoc. with increased blood glucose

20. Macrovascular CAD: MI CVD Peripheral vascular disease Arterial occlusion in lower extremities largely responsible for gangrene/amputation Microvascular Diabetic retinopathy: changes in the sm. vessels of the retina Nephropathy: renal disease Macro vs. Micro Vascular

22. Long Term Consequences

23. Diabetic Neuropathy • Neuropathy: damage to nerve cells • Diabetic: • Group of diseases that affect all types of nerves • Peripheral nerves (sensorimotor) • Autonomic

24. Peripheral Neuropathy • Peripheral neuropathy: • Initial symptoms: • tingling, prickling and burning sensations • As disease progresses, feet become numb • Decrease in proprioception (posture/movement of body) • Decreased sensation to temperature and pain **physical assessment and pt. teaching**

25. Diabetic Neuropathy

26. Diabetic Neuropathy

27. Autonomic Neuropathies • Autonomic Neuropathies • Broad range of dysfunctions affecting almost every organ system of the body • Cardiac: • Tachycardia, orthostatic hypotension, silent ischemia/infarction • GI: • Delayed gastric emptying, bloating, N/V • Renal: • Urinary retention, decreased sensation of bladder fullness

28. Nursing care of hospitalized Diabetic Patients • Self-care • Hyperglycemia • Hypoglycemia • Alterations in diet (NPO, clear liquids, NG) • Hygiene • Stress

29. Age Related Changes & Affect on DM management • Sensory changes • Gastrointestinal • Activity/Exercise pattern • Renal Function • Cognitive • Socioeconomic • Chronic • Potential drug-drug interactions

30. Nursing Process • Assessment • History & physical • Ability/desire to learn • Visual deficits • Motor coordination • Neurologic deficits

31. Diagnoses • Risk for Fluid Volume deficit r/t polyuria • Imbalanced Nutrition • Anxiety r/t loss of control, fear • Deficient Knolwedge

32. Planning • Long-term goals • Short-term outcomes

33. Interventions • Education (understanding the disease) • Simple pathophysiology • Treatments • S & S of complications • Survival tips (when to call Dr., etc)

34. Education: Continued for lifespan • Foot Care • Eye Care • General Hygiene • Risk Factor management

35. Foot Care Tips: • Inspect daily, use a mirror • Wash & dry daily (warm not hot water) • Be sure to dry well • Do not soak • Lotion daily to top & bottom, but not between • Wear shoes & socks • Protect from heat & cold • Trim nails straight across

36. Evaluation • Look at expected outcomes • Proper demonstration techniques • Verbalizes S & S • Proper disposal of lancets • Proper diet