Acute Complications Of Diabetes PDF

11/20/23, 5:28 PM Realizeit for Student Acute Complications of Diabetes There are three major acute complications of diabetes related to short-term imbalances in blood glucose levels: hypoglycemia, DKA, and HHS (Fayfman, Pasquel, & Umpeirrez, 2017). Hypoglycemia (Insulin Reactions) Hypoglycemia m...

11/20/23, 5:28 PM Realizeit for Student Acute Complications of Diabetes There are three major acute complications of diabetes related to short-term imbalances in blood glucose levels: hypoglycemia, DKA, and HHS (Fayfman, Pasquel, & Umpeirrez, 2017). Hypoglycemia (Insulin Reactions) Hypoglycemia means low (hypo) sugar in the blood (glycemia) and occurs when the blood glucose falls to less than 70 mg/dL (3.9 mmol/L) (ADA, 2020). It can occur when there is too much insulin or oral hypoglycemic agents, too little food, or excessive physical activity. Hypoglycemia may occur at any time of the day or night. It often occurs before meals, especially if meals are delayed or snacks are omitted. For example, midmorning hypoglycemia may occur when the morning insulin is peaking, whereas hypoglycemia that occurs in the late afternoon coincides with the peak of the morning NPH insulin. Middle-of-the-night hypoglycemia may occur because of peaking evening or predinner NPH insulins, especially in patients who have not eaten a bedtime snack. Clinical Manifestations The clinical manifestations of hypoglycemia may be grouped into two categories: adrenergic symptoms and central nervous system (CNS) symptoms. In mild hypoglycemia, as the blood glucose level falls, the sympathetic nervous system is stimulated, resulting in a surge of epinephrine and norepinephrine. This causes symptoms such as sweating, tremor, tachycardia, palpitation, nervousness, and hunger. In moderate hypoglycemia, the drop in blood glucose level deprives the brain cells of needed fuel for functioning. Signs of impaired function of the CNS may include inability to concentrate, headache, lightheadedness, confusion, memory lapses, numbness of the lips and tongue, slurred speech, impaired coordination, emotional changes, irrational or combative behavior, double vision, and drowsiness. Any combination of these symptoms (in addition to adrenergic symptoms) may occur with moderate hypoglycemia. In severe hypoglycemia, CNS function is so impaired that the patient needs the assistance of another person for treatment of hypoglycemia. Symptoms may include disoriented behavior, seizures, difficulty arousing from sleep, or loss of consciousness. Management https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX2deLl%2f4FdfKSHmHSZ7peJYyAcbNSqCsVXJC0jIBoVz… 1/9 11/20/23, 5:28 PM Realizeit for Student Treating With Carbohydrates Immediate treatment must be given when hypoglycemia occurs (ADA, 2020). The usual recommendation is for 15 to 20 g of a fast-acting concentrated source of carbohydrate. It is not necessary to add sugar to juice, even if it is labeled as unsweetened juice, because the fruit sugar in juice contains enough carbohydrate to raise the blood glucose level. Adding table sugar to juice may cause a sharp increase in the blood glucose level, and patients may experience hyperglycemia for hours after treatment. Diabetic Ketoacidosis DKA is caused by an absence or markedly inadequate amount of insulin. This deficit in available insulin results in disorders in the metabolism of carbohydrate, protein, and fat. The three main clinical features of DKA are as follows: Hyperglycemia Dehydration and electrolyte loss Acidosis Pathophysiology Without insulin, the amount of glucose entering the cells is reduced, and gluconeogenesis (the production and release of glucose by the liver) is increased, leading to hyperglycemia (see Fig. 46-6). In an attempt to rid the body of the excess glucose, the kidneys excrete the glucose along with water and electrolytes (e.g., sodium, potassium). This osmotic diuresis, which is characterized by polyuria, leads to dehydration and marked electrolyte loss (Norris, 2019). Patients with severe DKA may lose up to 6.5 L of water and up to 400 to 500 mEq each of sodium, potassium, and chloride over a 24-hour period. