PEDIA DIABETES MELLITUS Type I DM(Insulin Dependent DM) -partial/complete lack of secretory capacity of the beta cells of pancreas,insulin

deficiency Normal bld glucose:70-110 mg/dL Assessment: 1.3 Ps,enuresis(more common in type I DM) 2.Wt. loss 3.vaginitis(candida) 4.dehydration 5.hypo/hyperkalemia-complication Diet: -3 meals/day -Midafternoon CHO snack -Bedtime CHON snack Exercise: -dietary adjustment when exercising -extra food for activity(10-15 g CHO every 30-45 mins of activity) -monitor bd glucose before exercising Insulin: -Diluted insulin for infants to provide small enough doses to avoid hypoglycemia. -Glycosylated Hgb-tests every 3 mos -should not withheld during stress-hyperglycemia and ketoacidosis result -Glucagon-IM/SQ if unable to consume P.O. Bld glucose monitoring: -more accurate than urine testing -finger prick Urine testing: -tests ketones and glucose -2nd voided urine is most accurate ACUTE COMPLICATION: 1.Hypoglycemia -too much insulin -too much oral hypoglycemic agent -not enough food -excessive activity Intervention: -complex CHO and CHON(slice of bread or peanut butter cracker)

-extra snack,if next meal not planned for >30 mins or activity is planned. -if become UNCONCIOUS: >squeeze cake frosting or glucose paste onto the gums and retest bld glucose level >if does not improve w/in 15-20 mins and if reading remains low,administer additional sugar: Carbonated beverage 3-4 hard candies 2 or 3 glucose tabs Life savers 1 tsp honey >if child remains unconscious,administer GLUCAGON >Hosp setting:dextrose IV. 2.Hyperglycemia Notify physician if child unable to take food or fluids. Sick day rules: -always give insulin even if child does not have an appetite -test bld glucose level at least q 4 hrs. -test for urinary ketones w/ each voiding -calorie-free liquids to aid in clearing ketones -rest esp. if ketones are present 3.Diabetic Ketoacidosis -life-threatening condition -metabolic acidosis -bld glucose level:>300 mg/dl Interventions: -correct dehydration:IV 0.9% or 45% saline -correct hyperglycemia:IV Reg insulin -monitor potassium:potassium replacement -IV dextrose added when bld glucose reaches appropriate level.

ADULT DIABETES MELLITUS -chronic disorder of impaired CHO,CHON,and lipid(fat) metab.caused by deficiency of insulin. TYPE I:Insulin-dependent diabetes mellitus -nearly absolute deficiency of insulin -if insulin not given,fats metabolized,=ketonemia(acidosis) TYPE II:Non-insulin dependent DM -lack of insulin or resistance to action of insulin -insulin sufficient to stabilize fat and CHON metab but not to deal with CHO metab. Microvascular complications: retinopathy,nephropathy,neuropathy Assessment: 1.3 Ps(more common in type I DM) 2.wt.loss(common in type I DM) 3.vaginal infxns Diet: -food exchange from American Diabetic Association -dietary guidelines for Americans(Food Guide Pyramid)issued by US Dept. of Agri and Health and Human Services Exercise: - blood glucose level -dietary adjustments when exercising -monitor bld glucose before exercising -Initially,15 g CHO snack(a fruit exchange) or complex CHO + CHON before engaging in moderate exercise to prevent hypoglycemia -if bld glucose >250 mg/dL + urinary ketones(type I DM)-not to exercise until bld glucose is closer to normal and urinary ketones are absent Oral hypoglycemic meds: -prescribed for DM II -Type II DM-insulin may be needed during stress,surgery,or infxn Insulin: -for Type I DM -also for Type II DM when diet and weight control therapy have failed

