Assessment and Management of patients with Diabetes Mellitus

Adult Health IINUR315

Mr. Mahmoud NasrallahJ.U.S.T

Fall 2009

Definition and Types of DM:

Def.: DM is a group of metabolic disease characterized by elevated levels of glucose in the blood (Hyperglycemia)

Resulting from 1.defects in insulin secretion, 2.Insulin action 3. or both

Affected about 15 million people

Types of DM:

1. Type I (Insulin dependent DM…..IDDM): Absent of Insulin Due to destroyed Beta-cells that produces insulin hormone

- Acute onset, before age 30, 5-10% of DM patients has this type

2. Type II (Non-Insulin dependent DM….NIDDM): Decrease sensitivity of insulin ( insulin resistance) or decrease production of insulin

- represent 90-95% of Diabetic patients 3. Diabetes Mellitus associated with other conditions or

syndrome

4. Gestational diabetes mellitus (GDM) ( Impaired glucose tolerance, previous abnormality of glucose

tolerance, and potential abnormality of glucose tolerance)

Pathophysiology:

Type I: onset < 30 years, absent of Insulin Causes: 1. Genetic ( people Inherit genetic predisposing, or

tendency toward developing type I DM but do not inherit Type I DM),

2. Autoimmune response 3. Environmental Factors Insulin regulates the blood glucose levels by: 1.Inhibit glucogenolysis (Breakdown of stored glucose) 2. inhibit gluconeogenesis: production of glucose from

breaking down of amino acids and other substrates.3.Stimulates up taking of glucose by body cells.

Continue:

Type II: Onset > 30 years Causes:1. Insulin resistance due to obesity 2. Impaired insulin secretion (but still there is insulin

secretion3. Hereditary DKA does not occur in type II because there is enough

insulin to prevent breakdown of fat. Detected incidentally Gestational DM: Due to the secretion of placental

hormones….. Oral hypoglycemic agents are contraindicated.

Pathogenesis of Type 2 Diabetes

Clinical manifestations:

Three p’s (polyphagia, Polydepsia, Polyuria Fatigue Weakness Sudden vision changes Tinglings or numbness in the hands or feet Dry skin Sores that slow to heal and recurrent

infection Type 1 may have sudden weight loss,

nausea, vomiting, and abdominal pain if DKA has developed

Assessment and diagnostic tests:

Fasting plasma glucose (FPG or FBS): 126mg/dl (7.0 mmol/L) or more

Random plasma glucose: more than 200mg/dl (11.1 mmol/L) plus the Symptoms of DM

2-hour postload glucose: equal to or more greater than 200 mg/dl during an oral glucose tolerance test

Assessment Of Diabetic patients:

History: include history of hypo and hyperglycemia, Glucose level, complications, Dietary compliance, and exercise.

Physical examination: BP, WT, Check for the complications

Laboratory Examination: HgbA1c( every 3 months) Microalbuminuria or 24-hour urine collection ( annually) Fasting Lipids ( annually) Referals: to opthalmology and podiatry.

Treatment Goal Is to Normalize Blood Glucose Levels

•Intensive control dramatically decreases vascular and neuropathic complications

Management:

1. Nutritional Management: See meal planning

2. Exercise: - pt should use proper footwear - Avoid exercise in extreme heat or cold - inspect feet daily3. Monitoring glucose and Ketones4. Pharmacologic therapy5. Education

Dietary Management—Goals

Provide optimal nutrition including all essential food constituents

Meet energy needs

Achieve and maintain a reasonable weight

Prevent wide fluctuations of blood glucose levels

Decrease serum lipids, if elevated

Role of the Nurse

Be knowledgeable about dietary management

Communicate important information to the dietician or other management specialists

Reinforce patient understanding

Support dietary and lifestyle changes

Meal Planning

Consider food preferences, lifestyle, usual eating times, and cultural/ethnic background

Review diet history and need for weight loss, gain, or maintenance

Consider caloric requirements and calorie distribution throughout the day

Carbohydrates: 50% to 60% carbohydrates, emphasize whole grains

Fat: 20% to 30%, with >10% from saturated fat and >300 mg cholesterol

Fiber Provide exchange lists

Glycemic Index

Describes how much a food increases blood glucose Combining starchy food with protein- and fat-

containing food slows absorption and glycemic response

Raw or whole foods tend to have lower response than cooked, chopped, or pureed foods