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX2deLl%2f4FdfKSHmHSZ7peJYyAcbNSqCsVXJC0jIBoVz… 2/9 11/20/23, 5:28 PM Realizeit for Student Another effect of insulin deficiency or deficit is lipolysis, the breakdown of fat into free fatty acids and glycerol. The free fatty acids are converted into ketone bodies by the liver. Ketone bodies are acids; their accumulation in the circulation due to lack of insulin leads to metabolic acidosis. Three main causes of DKA are decreased or missed dose of insulin, illness or infection, and undiagnosed and untreated diabetes (DKA may be the initial manifestation of type 1 diabetes). An insulin deficiency may result from an insufficient dosage of insulin prescribed or from insufficient insulin being given by the patient. Errors in insulin dosage may be made by patients who are ill and who assume that if they are eating less or if they are vomiting, they must decrease their insulin doses. (Because illness, especially infections, can cause increased blood glucose levels, the patient does not need to decrease the insulin dose to compensate for decreased food intake when ill and may even need to increase the insulin dose.) Other potential causes of decreased insulin include patient error in drawing up or injecting insulin (especially in patients with visual impairments), intentional skipping of insulin doses (especially in adolescents with diabetes who are having difficulty coping with diabetes or other aspects of their lives), or equipment problems (e.g., occlusion of insulin pump tubing). Illness and infections are associated with insulin resistance. In response to physical (and emotional) stressors, there is an increase in the level of “stress” hormones—glucagon, epinephrine, norepinephrine, cortisol, and growth hormone. These hormones promote glucose production by the liver and interfere with glucose utilization by muscle and fat tissue, counteracting the effect of insulin. If insulin levels are not increased during times of illness and infection, hyperglycemia may progress to DKA (ADA, 2020). Prevention For prevention of DKA related to illness, “sick day rules” for managing diabetes when ill should be reviewed with patients. The most important concept in this is to never eliminate insulin doses when nausea and vomiting occur. Instead, the patient should take the usual insulin dose (or previously prescribed special sick day doses) and then attempt to consume frequent small portions of carbohydrates (including foods usually avoided, such as juices, regular sodas, and gelatin). Drinking fluids every hour is important to prevent dehydration. Blood glucose and urine ketones must be assessed every 3 to 4 hours. If the patient cannot take fluids without vomiting, or if elevated glucose or ketone levels persist, the provider must be contacted. Patients are taught to have foods available for https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX2deLl%2f4FdfKSHmHSZ7peJYyAcbNSqCsVXJC0jIBoVz… 3/9 11/20/23, 5:28 PM Realizeit for Student use on sick days (Down, 2018). In addition, a supply of urine test strips (for ketone testing) and blood glucose test strips should be available. The patient must know how to contact their primary provider 24 hours a day. These materials should be assembled in a “sick day” kit. After the acute phase of DKA has resolved, the nurse should assess for underlying causes. If there are psychological reasons for the patient missing insulin doses, the patient and family may be referred for evaluation and counseling or therapy. Clinical Manifestations The hyperglycemia of DKA leads to polyuria, polydipsia, and marked fatigue. In addition, the patient may experience 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 changing from a reclining to a standing position). Volume depletion may also lead to frank hypotension with a weak, rapid pulse. The ketosis and acidosis of DKA lead to gastrointestinal symptoms, such as anorexia, nausea, vomiting, and abdominal pain. The patient may have acetone breath (a fruity odor), which occurs with elevated ketone levels. In addition, hyperventilation (with very deep, but not labored, respirations) may occur. These Kussmaul respirations represent the body’s attempt to decrease the acidosis, counteracting the effect of the ketone buildup (Norris, 2019). In addition, mental status in DKA varies widely. The patient may be alert, lethargic, or comatose. Hyperglycemic Hyperosmolar Syndrome HHS is a metabolic disorder most often of type 2 diabetes resulting from a relative insulin deficiency initiated by an illness that raises the demand for insulin. This is a serious condition in which hyperosmolality and hyperglycemia predominate, with alterations of the sensorium (sense of awareness). At the same time, ketosis is usually minimal or absent. The basic biochemical defect is the lack of effective insulin (i.e., insulin resistance). Persistent hyperglycemia causes osmotic diuresis, which results in losses of water and electrolytes. To maintain osmotic equilibrium, water shifts from the intracellular fluid space to the extracellular fluid space. With glycosuria and dehydration, hypernatremia and increased osmolarity occur. Table 46-6 compares DKA and HHS. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX2deLl%2f4FdfKSHmHSZ7peJYyAcbNSqCsVXJC0jIBoVz… 4/9 11/20/23, 5:28 PM Realizeit for Student HHS occurs most often in older adults (50 to 70 years of age) who have no known history of diabetes or who have type 2 diabetes (Fayfman et al., 2017). HHS often can be traced to an infection or a precipitating event such as an acute illness (e.g., stroke), medications that exacerbate hyperglycemia (e.g., thiazides), or treatments such as dialysis. The history includes days to weeks of polyuria with adequate fluid intake. What distinguishes HHS from DKA is that ketosis and acidosis generally do not occur in HHS, partly because of differences in insulin levels. In DKA, no insulin is present, and this promotes the breakdown of stored glucose, protein, and fat, which leads to the production of ketone bodies and ketoacidosis. In HHS, the insulin level is too low to prevent hyperglycemia (and subsequent osmotic diuresis), but it is high enough to prevent fat breakdown. Patients with HHS do not have the ketosis-related gastrointestinal symptoms that lead them to seek medical attention. Instead, they may tolerate polyuria and polydipsia until neurologic changes or an underlying illness (or family members or others) prompts them to seek treatment. Clinical Manifestations The clinical picture of HHS is one of hypotension, profound dehydration (dry mucous membranes, poor skin turgor), tachycardia, and variable neurologic signs (e.g., alteration of consciousness, seizures, hemiparesis) (Down, 2018; Fayfman et al., 2017). Management The overall approach to the treatment of HHS is similar to that of DKA: fluid replacement, correction of electrolyte imbalances, and insulin administration. Because patients with HHS are typically older, close monitoring of volume and electrolyte status is important for prevention of fluid overload, heart failure, and cardiac arrhythmias. Fluid treatment is started with 0.9% or 0.45% NS, depending on the patient’s sodium level and the severity of volume depletion. Central venous or hemodynamic pressure monitoring guides fluid replacement. Potassium is added to IV fluids when urinary output is adequate and is guided by continuous ECG monitoring and frequent laboratory determinations of potassium (Fayfman et al., 2017). Extremely elevated blood glucose concentrations decrease as the patient is rehydrated. Insulin plays a less important role in the treatment of HHS because it is not needed for https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX2deLl%2f4FdfKSHmHSZ7peJYyAcbNSqCsVXJC0jIBoVz… 5/9 11/20/23, 5:28 PM Realizeit for Student reversal of acidosis, as in DKA. Nevertheless, insulin is usually given at a continuous low rate to treat hyperglycemia, and replacement IV fluids with dextrose are given (as in DKA) after the glucose level has decreased to the range of 250 to 300 mg/dL (13.8 to 16.6 mmol/L) (Fayfman et al., 2017). Other therapeutic modalities are determined by the underlying illness and the results of continuing clinical and laboratory evaluation. It may take 3 to 5 days for neurologic symptoms to clear, and treatment of HHS usually continues well after metabolic abnormalities have resolved. After recovery from HHS, many patients can control their diabetes with MNT alone or with MNT and oral antidiabetic medications. Insulin may not be needed once the acute hyperglycemic complication is resolved. Frequent SBGM is important in prevention of recurrence of HHS (Fayfman et al., 2017). Common Alterations in Diet Dietary modifications commonly prescribed during hospitalization require special consideration for patients who have diabetes (ADA, 2020). Nothing by Mouth For patients who must be NPO in preparation for diagnostic or surgical procedures, the nurse must ensure that the usual insulin dosage has been changed. These changes may include eliminating the rapid-acting insulin and giving a decreased amount (e.g., half the usual dose) of intermediate-acting insulin. Another approach is to use frequent (every 3 to 4 hours) dosing of rapid-acting insulin only. IV dextrose may be given to provide calories and to avoid hypoglycemia. Even without food, glucose levels may increase as a result of hepatic glucose production, especially in patients with type 1 diabetes and lean patients with type 2 diabetes. Furthermore, in type 1 diabetes, elimination of the insulin dose may lead to the development of DKA. Administration of basal insulin to patients with type 1 diabetes who are NPO is an important nursing action. For patients with type 2 diabetes who are taking insulin, DKA does not usually develop when insulin doses are eliminated because the patient’s pancreas produces some https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX2deLl%2f4FdfKSHmHSZ7peJYyAcbNSqCsVXJC0jIBoVz… 6/9 11/20/23, 5:28 PM Realizeit for Student insulin. Therefore, skipping the insulin dose altogether (when the patient is receiving IV dextrose) may be safe; however, close monitoring of blood glucose levels is essential. For patients who are NPO for extended periods (24 hours), glucose testing and insulin administration should be performed at regular intervals, usually four times per day. Insulin regimens for the patient who is NPO for an extended period may include NPH insulin every 12 hours, rapid-acting insulin only every 4 to 