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Assessment and Management of Pt w/ Diabetes Mellitus

Diabetes Mellitus
A group of metabolic disease characterized by increased levels of glucose in
the blood resulting from defects in insulin secretion, insulin action or both

Classification
Type 1 diabetes
Type 2 diabetes
Gestational diabetes
Diabetes mellitus associated w/ other conditions or syndromes
Different types of DM may vary in :
o
o
o

Cause
Clinical course
Treatment

Pathophysiology
Insulin

Secreted by beta cells in the islets of langerhans in the pancreas


Is anabolic /storage hormone
When a person eats a meal, insulin secretion increases and moves
glucose from blood into muscle , liver and fat cells
Functions of insulin in the cells :
o
Transport and metabolizes glucose for energy
o
Stimulates storage of glucose in the liver and muscle in the
o
o
o

form of glycogen
Signals the liver to stop the release of glucose
Enhances storage of dietary fat in adipose tissue
Accelerates transport of amino acids w/c derived from
dietary protein into cells

Inhibits the breakdown of stored glucose , protein and fat


During fasting periods, pancreas continuously releases a small
amount of insulin (basal insulin)

Glucagon

Another pancreatic hormone, glucagon (secreted by alpha cells) is

released when blood glucose level decrease


Stimulates the liver to release stored glucose

Glycogenolysis

Liver produces glucose through breakdown of glycogen

Gluconeogenesis

After 8 to 12 hours w/o food, liver forms glucose from the


breakdown of noncarbohydrate substances , including amino acids

Type 1 diabetes
5 % to 10 % of all diabetes
Previously classified as :
o
Juvenile diabetes
o
Juvenile-onset diabetes
o
Ketosis-prone diabetes
o
Brittle diabetes
o
Insulin-dependent diabetes mellitus (IDDM)
Onset any age, but usually young (<30 y)
Characterized by destruction of pancreatic beta cells
Possible contributors to beta cell destruction :
o
Genetic
o
Immunologic
o
Environmental (eg. viral)
Genetic susceptibility is a common underlying factor
People do not inherit type 1 itself but rather a genetic predisposition toward
development of type 1
The genetic tendency has been found in people w/ certain human leukocyte
antigen (HLA) types
There is also evidence of autoimmune response in w/c antibodies are
directed against normal tissues of the body
Destruction of beta cells results in :
o
Decreased insulin production
o
Unchecked glucose production by the liver
o
Fasting hyperglycemia
Glucose derived from food cannot be stored in the liver but instead remains
in the bloodstream and contributes to postprandial (after meals)
hyperglycemia

If concentration of glucose in blood exceeds the renal threshold for glucose


usually 180 to 200 mg/dL , kidneys may not reabsorb all the filtered
glucose , glucose then appears in urine (glycosuria)
When excess glucose is excreted in urine , it is accompanied by excessive
fluid and electrolyte loss (Osmotic diuresis)
Fat breakdown occurs resulting in increased production of ketone bodies

If the high risk women do not have GDM at initial screening , they should
retested bet. 24 and 28 weeks of gestation
All women of average risk should be tested at 24 to 28 weeks of gestation
Women considered to be at high or average risk should have either an oral
glucose tolerance test (OGTT) or a glucose challenge test (GCT)
Initial management include dietary modification and blood glucose monitoring
Goals for blood glucose levels during pregnancy :
o
105 mg/dL or less before meals
o
130 mg/dL or less 2 hr after meals
After delivery , blood glucose usually return to normal , however many
develop type 2 later in life

Prevention

Type 2 diabetes
90 % to 95 % of all diabetes
Previously classified as :
o
Adult-onset diabetes
o
Maturity-onset diabetes
o
Ketosis-resistant diabetes
o
Stable diabetes
o
Non-insulin dependent diabetes (NIDDM)
Onset any age, usually over 30 y & obese
2 main problems are insulin resistance (decreased tissue sensitivity) and
impaired insulin secretion
Increased amount of insulin must be secreted to maintain normal glucose
level
DKA does not typically occur
Gestational diabetes
Any degree of glucose intolerance
Secretion of placental hormones causes insulin resistance
High risk :
o
Obese
o
Personal history of GDM
o
Glycosuria
o
Strong family history of diabetes
High risk ethnic groups :
o
Hispanic Americans
o
Native Americans
o
Asian Americans
o
African Americans
o
Pacific Islanders

Type II DM can be prevented c appropriate changes in lifestyle


Persons at high risk for type II DM received either :
o
Standard lifestyle recommendations plus metformin
o
Standard lifestyle recommendations plus placebo
o
An intensive program of lifestyle modifications
The 16-lesson curriculum of the intensive program of lifestyle modifications
focused on :
o
Weight reduction of greater than 7 % of initial body weight
o
Physical activity of moderate intensity
o
Behavior modification strategies

Clinical Manifestations
Depend on the pts level of hyperglycemia
Classic clinical manifestations of all types of DM include 3 Ps :
o
Polyuria (increased urination)
o
Polydipsia (increased thirst) as a result of excess loss of fluid
o

associated c osmotic dieresis


Polyphagia (increased appetite) results from the catabolic state

induced by insulin deficiency & breakdown of protein and fats


Other symptoms :
o
Weakness
o
Skin lesions or wounds that are slow to heal
o
Fatigue
o
Recurrent infections
o
Sudden vision changes
o
Tingling or numbness in hands or feet
o
Dry skin
Onset of type I DM may also be associated c :
o
Sudden weight loss
o
Nausea
o
Vomiting
o
Abdominal pains

Medical Management

Main goal of DM treatment is to normalize insulin activity and blood glucose


(euglycemia) levels to reduce the development of vascular and

Assessment and Diagnostic Findings

Criteria for the Diagnosis of DM


Symptoms of DM plus casual plasma glucose concentration

200 mg/dL

. Casual is defined as any time of the day without regard to time since
last meal
Fasting plasma glucose 126 mg/dL . Fasting is defined as no caloric intake
for at least 8 hours
Two-hour postload glucose

200 mg/dL (glucose level 2 hours after

receiving glucose) during an oral glucose tolerance test


Gerontologic Considerations
App. 10 % to 30 % of elderly people have age related hyperglycemia
What causes age-related changes in CHO metabolism is not known
Possibilities that causes age related hyperglycemia :
o
Poor diet
o
Physical inactivity
o
Decrease in the lean body mass in w/c indigested CHO may be
o
o

stored
Altered insulin secretion
Increase in fat tissue w/c increases insulin resistance

neuropathic complications
Intensive glucose control / therapy :
o
3 or 4 insulin injections per day
o
Continuous SQ insulin infusion
o
Insulin pump therapy
o
Frequent blood glucose monitoring
o
Weekly contact c the diabetes educators
5 components of DM management
I. Nutritional Therapy
Foundations of DM management :
o
Nutrition
o
Meal planning
o
Weight control
Most important objective in dietary and nutritional management of DM :
o
Control of total caloric intake to attain or maintain a reasonable
body weight
o
Control of blood glucose levels
o
Normalization of lipids and BP to prevent heart disease
A registered dietitian has the major responsibility for designing and
teaching therapeutic plan
For obese pt c diabetes , weight loss is the key treatment
Overweight is considered to be a BMI of 25 to 29
Obesity is defined as 20 % above ideal body weight or BMI

30

BMI is a weight-to-height ratio calculated by dividing body weight (kg) by


the square of the height (m)
Meal planning and Related teaching

First step in preparing a meal plan is a thorough review of the pts diet

history to identify his or her eating habits and lifestyle


Have a thorough assessment of pts need for weight loss, gain or

maintenance
In most instances, people c type II DM require weight reduction
Initial education addresses :
o
Importance of consistent eating habits
o
Relationship of food and insulin
o
Provision of an individualized meal plan

Caloric Requirements

Calorie-controlled diets are planned by first calculating a persons


energy needs and caloric requirements based on age, gender, height and

o
Constipation if fluid intake is inadequate
If fiber is added in the meal plan , it should be done gradually and in
consultation c dietitian

weight
To promote a 1 to 2 pound weight loss per week, 500 to 1000 calories
are subtracted from the daily total
The calories are distributed into CHO, CHON, and fats and a meal plan

Soluble

is then developed
The priority for a young pt c type I DM should be a diet c enough

