Anda di halaman 1dari 81

By : Hj.

Muaeni, SKp, MKep

DIABETES MELLITUS
Suatu sindroma gangguan metabolisme dgn hiperglikemia yg tdk semestinya sebagai akibat suatu difisiensi sekresi insulin at. berkurangnya efektifitas biologis dari insulin atau keduanya. Karakteristik difisiensi insulin yg utama adl gg. dlm metabolisme carbohidrat, protein dan lemak DM refers to disorders characterized by fasting hyperglycemia or bloodglucose levels above defined limits. Diabetes akan mengalami pengobatan sepanjang hidup dan pd populasi dewasa membuat centers for disease control and prevention (CDC, 1997) is the seventh leading cause of death DM is major risk factor for morbidity an mortality due to coronary disease, cerebrovasculer disease and peripheral vascular disease Penting mempertahankan konsentiasi glucosa yg konstan satu-satunya bahan makanan dapat digunakan oleh otak, retina, epitelium germinal dari gonad.

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

PATOFISIOLOGI
Berkurangnya sekresi insulin oleh sel beta pulau langerhans. (faktor heriditer, heriditer obesitas) Salah satu efek utama Berkurangnya pemakaian glukosa oleh sel-sel tubuh naiknya konsentrasi glukosa darah (300 mg 1200 mg/dl) Sgt meningkatkan mobilitas lemak dari daerah penyimpanan lemah terjadinya metabolisme lemak yg abnormal & endapan kolesterol pd dinding pembentukan darah aterosklerosis Berkurangya protein dalam jaringan tubuh

Hj. Hj. Muaeni, Muaeni, SKp, SKp, MKep / Diabetes Mellitus

Selain itu terjadi yg tdk tampak dgn mudah Hilangnya glukosa dlm urine klien DM * Jumlah glukosa yg memasuki tubulus ginjal (filtiasi glomerulus) meningkat diatas kadar kritis * Suatu kelebihan yg bermakna tdk dpt direabsorpsi & sebaliknya dikeluarkan dlm urine (100 mg/dl at. lebih glukosa) glukosa Dehidrasi akibat kenaikan kadar glukosa darah * Pd klien yg tdk diobati (meningkat sampai tinggi) (12 x dr normal) efek yg bermakna Dehidrasi sel-sel jaringan glukosa tdk dpt dgn mudah berdiffusi melewati pori2 membran sel & naiknya tekanan osmotik dlm cairan ekstraseluler timbulnya perpindahan osmotik air keluar dari sel (dehidrasi selluler)

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Dehidrasi seluler, keduanya glukosa ke dalam urin, dpt menimbulkan diuresis osmotik Efek osmotik dari glukosa dlm tubulus ginjal yg sangat mengurangi ke absorpsi cairan tubulus Efek keseluruhan : kehilangan cairan yg sangat banyak dlm urin dehidrasi cairan ekstrasell yg selanjutnya dehidrasi kompensatorik intrasell

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Clasification of Diabetes Mellitus and Related Glucose Intolerances Current Classification Type I : Insulin Dependent Diabetes Mellitus (IDDM) (5% - 10% of all Diabetes Previous Classifications Juvenile diabetes Juvenile onset diabetes Ketosis prone diabetes Brittle diabetes Clinical Characteristic and Clinical Implications Onset any age, but usually young ( <30 yrs) Usually thin at diagnosis; with recent weight loss Etiology includes genetic, immunolig, or environmental factors (eg, virus Often have islet cell antibodies Often have antibodies to insulin even before insulin treatment Little or no endogenous insulin Need insulin to preserve life Ketosis prone when insulin absent

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Acute complication of hyperglicemia; diabetic ketoacidosis Type 2 : Non insulin dependent diabetes (NIDDM) (90% -95% of all diabetes : obese 80% of type 2; non obese 20% of type 2) Adult onset diabetes Maturity onset diabetes Ketosis resistant diabetes Stable diabetes Onset any age, usually over 30 yrs Usually obese at diagnosis Causes include obesity, heredity, or environtmental factors No islet cell antibodies Decrease in endogenous insulin, or increased with insulin resistance Most patients can control blood glucose through weight loss if obese Oral antidiabetic agents may improve blood glucose lefels if dietary modification and exercise are unsuccessful

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

May need insulin on a short or long term basis to prevent hyperglycemia Ketosis rate, except in stress or infection Acute complication ; hyperglycemic hyperosmolar non ketotic syndrome Diabetes Secondary mellitus diabetes associated with other conditions or syndrome Accompanied by conditions known or suspected to cause the disease pancreatic diases , hormonal abnormalities, drugs such as corticosteroid and estrogen containing preparations Depending on the ability of the pancreas to produce insulin,the patient may require treatment with oral antidiabetic agens or insulin

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Gestational Gestational diabetes Onset during pregnancy, usually in the diabetes second or third trimester Due to hormones secreted by the placenta, which inhibit the action of insulin Above normal risk for perinatal complications, especially macrosomia (abnormalmaly abnormalmaly large babies) Treated with diet and if needed, insulin to strictly maintain normal blood glucose levels Occurs in about 2%-5% of all pregnancis Glucose intolerance transitory but may recurs * In subsequent pregnancies

