Chapter 40 Diabetes (1).pptx

Diabetes Diabetes Mellitus – Disorder of carbohydrate (glucose) metabolism – The body is intolerant to glucose for one and/or two reasons – The pancreas has developed faulty production of insulin – Production of insulin is significantly decreased or production has ceased completed – The tissues h...

Diabetes Diabetes Mellitus – Disorder of carbohydrate (glucose) metabolism – The body is intolerant to glucose for one and/or two reasons – The pancreas has developed faulty production of insulin – Production of insulin is significantly decreased or production has ceased completed – The tissues have become insensitive to the insulin – There are two ways to classify Diabetes Mellitus – Type One Diabetes Mellitus (DM1) – Type Two Diabetes Mellitus (DM2) – How is an individual diagnosed with Diabetes? – There are various ways, but an elevated HbA1C is most common Type 1 Diabetes – Accounts for 5% of all Diabetes Mellitus – 1.25 million children and adults have Diabetes Mellitus Type 1 (DM1) – DM1 usually develops in childhood or adolescence and the onset of symptoms is abrupt – DM1 is an autoimmune disease – The body’s immune system destroys pancreatic Beta Cells – Pancreas is unable to secrete insulin because there are no beta cells to synthesize it – No insulin is produced within the body – A type one diabetic must have exogenous insulin to live – this person must administer insulin injections daily for the rest of their lives – Without exogenous insulin, blood sugar levels can become critically high Type 1 Diabete s Type 2 Diabetes – Insulin production is reduced and/or cells are resistant – Most prevalent form of diabetes – Accounts for 95% of all diagnosed cases – Can occur in all ages, however it most commonly forms in the middle-aged adult and progresses gradually – Risk factors for developing DM2 are: – Genetics – Obesity – Poor diet – Sedentary lifestyle Type 2 Diabetes – Most individuals with DM2 are still capable of some insulin synthesis, but insulin synthesis and secretion is impaired – There are less beta cells available to synthesize the insulin because they’ve been overworked for so long – The beta cells that are still alive have a decreased response to rising glucose levels, causing delayed or decreased release of insulin from the pancreas – Tissues & Cells within the body are insulin resistant – Liver, muscle, and adipose tissue don’t respond to insulin as quickly or efficiently – Cells don’t absorb and metabolize the glucose as efficiently as they once did – DM2 can be managed with diet, oral agents, or insulin – Depends on progression of disease process as to what will manage disease appropriately – Usually start off with diet control and lifestyle changes, adding on medications when necessary – Not uncommon to see patient on multiple oral agents or a combination of oral agents and insulin; depending on disease progression Type 2 Diabete s Complicatio ns of Diabetes Hyperglycemi a – Hyperglycemia occurs when glucose available exceeds the amount of insulin available – Blood Sugar Ranges should be: 74 to 106 mg/dL – Causes – Overeating – Stress & Illness – Releases cortisol, which in turn increases glucose levels – Not enough medication or inappropriate medication regimen – Chronically high blood glucose levels can lead to long-term complications Symptoms of Hyperglycemia – Symptoms occur because: – The body is attempting to rid the excess glucose from the serum – The body is reacting from cells starving – Polyuria, Polydipsia, Polyphagia – Glucosuria – Blurred Vision – Fatigue, Lethargy, Headache – Abdominal Pain – Eventual Coma Treatment of Hyperglyce mia in the Diabetic Patient Dietary Changes Increase Physical Activity Education Non-Insulin Oral Agents • Daily medications to assist with management of BGL control and lower HbA1C Insulin Coverage • Exogenous insulin administered to manage BGL and lower HbA1C Hypoglycemi a – Hypoglycemia occurs when there is not enough glucose available for the amount of insulin circulating in the blood – Defined as blood glucose less than 74 mg/dL – Patients react differently to blood glucose levels; symptoms may be felt at blood glucose levels higher or lower than 74 mg/dL – Causes – Not enough food, under eating, skipping a meal – Too much insulin – Exercise – Repeated episodes of hypoglycemia or extremely low BGL can cause neurological damage Symptoms of Hypoglycemia – Initial signs and symptoms are caused by activated by SNS – – – – – – – Hunger Shaky, Tremors Sweating Palpitations Pallor Headaches Remember: Cold & Clammy, need some candy! – If hypoglycemia progresses without treatment, neurological complications occur (neuroglycopenia) – Irritability – Confusion – Seizures, Coma Treatment of Hypoglyce #1 – Assess BGL first if glucometer available! – Glucometer available in both LTC and acute care setting – Want to assess the initial BGL before intervening! – May not be available if patient is out & about – If <74 mg/dL or patient is symptomatic: provide simple sugar! #2 – TWO OPTIONS DEPENDENT ON PATIENT’S PRESENTATION: – If patient is awake, alert, cooperative: – Administer 15 to 20 G Fast-Acting simple-carbohydrate – 4-6 oz. of juice or regular soda – 6-8 hard candies (such as lifesavers) – If patient is lethargic, unconscious, unable to safely swallow, uncooperative: – Administer Sub-Q or IM Glucagon – If individual has IV access: Administer Dextrose Treatment of Hypoglyce #3 After initial intervention, recheck glucose in 15 Min – Stay with patient during this time – If BGL continues to be below <74 mg/dL OR patient remains symptomatic, repeat step #2 ■ Treatment option depends on patient’s presentation – – If patient’s S/S improve but BGL is still below 74 mg/dL, repeat above steps! Even if patient is “feeling better” Repeat steps until the glucose is above 74 mg/dL ■ Once glucose has reached 74 mg/dL or greater, provide a snack of complex-carbohydrates – Peanut butter and crackers – Sandwich and chips – Meal (breakfast, lunch, dinner) Long Term Complicati ons of Diabetes Over time, chronic hyperglycemia causes a variety of serious complications • Take years to develop • Most deaths from diabetes are due to long term complications, not short-term Macrovascular Damage • Atherosclerosis and arteriosclerosis develop • More prone to developing HTN and elevated LDL & triglyceride levels • Increased risk of developing heart attack, stroke & poor circulation of the dependent extremities Microvascular Damage • Damage to small blood vessels and capillaries; blood flow decreases from thickening of vessel walls, target organ damage occurs • Retinopathy • Nephropathy Long Term Complications of Diabetes Neuropathy • Nerve damage due to chronic hyperglycemia • Causes numbness and pain or decreased sensation in extremities • Manage pain: Commonly prescribed anticonvulsant agents such as Gabapentin or antidepressants Increased risk for infection • Slowed healing due to impaired circulation Complications with the feet • Neuropathy  decreased sensation and unknown wounds • Risk for infection and slowed wound healing • Foot assessment and foot care is extremely important • Amputations of lower extremities common To prevent long term complications, individuals should: • Control BGL, blood pressure, cholesterol levels • Avoid smoking, maintain appropriate weight, exercise regularly Diet Treatment of Diabetes Mellitus Exercise • Some type 2 Diabetic individuals can control their DM with diet and exercise alone Maintain appropriate weight Monitor and manage blood glucose levels • Assess BGL based on orders • Some individuals have BGL checked weekly, some have BGL checked multiple times a day Medications • Insulin • Necessary for which type of Diabetic? • Non-Insulin Oral Medications Medication s Non-Insulin Oral Agents – Oral agents are oral medications that can be used by Type 2 Diabetics to control their Diabetes Mellitus and manage BGL – Oral agents require the pancreas to still have some function, so they cannot be used for a Type 1 Diabetic – Oral agents work in two different ways: – Produce more insulin through stimulating the pancreas – Make the tissues/muscles more sensitive to insulin – Oral agents are taken daily to help control blood glucose and manage HbA1C over time – Blood glucose does not have to be monitored before administration of these medications Metformin (Glucophage) – Drug class: Biguanide – Decreases glucose production in the liver and increases response to insulin by increasing cell uptake of glucose in the tissues – Can cause kidney damage  check kidney labs and avoid administration if patient recently had contrast dye Glimepiride (Amaryl) – Drug class: Sulfonylurea – Stimulates insulin production by the pancreas and increases response to insulin by increasing cell uptake of glucose in the tissues – Monitor for hypoglycemia because of the increase of insulin secretion Insulin – Used to treat all patients with DM1 and many patients with DM2 – Routes: Sub-Q – Where can a Subcutaneous injection be administered? – Tissue of the back fatty part of the arm – Abdomen (at least 2 inches from belly button!) – Anterior thigh – Buttocks – Rotation of sites is key to avoid complications with tissue distribution – RN must know the blood sugar before administering any type of insulin Insulin – Insulin is a high-risk drug because it can quickly cause a patient harm if too much is administered – Double RN Check: Two nurses verify the amount and type of insulin being administered – This is to avoid dosing errors and potentially fatal patient consequences – How to perform the double check? – You draw up the insulin, leaving the needle/syringe in the insulin vial – Ask another nurse to verify the amount of medication you have in your syringe – Do not tell the nurse what you should have – The nurse should look at the syringe and tell you the amount of insulin they see along with verifying the medication (insulin type) from the bottle Types of Insulin There are different types of insulin preparations – Rapid-acting, Short-acting, Intermediate-acting, Long-acting – Classified by “time course” which includes onset, peak, and duration of drug – Onset: how long it takes for the insulin to begin working and lowering glucose – Peak: when the insulin is working the very hardest to lower glucose levels – Duration: how long the insulin continues to work until it is completely used up Types of Insulin: Mealtime Insulin – Known as bolus insulin – Works quickly in the body to keep blood glucose levels under control after a meal – Given at or right before mealtime to combat hyperglycemia – Also given when blood sugars are extremely elevated – Insulins in this category: – Rapid-Acting Insulin – Short-Acting