Legumes, oats and some fruits


Plays more role in lowering blood glucose and lipid levels than does

insoluble fiber
Slows stomach emptying and movement of food through upper digestive

calories to maintain normal growth and development . The goal initially


may be to provide a higher-calorie diet to regain lost weight and blood

tract

glucose control
Caloric Distribution

A meal plan for diabetes focuses on the percentage of calories that

come from CHO, CHON and fats


American Dietetic Association recommend that for all levels of caloric
intake :
o
50 % to 60 % of calories should be derived from CHO (whole
o
o

grains)
20 % to 30 % from fats
10 % to 20 % from CHON

Insoluble

Food Classification Systems

The caloric distribution currently recommended is higher in CHO than

in fat and CHON


CHO foods have the greatest effect on blood glucose levels because :
o
More quickly digested than other foods
o
Converted into glucose rapidly
Consist of sugars and starches
Low glycemic index diets may reduce postprandial glucose levels
All CHO should be eaten in moderation to avoid high postprandial blood

glucose levels
Foods high in CHO such as sucrose (concentrated sweets) are not

totally eliminated from diet but should be eaten in moderation (up to


10% of total calories) because they are typically high in fat and lack
vitamins , minerals and fiber
Fats

It is recommended in the diabetic diet to both reduce the total


calories and limit the amount of saturated fats to 10 % of total calories
Limit the total intake of dietary cholesterol to less than 30 mg/dL

CHON

Use of some non animal sources of protein to help reduce saturated fat

and alcohol intake


Amount of protein intake may be reduced in pt c early signs of renal
disease

Fiber

May improve blood glucose levels


May decrease the need for exogenous insulin
Lower total cholesterol and LDL levels
2 types : Soluble and Insoluble
At least 25 g should be ingested daily
One risk involved in suddenly increasing fiber intake is that it may
require adjusting the dosage of insulin or oral agents to prevent

Exchange Lists

6 main exchange lists :


o
Bread/starch
o
Vegetable
o
Milk
o
Meat
o
Fruit
o
Fat
Foods within one group contain equal numbers of calories and app. equal

in grams of CHON, fat and CHO


Foods on one list may be interchanged c one another

Nutrition Labels

percentage of calories from fat sources to less than 30 % of total

Several systems have been developed in w/c foods are organized into
groups c common characteristics such as :
o Number of calories
o Composition of foods (amount of CHO, CHON, fats in the food)
o Effect on blood glucose levels

CHO

Found in whole grain breads and cereals and in some vegetables


Along c soluble fiber, increases satiety which is helpful for weight loss

hypoglycemia
Other problems may include :
o
Abdominal fullness
o
Nausea
o
Diarrhea
o
Increased flatulence

Nutrition contents of foods listed on package labels


Label includes information about how many grams of CHO are in a
serving of food and can be used to determine how much medication is

needed (ex : 1 unit of insulin for 15 g of CHO)


CHO counting is a nutritional tool used for blood glucose management
because CHO are the main nutrients in food that influence blood
glucose levels

Healthy food choices

Measuring serving or choices


Used more often by people c type II DM
One CHO serving is equivalent to 15 g of CHO
Vegetables and meat are counted as 1/3 of a CHO serving

Food Guide Pyramid

Commonly used for pt c type II DM who have a difficult time following


a calorie controlled diet
Consists of the ff food groups :
o
Grains
o
Vegetables
o
Fruits
o
Milk and other dairy products
o
Meats and beans
Foods that are lowest in calories and fats and highest in fiber should
make up the basis of the diet

Fats, oils, and sweets should be used sparingly to obtain weight and

blood glucose control and to reduce risk for CVD


Reliance on the Food guide pyramid may result in fluctuations in blood
glucose levels because high CHO foods may be grouped c low-CHO

Have minimal or no calories


Produce minimal or no elevation in blood glucose levels
Have been approved by FDA as safe for people c DM
Include saccharin, aspartame, acesulfame-K , and sucralose

foods
Glycemic Index

Used to describe how much a given food increases the blood glucose

level compared c an equivalent amount of glucose


Guidelines when making dietary recommendations :
o
Combining starchy foods c protein-containing and fat-containing
foods tend to slow their absorption and lower the glycemic
o

response
Eating foods that are raw and whole results in a lower glycemic

response than eating a chopped , pureed, or cooked foods


Eating a whole fruit instead of drinking juice decreases the

glycemic response because fiber in fruit slows absorption


Adding foods c sugars to the diet may result in lower glycemic
response if these foods are eaten c foods that are more slowly

absorbed
Pt can create their own glycemic index by monitoring their blood
glucose level after ingestion of a particular food

Other Dietary concerns


Alcohol consumption

Pt c diabetes do not need to give up alcoholic beverages entirely but he


must be aware of the potential adverse effects of alcohol specific to

diabetes
Alcohol is absorbed before other nutrients and does not require insulin
for absorption
Large amounts can be converted to fats increasing the risk for DKA
Moderation is recommended
May lead to :
o
Excessive weight gain (from the high caloric content of alcohol)
o
Hyperlipidemia
o
Elevated glucose levels
Lower calorie or less sweet drinks and food intake along c alcohol
consumption are advised
Hypoglycemia

A major danger of alcohol consumption esp for pt who take insulin


Alcohol may decrease the normal physiologic reactions in the body that

produce glucose (gluconeogenesis)


If a pt c DM consumes alcohol on an empty stomach, there is an

increased likelihood of hypoglycemia


Pt should be cautioned to consume food along c the alcohol however
CHO consumed c alcohol may raise blood glucose

Sweeteners

Use of artificial sweeteners is acceptable


Moderation is encouraged to avoid potential adverse effects
2 main types : Nutritive and Nonnutritive

Nutritive sweeteners

Contain calories
Include fructiose , sorbitol, and xylitol , all of w/c provide calories in

amounts similar to those in sucrose (table sugar)


Cause less elevation in blood sugar levels than sucrose does
Often used in sugar-free foods
Sweeteners containing sorbitol may have laxative effect

Nonnutritive sweeteners

Misleading food labels

Foods labeled sugarless or sugar-free may still provide calories


equal to those of the equivalent sugar-containing products if they are
made c nutritive sweeteners

The above foods should not be considered free foods to be eaten in


unlimited quantity because they can elevate blood glucose levels

physical examination and exercise stress may be warranted before an

II. Exercise
Extremely important in DM management because of its effects :
o
Lowers blood glucose levels by increasing the uptake of glucose by
o
o

body muscles and by improving insulin utilization


Improves circulation and muscle tone
Can increase lean muscle mass thereby increasing the resting

metabolic rate
Alters blood lipid concentrations, increasing HDL and decreasing

cholesterol and triglyceride levels


Effects are useful in DM in relation to :
o
Losing weight
o
Easing stress
o
Maintaining a feeling of wellbeing
o
Prevent occurrence of Cardiovascular disease in w/c diabetic pt
are at risk to
Exercise coupled c weight loss improves insulin sensitivity and may decrease
the need for insulin or oral diabetic agents
Exercise Recommendations

Ideally , a person c diabetes should exercise at the same time


(preferably when blood glucose levels are at their peak) and in the same

amount each day


Regular daily exercise rather than sporadic exercise should be

encouraged
Must be altered as necessary for pt c diabetic complications
Avoiding trauma to lower extremities is esp. important in pt c numbness

r/t neuropathy
Increased BP associated c exercise may aggravate diabetic retinopathy

and increase risk of hemorrhage into retina


In general, a slow , gradual increase in the exercise period is

encouraged
For pt older than 30 y/o and who have 2 or more risks factors for
heart disease , an exercise stress test is recommended

Exercise Precautions

Pt who have blood glucose levels exceeding 250 mg/dL and who have
ketones in their urine should not begin exercising until the urine test
results are negative for ketones and blood glucose level is closer to

normal
Exercising c elevated blood glucose level increases the secretion of
glucagon, GH, and catecholamines . Liver then releases more glucose

and the result is an increase in blood glucose level


The physiologic decrease in circulating insulin that normally occurs c

exercise cannot occur in pt treated c insulin


Pt who require insulin should be taught to eat a 15 g CHO snack before

engaging in moderate exercise to prevent unexpected hypoglycemia


Pt taking insulin and participating in extended periods of exercise
should test their blood glucose levels before, during and after exercise
period