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

* 30%-40% will develop overt diabetes (usually type 2) within 10 years (especially if obese) Risk factors includes obesity, age older than 30 years, family history of diabetes, previous large babies (over 9 lb) Screaning test (glucose challenge test) should be performed on all pregnant women between 24 and 2 weeks gestation Impaired glucose tolerence Borderline diabetes Latent diabetes Chemical diabetes Subclinical diabetes Oral glucose tolerence test value between 140 mg/dL (7.7 mmol/L) and 200 mg/dL (11 mmol/L) Impaired fasting glucose is defined as a fasting plasma glucose between

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Asympromatic 110 mg/dL (6 mmol/L) and 126 mg/dL (7 diabetes mmol mmol/L) 29% % eventually develop diabetes Above normal susceptibility to acherosclerosis disease Renal and retinal complications usually not significant May be obese or non obese; obese should reduce weight Should be screened for diabetes periodically Previous Latent abnormality of diabetes glucose Prediabetes tolerence (Pre AGT) Current normal glucose metabolism Previos history of hyperglycemia ( eg during pregnancy or illness) Periodic blood glucose screening after

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

age 40 if there is a family history of diabetes or if sympromatic Encourage ideal body weight, because loss of 10-15 lbs may improve glycemic control Potential abnormality of glucose tolerence (pot AGT) Prediabetes No history of glucose intolerence Increased risk of diabetes if : Positive family history Obesity Mother of babies over 9 lbs at birth Member of certain Native American Indian tribes with high prevalence of diabetes (eg. Pima) Screening and weight advice as in Pre AGT

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

CLINICAL MANIFESTATIONS :
Clinical manifestations of diabetes include the three Ps : polyuria, polydipsia, and polyphagia. Polyuria (increased urination) and polydipsia (increased thirst) occur as a result of the excess loss of fluid associated with osmotic diuresis. The patient also experiences polyphagia (increased appetite) resulting from the catabolic state incude by insulin defiency and the break down of proteins and fats. Other symptoms include fatigue and weakness, sudden vision changes, tingling or numbness in hands or feet, dry skin, sores that are slow to heal, and recurrent infections. The onset of type I diabetes may also be associated with nausea, vomiting, or abdominal pains.

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Mayor Risk Factors for type 2 Diabetes


Family histori of diabetes (parents or siblings) Obesity (more than 20% above a persons ideal body weight) Origin (African-Ameracan, Hispanic-American, American, Native American or Asian-American) Age older than 45 years plus any of the preceing factors Previously indetified impaire glucose tolerance or use of certain prescription drugs Hypertention (> 140/90 mmHg) High density lipoprotein cholesterol level < 35 mg/dL (0.90 mmol/L) and tryglyceride levels > 250 mg/dL (2.82 mmol/L) History of gestational diabetes or delivery of babies weighing more than 9 pounds From American Diabetes Association (1998 1998q). Position statement : screening for diabets. Diabets Care, 21 (suppl, 1) S20-22 22

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Problems of Regulation and Metabolism ACUTE COMPLICATIONS OF DIABETES Three emergencies related to major deviations from normal blood glucose level occur in clients who have diabetes Diabetic ketoacidosis (DKA) is associated with insulin defiency and ketosis Hyperglycemia hyperosmolar non ketotic syndrome (HHNS) is associated with insulin defiency, profound dehydration, and the absence of ketosis Hypoglicemia occurs in conditions of insulin excess All three conditions need emergency treatment and can result in death if inappropriatelly treated or not treated at all

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

CRONIC Macrovascular Cardiovaskular Didease : AMI, Congesti heart failure, dysrhythmias cardiogenic shock Peipheral vascular disease Cebrovascular disease Microvascular Ocular complication : retinopathy, non prolifhative retinopathy Diabetic neurophaty Diabete nephropathy Male erectile dysf

Hj. Hj. Muaeni, Muaeni, SKp, SKp, MKep / Diabetes Mellitus

NURSING PROSES : Assesment and Diagnostic Findings Darah Gula darah test Oral glucosa tolerance test Glycosylated Hemoglobin Assays mengukur % glukosa yg melekat pd HB glukosa tetap melekat pd hemoglobin selama hidup sel darah merah, rentang normal 5 6% Urine Urine testing for ketone bodies ( DM tipe I(+) ) Test fungsi ginjal Test urine glukosa

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Laboratory Profile : Blood Glucose Values Tes Fasting glucose Normal Range for Significance of Abnormal Finding Adult blood < 110 mg/dL (6.1 Elevayions > 126 mg/dL (7.0 mmol/L) mmol/L) (obtained on 2 occasions) Elderly : levels rise are diagnostic of diabetes, even in older adults 10 mg/dL per decade of age

Glucose Tolerance < 140 mg/dL (7.8 Test (2 hour post mmol/L) glucose load)

Levels > 140 mg/dL (7.8 mmol/L) and < 200 mg/dL (11.1 mmol/L) = IGT (Impaired Glucose Tolerance) Levels > 200 mg/dL diagnostic of diabets in non pregnants adults

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Glycosylated 4% - 6% (glycated) hemoglobin Alc (HbAlc)