REGULAR INSULIN-only insulin can be administered IV in emergency tx of DKA. -illness,infxn,stress need for insulin and not be withheld because hypoglycemia and ketoacidosis can result Complication of insulin therapy: 1.Local allergic reactions -avoid alcohol to cleanse skin before injxn. 2.Insulin lipodystrophy Lipoatrophy-use of HUMAN INSULIN helps to prevent this complication. Lipohypertrophy-caused by repeated use of an injxn site. 3.Insulin resistance -develops immune antibodies that bind insulin,decreasing insulin Tx:Purer Insulin Preparation 4. Dawn Phenomenon -reduced tissue sensitivity to insulin b/w 5 & 8 AM(prebreakfast hyperglycemia occurs) Tx:evening dose of INTERMEDIATE-ACTING INSULIN at 10 PM. 5.Somogyi Phenomenon -normal or elevated bld glucose present at BEDTIME -hypoglycemia 2-3 AM -hyperglycemic 7 AM Tx: a.decreasing evening(predinner or bedtime)dose of INTERMEDIATE OR LONG ACTING INSULIN b.increasing BEDTIME SNACK 6.Insulin Waning -progressive rise in bld glucose level from BEDTIME to MORNING Tx: a.increasing evening(predinner or bedtime)dose of INTERMEDIATE OR LONG ACTING INSULIN b.instituting dose of INSULIN before evening meal if one is not already prescribed.

Insulin Pumps -externally worn device contains syringe attached to long,thin,narrow-lumen tube w/ needle or Teflon catheter attached to end. -inserts needle or Teflon catheter into SQ(abdomen) -worn on a belt or in a pocket -needle/Teflon catheter changed every 3 days -delivers bolus of REGULAR INSULIN before each meal. Pancreas transplants -performed on a limited number of clients(mostly clients receiving kidney transplantations simultaneously) -immunosuppressive therapy to treat rejection. Bld glucose monitoring: -more accurate than urine testing -finger prick -caution with diabetic retinopathy and neuropathy Urine testing: -tests ketones and glucose -2nd voided urine is most accurate Urine ketone testing: -should be performed during illness -whenever TYPE I DM has glycosuria and with bld glucose level of >240 mg d/L for 2 consecutive periods. ACUTE COMPLICATIONS OF DM: 1.Hypoglycemia -too much insulin -too much oral hypoglycemic agent -not enough food -excessive activity *High-fat foods slow absorption of glucose and hypoglycemic symptoms may not resolve quickly. a.Mild hypoglycemia-<60 mg/dL Interventions: >10 to 15 g FAST-ACTING SIMPLE CHO: Glucose tablet 6-10 life savers or hard candy 4 tsp sugar 4 sugar cubes 1 tbs honey/syrup cup fruit juice/regular (nondiet softdrink) 6 saltine crackers 3 graham crackers >retest bld glucose in 15 mins.

b.Moderate-<40 mg/dL Interventions: >15-30 g FAST-ACTING SIMPLE CHO >low-fat milk or cheese after 10-15 mins. c.Severe-<20 mg/dL(unable to swallow,unconscious,seizures) Interventions: -unconcious/cant swallow:injxn of glucagon SQ or IM. -2nd dose in 10 mins.if client remains unconscious -small meal when awaken In Hosp/ER:IV injxn 25-50 mL of 50% dextrose in H2O.
2.DKA -complication of type I DM because of severe insulin deficiency. Causes: -/missed dose of insulin -illness/infxn -undiagnosed/untreated type I DM Assessment: -Hyperglycemia -dehydration/electrolyte loss -acidosis -Bld glucose 300-800 mg/dL -low Bicarb,low pH Interventions: -Dehydration: rapid IV 0.9%/0.45% saline -bld glucose 250-300 mg/dL: IV fluids + D5NS or 5% dextrose in 0.45% saline -Hyperglycemia: IV Regular insulin -monitor K level( level,K replacement) INSULIN IV ADMINISTRATION: -use REGULAR INSULIN only -5 to 10 units of Regular insulin by IV bolus before continuous infusion is begun. -Continuous infusion:IV dose of Reg.insulin + 0.9% or 0.45% saline -flush insulin solution thru entire IV infusion set and discard 1st 50 mL solution before connecting and administering to client(insulin molecules adhere to plastic IV infusion set) -always place Insulin infusion on an IV infusion controller -Insulin is infused continuously until SQ administration resumes

