Upload
anthonychapotin
View
10
Download
2
Embed Size (px)
DESCRIPTION
NURSING Gastrointestinal Disorders Conference 3 Fall 2014
Citation preview
Diabetes Mellitus Conference #3
Jackie Dorsey RN, MS, ANP
Exercise and the Diabetic patient
THERAPEUTIC BENEFITS OF EXERCISE
Decrease
Lower
May decrease need to reach target BG levels
Reduce
Reduce
Improve
BENEFITS SPECIFIC FOR THE TYPE 2 DIABETIC
Decreases
Decreases percentage
May delay onset of Type 2 diabetes
General Guidelines for Exercise
Exercise does not have to be vigorous
Exercise is best done after meals
Exercise plans should be individualized
It is important to monitor blood glucose before, during, and after exercise to determine the effect of exercise on the blood glucose.
General Guidelines for Exercise
Be alert to the possibility of delayed exercise-induced hypoglycemia Effects of exercise on BG level may last up to 48 hours
Stretch for 5-10 minutes before and after exercise
Maintain good posture during exercise
Hydrate before beginning exercise
Wear proper shoes for comfort and injury prevention
When is exercise related hypoglycemia likely to occur?
When insulin or antidiabetic medication is peaking
If exercise is strenuous or prolonged and CHO is not replaced
When would you suggest to a diabetic patient, who takes an antidiabetic agent, the
most appropriate time to exercise?
One hour after eating a meal
After the ingestion of 15 gm of CHO For every 45 minutes of activity the individual
should consume another 15 gm of CHO
What items would constitute 15 Gms of CHO?
17 grapes
8-10 life savers
4-6 oz. of juice
Sport drinks which contain 80-100 calories
from CHO
Why does exercise induced hyperglycemia occur?
Strenuous Activity or Exercise
Perceived by body as stress
Release of counterregulatory hormones (glucagon, epinephrine, growth hormone, cortisol)
Temporary elevation of blood glucose
Hyperglycemia
Type 1 diabetic should avoid exercise if BG level is > 300
mg/dl without urine ketones present or if BG level is > 250
mg/dl with urine ketones present.
INSTRUCTIONS FOR DIABETICS DURING ILLNESS/ SICK DAY GUIDELINES
Medications
Continue as before unless otherwise advised by health care team
Supplemental insulin doses may be required in Type 1 diabetes mellitus
INSTRUCTIONS FOR DIABETICS DURING ILLNESS/ SICK DAY GUIDELINES
Blood sugar monitoring
Increase frequency to every 4 hour
Assess urine for presence of ketones especially during fevers and when BG is > 240 mg/dl
INSTRUCTIONS FOR DIABETICS DURING ILLNESS/ SICK DAY GUIDELINES
Intake
Continue CHO intake by substituting regular soda, regular jello, popsicles, or Gatorade
Small, frequent meals
Drink adequate amount of fluids to prevent dehydration
INSTRUCTIONS FOR DIABETICS DURING ILLNESS/ SICK DAY GUIDELINES
Instruct pt. to keep good written records of BGs & urine ketones as soon as they become sick so that they are prepared to relay this information to the MD.
Contact MD
BG is > 240 mg/dl
Moderate to large amounts of ketones in the urine
unable to keep anything down
Prevention
Seasonal Flu vaccine
Good hand washing
Blood Glucose Monitoring A BG test measures the
amount of sugar (glucose) in a sample of blood
BG monitoring refers to the ongoing measurement of blood sugar (glucose)
Monitoring can be done at any time using a portable device called a glucometer
Blood Glucose Monitoring
The traditional glucose meter comes with test strips, small needles called lancets, and a logbook for recording numbers if the meter is used in the home
In the hospital setting, specific documentation flowsheets are used per agency policy
There are many different kinds of meters, but they all work essentially the same way
Blood Glucose Monitoring
Blood Glucose Monitoring
How the Test is Performed
Inform the patient Include slight discomfort
Gather all equipment timing is important
Wash your hands
Clean the area of the finger per agency policy
Avoid using the pads of the finger
Allow area to completely dry before pricking the finger
Provide the patient with a gauze pad for application of slight pressure
How the Test is Performed
Prick finger with lancet
Wipe away the first drop of blood, and then allow a full second drop of blood to fall onto the pad of test strip
The test strip uses a chemical substance to determine the amount of glucose in the blood Newer monitors can use blood from other areas of the body beside the
fingers, reducing discomfort.
