Diabetes Mellitus PDF

Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ Diabetes Mellitus Definition of diabetes mellitus: Diabetes mellitus (DM) is a chronic multisystem diseas...

Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ Diabetes Mellitus Definition of diabetes mellitus: Diabetes mellitus (DM) is a chronic multisystem disease related to abnormal insulin production, impaired insulin utilization, or both. Diabetes mellitus is a serious health problem throughout the world, and its prevalence is rapidly increasing. Diabetes mellitus is the seventh leading cause of death in the world. Fig. (26 ):Gastrointestinal tract The long-term complications of diabetes make it a devastating disease. Diabetes is the leading cause of adult blindness, end-stage kidney disease, and nontraumatic lower limb amputations. It is also a major contributing factor to heart disease and stroke. Adults with diabetes have heart disease death rates two to four times higher than adults without diabetes. The risk for stroke is also two to four times higher among people with diabetes. In addition, it is estimated that 67% of adults with diabetes have hypertension. Risk factors of diabetes mellitus: 1. Genetic factors: Family history of diabetes ( parents or siblings with diabetes) 2. Metabolic factors: obesity, emotional and physical stress. 3. Microbiological factors: viral infection in IDDM. 156 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ 4. Immunological factors. 5. Age ≥45 years. 6. Hypertension (≥140/90 mm Hg). 7. HDL cholesterol level and triglyceride. 8. History of gestational diabetes or delivery of babies over 9 lbs. Classification of diabetes: There are several different types of diabetes mellitus; they may differ in cause, clinical course, and treatment. The major classifications of diabetes are: - Type I: Insulin dependent diabetes mellitus (IDDM). Type 1 diabetes mellitus, formerly known as juvenile-onset diabetes or insulin-dependent diabetes, accounts for approximately 5% of all people with diabetes. Type 1 diabetes generally affects people under 40 years of age, and 40% develop it before 20 years of age. The incidence of type 1 diabetes has increased 3% to 5% over recent decades, and for unknown reasons it is occurring more frequently in younger children. - Type II: Non-insulin dependent diabetes (NIDDM). - Type 2 diabetes mellitus was formerly known as adult-onset diabetes (AODM) or non–insulindependent diabetes (NIDDM). Type 2 diabetes mellitus is, by far, the most prevalent type of diabetes, accounting for approximately 90% to 95% of patients with diabetes.2 Risk factors for developing type 2 diabetes include being overweight or obese, being older, and having a family history of type 2 diabetes. Although the disease is seen less frequently in children, the incidence is increasing due to the increasing prevalence of childhood obesity. - Gestational diabetes mellitus: occur during pregnancy - Secondary diabetes: Diabetes mellitus associated with other conditions as pancreatitis. 157 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ Physiology and pathophysiology of diabetes: ❑ Insulin is secreted by beta cells, which are one of four types of cells in the islets of Langerhans in the pancreas. Insulin is an anabolic, or storage, hormone. ❑ When a person eats a meal, insulin secretion increases and moves glucose from the blood into muscle, liver, and fat cells. ❑ In those cells, insulin : ❑ Transports and metabolizes glucose for energy. ❑ Stimulates storage of glucose in the liver and muscle (in the form of glycogen) Signals the liver to stop the release of glucose. ❑ Enhances storage of dietary fat in adipose tissue. ❑ Accelerates transport of amino acids (derived from dietary protein) into cells. ❑ Insulin also inhibits the breakdown of stored glucose, protein, and fat. During fasting periods (between meals and overnight), the pancreas continuously releases a small amount of insulin (basal insulin) Another pancreatic hormone called glucagon (secreted by the alpha cells of the islets of Langerhans) is released when blood glucose levels decrease and stimulate the liver to release stored glucose. ❑ The insulin and the glucagon together maintain a constant level of glucose in the blood by stimulating the release of glucose from the liver. ❑ Initially, the liver produces glucose through the breakdown of glycogen (glycogenolysis). 