Levels over 8% indicate poor diabetic control with need for adherence to regimen or chages therapy

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Education Guide : Plasma Gluce Testing Fasting plasma blood glucose Do not eat flood or drink any liquid for at least hours

Oral glucose tolerance test Eat a balanced diet with carbohydrate intake of at least 150 g for a minimum of 3 days while maintaining normal physical activity Carbohydrate restriction, bedrest, acute illness, and certaindrugs interfare with the test. Phenytoin (dilantin), anovularity drugs, diuretics, nicotinic acid, and glucocorticoids adversely affect results The test is ferformed in the morning after 1 10 to 12 hour fast

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

A fasting blood sample is obtained You will be asked to drink 300 ml (75 g) of a flavores beverage within 5 minutes of the fasting blood sample Blood sample are drawn at 30 minute intervals for 2 hours (60 90) During the test, you will remain at rest and not be able to smoke or drink liquids Report any signs sugesting hypoglycemia, such as weakness, dizziness, nervousness, and confusion

Hj. Hj. Muaeni, Muaeni, SKp, SKp, MKep / Diabetes Mellitus

Nursing Guidelines for assessing a patient with Diabetes Mellitus Assestment Item PATIENT HISTORY Duratation of diabetes Ask the patient when the diabetes diagnosis was reason for admission or made appointment Ask the patient to describe the reason in detail for seeking care Patients diet Ask the patient to write down from memory everything eaten for the previous 2 day to determine whether patient understands and complies with a previously taught diet If the patient has been administering insulin at home, observe patient prepare and administer insulin in the hospital. Ask the patient to state the name and dose of the insulin and time Special Considerations

Insulin therapy

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

taken and to describe its action according to onset, peak, and duration Antidiabetic oral agents If the patient takes oral antidiabtic agents, ask the patient to state name of the agents. Ask patient whether he or she knows the difference between insulin and oral antidiabetics agents Self blood glucose monitoring If the patient has been doing this procedure at home, observe whhile its performed. Ask the patient to describe low he or she interprets the result. Ask the patient to state the causes, symptoms, and treatment of hypoglycemia, hyperglycemia, and ketoacidosis

Knowledge of acute complications

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Knowledge of sick day Ask the patient to describe how he or she manages management sick days regarding diet and medication. Detemine whether patient understands implications of illness, especially infections, nausea, and vomiting, and diarhea. Foot care routine Ask the patient to describe how he or she takes care of the feet. Determine whether patient understand implications of foot care problems Determine whether the patient leads a sedentary or active lifestyle and whether he or she understands the effect of exercise on blood glucose levels Ask the patient to explain what diabetes is and how it effect the body

Exercise

Basic physiology of diabetes

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Long term degeneraive Ask the patient to list the long term changes that can occur with diabetes and how to delay their onset changes Personal history Find out whether patient lives alone or with others; lifestyle, including occupations hobbies, and weekend activities; whether patient receives social assistance and whether there is a family history of diabetes Ask to see the diabetic identification the patient wears or carries

Diabetic identification

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

PHYSICAL EXAMINATION Infections Asses for the presence or history of Candida albicans in the groin, the axillae, and under the breast, and of vaginal yeast infections in females Asses for urinary tract infections Examine the tibial area for the presence of shin spots; known ask diabetic dermopathy, and for necrobiosis, which is characterized by raised reddened lesions with sharply defined borders Examine the elbows and knees for xanthomas, which are you yellow fat defosit Examine insulin injection sites for the presence of lipodystrophy

Diabetic dermopathy

Xanthomas lipodystrophy foot and leg problems

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Examine the feet and legs for sores, blisters, reddened areas, or ulcers Examine the toenalis to see whether they are thick and hard to cut Palpate the dorsalis pedis and posterior tibial pulse Examine the dorsal part of the foot for hair loss Palpate ankles for edema Physical condition Asses weight, blood pressure and pulse Asses for symptoms of cardiovaskular disease dyspnea, irregular apical or brachial pulse, dependent edema, orhostatic hypotension Examine hands for sores, burn or muscle atrophy

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Asses for gastrointestinal disturbances, such as diarrhea, especially at night Asses for impotence or other reproductive problems Asses for loss of sensations in extrimities

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Hj. Hj. Muaeni, Muaeni, SKp, SKp, MKep / Diabetes Mellitus

Analysis Common Nursing Diagnoses and Collaborative Problems Common nursing diagnoses for the diabetic client include : 1. 2. 3. 4. 5. Risk for injury relate to hyperglicemia Risk for injury related to stress of surgery Risk for injury related to sensory alterations (diabetic neuropathy) Pain related to peripheral nerve dysfunction (diabetic neuropathy) Risk for injury related to visual sensory percetual alterations (diabetic neuropathy) 6. Altered renal tissue perfussion related to the renal effects of vascular abnormalities (diabetic nephropathy)

