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Care of Clients with Problems In Oxygenation, Fluids and Electrolytes, Metabolism and Endocrine (NCM103) Patients With Endocrine

Alterations IV
Topics Discussed Here Are: 1. ALL ABOUT DIABETES

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Disorders of the Pancreas


DM Fast Status
Diabetes Mellitus has continued to be a major and growing threat to global public health WHO estimates that more than 171 million world wide 3.36 million in the Philippines

Diabetes Mellitus
A. Definition A group of metabolic diseases characterized by elevated levels of GLUCOSE in the blood resulting from defects in/any combination of conditions, such as: 1. Insulin Secretion 2. Insulin Action 3. Insulin Receptors Basic Pathology: Insulin Problem 1. Deficiency 2. Impaired Action What is Insulin? - A hormone secreted by BETA CELLS of the pancreas - Stimulus of Insulin HYPERGLYCEMIA - Actions of insulin: It promotes entry of glucose into the body cells by binding to the insulin receptors in the cell membrane B. Classifications of Diabetes Mellitus 1. Type 1 Diabetes Mellitus (Formerly known as Insulin Dependent Diabetes Mellitus IDDM) 2. Type 2 Diabetes Mellitus (Formerly known as Non-Insulin Dependent Diabetes Mellitus NIDDM) 3. Gestational Diabetes 4. Diabetes Associated With Other Conditions (Also known as Secondary Diabetes) Type 1 Diabetes Mellitus o Little / No endogenous insulin, due to destruction of BETA CELLS o Must inject insulin to SURVIVE o Also known as Juvenile-onset DM o About 5 10% of those diabetics Etiologic Factors: 1. Genetic susceptibility Human Leukocyte Antigen (HLA) 2. Auto-immune Response 3. Toxins, unidentified viruses and environmental factors Pathophysiology

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Type 2 Diabetes Mellitus o Caused by a combination of insulin resistance and relative insulin deficiency o Approximately 90% of diabetic patients o Found primarily in adults over 30 years of age o Often controlled by diet and exercise or oral medications Etiologic Factors 1. Unknown 2. Probably GENETIC and OBESTY

REMEMBER the 3 Fs (Ha? XD)

Pathophysiology

Gestational Diabetes

Diabetes Associated With Other Conditions (Maraming kulang) o Results from certain intake of drugs that decrease insulin activity in hyperglycemia Corticosteroid, diuretics, estrogen, Phenytoin o Disease states affecting the pancreas or insulin receptor

C. Clinical Manifestations Diabetes Mellitus 3 Ps 1. Polydipsia (Excessive THIRST) 2. Polyuria (Frequent URINATION) 3. Polyphagia (Excessive HUNGER) Other Manifestations 1. Fatigue 2. Body weakness 3. Visual changes / Blurred vision

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4. Slow wound healing 5. Recurrent skin and mucous infections 6. Weight Loss D. Diagnostic Tests 1. Blood Glucose Monitoring 2. Oral Glucose Tolerance Test (OGTT) 3. Glycosylated Hemoglobin (HBA1c) BLOOD GLUCOSE MONITORING Classified Into: o Fasting Blood Sugar (FBS) Drawn at least an 8 hour fast to evaluate circulating amounts of glucose o Random Blood Sugar (RBS) Drawn at ANYTIME and non-fasting o Postprandial Blood Sugar Drawn usually 2 HOURS after a well-balanced meal Nursing Care and Considerations for Blood Glucose Monitoring o For FBS, ensure that client has MAINTAINED an 8 hour fast overnight, sips of water is allowed o Advise client to REFRAIN from smoking before glucose sampling o For postprandial test, advise client that NO FOOD be eaten*** o * Interpretation: o FBS = >126 mg/dL o RBS = > 200 mg/dL o FBS: 70 110 mg/dL o RBS: 80 120 mg/dL 4.4 6.6 mmol/L

ORAL GLUCOSE TOLERANCE TEST - Evaluates insulin response to glucose loading 1. 2. 3. FBS is taken from the client (NO FOOD / DRINK from 8 12 HOURS PRIOR to test) Client ingests 50 200g glucose load (Usually 75g) o Drink Glucose Blood sugar is drawn at hours, 1 hour, 2 hours, 3 hours*** o Blood is tested 2 hours later HIGH GLUCOSE LEVEL = POTENTIAL DIABETES

Nursing Care and Considerations for Oral Glucose Tolerance Test o Instruct client that: Usual diet and exercise pattern must be followed for 3 days before OGTT o During OGTT, the client must refrain from SMOKING and REMAIN SEATED o Oral contraceptives and other drugs must be withheld