158 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ ❑ After 8 to 12 hours without food, the liver forms glucose from the breakdown of no carbohydrate substances, including amino acids (gluconeogenesis) Fig. (27 ): Pathophysiology of diabetes Type1 diabetes mellitus: Risk factors of diabetes mellitus: Type1 - Genetic, People do not inherit type 1 diabetes itself; rather, they inherit a genetic predisposition, or tendency, toward developing type 1 diabetes - Autoimmune response, Autoantibodies against islet cells and against endogenous (internal) insulin have been detected in people at the time of diagnosis and even several years before the development of clinical signs of type 1 diabetes. Environmental factors, such as viruses or toxins, that may initiate destruction of the beta cell are being investigated. 159 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ Physiology of diabetes mellitus: Type1 Regardless of the specific etiology, the destruction of the beta cells results in decreased insulin production, unchecked glucose production by the liver and fasting hyperglycemia. In addition, glucose derived from food cannot be stored in the liver but instead remains in the bloodstream and contributes to postprandial (after meals) hyperglycemia. If the concentration of glucose in the blood exceeds the renal threshold for glucose, usually 180 to 200 mg/dL (9.9 to 11.1 mmol/L), the kidneys may not reabsorb all of the filtered glucose; the glucose then appears in the urine (glucosuria). When excess glucose is excreted in the urine, it is accompanied by excessive loss of fluids and electrolytes. This is called osmotic diuresis. Because insulin normally inhibits glycogenolysis (breakdown of stored glucose) and gluconeogenesis (production of new glucose from amino acids and other substrates), in people with insulin deficiency, these processes occur in an unrestrained fashion and contribute further to hyperglycemia. In addition, fat breakdown occurs, resulting in an increased production of ketone bodies, which are the byproducts of fat breakdown. Management of type I diabetes: - Insulin therapy Health education regard diet ,physical activity ,foot care Type 2 diabetes Type II: Non-insulin dependent diabetes (NIDDM). Risk factors of Type II - Genetic factors - People older than 30 years - Obese 160 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ Physiology and pathophysiology: Type II ❑ The two main problems related to insulin in type 2 diabetes are insulin resistance and impaired insulin secretion. ❑ Insulin resistance refers to decreased tissue sensitivity to insulin. Normally, insulin binds to special receptors on cell surfaces and initiates a series of reactions involved in glucose metabolism. ❑ In type 2 diabetes, these intracellular reactions are diminished, thus rendering insulin less effective at stimulating glucose uptake by the tissues and at regulating glucose release by the liver. The exact mechanisms that lead to insulin resistance and impaired insulin secretion in type 2 diabetes are unknown, although genetic factors are thought to play a role. To overcome insulin resistance and to prevent the buildup of glucose in the blood, increased amounts of insulin must be secreted to maintain the glucose level at a normal or slightly elevated level. However, if the beta cells cannot keep up with the increased demand for insulin, the glucose level rises, and type 2 diabetes develops. - Despite the impaired insulin secretion that is characteristic of type 2 diabetes, there is enough insulin present to prevent the breakdown of fat and the accompanying production of ketone bodies. Therefore, DKA does not typically occur in type 2 diabetes. Uncontrolled type 2 diabetes may, however, lead to another acute problem, HHNS. 161 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ Fig. (28 ): Pathogenesis of type II diabetes Management of type 2 diabetes: - Weight loss - Exercise is also important in enhancing the effectiveness of insulin. Oral ant diabetic agents may be added if diet and exercise are not successful in controlling blood glucose levels. - If maximum doses of a single category of oral agents fail to reduce glucose levels to satisfactory levels, additional oral agents may be used. - Insulin may be added to oral agent therapy, or patients may move to insulin therapy entirely. Gestational diabetes: Gestational diabetes is any degree of glucose intolerance with its onset during pregnancy. Risk factors of gestational diabetes: - Age 25 years or older; age 25 years or younger and obese. - Family history of diabetes in first-degree relatives; or - Member of an ethnic/racial group with a high prevalence of diabetes. 