Post exercise hypoglycemia

Potential concern for pt who take insulin


May occur many hours after exercise
Pt may need to eat a snack at the end of exercise session and at
bedtime and monitor blood glucose level more frequently

Gerontologic considerations

Advantages of exercise in elderly :

o
Decrease in hyperglycemia
o
General sense of well being
o
Better use of ingested calories resulting in weight reduction
Because there is an increased incidence of cardiovascular problems, a

exercise program is initiated


Physical impairment due to other chronic illness must also be
considered

III. Monitoring Glucose levels and Ketones


Self-Monitoring of Blood glucose (SMBG)
Using frequent SMBG and learning how to respond to the results enable

Responding to Self-Monitoring of Blood glucose results

people with diabetes to adjust their treatment regimen to obtain


optimal blood glucose control
Allows for detection and prevention of hypoglycemia and hyperglycemia
Various methods of SMBG are available , most involve :
o
Obtaining of blood from fingertip ,applying blood to a special

detect patterns
To evaluate the need for dosage adjustments :
o
Testing is done at the peak action time of the medication
To evaluate basal insulin and determine bolus insulin doses :
o
Testing is done before meals
To determine bolus doses of regular or rapid acting insulin :
o
Testing is done 2 h after meals
Pt c type II DM :
o
Encouraged to test daily before and 2 h after the largest meal

the amt of time specified by the manufacturer


The Meter gives a digital readout of the blood glucose value
Meters are also available to check both blood glucose and blood

ketone levels
Laboratory methods measure plasma glucose
o
Plasma glucose values are 10 % to 15 % higher than whole blood

of the day until stabilized


Pt who take insulin at bedtime or who use insulin infusion pump :
o
Should test at 3 am once a week to document that the blood

glucose values
It is important for pt c DM to know whether their monitor and

glucose level is not decreasing during the night


A tendency to discontinue SMBG is more likely to occur if :
o
Pt does not receive instruction about using the results to alter

Pt are asked to keep a record of blood glucose levels so that they can

reagent strip and allowing the blood to stay on the strip for
o
o

With stress or illnesses

strips provide whole blood or plasma results


Methods for SMBG must match the skill level of pt
Factors affecting SMBG performance :
o
Visual acuity
o
Fine motor coordination
o
Cognitive ability
o
Comfort c technology
o
Willingness to use it
o
Cost
A potential hazard of all methods of SMBG is that pt may obtain and

the treatment regimen


o
Positive reinforcement is not given
o
Costs of testing increase
Baseline patterns should be established by SMBG for 1 to 2 weeks

Using a continuous glucose monitoring system (CGMS)

Can be used to continuously monitor blood glucose levels


A sensor attached to an infusion set w/c is similar to an insulin pump
infusion set , is inserted SQ in the abdomen and connected to the

report erroneous blood glucose values as a result of using incorrect

device worn on a belt


After 72 h , the data from the device are downloaded , and blood

glucose readings are analyzed


Cannot be used for making decisions about specific insulin doses but

techniques
Some common causes of error in SMBG :
o
Improper application of blood (e.g drop too small)
o
Damage to the reagent strips caused by heat or humidity
o
Use of outdated strips
o
Improper meter cleaning and maintenance
Nurses play an important role in providing initial teaching about SMBG

techniques
Q 6 to 12 mos. Pt should conduct a comparison of their meter result c a

Testing for Glycated Hemoglobin

simultaneous laboratory-measured blood glucose level


Accuracy of the meter and strips can also be assessed c control

can be used determine whether treatment is adequate over a 24-h


period

solutions specific to that meter whenever :


o
A new vial of strips is used
o
The validity of the reading is in doubt

Also referred to as :
o
Glycosylated hemoglobin
o
HgbA1C
o
A1C
Blood test that reflects ave. blood glucose levels over a period of app.

Candidates for Self-Monitoring of Blood Glucose

2 to 3 mos.
When blood glucose levels are elevated, glucose molecules attach to

hemoglobin in RBC
The hemoglobin-glucose binding is permanent and lasts for the life of

an individual RBC ,app. 120 days


If the pt reports mostly normal SMBG results but the glycated

SMBG is recommended for pt c following conditions :


o
Unstable DM
o
Tendency to develop severe ketosis or hypoglycemia
o
Hypoglycemia s warning symptoms
For pt not taking insulin , SMBG is helpful for :
o
Monitoring effectiveness of exercise , diet and oral
o
For pt
o
o

antidiabetic agents
Motivate pt to continue c treatment
c type II DM , SMBG is recommended :
During periods of suspected hyperglycemia or hypoglycemia
When the medication or dosage of medication is modified

hemoglobin is high , there may be :


o
Errors in the methods used for glucose monitoring
o
Errors in recording results
o
Frequent elevations in glucose levels at times during the day

when the pt is not usually monitoring blood sugar levels


Normal values typically range from 4 % to 6%
Target range for people c DM is < 7 %

Frequency of Self-Monitoring of Blood glucose

For pt who require insulin :


o
2 to 4 x daily (usually before meals and bedtime)
For pt who take insulin before each meal:
o
At least 3 x daily before meals to determine each dose
For pt who is not receiving insulin :
o
At least 2 or 3 x per week , including a 2-hr postprandial test
For all pt :
o
Whenever hypoglycemia or hyperglycemia is suspected
o
With changes in medications , activity, diet

Testing for Ketones

Ketones are byproducts of fat breakdown and they accumulate in the


blood and urine
Ketonuria signal that :
o
There is a deficiency of insulin
o
Control of type I DM is deteriorating
o
Risk of DKA is high

Urine testing is the most common method used for self-testing of


ketone bodies by pt
A meter that enables testing of blood for ketones is available
Most commonly, pt uses a urine dipstick to detect ketonuria :
o
Ketostix or Chemstrip uK
o
The reagent pad on the strip turns purple when ketones are

Preparations

A number of insulin preparations are available


They vary acc. to 3 main characteristics : time course of action,
species, and manufacturer

present
Other strips are available for measuring both urine glucose and

Time course of Action

ketones (Keto-Diastix or Chemstrip uGK)


Large amt of ketones may depress the color response of the

glucose test area


Urine ketone testing should be performed whenever :
o
Pt c type I DM have glycosuria or persistently elevated glucose
o
o
o

levels ( > 240 mg/dL )


During illness
In pregnancy c preexisting Dm
In gestational DM

Insulins may be grouped into several categories based on :


o
Onset
o
Peak
o
Duration of action
Rapid acting insulins
o
Produce a more rapid effect than regular insulin
o
Because of their rapid onset, pt should be instructed to eat no
more than 5 to 15 min after injection
Short acting insulins
o
Also called regular insulin
o
A clear solution
o
Usually administered 20 to 30 min. before a meal either alone or
in combination c a longer-acting insulin
o
Only insulin approved for IV use
Intermediate acting insulins
o
Also called NPH insulin (neutral protamine Hagedorn) or Lente
o
o

insulin
Appear white and cloudy
If taken alone, it is not crucial that it be taken 30 min. before

the meal
It is important that pt eat some food around the time of the

onset and peak of these insulins


Function as basal insulins but may have to be split into 2

injections to achieve 24 h coverage


Very long acting insulins
o
Peakless basal insulin
o
Approved by the FDA for use as a basal insulin i.e the insulin is
o

absorbed very slowly over 24 h and can be given OD


Because the insulin is in a suspension c a pH of 4 , it cannot be

mixed c other insulin because this would cause precipitation


It was originally approved to be given OD at bedtime but has
now been approved to be given OD at any time of the day but
must be given at the same time each day to prevent overlap of

action
Basal insulin is necessary to maintain blood glucose levels

irrespective of meals
Nurse should emphasize w/c meals are being covered by w/c insulin
doses :
o
Rapid acting and short acting insulins are expected to cover the
increase in glucose levels after meals , immediately after
o

injection
Intermediate acting insulin are expected to cover subsequent

meals
Long acting insulin provide a relatively constant level of insulin
and act as a basal insulin

Species (source)

In the past , all insulins were obtained from beef (cow) and pork (pig)

IV. Pharmacologic Therapy

pancreases
Human insulins are now widely available
Human insulins are preferable to animal source because they are not