Insert the test strip into glucometer
The meter will display the blood sugar results as a number on a digital display
Sliding Scale Insulin
In order to normalize the blood sugar levels of the patient the MD may prescribe all or part of the patients insulin on a sliding scale basis
The dose or doses are determined on the basis of the patients blood sugar results
Sliding scale is broadly defined as a set of instructions meant to adjust the dose of insulin in accordance with the results of the patients blood sugar levels, activity level and meals
Sliding Scale Insulin
Sliding scale insulin provides for better control of blood glucose since the insulin dosage is matched to the patients current need which is indicated by the blood sugar at that specific time
The RN has a critical responsibility to document the test times, the patients blood sugar results and the amounts and types of insulin administered
Sliding Scale Insulin
Read example 1 & 2 and determine how much insulin to administer to the patient using the sliding scale below.
2 units regular insulin if blood sugar is less than 180
4 units regular insulin if blood sugar is 181-240
6 units regular insulin if blood sugar is 241-320
8 units regular insulin if blood sugar is 321-400
ANSWER: 1. 4 units
2. 2 units
Pages 41 and 42 should have been completed as part of your pre-conference
work.
Insulin (high alert medication) Critical Thinking Activities
Case Scenario #1
Determine the sliding scale insulin based on the BG results for listed coverage 0600
2 units
1200
0 units
1800
6 units
2400
0 units/Call MD
Insulin (high alert medication) Critical Thinking Activities
Case Scenario #2
Determine and document the amount of Insulin to be given at
0630
6 units
1130
6 units
1630
2 units
Insulin (high alert medication) Critical Thinking Activities
Case Scenario #2
Determine how much insulin is needed for the HS dose Regular Sliding Scale Insulin 4 units NPH Insulin 12 units
Draw this amount up and administer to the injection pad
Discard fluid from syringe into Dixie cup
Draw up equivalent amount of air into syringe then administer to injecta pad
(Most agencies require 2 nurses to witness drawing up the insulin and co-sign)
Case Study 1
What assessment data would you document for this patient?
NPO after 6 p.m.
Took her glyburide (high alert medication) today
c/o feeling weak, unsteady and jittery
Case Study 1
Based on your assessment what does the above data indicate?
low BG?
high BG?
Case Study 1
List 2 priority nursing diagnoses with two matching priority outcomes
Risk for unstable blood glucose
Risk for falls
Case Study 1
Priority outcomes for Mrs. Zimmer
Maintain normal blood glucose levels
No falls during hospitalization
Case Study 1
Mrs. Zimmers actual BG was 37. What therapeutic nursing intervention (TNIs) would you implement? List TNIs in priority order.
Notify MD
Anticipate administration of IV Dextrose (D50)
Teach how to prevent incident
Case Study 2
What assessment data would you document for this patient?
Type 1 Diabetic
Strenuous activity hiking
Weak, sweaty
Rapid pulse
Case Study 2
Based on your assessment what does the above data indicate?
low BG?
high BG?
Case Study 2
List at least 1 priority nursing diagnosis and one matching priority outcome.
Risk for unstable blood glucose
Case Study 2
Priority outcomes for Jimmy:
Maintains normal BG levels
Case Study 2
List TNIs in priority order
Simple CHO or oral glucose paste orally if awake
enough to swallow
Do not overtreat
Recheck BG 15 minutes after treatment
Repeat until BG > 60 mg./dl
Case Study 2
List TNIs in priority order
Jimmy should eat regularly scheduled meal/snack to prevent rebound hypoglycemia
If no improvement after 2 or 3 doses of simple CHO or Jimmy becomes unconscious
give Glucagon 1 mg 1M/SC
Have Jimmy eat a complex CHO after recovery
In acute care setting 20-50 ml. D50 IV push
Case Study 3
What assessment data would you document
for this patient?
Type 1 DM
Blurred vision
Polyuria, Polydipsia
Increased stress
Not following her dietary regimen and exercise plan
Case Study 3
Based on your assessment what does the above data indicate?
low BG?
high BG?
Case Study 3 List 2 priority nursing diagnoses with two
matching priority outcomes for Anne.
Diagnoses:
Risk for fluid volume deficient
Risk for unstable blood glucose
Outcomes:
- Maintain urine output 30 mL/hr
- Maintain normal blood glucose levels
Case Study 3
TNIs in priority order
Monitor intake and output
Provide Ann with information on diet and exercise
Case Study 3
What additional teaching would you include?
Reinforce BG monitoring
Pediatric Considerations
Chart on page 49 provides you with important material regarding diabetes and pediatrics. Should have been completed prior to conference. Review on your own.
View Video
Diabetic Emergencies: Hyperglycemia and Ketoacidosis
VHS-193A (10 min.)