162 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ Physiology of gestational diabetes: Hyperglycaemia develops during pregnancy because of the secretion of placental hormones, which causes insulin resistance. For women who meet one or more of the following: criteria, selective screening for diabetes during pregnancy is now being recommended between the 24th and 28th weeks of gestation: Management of gestational diabetes: - Initial management includes: dietary modification and blood glucose monitoring. - If hyperglycemia persists, insulin or oral antidiabetic agent is prescribed. - Goals for blood glucose levels during pregnancy are 105 mg/dL (5.8 mmol/L) or less before meals and 120 mg/dL (6.7 mmol/L) or less 2 hours after meals. Clinical manifestations of all diabetes mellitus: A. Classic symptoms; 1. Polyuria (increased urination) 2. Polydipsia (increased thirst) occur as a result of the excess loss of fluid associated with osmotic diuresis 3. Polyphagia (increased appetite) resulting from the catabolic state induced by insulin deficiency and the Breakdown of proteins and fats. B. Other symptoms include: - Fatigue, muscle weakness, weight loss, nausea, vomiting, or abdominal pains if ketoacidosis found in IDDM. - Sudden vision changes - Tingling or Numbness in hands or feet dry skin, skin lesions - Weight gain common in NIDDM. - Frequent infections. - Slow healing of wounds. Assessment and diagnostic findings for all diabetes: Fasting Plasma Glucose (FPG) Test The FPG is most reliable when done in the morning. Results and their meaning are shown in table 1. If your fasting glucose level is 163 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ 100 to 125 mg/dL, you have a form of prediabetes called impaired fasting glucose (IFG), meaning that you are more likely to develop type 2 diabetes but do not have it yet. A level of 126 mg/dL or above, confirmed by repeating the test on another day, means that you have diabetes. Plasma Glucose Result (mg/dL) Diagnosis 99 and below Normal 100 to 125 Prediabetes (impaired fasting glucose) 126 and above Diabetes* Change from mmol/l to mg/dl ❑ 1 mmol/L equals approximately 18 mg/dL. ❑ Therefore, in order to convert from mmol/L to mg/dL, the blood glucose value needs to be multiplied by 18 1 mg/dL Oral Glucose Tolerance Test (OGTT) The OGTT requires you to fast for at least eight hours before the test. Your plasma glucose is measured immediately before and two hours after you drink a liquid containing 75 grams of glucose dissolved in water. Results and what they mean are shown in table 2. If your blood sugar level is between 140 and 199 mg/dL 2 hours after drinking the liquid, you have a form of prediabetes called impaired glucose tolerance or IGT, meaning that you are more likely to develop type 2 diabetes but do not have it yet. A two-hour glucose level of 200 mg/dL or above, confirmed by repeating the test on another day, means that you have diabetes. 164 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ 2-Hour Plasma Glucose Result (mg/dL) Diagnosis 139 and below Normal 140 to 199 Prediabetes (impaired glucose tolerance) 200 and above Diabetes* Random plasma glucose test In a random plasma glucose test, your doctor checks your blood sugar without regard to when you ate your last meal. This test, along with an assessment of symptoms, is used to diagnose diabetes, but not prediabetes. - A random blood glucose level of 200 mg/dL or more, plus presence of the following symptoms, can mean that you have diabetes: - Increased urination - Increased thirst - Unexplained weight loss - Other symptoms include fatigue, blurred vision, increased hunger, and sores that do not heal. Your doctor will check your blood glucose level on another day using the FPG or the OGTT to confirm the diagnosis of diabetes. Hemoglobin A1c (HbA1c) Test for Diabetes The hemoglobin A1c test tells you your average level of blood sugar over the past 2 to 3 months. It's also called HbA1c, glycated hemoglobin test, and glycohemoglobin.  People who have diabetes need this test regularly to see if their levels are staying within range. It can tell if you need to adjust your diabetes medicines. The A1c test is also used to diagnose diabetes. 165 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ What Is Hemoglobin? ❑ Hemoglobin is a protein found in red blood cells. It gives blood its red color, and its job is to carry oxygen throughout your body. ❑ How the Test Works ❑ The sugar in your blood is called glucose. When glucose builds up in your blood, it binds to the hemoglobin in your red blood cells. The A1c test measures how much glucose is bound. ❑ Red blood cells live for about 3 months, so the test shows the average level of glucose in your blood for the past 3 months. ❑ If your glucose levels have been high over recent weeks, your hemoglobin A1c test will be higher. What's a Normal Hemoglobin A1c Test?  