Insulin Therapy

antigenic and do not depend on sufficient animal sources


Human insulin preparations have a shorter duration of action than from

In type I DM : Exogenous insulin must be administered for life

because the body loses the ability to produce insulin


In type II DM : Insulin may be necessary for a long term basis to
control glucose levels if meal planning and oral agents are ineffective
and temporarily during illness, infection , pregnancy , surgery or some
other stressful events

animal because the presence of animal protein triggers an immune


response that results in the binding of animal insulin w/c slows its
availability
Insulin regimens

Vary from 1 to 4 injections per day


Usually there is a combination of a short acting insulin and a longer

There is an immediate local skin reaction that gradually spreads into

acting insulin
There are 2 gen. approaches to insulin therapy : conventional and

generalized urticaria (hives)


Occasionally associated c generalized edema or anaphylaxis
Treatment is desensitization c small doses of insulin administrated in

intensive
Pt can learn to use SMBG results and CHO counting to vary insulin
doses
Complex insulin regimens require a strong level of commitment ,

Insulin Lipodystrophy

intensive education and close follow up by health care team


Pt should be very involved in the decision regarding which insulin

regimen to use
There are not set guidelines as to w/c insulin regimen should be used
for w/c pt

Conventional regimen

gradually increasing amt using a desensitization kit

A localized reaction in the form of either lipoatrophy or


lipohypertrophy occurring at the site of insulin injection

Lipoatrophy

Loss of SQ fat
Appears as a slight dimpling or more serious pitting of SQ fat
Use of human insulin has almost eliminated this disfiguring complication

This approach is to simplify the insulin regimen as much as possible c


the aim of avoiding acute complications of DM
Ex : One or more injections of a mixture of short acting and

Lipohypertrophy

intermediate acting insulins per day


Pt should not vary meal patterns and activity levels
Would be appropriate for :
o
Terminally ill
o
Frail elderly c limited self care abilities
o
Pt who are completely unwilling or unable to engage in the self-

Development of fibrofatty masses at the injection sites


Caused by repeated use of an injection site
If insulin is injected into scarred areas , absorption may be delayed
Rotation of injection sites is so important

Resistance to Injected Insulin

management activities that are part of a more complex insulin

Obesity is the most common reason


Daily insulin requirement of 200 units or more
In most pt c DM who take insulin , immune antibodies develop and bind

This approach is to use a more complex insulin regimen


Allows the pt more flexibility to change the insulin doses from day to

the insulin thereby decreasing the insulin available for use


All animal insulins and human insulins to a lesser degree , cause antibody

day in accordance c changes in eating and activity patterns , c stress

production in humans
Very few resistant pt develop high levels of antibodies , many of these

and illness
3 to 4 injections of insulin per day
It is found out that Risk of severe hypoglycemia was increased in pt

longer
Treatment consists of administering a more concentrated insulin

receiving intensive treatment


Pt who have received a kidney transplant because of nephropathy and

preparation such as U500


Prednisone is need to block the production of antibodies and this may

regimen
Intensive regimen

pt have a history of insulin therapy interrupted for several months or

chronic renal failure should follow an intensive insulin regimen to

be followed by a gradual reduction in the insulin requirement and

preserve function of the new kidney


Not candidates are pt c :
o
NS disorders rendering them unaware of hypoglycemic episodes
o
Recurring severe hypoglycemia
o
Irreversible diabetic complications
o
Cerebrovascular or Cardiovascular disease
o
Ineffective self care skills

therefore pt must monitor their blood for hypoglycemia


Morning hypoglycemia

Caused by several factors : dawn , insulin , somogyi


To determine the cause , pt must be awakened once or twice during the
night to test blood glucose levels (testing at bedtime , at 3 am, and on
awakening )

Dawn phenomenon
Complications of Insulin Therapy
Local Allergic Reactions

Relatively normal blood glucose level until app 3 am when the level

begins to rise
Result from nocturnal surges in GH secretion w/c create a greater

need for insulin in the early morning hours in pt c DM type I


Treatment is change time of injection of evening intermediate-acting

Redness , swelling, tenderness, and induration or a 2-4 cm wheal


May appear at the injection site 1 to 2 hrs after the insulin

administration
Usually occur during the beginning stages of therapy and disappear c

Insulin waning

continued use of insulin


Now becoming rare because of the increased use of human insulins
Physician may prescribe an antihistamine to be taken 1 hr before the

injection is such occurs


Systemic Allergic Reactions

Rare

insulin from dinnertime to bedtime

Progressive increase in blood glucose from bedtime to morning


Treatment is increase evening dose of intermediate acting or long
acting insulin or institute a dose of insulin before the evening meal if
one is not already part of the treatment regimen

Somogyi effect

Normal or elevated blood glucose at bed time , a decrease at 2-3 am to

Jet injectors

hypoglycemia levels and a subsequent increase caused by production of

counterregulatory hormones
Nocturnal hypoglycemia followed by rebound hyperglycemia

Used as an alternative to needle injections


Deliver insulin through skin under pressure in an extremely fine stream
More expensive and require thorough training and supervision when

first used
Pt should be cautioned that absorption rates, peak insulin activity, and

insulin levels may be different when changing to a jet injector


Insulin administered by jet injector is usually absorbed faster
Has been associated c bruising in some pt

Insulin pumps

Continuous subcutaneous insulin infusion


Use small , externally worn devices that closely mimic the functioning

of the normal pancreas


Contain a 3-mL syringe attached to a long (24-to 42-in) thin , narrow-

lumen tube c a needle or Teflon catheter attached to the end


Pt inserts the needle or catheter into subcutaneous tissue (usually on

abdomen) ad secures it c tape or a transparent dressing


Needle or catheter is changed at least q 3 days
Pump is worn either on belt or in a pocket
Insulin is delivered by subcutaneous infusion at a basal rate (eg 0.5 to

2.0 units/h)
When a meal is consumed , pt calculates a dose of insulin to metabolize
the meal by counting the total amount of CHO for the meal using a
predetermined insulin-to-CHO ratio ( eg. 1 unit of insulin for q 15 g

CHO would require 3 units of insulin for a meal c 45 g CHO )


Pump can easily be disconnected per pt preference , for limited periods
Pt must be willing to assess their blood glucose level several times daily
Most common risk is ketoacidosis w/c can occur if there is an occlusion

in the infusion set or tubing


Because only rapid acting insulin is used in the pump, any interruption in

the flow of insulin may rapidly cause the pt to be without insulin


Pt should be taught to administer insulin by manual injection if an

insulin interruption is suspected


Have been used in pt c type II DM whose beta-cell function has

diminished and who require insulin


No risk of DKA when there is an interruption of the flow of insulin in
people c type II DM

Possible disadvantages

Unexpected disruptions in the flow of insulin from the pump that may

occur (increases risk of DKA) :


o
If tubing or needle becomes occluded
o
If supply of insulin runs out
o
If battery is depleted
Potential for infection at needle insertion sites
Incidence of hypoglycemia unawareness (very gradual decline in serum
glucose level from > 70 mg/dL to < 60 mg/dL

Methods of Insulin delivery

Transplantation of pancreatic cells

Insulin pens

Use small (150-to 300unit ) prefilled insulin cartridges that are loaded

into a penlike holder


A disposable needle is attached to the device for insulin injection
Insulin is deliver by pushing a button for q 1- or 2-unit increment

administered
People still need to insert the needle for each injection but do not need

to carry insulin bottles or draw up insulin before each injection


Most useful in pt who need to inject only one type of insulin at a time

or who can use the premixed insulins


Convenient for those who administer insulin before dinner if eating out

or travelling
Also useful for pt c impaired manual dexterity , vision or cognitive
function w/c makes use of traditional syringes difficult

Transplantation of the whole pancreas or a segment of pancreas is


being performed on a limited population , mostly pt c DM who are

receiving kidney transplantation simultaneously


One main issue is weighing the risks of antirejection medications

against the advantages of pancreas transplantation


Implantation is under investigation
Independence from exogenous insulin has been limited to 2 yrs after
transplantation of islet cells