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GLYCOSYLATED HEMOGLOBIN (HBA1c) - Definite glycemix control over a 60 120 day period - Measures the inconceivable action of glucose to hemoglobin through freely permeable erythrocytes during their 120-day life cycle - Normal Value is: 4% - 6% - Not usually a diagnostic test Nursing Care and Considerations for Glycosylated Hemoglobin (HBA1c) 1. No prior preparation such as fasting / withholding insulin 2. Test can be affected by RBC disorders, room temperature 3. Many methods exist in performing the test**

Diabetes Mellitus Management


The main goal is to normalize insulin action and blood glucose level by: o Nutrition Modification o Regular Exercise o Regular Glucose Monitoring o Drug Therapy o Client Education NUTRITIONAL THERAPY - Goal: Improving blood glucose levels and lipid levels o Weight reduction is of primary treatment for DM Type 2 o SMBG, lipid levels, BDG, Renal status must be assessed 1. 2. 3. Review the clients diet history to identify eating habits and lifestyles Coordinate with the dietitian in meal planning for weight loss Plan for the caloric intake distributed as follows: o CHO: 50 60% o Fats: 20 30% o CHON: 10 20% Advise moderation in alcohol intake Using artificial sweeteners is acceptable

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Meal Plan for DM Patients - Plate Method - Exchange List REGULAR EXERCISE - Teach that exercise can lower the blood glucose level, improves circulation and muscle tone, Cholesterol - Diabetics must 1st CONTROL the glucose level BEFORE initiating exercise - Offer extra food / calories before engaging in exercise - Offer snacks at the end of the exercise period if client is on an insulin therapy - Advise that exercise should be done regularly, SAME TIME, and SAME AMOUNT EVERYDAY (Preferably when blood glucose levels are at their peak) MEDICAL MANAGEMENT Medications: Oral Antidiabetic Agents (Oral Hypoglycemic Agents) OHA o Employed only if diet modification and exercise CANNOT control the blood glucose levels o NEVER USED in pregnancy

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Sulfonylureas: Helps your pancreas make EXTRA INSULIN Biguanides: Biguanides STOP the Liver from making EXTRA sugar when it is not needed Alpha Glucosidase Inhibitor: Alpha Glucosidase Inhibitor slows the digestion of STARCH Thiazolidinedione: Thiazolidinedione help body cells use insulin better Meglitinide: Same as Sulfonylureas, SHORT acting BUT FAST ACTING INSULIN THERAPY - Categorized according to: 1. Source: Human, Pig / Cow 2. Onset of Action a. Rapid Acting b. Short Acting c. Intermediate Acting d. Long Acting e. Very Long Acting 3. Pure / Mixed Concentration Rapid Acting Insulin - Lispro (Humalog) and Insulin Aspart (Novalog) - Produces a more rapid effect and with a SHORT duration than any other insulin preparation - Instruct client to eat within 5 15 minutes after injection Short Acting / Regular Insulin - Humulin R - Usually CLEAR solution acting 30 minutes BEFORE a meal Intermediate Acting - Called NPH or Lente - Appears White and CLOUDY Long Acting Insulin - Ultra Lente - Referred to as Peakless insulin Time Course
Rapid-Acting

Agent
Lispro (Humalog) Aspart (Novolog) Glulisine (Apidra)

Onset
10 15 min 5 15 min 5 15 min

Peak
1h 40 50 min 30 30 min

Duration
24h 24h 2h

Indications
Used for rapid reduction of glucose level, to treat postprandial hyperglycemia, and or to prevent nocturnal hypoglycemia Usually administered 20 30 min before a meal; may be taken alone or in combination with longer acting insulin Usually taken after food

Short-Acting

Regular (Humalog R, Novolin R)

-1h

23h

46h

Intermediate-Acting

Very Long-Acting

NPH (Neutral Protamine Hagedorn) Humulin N Glargine (Lantus) Detemir (Levemir)

24h 34h 1h

4 12 h 4 12h Continuous (No peak)

16 20 h 16 20 h 24 h

Used for basal dose

Generativity for Insulin 1. Human Insulin preparation have a shorter duration of action than animal source 2. Animal source of insulin have animal proteins that may trigger allergic reactions that may stimulate antibody production that may bind the insulin, SLOWING the action 3. ONLY REGULAR INSULIN can be used INTRAVENOUSLY 4. Insulin is measured in International Units or i.u.