For people without diabetes, the normal range for the hemoglobin A1c level is between 4% and 5.6%. Hemoglobin A1c levels between 5.7% and 6.4% mean you have a higher chance of getting diabetes. Levels of 6.5% or higher mean you have diabetes. Setting Goals for A1c Levels  The target A1c level for people with diabetes is usually less than 7%. The higher the hemoglobin A1c, the higher your risk of having complications related to diabetes. Management of all diabetes mellitus: There are five components of diabetes management: 1. Nutritional management 2. Exercise 3. Pharmacologic therapy 4. Monitoring 5. Education 166 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ Fig. (29 ): Component of diabetes management Medical management of diabetes mellitus: Goals: 1. Maintain blood glucose and lipids level within normal limits. 2. Prevent complications. 1- Diet management: - Diet is the corner stone of diabetes treatment. - Weight loss is a goal for most patients with type II diabetes. - The individual diet is based on: - The patients' types of diabetes. - Height to weight ratio. - Usual dietary intake. - Cultural and personnel preference. - Life style component: eating pattern. Components of diet: For diabetic patient diet must contain: - 50 % to 55 % of carbohydrate. - 12 % to 20 % of protein. - And 30 % of fat (unsaturated fat). 2-. Activity and exercise: - Exercise is an important part of managing diabetes. - Exercise program should be designed for the individual patient. 167 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ - All exercise programs should begin with milder forms of exercise and gradually increase. - Exercise should not be started until the blood glucose control. - Exercises are performed at the same time every day. - Blood glucose should be checked before beginning to exercise. - Every diabetic patient should have emergency supplies for treatment for hypoglycemia available when exercising Benefits of exercises for person with diabetes: - Improve glucose utilization for energy and also improves circulation. - Improve insulin sensitivity. - Improve lipid profile. - May improve hypertension. - Increase energy expenditure to assist with weight loss and preserve lean body mass. - Promotes cardiovascular fitness. - Increases strength and flexibility. - Improve sense of well being 3- Pharmacotherapy management: 1. Insulin therapy. 2. Oral hypoglycemic agents. Common types of insulin Types of insulin Onset Duration 1. Short – acting insulin ½ - 1 hrs 6 - 8 hrs 2. Intermediate – acting insulin 1 - 2 hrs 18 - 16 hrs. 3. Long acting insulin 8 hrs 24 - 36 hrs Oral hypoglycemic agents (as sulfonylurea): Oral hypoglycemic agents are the most commonly used with NIDDM who are not controlled by diet and exercise alone. Sulfonylureas: stimulating the pancreas to secrete insulin. Biguanides : Metformin (Glucophage) produces its antidiabetic effects by facilitating insulin’s action on peripheral receptor sites. Insulin Pump: Continuous subcutaneous insulin infusion can be administered using an insulin pump, a small battery operated 168 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ device that resembles a standard paging device in size and appearance. Fig.(30 ):Insulin pump Mechanism of action: Most insulin pumps are worn on the belt or under clothing and loaded with rapid-acting insulin, which is connected via plastic tubing to a catheter inserted into the subcutaneous tissue in the abdominal wall. Insulet Corporation has an insulin pump that is a tubing-free system. All insulin pumps are programmed to deliver a continuous infusion of rapid-acting insulin 24 hours a day, known as the basal rate. Basal insulin can be temporarily increased or decreased based on carbohydrate intake, activity changes, or illness. Some individuals require different basal rates at different times of the day. At mealtime, the user programs the pump to deliver a bolus infusion of insulin appropriate to the amount of carbohydrate ingested and an additional amount, if needed, to bring down high preprandial blood glucose. The insertion site is changed every 2 to 3 days to avoid site infection and to promote good insulin absorption. Insulin pump users must check their blood glucose level at least four times per day. Testing eight times or more per day is common. A major advantage of the insulin pump is the potential for tight glucose control. This is possible because insulin delivery is similar to the normal physiologic pattern. Pumps offer the benefit of a more normal lifestyle, allowing users more flexibility with meal and activity patterns. Problems and complications of insulin pump therapy are infection at the insertion site, an increased risk 169 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ for DKA if the insulin infusion is disrupted because of a problem at the infusion site, and the increased cost of the pump and supplies. 