Oral Antidiabetic agents

May be effective for pt who have type II that cannot be treated

effectively c MNT and exercise alone


Include :

o
o
o
o

First and second generation sulfonylureas


Biguanides
Alpha-glucosidase inhibitors
Non-sulfonylurea insulin secretogogues (meglitinides and

phenylalanine derivatives )
o
Thiazolidinediones (glitazones)
o
Dipeptide-peptidase-4 (DPP-4) inhibitors
Sulfonylureas and meglitinides are considered insulin secretagogues
because their action increases the secretion of insulin by the

pancreatic beta cells


Prescribed in addition to , not substitute for other treatment

modalities such as MNT or exercise


In time, they may no longer be effective in controlling DM because of
decline in function of beta cells . In such cases, pt is treated c insulin

Secondary failure

App. half of all pt who initially use oral antidiabetic agents eventually
require insulin

Primary failure

Blood glucose remains high 1 mos. After initial medication use

Other pharmacologic therapy


Pramlintide (Symlin)

A synthetic analogue of human amylin , a hormone that is secreted by

beta cells of pancreas


Approved for treatment of both type I and type II DM
Used to control hyperglycemia in adults who have not achieved
acceptable levels of glucose control despite the use of insulin at

mealtimes
Used c insulin , not in place of insulin
Hypoglycemia is an associated risk
Must be injected in the abdomen or thigh because of variable

absorption rates if it is injected into the arm


Should not be injected close to an insulin injection site
Pt are instructed to monitor blood glucose level before each meal, 2 h
afterward, and at bedtime during the initial period of use

Exenatide (Byetta)

Approved for the treatment of type II DM in combination c metformin

or sulfonylureas
Derived from a hormone that is produced in the small intestine and has

been found to be deficient in type II DM


Normally released after food is ingested to delay gastric emptying and
enhance insulin secretion resulting in dampening of the rise in blood

glucose levels after meals and a feeling of satiety


Return of blood glucose level to normal results in decreased production

of the hormone
Hypoglycemia is not a side effect if adjustments are made in the

sulfonylurea dose
Has been shown to result in weight loss because of the increased

satiety produced
Must be injected 2 x a day within 1 h before breakfast and dinner
Not a substitute for insulin in pt who require insulin to control their
DM

3 sizes of U-100 insulin syringes are available :


o
1 mL syringes that hold 100 units
o
0.5 mL syringes that hold 50 units
o
0.3 mL syringes that hold 30 units
Most insulin syringes have disposable 27 to 29 gauge needle that is app. 0.5

inch long
The 1-mL syringes are marked in 1 and 2 unit increments
A small disposable insulin needle 31 gauge , 8 mm long is available for very

thin pt and children


Mixing Insulins

When short-acting insulins are to be given simultaneously w/ longer-acting

insulins , they are usually mixed together in same syringe


Longer-acting insulins must be mixed thoroughly before drawing into syringe
Regular insulin should be drawn up first
Patients should be consistent in how they prepare their insulin injections
from day to day :
o
So as not to draw up the wrong dose in error or wrong type of
o

insulin
So as not to inject one type of insulin into the bottle containing a

diff. type of insulin


Injecting cloudy insulin into a vial of clear insulin :
o
Contaminates the entire vial of clear insulin
o
Alters action of clear insulin
For pt who have difficulty mixing insulins , several options are available :
o
Pt may use Premixed insulin
o
May have Prefilled syringes prepared
o
Pt may take 2 injections
Premixed insulin

Available in several diff. ratios of NPH insulin to regular insulin :


o
Ratio of 70/30 (70% NPH and 30% regular insulin in one bottle) is
o

the most common


Available as Novolin 70/30 (Novo-Nordisk) and Humulin 70/30

(Lilly)
Combinations w/ a ratio of 75 % NPL (neutral protamine lispro) and 25%
insulin lispro are also available
o
NPL is used only in the mix w/ Humalog
o
NPL action is same as NPH
Prefilled syringes

Nursing Management

V. Education
Storing Insulin

Should
Should
Should
Should

be refrigerated
not be allowed to freeze
not be kept in direct sunlight or in a hot car
be kept at room temperature to reduce local irritation at the

injection site w/c may occur if cold insulin is injected


Pt should be instructed to always have a spare vial of the type or types of

For pt who can inject insulin but who have difficult drawing up a single or

mixed dose
May be done with the help of home care nurses or family and friends
A 3-week supply of insulin syringes may be prepared and kept in ref
Should be stored w/ the needle in an upright position to avoid clogging of

the needle
Should be mixed thoroughly before the insulin is injected
Withdrawing Insulin

insulin to be withdrawn to prevent the formation of a vacuum inside the


bottle w/c would make it difficult to withdraw the proper amount of insulin

insulin he or she uses


Cloudy insulins should be thoroughly mixed by gently inverting the vial or

Selecting and Rotating the Injection Site

rolling it bet. the hands before drawing the solution into a syringe or pen
Bottles of intermediate-acting insulin should also be inspected for
flocculation ,
o
There is a frosted, whitish coating inside the bottle
o
Occurs most commonly w/ human insulins that are exposed to
o

extremes of temp.
If present, some of the insulin is bound and it should not be used

Selecting syringes

Syringes must be matched w/ the insulin concentration (e.g U-100)

Inject air into the bottle of insulin equivalent to the number of units of

Four main areas for injection :


o
Abdomen (speed of absorption is greatest)
o
Posterior upper arms
o
Anterior surface of thighs
o
Hips
Systemic rotation of injection sites within an anatomic area
o
To prevent localized changes in fatty tissue (lipodystrophy)
o
To promote consistency in insulin absorption

Use all available injection sites within one area rather than
randomly rotating sites from area to area (e.g pt may exclusively
use the abdominal area , administering each injection 0.5 to 1 inch

away from the previous injection )


Always use the same area at the same time of day (e.g pt may
inject morning doses into abdomen and evening doses into arms or

legs)
Few general principles to all rotation patterns :
o
Pt should not try to use the same site more than once in 2 to 3
o

weeks
If pt is planning to exercise, insulin should not be injected into the
limb that will be exercised because this will cause drug to be

o
o

absorbed faster w/c may result in hypoglycemia


Avoid repeated injections into the same site within an area
Use the same anatomic area at the same time of the day
consistently

Preparing the Skin

Use of alcohol to cleanse the skin is not recommended


Pt should be cautioned to allow the skin to dry after cleansing w/ alcohol
Alcohol may be carried into the tissues if skin is not allowed to dry before
injection w/c may result in a localized reddened area and burning sensation
Inserting the needle

Technique is based on the need for the insulin to be injected into the SQ

tissue
Injection that is too deep or too shallow may affect the rate of absorption

of insulin
A 90 degree angle is the best insertion angle for a normal or overweight

person
Some pt may be taught to insert needle at 45 degree angle
Aspiration is generally not recommended

Disposing of Syringes and Needles

Used sharps should be placed in a puncture-resistant container


Filled containers should not be mixed w/ containers to be recycled

oTremor
oNervousness
oTachycardia
oHunger
Moderate hypoglycemia
Inability to concentrate
Confusion
Emotional changes
Headache
Memory lapses
Irrational or combative behavior
Lightheadedness
Numbness of lips and tongue
Double vision
Slurred speech
Impaired coordination
Drowsiness

o
o
o
o
o
o
o
o
o
o
o
o

Severe hypoglycemia
Disoriented behavior
Seizures
Difficulty arousing from sleep
Loss of consciousness

o
o
o
o

III. Assessment and Diagnostic Findings


Symptoms may occur suddenly and vary considerably from person to person
Acute Complications of Diabetes

Hypoglycemia (Insulin Reactions)

Occurs when blood glucose falls to less than 50 to 60 mg/dL because


of :
o
o
o

Too much insulin or oral hypoglycemic agents


Too little food
Excessive physical activity

I. Gerontologic considerations

Hypoglycemia is a particular concern for many reasons :


o
Elderly frequently live alone and may not recognize symptoms
o

of hypoglycemia
With decreasing renal function , it takes longer for oral

hypoglycemic agents to be excreted by kidneys


Skipping meals may occur because of decreased appetite or

financial limitations
Decreased visual acuity may lead to errors in insulin
administration

II. Clinical Manifestations

May be grouped into 2 categories :


o
Adrenergic symptoms
o
CNS symptoms

Decreased hormonal (adrenergic) response

Usually occurs in some pt who have had diabetes for many years
May be r/t autonomic neuropathy
May Contribute to lack of symptoms of hypoglycemia
As the blood glucose level falls, the normal surge in adrenalin

does not occur , and usual adrenergic symptoms do not take place
The hypoglycemia may not be detected until moderate or severe
CNS impairment occurs

IV. Management
Treating w/ CHO

Usual recommendation is 15 g of a fast-acting concentrated

source of CHO such as the ff give orally :


o
3 or 4 commercially prepared glucose tablets
o
4 to 6 oz of fruit juice or regular soda
o
6 to 10 hard candies
o
2 to 3 teaspoons of sugar or honey
It is not necessary to add sugar to juice , fruit sugar in juice

contains enough CHO to raise the blood glucose level


Blood glucose level should be retested in 15 min. and retreated if

it is less than 70 to 75 mg/dL


If symptoms persist for longer than 10 to 15 min. after initial

treatment, treatment is repeated


Once symptoms resolve, a snack containing CHON and starch is
recommended unless pt plans to eat a regular meal or snack w/in
30 to 60 min.