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Primary collaborative for the diabetic client include : 1. Potential Complications : Hypoglicemia 2. Potential Complication : Diabetic Ketoacidosis 3. Potential Complication : Hyperglycemic Hyperosmolar Nonketotic Syndrome Additional Nursing Diagnoses and Collaborative Problems In addition the common nursing diagnoses and collaborative problems, some clients with diabetes have one or more of the following : Altered Nutrition : more than body requirentment related to an imbalance of food intake and physical activity, lack of knowledge, and ineffective coping skills Risk for fluuid volume deficit related to fluid shifts, failure of regulatory mechanisms, hyperglycemic osmotic diuresis, polyuria, vomiting, diarrhea, decreased oral intake and dehydration Pain related to insulin injections or capilarry blood glucose testing

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Altered oral mucous membranes related tomicrovascular circulatory changes and uncontrolled blood glucose levels Knowledge deficit related to a lack of familiarity with information resources about disease process, nutrition management, exercise, medications, weight control and mouth care Altered urinary eliminationwith overflow incontinence related to diabetic neuropathy Chronic constipation related to diabetic neuropathy Diarrhea related to diabetic neuropathy Risk for impaired skin integrity related to decreased circulation, increased bloods glucose levels, decreased mobility and decreased sensation Risk for infection related to encreased blood glucose levels, decreased tissue perfussion, inadequity primary defenses (e.g break in skin integrity) and the effect of chronic disease Risk for infection related to wounds, urinari tract infection, intravenous acces site, or the gums

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Risk for altered sexuality patterns (male) related to autonomic neuropathy, decreased cisculation or phsichological considerations Risk for altered sexuality patterns (female) related to the physical and psychological stressors of diabetes lubrication, painful inter course with the changes in neurologic control of genitalia, the effect of actual or perceived limitations imposed by the disease or theraphy and altered self concept Anticipatory grieving related to perceived loss of body functions as a consequence of diabetes Dysfunctional grieving related to perceived loss of body functions as a consequence of diabetes Self esteem disturbance related to inability to deal with the self care demands of diabetic regimen Anxiety related to the diagnosis of diabetes, potential complications of diabetes and self care regimens Fear related to the diagnosis of diabetes, potential complications of diabetes and self care regimens

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Risk for ineffective individual coping relatedto a chronic disease, a compleks self care regimen and decreased social support Risk for ineffective family coping, compromised, related to a chronic disease, a comples self care regimen and decreased social support Powerlesness related to the complications of diabetes (blindness, amputations, renal failure, renal failure and neuropathy) Social isolation related to visual impairment or blindness, adoption of sick role and a complex self care regimen) Risk for noncomplience with self care related to the complexityand chronicity of the prescribed regimen Risk for altered health maintenance related to insuficient knowledge of nutition therapy, weight control, weight maintenance, benefit and risk of exercise, self mo nitoring of blood glucose, medications, sick day care, foot care hypoglycemia and available resources

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

NURSING CARE PLAN : PATIENT WITH DIABETES MELLITUS Expected Patient Outcomes Nursing Interventions and Rationales

Ambulatory and Home Care


NURSING DIAGNOSIS : ineffective management of therapeutic related to inadequate knowledge of adequate exercise program, diet dan weight control, administration and potensil side effect of glucose lowering agents (GLAs), glucose monitoring, and care during acute minor illness as manisted by frequent questioning regarding diabetic management, inaccurate responses to questions about diabetic management. Participation in exercise program Appropriate dietary preperation and intake Safe, effecive administration of GLA Demonstration of proper blood glucose testing and recording of meaurements Plan of action for self in event of illness and symptoms lasting > 24 hr Plan individualized exercise program with patient because exercise is an integral part of diabetic management Review step to prevent hyperglycemia and hypoglycemia because activity changes and cause changes in insulin needs Review diet and problem areas with patient to provide appropriate teaching

Hj. Hj. Muaeni, Muaeni, SKp, SKp, MKep / Diabetes Mellitus

Counsel on weight loss if appropriate because excess weight complicates diabetic management Refer to dietician because dietary management of diabetes can be complex and requires ongoing monitoring Review GLA administration; have patient give return demonstration of insulin injection to ensure profer technique Assess injection sites to determine need for changing sites or initiating treatment to problematic areas Review symptoms and treatment of hypoglycemia so early treatment can be initiated

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Demonstrate glucose testing; have patient give return demonstration to ensure proper technique Review glucose records with patient and explain how to identify trends to improve glucose control Remind patient to call physician if blood glucose is > 250 mg/dl (13.9 mmol/L) and ketonuria is present so appropriate adjustments can be made to prevent developtment of diabetic ketoacidosis (DKA) Review effect of stress on glycemic control so patient is aware that stress can increase glucose level Review sick day care so patient can make appropriate adjustment in diabetic management

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Assist patient in devising a sick day plan, including foods to have on hand and family member or friend who can be with patient during illness episode, to be ready to properly manage diabetes when illness occurs Review symptoms needing attention of physician, including blood glucose level > 250 mg/dl (13.9 mmol/L), ketonuria, fever, nausea, and vomiting so patient can contact physician when necessary to prevent occurrence of DKA and hyperglycemia hypersmolar nonketosis (HHNK)