4-Monitoring glucose levels and ketones: - Blood glucose monitoring is a corner stone of diabetes management, and self-monitoring of blood glucose (SMBG) levels by patients has dramatically altered diabetes care. 5-Education: - Self-management behaviours change include; diet, physical activity, and physical and emotional stress affect diabetic control, patients must learn to balance a multitude of factors. - They must learn daily self-care skills to prevent acute fluctuations in blood glucose. - Diabetic patients must become knowledgeable about nutrition, medication effects and side effects, exercise, disease progression, prevention strategies, blood glucose monitoring techniques, medication adjustment. - They must learn the skills associated with monitoring and managing diabetes and must incorporate many new activities into their daily routines. Complications of insulin therapy: 1- Insulin resistance: this is the result of antibodies binding to insulin molecules and rendering them inactive this response is seem with patients who require 100 – 200 units a day. 2- Insulin hypersensitivity: (allergic reaction) - Local reaction (itching and erythema at the injection site). - Systemic response (anaphylactic reaction). 3- Lipodystrophy: Atrophy or hypertrophy of the subcutaneous tissue at the injection site. 4- Hypoglycemia: A major complication of insulin therapy or oral hypoglycemic agents. Complications of diabetes mellitus: Acute complications (Short term): - Diabetic ketoacidosis. 170 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ - Hyperglycemic hyperosmolor non ketosis coma or syndrome. - Hypoglycemia. Definition of hypoglycemia: It defined as low blood glucose (fasting 50 – 60 mg/dl) (2.7 to 3.3 mmol/L). A common complication of type I diabetes. Causes of hypoglycemia: 1. Too much dose of insulin. 2. Too much, exercise in relation to the amount of food eaten. 3. Skipped, or delayed meal. Signs and symptoms of hypoglycemia: 1. Hunger. 2. Headache. 3. Pallor, blurred vision, weakness, fatigue. 4. Palpitation. 5. Trembling. 6. Numbness of lips and tongue. 7. Diaphoresis with cool, clammy skin. 8. Confusion, coma (late). Management: Immediate treatment must be given when hypoglycemia occurs. The usual recommendation is for 15 g of a fast-acting concentrated source of carbohydrate such as the following, given orally: Three or four commercially prepared glucose tablets 4 to 6 oz of fruit juice or regular soda 6 to 10 Life Savers or other hard candies 2 to 3 teaspoons of sugar or honey Initiating Emergency Measures For patients who are unconscious and cannot swallow, an injection of glucagon 1 mg can be administered either subcutaneously or intramuscularly. Glucagon is a hormone produced by the alpha cells of the pancreas that stimulates the liver to release glucose (through the breakdown of glycogen, the stored glucose). 171 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ After injection of glucagon, it may take up to 20 minutes for the patient to regain consciousness. In the hospital or emergency department, patients who are unconscious or cannot swallow may be treated with 25 to 50 mL 50% dextrose in water (D50W) administered intravenously. The effect is usually seen within minutes. Patients may complain of a headache and of pain at the injection site. Assuring patency of the intravenous (IV) line used for injection of 50% dextrose is essential because hypertonic solutions such as 50% dextrose are very irritating to the vein. Diabetic ketoacidosis: DKA is caused by an absence or markedly inadequate amount of insulin. The three main clinical features of DKA are: - Hyperglycemia - Dehydration and electrolyte loss - Acidosis Clinical manifestations: The signs and symptoms of DKA are: - Polyuria and polydipsia (increased thirst). - Blurred vision, weakness, and headache. - Patients with marked intravascular volume depletion may have orthostatic hypotension (drop in systolic blood pressure of 20 mm Hg or more on standing). - Hypotension with a weak, rapid pulse. - The ketosis and acidosis of DKA lead to GI symptoms such as anorexia, nausea, vomiting, and abdominal pain. - Patients may have acetone breath (a fruity odor), which occurs with elevated ketone levels. - Hyperventilation (with very deep, but not labored, respirations) may occur. - These Kussmaul respirations represent the body’s attempt to decrease the acidosis, 172 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ - Mental status changes in DKA vary widely from patient to patient. Patients may be alert, lethargic, or comatose Assessment and diagnostic findings: - Blood glucose levels may vary from 300 to 800 mg/dL (16.6 to 44.4 mmol/L). - Evidence of ketoacidosis is reflected in low serum bicarbonate (0 to 15 mEq/L) and low pH (6.8 to 7.3) values. - A low PCO2 level (10 to 30 mm Hg) reflects respiratory compensation (Kussmaul respirations) for the metabolic acidosis. - Accumulation of ketone bodies (which precipitates the acidosis) is reflected in blood and urine ketone measurements. - Sodium and potassium levels may be low, normal, or high, depending on the amount of water loss (dehydration). Medical management: Goals of III are: Treating hyperglycemia, correcting dehydration, electrolyte loss, and acidosis. Nursing Management: - Nursing care of the patient with DKA focuses on monitoring fluid and electrolyte status as well as blood glucose levels; administering fluids, insulin, and other medications; and preventing other complications such as fluid overload. Urine output is monitored to ensure adequate renal function before potassium is administered to prevent hyperkalemia. The electrocardiogram is monitored for dysrhythmias indicating abnormal potassium levels. Vital signs, arterial blood gases, and other clinical findings are recorded on a flow sheet. The nurse documents the patient’s laboratory values and the frequent changes in fluids and medications that are prescribed and monitors the patient’s responses. 173 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ Hyperglycemic hyperosmolar non-ketotic syndrome: - HHNS is a serious condition in which hyperosmolarity and hyperglycemia predominate, with alterations of the sensorium (sense of awareness). At the same time, ketosis is minimal or absent. Clinical manifestations: 1. Hypotension 2. Profound dehydration (dry mucous membranes, poor skin turgor) 3. Tachycardia 4. Variable neurologic signs (e.g., alteration of sensorium, seizures, hemiparesis). 5. The mortality rate ranges from 10% to 40%, usually related to an underlying illness Assessment and diagnostic findings: 1. Blood glucose 2. Electrolytes 3. BUN 4. Complete blood count 5. Serum osmolality 6. Arterial blood gas analysis. - The blood glucose level is usually 600 to 1,200 mg/dL, and the osmolality exceeds 350 mOsm/kg. - Electrolyte and BUN levels are consistent with the clinical picture of severe dehydration. - Mental status changes, focal neurologic deficits, and hallucinations are common secondary to the cerebral dehydration that results from extreme hyperosmolality. Medical management: The Goals of III are: 1. Fluid replacement 2. Correction of electrolyte imbalances 3. Insulin administration. 174 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ Nursing management: - Close monitoring of vital signs, fluid status, and laboratory values. - In addition, strategies are implemented to maintain safety and prevent injury related to changes in the patient’s sensorium secondary to HHNS. - Fluid status and urine output are closely monitored because of the high risk for renal failure secondary to severe dehydration. - In addition, the nurse must direct nursing care to the condition that may have precipitated the onset of HHNS. Chronic complications (Long term): - Cardiovascular disease: person with diabetes has a 50% higher chance of suffering from heart disease or stroke. - Nephropathy: large percentages of patient on renal dialysis are diabetic. - Peripheral vascular disease: are 40 to 50 times more prevalent among diabetes. - Retinopathy: can cause visual impairment and blindness. - Neuropathy: can lead to impotence, neurogenic bladder and pain or loss of feeling in the lower extremities. Nursing process of patient with DM: Nursing assessment: - Patient should be assessed for signs of diabetes mellitus. - General assessment should include questions about: 1. Family history of diabetes. 2. Weight loss. 3. Increased hunger, thirst. 4. Increased urination. 5. Poor wound healing and fatigue. - Patients known to be diabetic should be assessed for signs of complications. - Assessment of patient performance on blood glucose monitoring and technique for insulin injection. 