Notetaking Guide Provided on page 50
Acute Complications: Hyperglycemia & DKA
Definition
Precipitating Factors
Assessment Data
Treatment
Acute Complications: Hyperglycemia & DKA
Prevention
Teach patient:
to take antidiabetic medications as prescribed
proper technique to draw up and administer insulin with return demonstration
maintain target blood glucose range
to monitor blood glucose as ordered
Acute Complications: Hyperglycemia & DKA
Prevention
Teach patient:
lifestyle changes that may be required to control disease (exercise plan, adherence to diet)
S/S and how to treat
wear or carrying medical alert identification
ways to prevent hypo/hyperglycemia since activity chances can effect insulin needs
DKA
Diabetic Ketoacidosis Case Study
Diabetic Ketoacidosis Case Study Group Activity
pp. 54-57
Faculty may choose to do some or all of this
pre-conference activity if time allows.
Diabetic Ketoacidosis Case Study p 55
1. Briefly explain the pathophysiology of the development of diabetic ketoacidosis (DKA) in this patient.
Answer
Diabetic ketoacidosis (DKA), also referred to as diabetic acidosis and diabetic coma, can develop quickly or over several days or weeks
For Mr. John, DKA developed as a result of too little insulin accompanied by increased physical stress (the flu), which increases the demand of the body for insulin
Diabetic Ketoacidosis Case Study
2. What clinical manifestation(s) of DKA does this patient exhibit?
Answer:
Breathing deep and rapid, acetone smell on breath, skin flushed and dry
Diabetic Ketoacidosis Case Study
3. What factors precipitated this patients DKA?
Answer: Flu x 1 week
Vomiting and anorexia resulted in decreased caloric intake
Stopped taking his insulin
When insulin supply is inadequate, glucose cannot be properly used for cellular energy
In response to cellular starvation, the boy releases and breaks down stored fats and protein to provide the needed energy
Diabetic Ketoacidosis Case Study
What factors precipitated this patients DKA?
Answer:
Free fatty acids from stored triglycerides are released & metabolized in the liver in such large quantities that ketones are formed (ketonemia)
Excess ketones alter pH balance & acidosis develops
More H2O is lost as ketones are excreted (ketonuria) in an attempt to balance the pH
Diabetic Ketoacidosis Case Study
What factors precipitated this patients DKA?
Answer:
Gluconeogenesis from protein is the last resource used by the body as a compensatory response to provide a cellular energy source
Result is increase in BG and nitrogen levels
Due to prevailing insulin deficiency, this glucose resource cannot be used and the BG level rises further, adding to the osmotic diuresis
Diabetic Ketoacidosis Case Study
What factors precipitated this patients DKA?
Answer:
Dehydration and loss of electrolytes, particularly potassium
Patients skin becomes dry and loose, and
Eyeballs become soft and sunken
Hypotension with a weak, rapid pulse may also develop
Diabetic Ketoacidosis Case Study
4. What teaching should be done with this patient and his family?
Answer: Food intake is important during illness because the
body requires extra energy to deal with the stress
When he has a minor illness, such as a cold or the flu, continue drug therapy and food intake A carbohydrate liquid substitution, such as regular soft
drinks, gelatin dessert, or beverages such as Gatorade, may be necessary
Diabetic Ketoacidosis Case Study
What teaching should be done with this patient and his family?
Answer: Extra insulin may be necessary to meet the extra energy
demand and prevent DKA
BG monitoring should be done every 1 to 2 hours by either John or a person who can assume responsibility for care during the illness
Urine output ,presence & degree of ketonuria should be monitored, particularly when fever is present
Diabetic Ketoacidosis Case Study
What teaching should be done with this patient and his family?
Answer: Fluid intake should be increased to prevent
dehydration, with a minimum of 4 oz per hour for an adult
Mr. John should be instructed to contact the health care provider when BG is > 250 mg/dl (13.9 mmol/L), fever, ketonuria, & N/V occurs
Diabetic Ketoacidosis Case Study
5. What role should Mr. Johns wife have in the management of his diabetes?
Answer:
If Mr. John is not able to effectively manage his DM his wife can assist by
Frequent monitoring of BG levels
Encouraging fluids and food intake
Reporting abnormal BGs to MD as prescribed
Diabetic Ketoacidosis Case Study
6. Appropriate nursing diagnoses
Answer:
Deficient fluid volume
Risk for unstable blood glucose
Diabetic Ketoacidosis Case Study
Collaborative problems/Potential complications
Answer:
Diabetic ketoacidosis
Hyperglycemia
Diabetes Mellitus Conference #3
Please review post conference
activities and the Diabetes
Mellitus Comprehensive review