-K level fall rapidly w/in 1st hr of tx as dehydration and acidosis are treated -K administered IV in diluted solution(when K reaches normal to prevent hypokalemia) Guidelines during illness: -test bld glucose,test urine for ketones every 3-4 hrs -if usual meal plan cannot be followed,substitute soft foods 6-8 x per day -vomiting/diarrhea/fever:consume liquids every to 1 hr. to prevent dehydration and to provide calories. 3.HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC SYNDROME(HHNS) -extreme hyperglycemia w/o ketosis and acidosis -occurs most often with TYPE II DM Assessment: -bld glucose 600-1200 mg/dL -low BP,low HR -dehydration -seizures Interventions: -Tx similar to DKA -Insulin plays less critical role in tx of HHNS because insulin is not needed for reversal of acidosis in HHNS. CHRONIC COMPLICATIONS OF DM 1.Retinopathy a.Photocoagulation(laser therapy):removes hemorrhagic tissue to scarring. b.Vitrectomy:removes vitreous hemorrhages thus tension on retina,preventing detachment c.Cataract removal w/ lens implant 2.Nephropathy -microalbuminuria Interventions: -restrict CHON,Na,K -prepare for dialysis -prepare for kidney transplant -prepare for pancreas transplant 3. Neuropathy -erectile dysfunction/impotence -loss sensation in CN III,IV,V,VI -dyspareunia r/t yeast infxn Interventions: -dont treat corns,blisters, ingrown toenails -dont wear same pair of shoes 2 days in a row -estrogen-containing lubricants for female

OPERATIVE CARE Preop care: -Long-acting oral antidiabetic meds are d/c 24-48 hrs. before surgery. -Insulin may be adjusted/withheld if IV insulin administration during surgery is planned. Postop care: -IV glucose and Reg.insulin infusion until client can tolerate oral feedings -supplemental short-acting insulin -monitor bld glucose if client receiving TPN.

MEDICATIONS FOR DIABETES MELLITUS A.INSULIN -prescribed for clients with Type I DM - glucose transport into cells and promotes conversion of glucose to glycogen, serum glucose levels. -primarily acts in the liver,muscle,and adipose tissue by attaching to receptors on cellular membranes and facilitating passage of glucose,K,and Mg. Storing insulin: -avoid exposing insulin to extremes in temp. -shoud not be frozen or kept in direct sunlight. -before injxn,should be at room temp. -if vial of insulin will be used up in a month,may be kept at room temp;otherwise,vial should be refrigerated. Insulin injxn site: a.abdomen-may absorb more evenly and rapidly than the other sites. b.arms(posterior surface) c.thighs(anterior surface) d.hips -systematic rotation w/in 1 anatomical area is recommended to prevent lipodystrophy -dont use same site more than once in a 2-3 wk period. -injxns should be 1.5 inches apart within the anatomical area. -heat,massage,&exercise of injected area can absorption rates and may result in hypoglycemia.