Mild hypoglycemia
SNS is stimulated resulting in a surge of epinephrine and norepinephrine
oSweating
oPalpitation

Initiating Emergency Measures

For adults who are unconscious and cannot swallow :

An injection of glucagon 1 mg can be administered SQ

or IM
Glucagon is a hormone produced by alpha cells to

stimulate the liver to breakdown glycogen


Injectable glucagon is packaged as a powder in 1-mg
vials and must be mixed w/ a diluents immediately

o
o

before being injected


Onset : 8 to 10 min ; Action : 12 to 27 min.
After injection , pt may take as long as 20 min. to

regain consciousness
For awakened pt :
o
A concentrated source of CHO followed by a snack
should be given to prevent recurrence of hypoglycemia
o

because duration of action of 1mg glucagon is brief


Some pt experience nausea after administration of
glucagon , pt should be turned to the side to prevent

aspiration just in case


In hospitals , for pt who are unconscious or cannot swallow
o
25 to 50 mL of 50% dextrose in water (D50W) may be
o
o

administered IV
Pt may complain of headache and pain at injection site
Assessing patency of IV line is essential because
hypertonic solutions such as D50W are very irritating
to veins

Providing pt education

Hypoglycemia is prevented by :
o
Consistent pattern of eating
o
Administering insulin
o
Exercising
Routine blood glucose tests are performed so that changing

insulin requirements may be anticipated and dosage adjusted


Pt and family members must be instructed to recognize symptoms

of hypoglycemia
Autonomic neuropathy or beta blockers such as propranolol

(Inderal) may mask the typical symptoms of hypoglycemia


Pt who have type 2 diabetes and who take oral sulfonylurea

agents may also develop hypoglycemia


It is important for pt w/ diabetes to learn to carry some form of

simple sugar w/ them at all times


Pt are advised to refrain from eating high-calorie high-fat desert

foods to treat hypoglycemia because their high fat content may


slow absorption of the glucose and resolution of the hypoglycemic

symptoms
Pt may subsequently eat more of the foods mentioned when
symptoms do not resolve rapidly w/c may cause very high blood
glucose levels for several hours and may contribute to weight gain

If vomiting, diarrhea or fever persists , take liquids q to 1 hr to

prevent dehydration and to provide calories


Report nausea, vomiting and diarrhea to your health care provider ,

because extreme fluid loss may be dangerous


Never eliminate insulin doses when n/v occur
If you are unable to retain oral fluids , you may require
hospitalization to avoid diabetic ketoacidosis and possibly coma

IV. Clinical Manifestations


Hyperglycemia leads to the ff

Polyuria
Polydipsia
Blurred vision
Weakness
Headache
Mental status varies widely
(alert, lethargic, comatose)

Ketosis and Acidosis lead to GI


symptoms

Diabetic Ketoacidosis
I. Definition
Caused by an absence or inadequate amount of insulin
Insulin deficiency results in disorders in the metabolism of CHO,

CHON, and fat


3 main clinical features :
o
Hyperglycemia
o
Dehydration and electrolyte loss
o
Acidosis
Main causes of DKA :
o
Decreased or missed dose of insulin
o
Illness or infection
o
Undiagnosed and untreated diabetes (DKA may be the initial

volume depletion

glucose production by the liver and interfere w/ glucose


utilization by muscle & fat tissue, counteracting the effect of

Take insulin or oral antidiabetic agents as usual


Test blood glucose and test urine ketones q 3 to 4 h
Report elevated glucose levels (>300 mg/dL) or urine ketones to the

health care provider


If you take insulin , you may need supplemental doses of regular

insulin q 3 to 4 h
If you cannot follow you usual meal plan, substitute soft foods 6 to
8 x per day

Orthostatic hypotension

Vomiting
Abdominal pain
Acetone breath (fruity odor)
Kussmaul respiration

Frank hypotension
Weak, rapid pulse

Blood glucose levels may vary bet. 300 and 800 mg/dL
Evidence of ketoacidosis Low serum bicarbonate (0 to 15 mEq/L) ,

low pH (6.8 t 7.3)


Respiratory compensation Low partial pressure of CO2 (PCO2; 10 to

30 mm Hg)
Metabolic acidosis - Kussmaul respirations
Accumulation of ketone bodies Blood and urine ketone

measurements
Sodium & potassium concentrations may be low, normal or high

depending on the amount of water loss


Dehydration Increased levels of Creatinine, blood urea nitrogen and
hematocrit may also be seen

III. Prevention

Nausea

V. Assessment and Diagnostic Findings

cortisol, growth horme) in response to stress w/c promote

Guidelines to follow during periods of illness (Sick day rules)

Anorexia

Pt w/ marked intravascular

manifestation of diabetes)
Insulin deficit may result from :
o
Insufficient dosage of insulin prescribed
o
Errors in insulin dosage
o
Pt error in drawing up or injecting insulin
o
Intentional skipping of insulin doses
o
Equipment problems
o
Illness and Infection are associated w/ insulin resistance
o
Stress hormones (glucagon, epinephrine, norepinephrine,

VI. Management
Rehydration

Important for maintaining tissue perfusion


Enhances excretion of excessive glucose by kidneys
Pt may need as much as 6 to 10 L of IV fluid to replace fluid caused by

Polyuria, hyperventilation, diarrhea, and vomiting


Initially , 0.9 % sodium chloride (normal saline) solution is administered
at a rapid rate, usually 0.5 to 1L/h for 2 to 3 h

Half strength normal saline (0.45%) solution (hypotonic saline solution)

Must be infused continuously until SQ administration of insulin can be

resumed
Any interruption in administration may result in the reaccumulation of

for heart failure


After the first few hrs, half-strength nss is the fluid of choice for

ketone bodies
Even if blood glucose levels are decreasing and returning to normal ,

continued rehydration
Moderate to high rates of infusion (200 to 500 mL/h) may be needed

for several more hrs


When blood glucose level reaches 300 mg/dL or less , IV solution may

may be used for pt w/ hypertension or hypernatremia and those at risk

be changed to dextrose 5 % in water (D5W) to prevent a precipitous


decline in blood glucose level
Monitoring of fluid volume status involves :
o Frequent measurements of v/s
o Lung assessment
o Monitoring of I & O
Plasma expanders may be necessary to correct severe hypotension that

does not respond to IV fluid treatment


Monitoring for signs of fluid overload is essential esp for pt who are :
o
Older
o
Have renal impairment
o
At risk for heart failure

