Acute Care of Diabetes Mellitus

NURS 3071: Acute Health Challenges

Feb. 12, 2019
Definition

Diabetes mellitus – group of metabolic diseases

characterized by hyperglycemia resulting from defects in
insulin secretion, insulin action, or both.
(Paul et al., p. 1272)

2
Risk factors (for developing DM)
• Type 1

• Type 2

• Gestational Diabetes

• Other types (DM secondary to another condition)

3
Assessments
• 3Ps  S&S of DM
• What are they?
What is the pathophysiology behind the 3Ps?

• Chronic conditions/complications
• What are the chronic conditions associated with DM?
• What is the pathophysiology behind each?

• Think about the nursing assessments that would be

most relevant for the diabetic patient.

4
Lab & diagnostic tests
• Blood glucose (Self-monitoring of blood glucose [SMBG])
• HbA1C (glycosylated hemoglobin)
• Ketones
• Urine glucose

Normal blood glucose:

• HbA1c: 7.0% or less
• Blood glucose:
• Fasting and before meals: 4.0 to 7.0 millimoles per litre (mmol/L)
• 2 hours after meals: 5.0 to 10.0 mmol/L or 5.0 to 8.0 mmol/L if A1c
targets are not being met
(Retrieved from: https://myhealth.alberta.ca/Health/pages/conditions.aspx?hwid=aa135726)

5
Pharmacological management

6
Non-pharmacological management
• Diet
• Exercise
• Weight control
• Education
• Think about how overwhelming this must be to the newly diagnosed
patient and/or their family!
• Teaching them how to eat, what medications to take, maybe how to
give injections.
• Carb counting.
• Survival skills!
• Assess readiness to learn.

7
Determinants of Health
• How would the determinants of health impact the
patient with diabetes mellitus?

• What particular struggles have you seen in our local

population in relation to diabetes mellitus and the
determinants of health?

• Can you think of an example, or a case, when you

felt that the determinants of health really hindered
the diabetic patient from living a health life?

8
Acute complications
Most DM complications are chronic.

The 3 main ACUTE complications are:

• Hypoglycemia
• DKA
• HHNS

9
Prioritization of care
• You are the nurse working on a busy medical unit
with many diabetic patients. You are working in a
team with an LPN and PSW. The LPN reports that the
patient in 50C has a blood glucose of 2.0 mmol/L,
and the patient in 50D has a blood glucose of 32.5
mmol/L.

• Who will you treat first?

• Why?
• What treatments would you anticipate in each
situation?

10
Hypoglycemia
• Blood glucose drops too low
• <2.7-3.3 mmol/L
• Check agency guidelines (may treat <4.0 mmol/L depending on
context)

• Causes:
• Too much insulin
• Too little food
• Excessive physical activity

11
Hypoglycemia
• 2 categories of clinical manifestations:
• Adrenergic symptoms
Mild hypoglycemia:
• SNS stimulation  epi and norepi released  sweating, tachycardia,
palpitation, nervousness, hunger.

• Central nervous system symptoms

Moderate hypoglycemia:
• CNS impairment  glucose deprived brain cells  can’t concentrate, light-
headed, numbness around mouth, slurring, headache, combative/irrational.
Severe hypoglycemia:
• CNS function even worse  decreased LOC, patient needs assistance to
treat. Disoriented, seizures, loss of consciousness, death if not treated.

12
Hypoglycemia
• Treatment:

If able to take PO:

• Immediate treatment with 15 g carbs.
• Give orally if patient is able to take PO.
• Follow up with a snack that balances protein and longer acting carb
source.

If unable to take PO (i.e. decreased LOC)

• Glucagon 1 mg SC or IM
• Brief duration of action  provide snack when awake.
• D50W 25 to 50 mL IV

13
Patient Teaching
• What are the key teaching points related to
prevention of hypoglycemia?

• What about treatment?

• Family perspective:

https://www.youtube.com/watch?v=_t6-2CVwDCU

14
DKA Pathophysiology
• Know cause & 3 main clinical features

15
DKA Treatment
3 areas of focus correct dehydration, correct hyperglycemia, correct
electrolytes (Potassium).

Correct the dehydration  IV fluids.

• Usually start with 0.9 NaCl. Expect higher rates (i.e. boluses at first).