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

NURSING DIAGNOSIS : Risk for infection related to depressed immune system, inadequate circulation and environtmental pathogens Verbelazation of steps to prevent infection (skin care, foot care, regular dental care) Recognition of signs of infection and need for intervention Asses for sign of infection such as fever, redness, swelling or pus at trauma of pressure site; fever to ensure early recognition and treatment Asses oral civity, skin, pulses, particulary lower extremities and pedal pulses to detect areas of infection or poor circulation Review skin and foot care, have patient give return demonstration of foot care to ensure patient understanding Review signs of infection, including redness, swelling, pus and when to contact health care provider to ensure patient recognizes infection and notifies health care provider if indicated so treatment can be initiated

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

NURSING DIAGNOSIS : Self esteem disturbance related to lifestyle changes imposed by diabetes and its treatment and frustation at progerssion of disease as manifested by negative feelings about self, resistence to incorporating treatment regimen into lifestyle Verbelazation of positive attitude about self and ability to manage disease Plan for continued contact with health care provider for health monitoring Encourage patient to discuss diagnosis and its implications so appropriate counseling and interventions can be palnned Suggest individualized diabetes education and support group toincrease patients knowledge base and meet other people with diabetes Suggest creative approaches to problems with patient because patient may be overwhelmed initially by compexity of disease management Assure patient of continued value and self worth to minimize impact of diabetes onpatients self esteem

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

COLLABORATIVE PROBLEMS Nursing Interventions and Rationales Acute Management DKA and HHNK related to in adequate POTENTIAL COMPLICATION insulin and excess blood glucose secondary to increased caloric intake, physical or emotional stress, or undiagnosed Monitor for signs of DKA and HHNK Asses for signs of DKA such as Report deviations from acceptable increase in urination; vomiting; somnolence; dehydration; dry; loose parameters Carry out appropriate medical and skin; hypotention with weak, rapid pulse, coma; hyperglicemia > 250 nursing intervention mg/dl (13.9 mmol/L); presence of urine ketones; PH < 7.3 to ensure early recognitzion and intervention Nursing Goals

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Asses for signs of HHNK such as hyperglycemia > 00 mg/dl (27.8 mmol/L), serum osmolality > 300 mOsm/kg (300 mmol/kg, absence of ketonuria to detect signs of HHNK Administer insulin per physician order to stabilize blood glucose level Administer fluid and alectrolyte replacement as ordered to correct dehydration monitor input and out put and vital signs to detect signs and symptoms of iadequate tissue perfusion Asses for precipitating factors to prevent resurrence and identify teaching needs

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

POTENTIAL COMPLICATION Monitor for signs of hypoglycemia Report deviations from acceptable parameters Carry out appropriate medical and nursing intervention

Hypoglycemia related to low blood glucose secondary to too much insulin Assess for signs of hypoglicemia such as cold sweats; weakness; trembling; nervousness; irritability; pallor; increase in heart rate; confusion; fatigue; abnormal bahavior to ensure prompt identification and treatment Check blood glucose if time permits (e.g when symptoms are mild) to provide an indicator for treatment Provide quick acting carbohydrate sources such as 6-8 oz orange juice, 1 cup milk, or 6-8 oz soft drink to quickly reverse hypoglycemia; give orally only if patient is alert enough to swallow to prevent aspiration.

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Rimprovement or patient is comatose, administer 1 mg glucagon subcutaneously or 30-50 ml of 50% IV dextrose per physician order to stimulate hepatic response to convert glycogen to glucose When patient improves and is alert, provide long acting carbohydrate or next scheduled meal to keep blood glucose levelwithin acceptable range Asses for precipitating factors such as history of too much insulin, to little food, unusual amounts of exercise, or delayed eating to prevent recurrence and identify precipataring epeat oral dose in 10-15 min if no factors

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Lima komponen dari management untuk DM (United Kingdom Prospective Diabetes Study Group / UKPD98)

Nutritional Management Education Exercise

Pharmacologic

Monitoring

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Oral Antidiabetics Agents Used in the United States


Generic (Trade) Name Table Size (mg) Usual Daily Dose (mg) Maximum Duration of Dose (mg) Action (h)

First Generation Sulfonylureas accrohexamile (dymelor) 250 500 250-1500 (D) chlorpropamide (diabinese) 100-500 (S) 100, 250 tolazamide (tolinase) 100, 20, 500 100-750 (D) tolbutamide (orinase) 250, 500 500-2000 (D) Second Generation Sulfonylureas glipizide (glucatrol) glipizide (glucatrol XL) gliburide (micronase)

1500 750 1000 3000

12 24 60 12 24 6 12

5, 10 5, 10 1.25, 2.5, 5

5-25 (D) 5 (S) 2.5 10 (D)

40 10 20

10 24 24 12 24

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

glimeperida (amaryl) biguanides merformin (gluphages) Alpha Glucosidase Inbitors acarbose (precose) Thiazolidinediones troglitazone (rezulin) Meglitinides repaglinide (parandin)

1, 2, 4 500

1 2 (S) 1500 (D)

8 2500

24 8

50, 10 200, 400 1.5, 1, 2

1500 (D) 200400 (S) 0.5 - 4

2500 600 16

8 2

D = Divided Dose S = Single Dose

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Long Theraphy for Diabetes Mellitus : Oral Agents


Drug Usual Dosage & Duration Nursing Interventions Rationale

First Generation Sulfonylurea 250-750 mg q 12-24 h Acetohexamide Maximum : 1500 mg/day (Dymelor, Duration : 24 60 h Dimelor)