Eating whole fruits rather than juices decreases the glycemic response due to fiber-slowing absorption

Adding food with sugars may produce lower response if eaten with foods that are more slowly absorbed

Other Dietary Concerns

Alcohol

Nutritive and non-nutritive sweeteners

Reading labels

Exercise

Lowers blood sugar

Aids in weight loss

Lowers cardiovascular risk

Exercise Precautions

Exercise when blood sugar levels are elevated (above 250 mg/dL) and ketones are present in urine should be avoided

Insulin normally decreases with exercise; patients on exogenous insulin should eat a 15-g carbohydrate snack before moderate exercise to prevent hypoglycemia

If exercising to control or reduce weight, insulin must be adjusted

Potential exists for post exercise hypoglycemia

Need to monitor blood glucose levels

Exercise Recommendations

Encourage regular daily exercise Gradual increase in exercise period is encouraged Modify exercise regimen to patient needs and

presence of diabetic complications or potential cardiovascular problems

Conduct exercise stress test for patients older than age 30 who have 2 or more risk factors is recommended

Gerontologic considerations See Chart 41-5

Monitoring:

1. Self-Monitoring of blood glucose( SMBG): Enables people with DM to adjust the treatment regimen to obtain optimal blood glucose control. Allow early detection of hypo and hyperglycemia and normalizing blood glucose levels.

Disadvantages of SMBG are in the need for good visual acuity, fine motor coordination, cognitive ability, comfort with technology, willingness and cost

Candidates for SMBG: - Unstable DM - A tendency for sever ketosis and hypoglycemia - Hypoglycemia without warning symptoms - Abnormal renal glucose threshold Frequency: 2-4 times per day is recommended (before

meals and bedtime)

Cont….

2. Glucosylated Hemoglobin: HgbA1c (2-3 month) 3. Urine testing for glucose4. Urine testing for Ketones (Ketonuria): should be

performed whenever patients with type 1 have glucosuria or persistently elevated blood glucose levels ( more than 240mg/dl for two testing periods), and during illness and pregnancy.

4. Pharmacological therapy:

I. Insulin therapy: taken one or two times per day( or even more often) to control blood glucose. Accurate monitoring of blood glucose levels is essential

Insulin preparations: - Time course: onset, peak, and duration of action

( rapid acting (lispro), short acting (HR), intermediat-acting (NPH or Lent), Long acting (Ultralent), and Mixed (70% NPH and 30% R) (table 41-3)

Source: beef, pork, and Human insulin which is now widly used

Insulin regimens:

1. Conventional regimen: is to simplify the insulin regimen ( 1-2 injections/day). May be appropriate for the terminally ill, unwilling or unable to engage in the self-management activities that are part of amore complex insulin regimen

2. Intensive regimen: 3-4 injection/day to achieve as much control over blood glucose levels as is safe and practical and to decrease complications

Teaching Patients Insulin Self-Management Use and action of insulin

Symptoms of hypoglycemia and hyperglycemia

Required actions

Blood glucose monitoring

Self-injection of insulin: see Charts 41-7 and 41-8

Insulin pump use

Insulin Pump

Complications of insulin therapy:

The most common complication of insulin therapy is hypoglycemia.

Local allergic reaction: swelling, redness, tenderness and induration… 2-4 cm wheal may appear in the sight of injection 1-2 hours after injection administered. (occur at the beginning stage of therapy).

Systemic allergic reactions: Are rare. Can treated with giving small doses of insulin which gradually increased.

Insulin lipodystrophy: local reaction cause either lipoatrophy or lipohypertrophy (fibrofatty masses) at the site of injection.

Cont… Insulin resistance: due to obesity or

immune antibodies. Morning Hyperglycemia: insufficient level of

insulin due to dawn phenomena (normal glucose level up to 3 am when Bld glucose start to rise) and Somogyi effect (nocturnal hypoglycemia followed by rebound hyperglycemia)

- Insulin waning: the progressive increase in blood glucose from bed time to morning and is prevented by moving the evening dose of NPH insulin to bed time

Alternative Methods of insulin therapy:

Insulin pens Jet injection: deliver insulin through skin under

pressure( absorbed faster) Insulin pumps: continuous s/c insulin infusion Implantable and inhalant insulin Delivery. Transplantation.

