1. Chapter 40 Nursing Care of Patients with Disorders of the Endocrine Pancreas

2. Diabetes Mellitus • Pathophysiology • GlucoseIntolerance • FaultyProductionofInsulinor • TissueInsensitivitytoInsulin • Altered CHO,Fat,Protein Metabolism • Long-term Complications

3. Blood Glucose Levels

4. Cell Membranes

5. CDC Statistics • 20.8 Million in U.S. have Diabetes • 6.2 Million are Unaware • Cost: $132 Billion per Year

6. Type 1 Diabetes • IDDM,Juvenile(Old Names) • 5%to 10% ofDiabetes Cases • SomeGenetic Component (10%) • AutoimmuneResponsetoVirus • Destruction ofBeta Cells • PancreasSecretesNOInsulin • MoreCommoninYoung, Thin Patients • Prone toKetosis

7. Type 2 Diabetes • NIDDM,Adult Onset (Old Names) • 90%to 95% ofDiabetes Cases • LargeGenetic Component (90%) • DecreasedBeta Cell Responsiveness toGlucose • ReducedNumberofBeta Cells • ReducedTissue Sensitivity toInsulin • LargestRisk Factor isObesity • NotKetosis-Prone

8. LADA • Latent Autoimmune Diabetes of Adulthood • Initial Type 2 Diagnosis • Islet Cell Antibodies Like Type 1

9. Type 2 in Youth • More Obesity in Children • Type 2 Epidemic • A Nursing Challenge

10. Other Types • Gestational: Pregnancy • Prediabetes: Glucose Intolerance • SecondaryDiabetes • Drugs • PancreaticTrauma

11. Metabolic Syndrome • ElevatedWaist Circumference • ElevatedTriglycerides • Low HDLCholesterol • ElevatedBlood Pressure • ElevatedFasting Plasma Glucose

12. SignsandSymptoms • The 3 Ps • Polyuria • Polydipsia • Polyphagia • Fatigue • BlurredVision • InfectionProne • AbdominalPain • Headache • Ketosis/Acidosis

13. Diagnosing Diabetes • FastingPlasma Glucose≥ 126 mg/dL • CasualPlasma Glucose ≥ 200 mg/dL • GlucoseTolerance Test> 200 mg/dL after2 Hr

14. Additional Tests • Glycohemoglobin: Normal 4% to 6% • Lipid Profile • Serum Creatinine • Urine Microalbumin

15. Prevention of Type 2 • Lose 5% to 7% Body Weight • 30 Minutes of Exercise 5 Days per Week • Reduce Fat and Calories

16. Goals of Treatment • PreprandialGlucose90 to130 mg/dL • PeakPostprandial Glucose < 180 mg/dL • BloodPressure< 130/80 Mm Hg • Glycohemoglobin < 7%

17. Therapeutic Interventions • MedicalNutrition Therapy • Exercise • Medication • Monitoring • Education

18. Medical Nutrition Therapy (MNT) • ADAExchange Lists • CarbohydrateCounting • GlycemicIndex • REMEMBER CULTURAL DIETARY NEEDS

19. GeneralPrinciplesof MNT • LowFat • LowSodium • LimitSimple Sugars • UseComplex Carbohydrates • ConsistentDay-to-day

20. Exercise • LowersGlucoseup to 24Hours • LowersBlood Lipids • BestDone Regularly • Refer to MD orExercise Physiologist • AvoidExercise During Acute Hyperglycemia • CarryFast Sugar

21. Medication • Insulin for Type 1 or 2 • OralHypoglycemicsfor Type 2

22. Insulin • Action • Routes • Subcutaneous • IM • Inhaled • Insulinpump

23. Insulin(cont’d) • SiteRotation • Timing • Onset • Peak • Duration

24. Insulin Pump

25. Oral Hypoglycemics • AreNot Insulin • ActionDependsonMedication • StimulatePancreas • IncreaseTissue Sensitivity toInsulin • Slow CHODigestionandAbsorption

26. New Developments • Exenatide (Byetta) • Pramlintide (Symlin)

27. Self-Monitoring of Blood Glucose • Test AC and HS • RecordResults • AnalyzeMeaningofResults • KnowTarget Glucose Levels • CallProviderifOutofRange

28. Glucose Diary

29. UrineTesting • Glucose • Ketones • IfBlood Sugar Greater than 300

30. Alterations in Blood Glucose • Hyperglycemia • Hypoglycemia = “Insulin Reaction”

31. Hyperglycemia • Blood Glucose>126 mg/dL • Causes • Overeating • Stress • Illness • NotEnough Medication

32. Symptoms of Hyperglycemia • 3 Ps • BlurredVision • Fatigue,Lethargy • Headache • AbdominalPain • Ketonuria • Coma

33. Treatment of Hyperglycemia • CheckBlood Glucose • Use Sliding Scale Insulin • IfBlood Glucose is Greater Than 300,Check Ketones • DetermineCauseandEliminate • If Blood Glucose is Greater Than 180 for2 Days, Call MD • Call MD ifIllorVomiting

34. Hypoglycemia • Blood Glucose Greater Than70 • Causes • TooMuch Insulin • Exercise • NotEnough Food

35. Hypoglycemia Symptoms • Headache • Hunger • Fight orFlight • Shaky • ColdSweat • Palpitations • Neuroglycopenia • Irritability • Confusion • Seizures,Coma • CAUTION • AutonomicNeuropathy=No Symptoms

36. Hypoglycemia Treatment • CheckBlood Glucose • Administer15 to 20GFast-ActingCHO • Recheck in 15 Min • RepeatPRN • Snack ifGreater Than 1Hr Until Meal

37. Fast Sugars • 4 oz Orange Juice • 6 oz Regular (not diet) Soda • Miniature Box of Raisins • Commercial Glucose Tablets • 6 to 8 Life Savers

38. Acute Treatment • IV D50 • SQGlucagon

39. Diabetic Ketoacidosis (DKA) • Causes • HighBlood Glucose • Most Common in Type 1 • Stress • Illness

40. Pathophysiology • InsulinDeficiency • CellsStarving • FatBreaks Down • Byproduct ofFat Breakdown isKetones • Ketones areAcidic

41. Signs and Symptoms • Flu-likeSymptoms • Symptoms ofHyperglycemia • Kussmaul’sRespirations • FruityBreath • ElectrolyteImbalance • Dehydration • Coma • Death

42. Therapeutic Interventions • IVFluids • IVInsulin Drip • FrequentGlucose Monitoring • ElectrolyteMonitoring

43. Prevention • CheckKetonesifBlood Sugar is Greater Than 300 • DrinkFluids • CheckAgain • Call MD ifStill Present • GoodDiabetes Control!

44. Hyperosmolar Hyperglycemia • Causes • Hyperglycemia inType2Diabetes • Stress • Illness • MostCommoninElderly

45. Pathophysiology • BloodGlucose Elevated • Polyuria • ProfoundDehydration • NoNauseaandVomiting, SoSlowertoGet Help

46. Signs and Symptoms • ExtremeDehydration • Lethargy • BloodGlucosemay be1,000 to 1,500 mg/dL • ElectrolyteImbalance • Coma • Death

47. Therapeutic Interventions • IVFluids • IVInsulin Drip • FrequentGlucose Monitoring • ElectrolyteMonitoring

48. Prevention • SMBG • IfGlucose Rising • DrinkFluids • LowerGlucose

49. Long-Term Complications • MacrovascularChanges • Stroke • MI • PeripheralVascular Disease

50. Long-Term Complications(cont’d) • MicrovascularChanges • Retinopathy • Nephropathy • Neuropathy • Infection • FootProblems