• Physician may change to 0.45 NaCl next (rate lowered, if patient does not
have hyponatremia. Remember this is hypotonic and so will cause cellular
swelling in the patient with hyponatremia).

• When blood glucose comes down to <16.6 mmol/L  may change to d5W.
• Keeps glucose from dropping too far too fast, especially if still receiving IV insulin.

16
DKA Treatment
Correct the hyperglycemia/acidosis  Insulin administration
• These patients are suffering from a lack of insulin…so expect to give
insulin!
• Insulin usually administered by IV infusion.
• You will have an insulin infusion protocol to follow. Nurse is
responsible for determining appropriate titration according to the
protocol orders.
• Check accu’s q1h and/or as per protocol.
• Blood glucose may normalize before acidosis resolves…expect to
keep insulin going until acidosis is corrected. This may mean you
need to add dextrose to the IV solution to prevent hypoglycemia.

17
DKA Treatment
• Correcting electrolytes  POTASSIUM is the big one
here.
• When the patient initially presents, K+ may be low, normal, or high (lack of
insulin  K+ comes out of cells to exchange with acidotic H+ ions). During
the treatment of DKA, things shift. Patient will become hypokalemic.

• Rehydration  lowers K+ concentration in blood.

Increases renal excretion of K+.

• Insulin  Shift K+ from ECF to ICF.

TREATMENT  Give potassium

18
Nursing Management
• Physician writes the orders.
• You will monitor:
• Vitals
• Blood glucose
• Insulin infusion (follow protocol)
• Fluid volume status
• Urinary output
• Acid/base balance; Electrolytes (Labs sent as prescribed)
• ECG (watch for tall T waves which could indicate dangerous
hyperkalemia)
• Collaboration with the medical team is important
when managing these patients. Keep the team
informed.

19
Diabetes in Children/Adolescents
• Diabetes is the most common endocrine disorder in
children.
• Many Type 1 DM diagnosed in childhood
• Type 2 DM is becoming more common in childhood/adolescence as
well.

• Consider determinants of health.

• Can the family cope with this diagnosis and all that comes with it?

• Consider developmental stage.

• Why would this matter?

• Risks for DKA in children vs. adults

20
Diabetes in Adolescents
(Chow et al., 2013)

• Of particular concern:

• Parents have less control

• Management often worsens
• More admissions with complications
• May omit insulin on purpose
• Higher rates for eating disorders
• High risks if teenage pregnancy

21
Hyperglycemic Hyperosmolar
Nonketotic Syndrome (HHNS)
• Overview of pathophysiology:

https://www.youtube.com/watch?v=iKKF5yuxvg8

Treatment:
 ICU (or close monitoring)
 IV insulin
 Fluid volume resuscitation (0.9 or 0.45 NaCl depending
on serum sodium)
 Potassium replacement (watch U/O and EKG)

22
Sick Day Rules
• Take usual insulin/oral antihyperglycemics.

• Check accu q 3-4 hours.

• Report accu>16.6 mmol/L and urine ketones to physician.

• Supplemental insulin may be required (stress response).

• 6-8 small meals per day if possible.

• Liquids (cola, OJ, broth, Gatorade, etc.) q30min-q1h

• T1DM  if unable to keep food/fluids down may need to be

hospitalized for monitoring. Risk for DKA.

23
Diabetes and addictions
• Alcohol
• Moderation is key (problematic if you are an alcoholic)
• Not on an empty stomach
• Hypoglycemia main risk
• Hyperglycemia and weight gain for sweet drinks/increased calories

• Other drugs
• Impaired judgement leads to issues with DM control
• Increased risk for complications from poor control
• Compounds risk factors

24
Wrap-up
• DM is very common so you really need to have a
solid understanding of this content.
• Know types, chronic complications.
• Lab data associated with DM.
• Medications to treat DM  how do the classes work
differently?
• Patho of chronic complications is review
information.
• Patho of acute complications is new information
(building upon foundation).

25
Wrap-up
• Treatment of hypoglycemia.
• Treatment plan for DKA.
• Treatment plan for HHNS.
• Connect determinants of health.
• Pediatric considerations with DM and DKA.
• Developmental stage as a factor in management.

26
Feedback

Please take a few minutes to complete the feedback

form and hand in on your way out.

Thanks!
Angela

27