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There is a specialized insulin injection calibrated in units Insulin is absorbed fastest in the ABDOMEN and slowed in the HIPS Instruct the client to rotate the areas of injection, but exhaust all available sites in one area before moving into another area

Complications of Insulin Therapy


1. Local Allergic Reaction Redness, swelling, tenderness and indurations appearing 1 2 hours after injection Usually occurs in the beginning stage of therapy Antihistamines can be given 1 hour before injection time Systemic Allergic Reaction Very RARE Generalized urticaria is the manifestation Treatment is desensitization Insulin Dystrophy A localized reaction in the form of LIPOATROPHY or LIPOHYPERTROPHY Lipoatrophy = Loss of subcutaneous fat usually caused by utilization of animal insulin Lipohypertrophy = Insulin Resistance Most commonly caused by obesity Defined as daily insulin requirement of more than 200 units Management Stored and used more concentrated insulin Morning Hyperglycemia Elevated blood sugar upon rising in the morning Caused by insufficient levels of insulin DAWN Phenomenon SOMOGYI Effect INSULIN WANING DAWN PHENOMENON - Relatively normal blood glucose until about 3 am, when the glucose level begins to rise - Results from the nightly surges of growth hormone secreted - Management: Bed time injection of NPH SOMOGYI EFFECT

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INSULIN WANING - Progressive rise in blood sugar from bedtime to morning - Seen when NPH evening dose is administered before dinner - Management: Move the insulin injection to bed

Diabetes Mellitus Related Complications


Acute Complications of DM o Hypoglycemia o Diabetic Ketoacidosis o Hyperglycemic Hyperosmolar Non-ketotic Syndrome (HHNS) HYPOGLYCEMIA - Blood Glucose Level <50 60 mg/dL - Causes: Too much insulin / OHA, too little food and excessive physical activity - Level of Hypoglycemia o Mild: 40 60 mg/dL o Moderate: 20 40 mg/dL o Severe: Less than 20 mg/dL Assessment Findings: 1. Sympathetic Manifestations Sweating, tremors, palpitations, nervousness, tachycardia and hunger 2. CNS Manifestations Inability to concentrate, headache, lightheadedness, confusion, memory lapses, slurred speech, impaired coordination, behavioral changes, double vision and drowsiness DIABETIC KETOACIDOSIS - This is caused by the absence of insulin, leading to fat breakdown and production of ketone bodies Risk Factors: 1. Infection / Illness COMMON 2. Stress 3. Undiagnosed DM 4. Inadequate insulin, missed dose of insulin
No Insulin Reduced glucose breakdown and liver glucose Hyperglycemia Kidneys attempt to excrete glucose

Hyperglycemia

Osmotic load

Blood glucose level of 300 800 mg/dL

Diuresis

Dehydration (Electrolyte Imbalance Potassium levels may be HIGH due to acidosis and dehydration)

Diabetic Ketoacidosis

No glucose in the cell Fat is broken down for energy Ketone bodies are products Ketoacidosis

Urinary Ketones ABG result of metabolic acidosis LOW pH, LOW pCO2, Low HCO3

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Assessment Findings 1. 3 Ps 2. Headache, blurred vision and weakness 3. Orthostatic hypotension 4. N/V and abdominal pain 5. Acetone (Fruity breath) 6. Hyperventilation / Kussmauls Breathing HYPERGLYCEMIC HYPEROSMOLAR NON-KETOTIC SYNDROM (HHNS) - A serious condition in which Hyperosmolar and extreme hyperglycemia predominate - Ketosis is minimal - Onset is slow and takes hours to days to develop - Occurs most commonly in Type 2 DM, ages 50 70 years old Precipitating Factors 1. Infection 2. Stress 3. Surgery 4. Medications like Thiazides 5. Treatment like dialysis

Assessment Findings 1. Profound Dehydration 2. Hypotension 3. Tachycardia 4. Altered sensorium 5. Seizures and hemiparesis

Chronic Complications of Diabetes Mellitus


Macrovascular Complication: MI, Stroke, Atherosclerosis, CAD, and Peripheral vascular disease Microvascular Complication: Micro angiopathy, retinopathy, nephropathy Peripheral: Neuropathy Diabetic Retinopathy - A painless deterioration of the small blood vessels in the retina, may be classified as to background pre-proliferative and Proliferative retinopathy - Permanent vision changes and blindness can occur Diabetic Nephropathy

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Progressive deficiency of kidney functions

Diabetic Neuropathy - A group of disorders that affect all types of nerves including the peripheral, autonomic and spinal nerves

Diabetic Foot
Related Factors for the Development of Foot and Leg Ulcers 1. More than 10 years diabetic 2. Age of greater than 40 years 3. Smoking 4. Anatomic deformities 5. History of previous leg ulcers Management: - Teach patient proper care of the foot - Daily assessment of the foot - Use of mirror to inspect and monitor - Inspect the surface of shoes for any rough spots or foreign objects - Properly dry the feet - Instruct to wear closed-toe shoes that fit well, recommend use of low heeled shoes - Instruct client NEVER to walk barefoot, NEVER to use heating pads, OPEN-TOED shoes and SOAKING FEET! - Trim toenails straight across and file sharp corners - Instruct to avoid smoking and over the counter medications and HOME remedies for foot problems

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