Emphasize eating habits and pattern Monitor renal function

There Is high incidence of hypoglycemia in diabetics with renal impairment

chlorpropamide 100-500 mg q 24h (Diabenese, Maximum : 500 mg/day Novopropamid Duration : 24 60 h e)

Emphasize eating The long half life of drug is habits and pattern the associated with a s high incidence of hypoglycemia

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Tolazimide (Tolinase)

100-500 mg q 12 24 h Administers meal Maximum : 2000 mg/day Duration : 12 24 h

with Taking with meal helps to avoid gastrointestinal upset

Tolbutamide (Orinase, Mobenol)

750-1500 mg q 1224 30 Taking 30 minutes 24 h Administers minutes before before meals give Maximum : 3000 the best reduction meals mg/day in postprandial Duration : 16 12 h hyperglicemia 2.4 5 mg q 12-24 h Maximum : 40 mg/day Duration : 12-24 h Administer 30 Taking 30 minutes minute before before meals give the best reduction meals in postprandial hyperglicemia

Second Generation Sulfonylurea Agents

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Emphasize eating The long hal life habits and patterns the drug associated with high incidence hypoglicemia

of is a of

Glyburide (Micronase, DiaBeta, Euglocon)

2.5 20 mg q 24 h Maximum : 20 mg/day Duration : 16-24 h

Administers meals

with Taking with meals helps to avoid gastrointestinal upset of is a of

Emphasize eating The long hal life habits and patterns the drug associated with high incidence hypoglicemia

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Glimepiride (Amaryl)

1-4 mg q 12-24 h Maximum : 8 mg Duration : 24 h

Take with first main meal Emphasize eating habits and patterns, and blood glucose monitoring result

Client with impaired renal function are more sensitive to glucose lowering effects of glimepiride

Biguanides Metformin (Glucophage)

500 mg q 12-24 h Maximum : 2500 mg/day Duration : 12 h

Administer with Taking with meals monitoring and help to avoid evening meals gastrointestinal upset

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Alpha Glucosidase Inhibitors acarbose (Precose)

25 mg three times/day Maximum : 100 mg three times/day Duration : 4-8 h

Administer with first Delays carbohidrate bite of food absorption

Thiazolidinedione 200-600 mg q 24 h antidiabetic Maximum : 600 mg/day Agents (Rezulin) Duration : 24 h

Administers meals

with Taking with meals help to avoid gastrointestinal upset

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Insulin Preperations
Type Rapid Acting Insulin insulin analog (Insulin lispro) humalog (Lilly) Short Acting Insulins insulin injection (regular crystaline insulin) illetin II R (Lilly) regular (novo nordisk) humalin R (lilly) novolin R (novo nordisk) velosulin BR (Novo nordisk) illetin II U-500 (lilly) Source Onset (hr) 0.3 0.5 DNA technology Peak (hr) 0.5 2.5 Duration 3.0 4.3

Pork (purified) Pork DNA technology DNA technology Semisynthetic Pork (purified)

0.5 1 0.5 0.5 1 0.5 0.5 0.5

24 2.5 5 24 2.5 5 13 -

68 8 68 58 8 24

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Intermediate Acting Insulins isophane insulin suspension (NPH insulin) illetin II (lilly) NPH (novo nordisk) NPH pork (novo nordisk) humulin N (lilly) novolin N (novo nordisk) Insulin zinc suspection (lente insulin) illetin II (lilly) lente (novo nordisk) humulin L (lilly) novolin L (novo nordisk)

Pork (purified) Beef Pork (purified) DNA technology DNA technology

2 1.5 1.5 12 1.5

6 12 4 12 4 12 6 12 4 12

18 26 24 24 18 24 18 24

Pork (purified) Beef Pork (purified) DNA technology DNA technology

24 2.5 2.5 13 2.5

6 12 7 15 7 15 6 12 7 15

18 24 24 22 18 24 18 24

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

fixed combination insulins humulin 70/30 (lilly) humulin 50/50 (lilly) novolin 70/30 (novo nordisk) Long Acting Insulins (Ultralente) humulin U (lilly) Buffered Insulins for use in eksternal pumps humulin BR (lilly) velosulin R (novo nordisk)

DNA technology DNA technology DNA technology

0.5 0.5 0.5

2 12 35 2 12

24 24 24

DNA technology

46

8 20

24 28

DNA technology Pork (purified)

0.5 1 0.5

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Education Guide : Subcutaneous Insulin Administration


Wash your hands Inspect the bottle for the type of insulin and the expiration date Gently roll the bottle of intermediate acting insulin in the palms of your hands to mix it Clean the rubber stopper with an alcohol swab Remove the needle cover and pull back the plunger to draw air into the syringe. The amount of air should be equal to the insulin dose. Push the needle through the rubber stoper and inject the air into the insulin bottle Turn the bottle upside down and draw the insulin dose into syringe Remove air bubbles in the syringe by tapping on the syringe or injection air back into the bottle; Redraw the correct amount Make certain the tip of the plunger is on the line for your dose of insulin. Magnifers are available to ssist in measuring accurate doses of insulin Remove the needle from the bottle. Recap the needle if the insulin is not to be given immediatelly