Administering insulin: Usual concentration:U 100(100 units/mL) -most insulin syringes have 27-29 gauge needle,0.5 inch long. -before use,roll bottle to ensure ingredients are mixed. -dont shake may cause bubbles. -premixed insulin:Humulin 70/30-most commonly used. -mixtures of insulin in prefilled syringes should be kept in the refrigerator,stable for 1 wk. -prefilled syringes should be kept flat or with needle in upright position to avoid clogging of needle. -inject air into the insulin bottle(vacuum makes it difficult to draw up the insulin) -when mixing,Regular(short-acting)insulin first. -Regular insulin may be mixed with any other type of insulin. -Insulin zinc suspension only mixed with each other and regular insulin. -administer mixed dose of insulin w/in 5-15 mins of prep,after this time regular insulin binds with NPH and action is reduced. -aspiration is not recommended with self-injxn. -administer at 45-90 degree/45-60 degree in thin persons. Remember:Regualr insulin is the only type of insulin that can be administered IV. B.ORAL HYPOGLYCEMIC MEDICATIONS -Prescribed for Type 2 DM -stimulate pancreas to produce more insulin - sensitivity of peripheral receptors to insulin - hepatic glucose output or delay intestinal absorption of glucose ,thus serum glucose levels. 1.Sulfonylureas -stimulate beta cells to produce more insulin -can affect cardiac function and 02 consumption=cardiac dysrhythmias. Side effects:GI sx & dermatological rxns Ex: a.Chlorpropamide(Diabenese)-can cause disulfiram(Antabuse) type of rxn wen alcohol is ingested. b.Tolbutamide(Orinase) 2.Nonsulfonylureas -affect hepatic & GI production of glucose -used alone or with sulfonylurea

Ex: Acarbose(Precose) Metformin(Glucophage) Rosiglitazone(Avandia) Contraindications and concerns: *Hypoglycemic meds+-adrenergic blocking agents=masks s/sx of hypoglycemia Meds that cause of hypoglycemia: Anticoagulants Chloramphenicol Salicylates Propranolol(Inderal) MAOI Pantamidine(pentam 300) Sulfonamides Meds that cause hyperglycemia: Corticosteroids Thiazide diuretics Phenytoin(Dilantin) Throid preps Oral contraceptives Estrogen compounds C.GLUCAGON -hormone secreted by alpha cells of the islets of Langerhans in pancreas - bld glucose by stimulating glycogenolysis in liver. -by SQ,IM,IV -used to treat insulin-induced hypoglycemia when client is semiconscious or unconscious and unable to ingest liquids. -bld glucose level begins to w/in 5-20 mins after admin. D.DIAZOXIDE(Proglycem) - bld glucose by inhibiting insulin release from beta cells and stimulating release of epinephrine from adrenal medulla -used to treat chronic hypoglycemia caused by hyperinsulinism resulting from islet cell cancer or hyperplasia. -not used for hypoglycemic rxns from insulin.

GLUCOSE STUDIES 1.Fasting Blood Glucose >70-110 mg/dL Int: -fast for 8-12 hrs before the test -DM patient:withhold morning insulin or oral hypoglycemic med. 2.Glucose tolerance test >70-110 mg/dL -if glucose levels peak at higher than normal at 1 and 2 hrs after injxn or ingestion of glucose,and slower than normal to return to fasting level,DM is confirmed. Int: -eat high-CHO(200-300g)diet for 3 days before test -fast for 10-16 hrs before the test -avoid strenuous exercise for 8 hrs before and after test. -DM patient:withhold morning insulin or oral hypoglycemic med -test takes 3-5 hrs -IV or oral admin of glucose,and multiple bld samples 3.Glycosylated hemoglobin Hemoglobin A1c-reflection of how well bld glucose levels have been controlled for up to the prior 4 mos. -fasting not required before the test. >good control:7.5% or less 4.Glucose,2hr postprandial Value:<140 mg/dL COMMON TYPES OF INSULIN PEAK (HOURS) RAPID-ACTING Lispro (Humalog) Insulin aspart (Novolog) SHORT-ACTING Regular (Humulin R,Novolin N) INTERMEDIATE-ACTING NPH (Humulin N, Novolin N) Lente (Humulin L, Novolin L) LONG-ACTING Ultralente (Humulin U) Insulin glargine (Lantus) PREMIXED 70% NPH / 30% Regular (Humulin 70/30 -1 1-3 2-4 6-14 6-14 18-24 2-12 DURATION(HOURS) 4-5 3-5 5-7 24 24 36 24 18-24