II. Oral Antidiabetic Agents Used for patients with type 2 diabetes who

cannot be treated with diet and exercise alone

Combinations of oral drugs may be used

Major side effects: hypoglycemia

Nursing interventions: monitor blood glucose and assess for hypoglycemia and other potential side effects

Patient teaching

See Table 41-6

Sites of Action of Oral Antidiabetic Agents

II- Oral Antidiabetic Agents:

Used for the treatment for type II Diabetic patients who can’t treated by diet and exercise alone

Cant be used during pregnancy Are Five groups:1. Sulfonylureas: Action: - Stimulating the pancreas to secret insulin. Cant be used with

Type I DM - also improve insulin action at the cellular level. - May directly decrease glucose production by the liver. Side effects: GI symptoms, dermatology reactions and

hypoglycemia (most one) specially with delayed food intake or exercise is increased.

2nd generation of this group have shorter half- life than 1st generation which make them safer to use in elderly and even in adults in regards to hypoglycemia

2. Biguanides:

Metphormin (glucophage). Action: Facilitating insulin’s action on peripheral receptors

sites. Used in combination with Sulfonylureas agent Side effects: Hypoglycemia, Lactic acidosis is a potential

serious side effect Contraindicated in patient with renal impairment or at risk for

renal impairment Nursing measures: renal function should be monitored, should

not be administered 2 days before any diagnostic test requires use of contrast agent.

3. Oral Alpha Glucosidase inhibitors:

Acarbose (Precose) Action: Delaying absorption of glucose from the intestinal system

resulting in a lower postprandial blood glucose level. Should be taken immediately before meals.

They are not systemically absorbed. Side effect: diarrhea and flatulence

4. Thiazolidinedions: Troglitazone (Rezulin) First line agent to treat type II DM, in conjunction of diet Action: enhance insulin action at the receptor site without increasing

insulin secretion. Side effect: can affect liver function, LFT showed be taken as base

line and monthly for 12 months Can cause resumption of ovulation in perimenopausal women putting

them at risk for pregnancy.

Meglitinides:

Repaglinides (Prandin) Action: stimulate the release of insulin from the pancreas Has fast action and short duration and should be taken before

each meal. Side effect: Hypoglycemia

5. Education: the diabetic patient should be knowledgeable about

nutrition, medication effects and side effects, exercise, disease progression, prevention strategies, monitoring techniques, and medication adjustment.

Acute complications of Diabetes:

1. Hypoglycemia (insulin reaction): when the blood glucose falls to less than 50 to 60 mg/dl

- may caused by too much medication, too little food, or excessive exercise.

Manifestation: Sweating, tremor, tachycardia, palpitation, nervousness and hunger, inability to concentrate, headache, lightheadedness, confusion, numbness of the lips and tongue, slurred speech, emotional changes, double vision…. Sever hypoglycemia lead to loss of consciousness.

Hypoglycemic unawareness. Medical management: correction of hypoglycemia.

2. Diabetic ketoacidosis

Cause by an absence or markedly inadequate amount of insulin this result in disorder in the metabolism of CHO, protein, and fat.

Main clinical features are: 1. hyperglycemia: decrease glucose uptake and glucose production by

liver increases. 2. Dehydration and electrolyte loss: Due to polyuria ( 6.5 L of water and

up to 400-500mEq of NA,K, CL may lost in 24 hours) 3. Acidosis: due to breakdown of fat into free fatty acid and glycerol.

Free fatty acids converted to ketones by the liver Causes: 1. Decreased or missed dose of insulin. 2. illness (stress………> which stimulate the secretion of certain

hormones such as glucagon, epinephrine and norepinephrine, cortisol, and growth hormone….. Promote production of glucose from liver and interfere glucose utilization

3. Undiagnosed and untreated diabetes

Cont……

Clinical manifestations: Polyuria and polydipsia Blurred vision Weakness and headache Orthostatic hypotension due to dehydration Gastrointestinal symptoms such as anorexia, nausea,

vomiting and abd pain and acetone breath Hyperventilation to decrease the acidosisDiagnostic Findings: Glucose level vary from 300-800 mg/dl Low serum bicarbonate and low PH (6.8 to 7.3) Blood and urine ketone measurements NA and K may be low, normal, or high.