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Select a site within your injection area that has not been used in the past month Clean your skin with an alcohol swab. . Lightly grasp an area of skin and insert the needle at 90 degree angle Push the plunger all the way down. This will push the insulin into your body. Release the pinched skin Pull the needle straight out quickly. Do not rub the place where you gave the shot Dispose of the syringe and needle without recapping in a puncture proof container

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Education Guide : How to mix a prescribed dose of 10 U of reguler insulin and 20 U of NPH Insulin Wash your hands Inspect the bottle for the type of insulin and the expiration date Gently roll the bottle of intermediate acting insulin in the palms of your hands to mix it Clean the rubber stopper with an alcohol swab INJECT 20 U of air into the NPH insulin bottle. The amount of air should be equal to the dose of insulin needed. . Always inject air into the intermediate acting insulin first. Withdraw the syringe. syringe Inject 10 U of air into the reguler insulin. insulin Be sure that the syringe is free of air bubbles. Always withdraw the shorter acting insulin first. Withdraw 20 U of NPH insulin with the same syringe, being careful not to inject any short acting insulin into the bottle. (A total of 30 U should be in the syringe)

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Gambar : Common Insulin Injection Sites

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Gambar : Self Injection of Insulin

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Outcome Criteria for Determining Efectiveness of Self Injection of Insulin Education Insulin : 1. Identifies information on label of insulin bottle : * Type (eg, NPH, regular, 70/30) * Species (human, biosynthetic, pork) * Manufacture (lilly, novo nordisk) * Concentration (eg, U-100) * Experation date 2. Checks appearance of insulin * Clear or milky white * Checks for flocculaton (clumping, frosted appereance) 3. Identifies where to purchase and score insulin : * Indicates approximately how long bottle will last (1000 units per bottle U 100 insulin) * Indicates how long pened bottles can be used

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Syringes : 1. Identifies concentration (U-100) marking on syringe 2. Identifies size of syringe (eg, 100-unit, 30-unit) 3. Describe appropriate disposal of used syringe Preparation : 1. Draws up correct amount and type of insulin 2. Properly mixes two insulin if necessary 3. Insert needle and injects insulin 4. Describes site rotation * Demonstrates injection with all anatomic areas to be used * Describes pattern for rotation, such as using abdomen only or using certain areas at the same time of day * Describes system for remembering site locations, such as horizontal pattern across the abdomen as if drawing a dotted line

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Knowledge of insulin action : 1. List presciption * Type and dosage of insulin * Timing of insulin injections 2. Describes approximate time course of insulin action : * Identifies long and short acting insulins by name * States approximate time delay until onset of insulin action * Identifies need to delay food until 15 to 30 minutes after the injection (indicated when injecting regular insulin) * Knows that longer time delay are safe when blod glucose level is high, and time delays may need to be shortened when blood glucose level is low * Describes system for remembering site locations, such as horizontal pattern across the abdomen as if drawing a dotted line

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Incorporation of insulin injections into daily schedule : 1. Recites proper order of premeal diabetes activities : * May usemnemonic device such as the word tie. which helps that patient remember the order of activities (t = test blood glucose. I = insulin injection, e = eat) * Describes information regarding hypoglycemia such as test, insulin, eat before breakfast and dinner, test and eat, before lunch and bedtime 2. Describes information regarding hypoglicemia * Symptoms : shakiness, sweating, neervousness, neervousness hunger, weakness * Causes : too much insulin, too much exercise, not enough food * Treatment : 10 to 15 g simple carbohydrate, such as two or three glucose tablets, 1 tube glucose gel, 0.5 to 1 cup juice * After initial treatment, follow with snack including strach and protein, such as cheese and crackers, milk and cracjers, cracjers half sandwich

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

3. Desribes information regarding prevention of hypoglicemia : * Avoid delays in meal timing * Eat a meal or snack approximately every 4 to 5 hours (while awake) * Do not skip meals * Increase food intake before exercise * Chech blood glucose regularly * Change insulin dosoes only with medical supervision * Carry a form of fast acting sugar at all times * Wear a medical identification bracelet * Teach family, friends, coworkers about sign and treatment of hypoglycemia * Have family, roommates, travelling companions learn to use injectable glucagon for severe hypoglicemic reactions. reactions

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

4. Regular follow up for evaluation of diabetes controll : * keeps written record of blood glucose, insulin doses, hy[oglicemia reactions, variations in diet. * Keeps all appointments with health professionals * Sees physician regularly (usually two four times per year) * States how to contact physician in case of emergency * States when to call physician to reprt variations in blood glucose levels

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Focused Assestment of the Insulin Dependent Diabetic Client During a Home or Clinic Visit
Asess overall mental status, wakefulness, ability to converse Take vital signs and weight - Fever could indicate infection - Is blood pressure and weight within target range? Why or why not Question client regarding any change in visual acuity; check current visual acuity Question client about injection areas used ; inspect areas being used; asses whether client is utilizing areas and sites appropriatelly Inspect skin for inactness; wounds that have not healed, new sores, ulcers, bruises, or burns. Assess any previously known wounds for infection, progression of healing Question client regarding foot care Assess lower extremities and feet for peripheral pulses, lack of or decreased sensation, abnormal sensations, breaks in skin integrity, condiion of toes and nails