175 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ Nursing diagnosis: - High risk for fluid volume deficit related to excess urination. - Alteration in nutrition less than (or more than) body requirements, related to food and energy needs. - Risk for infection related to elevated blood glucose. - Knowledge deficit related to disease, drugs, self-care skills (insulin injection), diet needs, activity needs and possible complications. - Risk for injury related to severe decease in tissue perfusion in feet and possibly of gangrene requiring amputation. - Sensory, perceptual alteration related to effect of elevated blood glucose on nervous system. - Sexual dysfunction related to effect of elevated blood glucose on nervous system. - Self-esteem disturbance related to diagnosis of chronic disease requiring insulin injection for survival. Planning: - Maintain blood glucose within normal limits. - Maintain electrolyte and acid base balance. - Maintain optimal weight. - Acquire knowledge for self care. - Comply with treatment regimen. - Prevent complications. Nursing diagnosis: Alteration in nutrition less than (or more than) body requirement related to energy need. Nursing intervention: - Perform dietary assessment. - Instruct diabetic patient on diet planning. - Assist with construction of an acceptable meal plan for attaining desired weight and to normalize serum glucose level. - Instruct patient about the disease process of diabetes. - Instruct regarding potential complications and how to decrease the risk of complications. 176 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ - Instruct in insulin or oral medication administration. Nursing diagnosis: Risk of infection related to elevated blood glucose level. Nursing intervention: - Instruct patient about glucose monitoring technique. - Ask patient to chart blood glucose after testing. - Instruct patient about signs of infection to report. Nursing diagnosis: Risk for injury related to severe decrease in tissue perfusion in feet. Nursing intervention: - Verify that patient can perform correct foot care. - Ascertain whether patient complies with need for daily foot assessment and proper self-care of foot. - Encourage to report even minor injuries of the food to the physician. Nursing diagnosis: Sensory perceptual alteration related to effect of elevated blood glucose in nervous system. Nursing intervention: - Reinforce the importance of foot care if patient has reduced sensation in feet. - Encourage at least yearly eyes exams. - Measure to counteract constipation (increase fluid and fiber within meal plan). Health education for diabetic patient: The patient must learn enough about the disease and treatment to take charge of his or her own care topics includes: 1. Insulin self-administration. 2. Skin and foot care 3. Pointers for traveling 1- Insulin self-administration: For safe insulin administration, patient must know: - How to draw insulin into the syringe. 177 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ - Mix two insulin. - Select and prepare the injection site. - Rotate site and inject insulin. Fig. (31 ): Sites of insulin injection When hypoglycemia occurs at home: A. If the patient is able to swallow give the following: - ½ cup of juice (apple or orange) - ½ cup of 2% or skim milk. - ½ cup of regular soda (not sugar free) - 6-7 hand candies. - 3 glucose tablets. - 1 table spoon of honey. - 1 table spoon of sugar. B. If the patient is unable to swallow (unconscious): - Turn the patient on the side. - Administer 1 mg of glycogen by injection. - Feed the patient as soon as awake and able to swallow. - Give a fast-acting source of sugar and a longer acting source such as crackers and cheese or a meat sandwich. - If the patient does not awaken within 15 min give another dose and inform physician immediately or call emergency. 2- Skin and foot care: - Inspect feet daily for temperature, cuts blisters, abrasions or discoloration of the toes. - Tell any abnormalities to the health care provider. - Use a mirror if unable to bend to see the bottom of the foot. - Be certain to check between the toes, wash the feet in warm 178 Medical Surgical Nursing Dept. Adult Nursing I _____________________________________________________________________________ water (not hot) using mild soap and do not soak the feet. - Thoroughly dry the feet after washing. - Pay attention to dry between the toes. - Do not put the cream between toes and cut the nails straight. - Wear properly fitted shoes, never walk barefoot and never wear open sandals or sandals with straps between the toes. - Do not use a heating bad or hot water bottle near them. - Test the temperature of bath water before stepping into tub. - Elevate the feet wherever possible to improve circulation. 3- Pointers for traveling: - Carry extra medication or insulin and wear Medic- Alert tag. - Carry an emergency supply of fast, acting sugar at all times. - Obtain sufficient rest and avoid stressful situations - Drink a glass of water every 2 hrs to prevent dehydration. - Check blood glucose level frequently. 179