Insulin Drug Class Rapid-Acting Insulin Common Medications Insulin Lispro (Humalog) Insulin Aspart (Novolog) How to remember? “-Logs” roll rapidly down the hill How does it work? Assists in lowering blood glucose levels quickly Onset: 5-20 minutes Peak: 30 minutes – 3 hours Duration: 2 – 5 hours How is it administered? Subcutaneously Why is it given? To decrease blood sugar to normal limits for a diabetic patient When is it given? During hyperglycemic episodes Assessments? Assess BGL prior to administration (no sooner than 30 minutes prior to administration) Extra Info • • • Must know blood glucose before administering Do not give medication more than 15 minutes before meal ingestion • Can cause hypoglycemia Be mindful of hypoglycemic episodes Drug Class Short-Acting Common Medications Regular Insulin (Novolin R or Humulin R) How does it work? Assists in lowering blood glucose levels quickly Onset: 30 minutes Peak: 2 – 5 hours Duration: 5 – 8 hours How is it administered? Subcutaneously Extra info: Regular insulin is the only insulin that can be given intravenously Why is it given? To decrease blood sugar to normal limits for a diabetic patient When is it given? During hyperglycemic episodes Assessments? Assess BGL prior to administration (no sooner than 30 minutes prior to administration) Extra Info • • • Must know blood glucose before administering Do not give more than 30 minutes before meal ingestion • Can cause hypoglycemia Be mindful of hypoglycemic episodes Types of Insulin: Daily Control Insulin – Known as basal insulin – Works slowly throughout the day to keep glucose levels at consistent levels – This medication most closely mimic the pancreas’ secretion of insulin – A healthy pancreas constantly releases small amounts of insulin to control blood glucose levels – Basal insulin is administered if glucose levels are within appropriate ranges – Administered even if the patient is not experiencing hyperglycemia to keep blood sugar stable throughout the day – If patient is hypoglycemic, this medication is not administered and the hypoglycemia protocol is put into place – Insulins in this category: – Intermediate-Acting Insulin – Long-Acting Insulin Drug Class Intermediate-Acting Common Medications NPH Insulin (Novolin N or Humulin N) How does it work? Assists in lowering blood glucose levels over the course of the day Onset: 1 – 2 hours Peak: 6 – 12 hours Duration: 18 – 26 hours How is it administered? Subcutaneously Why is it given? To control blood sugar levels over the course of many hours When is it given? One to two times a day Given even if patient’s blood glucose is in an appropriate range; this controls blood sugar for a longer period of time Assessments? Assess BGL prior to administration (no sooner than 30 minutes prior to administration) Extra Info • • Must know blood glucose before administering Be mindful of hypoglycemic episodes Drug Class Long-Acting Common Medications Insulin Glargine (Lantus) How does it work? Assists in lowering blood glucose levels over the course of the day Onset: 1 – 2 hours Peak: No peak Duration: Up to 24 hours How is it administered? Subcutaneously Why is it given? To control blood sugar levels over the course of many hours When is it given? One to two times a day Assessments? Assess BGL prior to administration (no sooner than 30 minutes prior to administration) Extra Info • • • Must know blood glucose before administering Give at the same time each day Be mindful of hypoglycemic episodes, not as likely with this medication Bolus and Basal Insulins Insulin Regimens – Insulin regimens will be different for every person dependent upon their body’s needs and their lifestyles – Some patients will take one injection of long acting insulin (basal) a day – Some patients may require long acting insulin (basal) and rapid acting insulins (bolus) – Some patients will be scheduled for insulin (bolus) every 6 hours – It is common for individuals to be on two different types of insulin – May be on both bolus and basal insulin – Basal insulin daily, bolus insulin at meal times and before bed (ACHS) – Insulin orders may change frequently due to the patient’s response! – Frequently check your eMAR Insulin Regimen: Sliding Scale Insulin Orders – Sliding scales can differ based on the patient and their condition, the provider will determine the most accurate sliding scale to use – Sliding scales are only used with bolus insulin – The dose of bolus insulin (rapid or short acting insulin) administered is dependent upon glucose reading – An example of a sliding scale might read as follows: – BG <149, 0 units – BG 150–199, 2 units – BG 200–249, 4 units – BG 250–299, 6 units – BG 300–349, 8 units – BG <350, 10 units and call Health Care Provider (HCP) Insulin Regimen: Standing Insulin Orders – Standing insulin orders are independent from the glucose level – Basal insulins are administered using standing insulin orders – A set amount is given for each dose, independent of glucose level – What must the nurse assess prior to administering this insulin? – Nurse may need to use more critical thinking with this order – What is the blood sugar? What kind of insulin am I giving? Is it safe to give this? – Example: Give 15 units of Insulin Glargine (long-acting) at 0700. – Example: Give 4 units of Insulin Aspart (rapidacting) q6h. Prior to administration, we need to do what?