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Questions client regarding color and consistensy of stools and frequensy of bowel movements; assess abdomen for bowel sounds. Review clients home health diary : * Is blood glucose within targeted range? Why or why not? * Is glucose mnitoring being recorded often enough? * Is the clients food intake adequate and approoriate? Why or why not? * Is exercise occuring regularly? Why or why not? Assess clients ability to perform self monitoring of blood glucose Assess clients procedures for obtaining and storing insulin and syringes, cleaning of equipment, disposing of syringes and needles Assess clients insulin preparation and injection technique

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Education Guide : Treatment of Hypoglicemia at Home For mild hypoglicemia (hungry, irritable, shaky, weak, headache, fully conscious, blood glucose usually less than 60 mg/dL [3.4 mmol/L] :
Treat the symptoms of hypoglycemia with 10 to 15 g of carbohydrate. You can use one of the following : * 2-3 glucose tablets * cup of orange or grape juice * cup of regular soft drink * 8 oz of skin milk * 6-10 hard candies * 4 cubes of sugar * 2 packets of sugar * 6 saltines * 3 graham crackers Retest blood glucose in 15 minutes

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Retest blood glucose in 15 minutes Repeat this treatment if symptoms do not resolve Take same food or the next scheduled meal within 15 to 30 minutes For moderate hypoglicemia (pale, cold and clammy skin, rapid pulse, rapid and shallow respirations, marked change in mood, drowsiness, blood glucose usually lessnthan 40 mg/dL [2.2 mmol/L] /L] Treat the symptoms of hypoglicemia with 15 to 30 g of rapidly absorbed carbohydrate Take additional food, such as low fat milk or cheese, after 10 to 15 minutes For severe hypoglicemia (unable to swallow, unconsciousness or convulsions, blood glucose usually less than 20 mg/dL (1.0 mmol/L), treatment administered by family members : Administer 1 mg of glucagon as intramuscular or subcutaneous injection Administer a second dose in 10 minutes if the person reains unconscious

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Notify a primary care provider immediatelly and follow instructions If still unconscious, transport the person to the emergency department Give a smell meal when the person wakes up and is no longer nauseated EVALUATION The ultimate evaluation of success of survival level and in depth diabetic education is the ability of the client to maintain blood glucose levels within the normal range. Specific outcome criteria for client education are listed below. Maintain blood glucose levels within the normal range Avoid acute and chronic complications of diabetes Have a satisfactory and complete postoperative recovery without complications Identify factors that increase potential for injury Practice proper foot care to prevent injury Maintain intact skin of pain Experience relief of pain

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Identify measures that increase comfort Maintain optimal vision Be free from injury related to decreased visual acuity Maintain optimal urinary output Have an optimal level of mental status functioning Have decreased episodes of hypoglicemia Have minimized episodes of hyperglicemia

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

NUTRITIONAL THERAPY Factor Total Calories Type 1 Diabetes Mellitus Type 2 Diabetes mellitus

Increase in caloric intake Reduction in caloric intake possibly necessary to achieve desirable for the obese patient desirable body weight and restore body tissues Diet and insulin necessary for Diet alone possibly sufficient for glucose control glucose control

Effect of diet

Distributio Equal distribution of Equal distribution not essential; n of carbohydrates for insulin low fat desirable; consistency calories activity of carbohydrate intake at meals desirable

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

Consistency Necessary for glucose control in daily intake Uniform timing of meals

Desirable for weight reduction

Grucial for NPH / Lente insulin Desirable but not essential programs; flexibility with multidose rapid actin insulin

Intermeal Frequently necessary Not recommended and bedtime snacks Carbohydrates 20 g/hr for Necessary if patient controlled Nutritional moderate physical activities supplement of sulfonylurea or insulin for exercise programs

Hj. Muaeni, SKp, MKep / Diabetes Mellitus

DIABETES MELLITUS
USA 15,7 million people 162.000 kematian 60 65 % Hipertensi

Afrika & Amerika, Caucasians

Etiologi not single disease group (Genetally and dinically neterogenesus disorders charaktestined abnormal keseimbangan glucosa hyperglycemia DM penyebab pe pe sekresi at aktivitas dr insulin gangguan metabolisme C.H, Fat and protein ^ Structural abnormalities in variety of organs and organ systems (the hearth, kidneys and eyes, develop (mikroangiophaty mikroangiophaty, macroangiopathy, neuropathy) ^ Chrome hyperglycemia gabungan dari semua DM is a associated with coplications in pregnancy DM type 2 (90%)

Diabetes Mellitus / Hj. Muaeni, SKp, MKep

Auto immune sel destruction, atributed genetic predisposisi satu banyak agenuimun dan kemungkinan zat-zat kimia huma leukocyte antigens (HL Ag), protein on the cell surface concrolled by gens on chromosome G five groups of the amtigens have been regornized (A, B, C, D and DR) SUS ceptibility type I strongly linked to the HR Ag, DR3, DR4 loci.

Diabetes Mellitus / Hj. Muaeni, SKp, MKep