Restoring Electrolytes
The major electrolyte of concern during treatment of DKA is potassium
Serum level of potassium decreases as potassium reenters the cells

during the course of treatment of DKA

Some factors r/t to treating DKA that reduce serum potassium


concentration :
1. Rehydration

Leads to increased plasma volume and subsequent decreases in the

concentration of serum potassium


Also leads to increased urinary excretion of potassium

2. Insulin administration
Enhances the movement of potassium from the extracellular fluid into

the cells

Potassium replacement

Cautious but timely replacement is vital to avoid dysrhythmias that

may occur w/ hypokalemia


As much as 40 mEq/h may be needed for several hrs
Because extracellular potassium levels decrease during DKA
treatment, potassium must be infused even if plasma potassium level

is normal
Frequent (q 2 to 4 hr initially) ECGs and laboratory measurements of

potassium are necessary during the first 8 hrs of treatment


Withheld only if hyperkalemia is present or if the pt is not urinating

Reversing Acidosis

Acidosis that occurs in DKA is reversed w/ insulin w/c inhibits fat

breakdown thereby topping acid buildup


Insulin is usually infused IV at a slow, continuous rate (5 units/h)
Hourly blood glucose values must be measured
IVF solutions w/ higher concentrations of glucose such as NSS are

administered when blood glucose levels reach 250 to 300 mg /dL


Regular insulin is the only type of insulin approved for IV use , may be

added to IV solutions
Nurse must convert hourly rates of insulin infusion (units/hr) to IV
drip rates i.e 1 unit of insulin = 5 mL
(5 units/h = 25 mL/h)

insulin drip must not be stopped until SQ insulin therapy has been
started . Rather the rate or concentration of the dextrose infusion

should be increased
IV insulin may be continued for 12 to 24 hr until serum bicarbonate

level increases (15 to 18 mEq/L) and until the pt can eat


Bicarbonate infusion to correct severe acidosis is avoided during
treatment of DKA because it precipitates further, sudden decreases
in serum potassium levels

III. Assessment and Diagnostic Findings

Hyperglycemic Hyperosmolar Nonketotic Syndrome

Laboratory Tests

Assessment

I. Definition

Hyperosmolarity and hyperglycemia predominate w/ alterations of the

sensorium (sense of awareness)


Ketosis is usually minimal or absent
The basic biochemical defect is lack of effective insulin i.e insulin

resistance
Persistent hyperglycemia causes osmotic diuresis w/c results in loss

of water and electrolytes


To maintain osmotic equilibrium , water shifts from intracellular fluid

space to extracellular fluid space


With glycosuria and dehydration , the ff occur :
o
Hypernatremia
o
Increased osmolarity
Occurs most often in older people (50 to 70 years of age) who have

Blood glucose - 600 to 1200 mg/dL


Electrolytes and BUN levels are consistent
w/ clinical picture of severe dehydration
CBC
Serum osmolality exceeds 350 mOsm/kg
ABG analysis

Mental status changes . Focal neu


and Hallucinations are common
dehydration that results from
hyperosmolality
Postural hypotension accompanie

IV. Management

Similar to that of DKA : fluid replacement, correction of

electrolyte imbalances, and insulin administration


Because pt of HHNS are typically older, close monitoring of

no known history of diabetes or who have type 2


Often can be traced in a precipitating events :
o
Acute illness
o
Medications that exacerbate hyperglycemia (e.g thiazides)
o
Treatment (e.g dialysis)
History includes days to weeks of Polyuria w/ adequate fluid intake
Insulin level is too low to prevent hyperglycemia and subsequent

volume and electrolyte status is important for prevent of :


o
Fluid overload
o
Heart failure
o
Cardiac dysrhythmias
Fluid treatment is started w/ 0.9 % or 0.45% NS depending on

osmotic diuresis but is high enough to prevent fat breakdown


Pt may tolerate Polyuria and Polydipsia until neurologic changes

pts sodium level and severity of volume depletion


Central venous or hemodynamic pressure monitoring guides fluid

prompts them to seek treatment


Mortality ranges from 10 % to 40 %

replacement
Potassium is added to IVF when urinary output is adequate and

guided by continuous ECG monitoring and lab. determination of


II. Clinical Manifestations

Hypotension
Dehydration
Dry mucous membranes
Poor skin turgor
Tachycardia
Variable neurologic signs (alteration of sensorium, seizures,
hemiparesis )

potassium
Extremely elevated blood glucose concentration decrease as the
pt is rehydrated , Insulin is not needed

Long term Complications of Diabetes


Macrovascular Disease
Microvascular Disease
Neuropathy

Macrovascular Complications

Result from changes in the medium to large blood vessels


Blood vessel walls thicken, sclerose and become occluded by plaque ,
eventually blood flow is blocked
Tend to occur more often and at an earlier age in pt w/ diabetes
Main types of Macrovascular complications :
o
CAD
o
CVD
o
PVD

Myocardial infarction

Twice as common in men w/ diabetes and three times as common in

women w/ diabetes compared to people w/o diabetes


The typical ischemic symptoms may be absent in pt w/ diabetes
Pt may not experience the early warning signs and may have silent MIs
Lack of ischemic symptoms may be s/t autonomic neuropathy

Cerebrovascular disease
People w/ diabetes have twice the risk
Recovery from stroke may be impaired in pt who have elevated blood
glucose levels at the time & immediately after stroke
Symptoms of CVA may be similar to symptoms of acute diabetic
complications , it is very important to assess blood glucose level rapidly
Peripheral vascular disease

Two to three times higher risk in diabetic pt


S/S :
o
Diminished peripheral pulses
o
Intermittent claudication (pain the buttock, thigh, calf during

walking)
Severe form is largely responsible for increased incidence of gangrene

and subsequent amputation


Neuropathy and impairments in wound healing also play a role in
diabetic foot disease

Management

Modification and reduction of risk factors


MNT and exercise
Smoking cessation
Control of blood glucose levels

o
o
o

Floaters or cobwebs in the visual field


Spotty or hazy vision
Complete loss of vision

Microvascular Complications/Microangiopathy

Capillary basement membrane thickening


The basement membrane surrounds the endothelial cells of capillary
Increased blood glucose levels react through series of biochemical

III. Assessment and Diagnostic Findings

Diagnosis is by direct visualization of the retina through dilated

responses to thicken the basement membrane to several times its

pupils w/ an ophthalmoscope or w/ a technique known as fluorescein

normal thickness
Two areas affected are retina and kidneys

angiography
Fluorescein angiography

Diabetic Retinopathy

I. Definition

brain
Changes in the microvasculature :
o
Microaneurysms
o
Intraretinal hemorrhage
o
Hard exudates
o
Focal capillary closure

3 Main Stages :

body through blood but esp. through vessels of retina of eye


Side effects :
o Nausea during dye injection
o Yellowish, fluorescent discoloration of the skin and urine lasting
12 to 24 hrs
o Occasionally allergic reactions usually manifested by hives or

Leading cause of blindness


Occurs in both type 1 and type 2
Caused by changes in the small blood vessels in the retina , area of eye
that receive images and sends information about the images to the

Can document the type and activity of the retinopathy


Dye is injected into an arm vein and is carried to various parts of

itching
Generally safe

IV. Medical Management

Maintenance of blood glucose to normal or near-normal level


Intensive insulin therapy
Pt education
Control of HTN
Control of blood glucose
Cessation of smoking

Nonproliferative retinopathy
Photocoagulation
Macular edema is a complication w/c occurs in app. 10 % of people w/ type 1
or type 2 diabetes
May lead to visual distortion and loss of central vision
Preproliferative retinopathy

Advance form of retinopathy


Precursor to the more serious proliferative retinopathy
There are more widespread vascular changes and loss of nerve fibers
If visual changes occur during this stage, they are usually caused by macular
edema
Proliferative retinopathy

Represents the greatest threat to vision


Characterized by proliferation of new blood vessels growing from retina into
the vitreous
The new vessels are prone to bleeding
Visual loss is caused by vitreous hemorrhage , retinal detachment or both
Vitreous hemorrhage
o
Vitreous is normally clear , allowing light to be transmitted to
the retina
o
When hemorrhage occurs , vitreous is clouded and cannot
transmit light
o
Another consequence is resorption of blood in the vitreous leads
to formation of fibrous scar tissue
o
Scar tissue may place traction on the retina resulting in retinal
detachment and subsequent visual loss

II. Clinical Manifestations

Retinopathy is a painless process


Blurry vision s/t mascular edema
Indicative of hemorrhaging :

Usually performed on an outpatient basis


Limitations may be placed on activities involving weight bearing and

bearing down
Usually an anesthetic eye drop is all that is needed during the
treatment

Argon Laser photocoagulation

For advanced cases of retinopathy


Destroys leaking blood vessels and areas of neova
Panretinal photocoagulation

For pt who are at increased risk for hemorrhage


Involves systemic application of multiple laser burns
retina except in the macular region
Stops widespread growth of new vessels and hemorr
damaged vessels

Focal photocoagulation

For pt w/ macular edema


Used to apply smaller laser burns to specific areas o
microaneurysms in the macular region
Vitrectomy