Medical management:

Rehydration and correction of electrolyte imbalance.

Treat acidosis: IVF (normal saline), Insulin infusion ( 5unit/hr), Bicarbonate infusion is contraindicated because causing sever sudden hypokalemia

Nursing management: - Monitoring

3. Hyperglycemic hyperosmolar Nonketotic Syndrom:

Hyperglycemia and hyperosmolarity predominate, with alteration of awarness, with same time ketonsis is minimal or absent

Cause: Lack of effective insulin ( insulin resistance). Persistent of hyperglycemia causes osmotic diuresis,

resulting in losses of water and electrolyte……….> water shifts from intracellular fluid space to the Extracellular fluid space

With glucosuria and dehydration, hypernatremia and increased osmolarity occur.

Hyperglycemia and dehydration may be more sever.

Clinical manifestation: hypotension, profound dehydration, tachycardia, alteration in awareness, hemiparesis.

Long-Term Complications of Diabetes:

1. Macrovascular disease: changes in the medium to large blood vessels

Blood vessels walls thicken, sclerose, and become occluded by plaque ( atherosclerosis).

May happened due to other diseases Coronary artery disease, Cerebrovascular disease, and

peripheral vascular disease are the three main types of Macrovascular.

2. Microvascula complications( Diabetic Retinopathy and Nephropathy)

Unique to DM Capillary basement membrane thickening of the retina

(microangiopathy) and kidneys (Nephropathy) Proliferative retinopathy is characterized by the proliferation of

new blood vessel of new blood vessels growing out of the retina into the vitreous which are prone to bleeding.

Cont….

Nephropathy: changes in the microvascular changes in the kidney.

The kidney’s filtration mechanism is stressed, allowing blood protein to leak into the urine. As a result pressure in the blood vessels of the kidney increased, this increases in the pressure stimulate the development of Nephropathy.

Diagnostic findings: Microalbuminuria if present in two tests ACE inhibitor should prescribed to lower pressure and reduce microalbuminurea. Serum creatinine and BUN

3. Diabetic Neuropathies:

Group of disease that all types of nerves, including peripheral (sensorimotor), autonomic, and spinal nerves

Causes: Vascular or a metabolic mechanism or both, and demylinization of the nerves ( result in disruption of conduction.

Most common types are: 1. sensorimotor polyneuropathy (peripheral neuropathy): Clinical manifestation: parasthesias, burning sensations,

feet become numb, decrease awareness of position and WT of objects, decrease sensation of light touch lead to an unsteady gait,decrease sensation of pain and tempreture

2. autonomic neuropathy: Neuropathy of autonomic nervous system.

Clinical manifestation:

1. Cardiovascular: Slight tachycardia, orthostatic hypotension, silent or painless myocardial ischemia and infarction

2. Gastrointestinal: Delayed gastric emptying, bloating ,nausea, and vomiting, Diabetic constipation or diarrhea may occur.

3. Urinary: Urinary retention, decreased sensation of bladder fullness, increase risk of UTI.

4. Adrenal gland (Hypoglycemic Unawareness): Diminished or absent of adrenegic symptoms of hypoglycemia

5. Sudomotor neuropathy: decrease or absence of sweating of the extremities, with a compensatory increase in upper body sweating. Dryness of feet increase the risk of foot ulcer

6. Sexual dysfunction: impotence in men ( This complication makes the patients to seek health and mainly DM discovered after that).

Diabetic foot:

Three diabetic complications increase risk of foot infection:

1. Neuropathy: sensory neuropathy leads to loss of pain and pressure sensation, autonomic neuropathy lead to increase dryness and fissuring of the skin

2. Peripheral vascular disease: poor circulation…. Poor wound healing

3. Immunocompramise DM impairs the ability of specialized WBC’s to destroy bacteria.

Medical management: Control of Glucose level, bed rest, antibiotic, debridement.

Nursing management:

Nursing diagnosis of newly diagnosed with DM

1. Risk for fluid volume deficit related to polyuria and dehydration

2. Altered nutrition related to imbalance of insulin, food and physical activity

3. Knowledge deficit about diabetes self- care skills4. Potential self-care deficit related to physical impairment or

social factors5. Anxiety related to loss of control, fear of inability to manage

diabetes