Surgical procedure in w/c vitreous humor filled w/ b


tissue is removed w/ a special drill-like instrume
w/ saline or other liquid
Performed in pt who have visual loss and in whom w/
hemorrhage has not cleared on its own after 6 m
Purpose is to restore useful vision , recovery to near
not usually expected

V. Nursing Management
Teaching pt self care

Control of glucose levels and BP


Frequent eye examination
Retinopathy may appear after many years of diabetes

Continuing care

Need to see an ophthalmologist regularly


Referral for home care for those :
o
Who live alone
o
Who are not coping well
o
Who have other health problems

Nephropathy

I. Definition

Renal disease s/t diabetic microvascular changes in the kidney


Pt w/ type 1 frequently show initial signs of renal disease after 10 to

15 yrs
Pt w/ type 2 develop renal disease within 10 yrs after the diagnosis of
diabetes , many of them have had diabetes for many years before
diabetes is diagnosed and treated . Therefore , they may have evidence
of nephropathy at the time of diagnosis

Consistently high blood

Kidneys filtration

Blood proteins leak into the

Pressure in the blood

IV. Management
NEPHROPATHY
II. Clinical manifestations
Catabolism / breakdown of both exogenous and endogenous insulin decreases
Frequent hypoglycemic episodes
As renal function decreases , pt commonly have multiple-system failure :
o
Declining visual acuity
o
Impotence
o
Foot ulcerations
o
Heart failure
o
Nocturnal diarrhea

2 treatments in chronic / end-stage of renal failure :


1. Dialysis
Hemodialysis

III. Assessment and Diagnostic Findings

Albumin is one of the most important blood proteins that leaks into

the urine
Clinical nephropathy develops in more than 85 % of people w/

microalbuminuria
If microalbumin exceeds 30 mg/24 hours on 2 consecutive random

Requires anticoagulants that can increase the risk of bleeding after

surgery
Creates additional stress on pt w/ CV disease

Peritoneal dialysis

urine tests , a 24 hr urine sample should be obtained and tested , if

results are positive , treatment is indicated


Serum Creatinine and BUN levels should be conducted annually
Contrast agents and dyes used for some diagnostic tests may not be

easily cleared by damaged kidneys


Hypertension often develops in pt w/ and w/o diabetes who are in the

early stages of renal disease


Hypertension also occurs in people w/ diabetes for unknown reasons

Control of HTN w/ the use of ACE inhibitors (captopril [Capoten] )


Prevention or treatment of UTI
Avoidance of nephrotoxic substance s
Adjustment of medications as renal function changes
Low sodium diet
Low protein diet

Major risks : infection and peritonitis


Minimizes pressure changes in the eyes
Recommended for pt who require eye surgery

2. Transplantation from a relative or cadaver

Transplanted kidneys can eventually be damaged if blood glucose


levels are consistently high after the transplantation

Diabetic Neuropathies

Group of diseases that affect all types of nerves including :


o
Peripheral (sensorimotor)
o
Autonomic
o
Spinal nerves
Etiology may involve elevated blood glucose levels over a period of
years

Peripheral Neuropathy

Gastrointestinal symptoms
I. Definition

Also called Sensorimotor polyneuropathy


Most commonly affects the distal portions of the nerves esp. nerves of

the lower extremities


Affects both side of the body symmetrically
May spread in a proximal direction

Delayed gastric emptying


Early satiety
Bloating
Nausea
Vomiting
Diabetic constipation or diarrhea
Unexplained wide swings in blood glucose levels r/t incon
absorption of glucose from ingested foods s/t incons
gastric emptying

Urinary retention
Decreased sensation of bladder fullness
Risk for UTI
Hyperglycemia impairs resistance to infection

Urinary symptoms

II. Clinical Manifestations

Paresthesias (prickling , tingling or heightened sensation)


Burning sensations esp. at night
Feet become numb
Decrease in proprioception (awareness of posture and movement of

body and of position and weight of objects in relation to the body)


Decreased sensations of pain & temperature
Deformities of foot
Charcot joints may result from abnormal weight distribution on joints

resulting from lack of proprioception


Decrease in deep tendon reflex and vibratory sensation

It is important to rule other possible causes like :

Hypoglycemic Unawareness

Autonomic neuropathy that affects the adrenal medulla is responsible

for diminished adrenergic symptoms of hypoglycemia


Pt may no longer feel the typical adrenergic symptoms that associated

w/ hypoglycemia :
o
Shakiness
o
Sweating
o
Nervousness
o
Palpitations
Frequent blood glucose monitoring is recommended for these pt
Their inability to detect and treat the warning signs of hypoglycemia

Alcohol-induced
Vitamin-deficiency neuropathies

III. Management

Intensive insulin therapy


Control of blood glucose level
Pain management for pain particularly in lower extremities s/t

diabetes
Transcutaneous electrical nerve stimulation (TENS)

puts them @ risk for development of dangerously low blood glucose


levels
Pt and family need to recognize subtle and atypical symptoms of

hypoglycemia such as numbness around the mouth and impaired ability


to concentrate
Subdomotor Neuropathy

Decrease or absence of sweating (anhidrosis) of the extremities

w/ a compensatory increase in upper body sweating


Dryness of the feet increases the risk for the development of
foot ulcers

Sexual Dysfunction
Diabetic Male pt
Erectile dysfunction
Impotence
Some may have normal erectile function and can experience orgasm but

do not ejaculate normally (Retrograde ejaculation seminal fluid is


propelled backward through posterior urethra and into the urinary
bladder)
Examination of urine confirms diagnosis of retrograde ejaculation

Autonomic Neuropathies

because of the large number of active sperm present


Other factors for impotence aside from diabetes :

I. Clinical Manifestations

o
o
o

Cardiovascular symptoms
Tachycardic HR
Orthostatic hypotension
Silent or painless MI

Antihypertensive agents
Psychological factors
Other medical conditions

Diabetic Female pt

Reduced vaginal lubrication


Decreased libido

Lack of orgasm
Vaginal infection may be associated w/ decreased lubrication
Vaginal pruritus
Tenderness
UTI and Vaginitis may affect sexual function

II. Management
Avoiding strenuous exercise
Orthostatic hypotension may respond to a diet high in sodium
Discontinuation of medications that impede autonomic nervous system

response
Use of sympathomimetics
Mineralocorticoid therapy
Treatment of delayed gastric emptying :
o Low fat diet
o Frequent small meals
o Frequent blood glucose monitoring
o Use of agents that increase gastric motility (metoclopramide

[Reglan] , bethanecol [Myotonachol] )


Treatment of diabetic diarrhea :
o Laxatives
o Antidiarrheal agents
Treatment of diabetic constipation :
o High fiber diet
o Adequate hydration
o Medications
o Laxatives
o Enemas

Foot and Leg Problems


I. Complications of Diabetes that contribute to increased risk of foot
problems and infections
Neuropathy
Sensory neuropathy leads to :

Loss of pain and pressure sensation

Autonomic neuropathy leads to :

Increased dryness
Fissuring of skin s/t decreased sweating

Motor neuropathy results in :

Muscular atrophy w/c may lead to changes in the shape of foot

Peripheral vascular disease

Poor circulation of the lower extremities contributes to poor wound


healing and development of gangrene

Immunocompromise
Development of a diabetic foot ulcer begins w/ a soft tissue injury of

Hyperglycemia impairs the ability of specialized leukocytes to destroy


bacteria
In poorly controlled diabetes, there is a lowered resistance to certain
infections

the foot, formation of a fissure bet. toes or in an area of dry skin or


formation of a callus
Pt with an insensitive foot do not feel injuries (thermal, chemical,

Teaching pt proper foot care


Controlling blood glucose levels

thoroughly inspecting both on a

Treatment for foot ulcers :

o
o
o

daily bass , injury or fissure may


go unnoticed until a serious

Bed rest
Antibiotics
Debridement
o
o
o

traumatic)
if pt is not in the habit of

infection has developed


First sign of foot problems :
o
Drainage

Swelling
Redness of the leg from cellulitis
Gangrene

II. High Risk characteristics

Duration of diabetes more than 10 years


Age older than 40 years
History of smoking
Decreased peripheral pulses
Decreased sensation
Anatomic deformities or pressure areas (e.g bunions, calluses, hammer

toes)
History of previous foot ulcers or amputation

III. Management