6 hours, or an IV insulin drip. These patients should receive dextrose infusions to provide some calories and limit ketosis. To prevent the problems that result from the need to withhold food, diagnostic tests and procedures and surgery should be scheduled early in the morning when possible. Clear Liquid Diet When the diet is advanced to include clear liquids, patients with diabetes receive more simple carbohydrate foods, such as juice and gelatin desserts, than are usually included in the diabetic diet. Because patients who are hospitalized should maintain their nutritional status as much as possible to promote healing, the use of reduced-calorie substitutes such as diet soda or diet gelatin desserts would not be appropriate when the only source of calories is clear liquids. Simple carbohydrates, if eaten alone, cause a rapid rise in blood glucose levels; therefore, it is important to try to match peak times of insulin effect with peaks in the blood glucose concentration. If the patient receives insulin at regular intervals while NPO, the scheduled times for glucose tests and insulin injections should match mealtimes. Enteral Tube Feedings Tube feeding formulas contain more simple carbohydrates and less protein and fat than the typical meal plan for diabetes. This results in increased levels of glucose in patients with diabetes who are receiving tube feedings. Insulin doses must be given at regular intervals (e.g., NPH every 12 hours or regular insulin every 4 to 6 hours) when continuous tube feedings are given. If insulin is administered at routine (prebreakfast and predinner) times, hypoglycemia during the day may result (because the patient receives more insulin without more calories); hyperglycemia may occur during the night if feedings continue but insulin action decreases. A common cause of hypoglycemia in patients receiving both continuous tube feedings and insulin is inadvertent or purposeful discontinuation of the feeding. The nurse must discuss with the medical team any plans for temporarily discontinuing the tube feeding https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX2deLl%2f4FdfKSHmHSZ7peJYyAcbNSqCsVXJC0jIBoVz… 7/9 11/20/23, 5:28 PM Realizeit for Student (e.g., when the patient is away from the unit). Planning ahead may allow for alterations to be made in the insulin dose or for administration of IV dextrose. In addition, if problems with the tube feeding develop unexpectedly (e.g., the patient pulls out the tube, the tube clogs, the feeding is discontinued when residual gastric contents are found), the nurse must notify the primary provider, assess blood glucose levels more frequently, and administer IV dextrose if indicated. Parenteral Nutrition Patients receiving parenteral nutrition may receive both IV insulin (added to the parenteral nutrition IV bag) and subcutaneous intermediate- or short-acting insulins. If the patient is receiving continuous parenteral nutrition, the blood glucose level should be monitored and insulin given at regular intervals. If the parenteral nutrition is infused over a limited number of hours, subcutaneous insulin should be given so that peak times of insulin action coincide with times of parenteral nutrition infusion. Hygiene Nurses caring for hospitalized patients with diabetes must focus attention on oral hygiene and skin care. Because these patients are at increased risk for periodontal disease, the nurse assists with at least daily dental care. The patient may also require assistance in keeping the skin clean and dry, especially in areas of contact between two skin surfaces (e.g., groin, axilla, under the breasts), where chafing and fungal infections tend to occur. Careful assessments of the oral cavity and the skin are important. The skin is assessed for dryness, cracks, breakdown, and redness, especially at pressure points and on the lower extremities. The patient is asked about symptoms of neuropathy, such as tingling and pain or numbness of the feet. Deep tendon reflexes are assessed. As with any patient confined to bed, nursing care must emphasize the prevention of skin breakdown at pressure points. The heels are particularly susceptible to breakdown because of loss of sensation of pain and pressure associated with sensory neuropathy. Feet should be cleaned, dried, lubricated with lotion (but not between the toes), and inspected frequently. If the patient is in the supine position, pressure on the heels can be alleviated by elevating the lower legs on a pillow, with the heels positioned over the edge of the pillow. When the patient is seated in a chair, the feet should be positioned so that pressure is not placed on the heels. If the patient has an ulceration on one foot, https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX2deLl%2f4FdfKSHmHSZ7peJYyAcbNSqCsVXJC0jIBoVz… 8/9 11/20/23, 5:28 PM Realizeit for Student the nurse provides preventive care to the unaffected foot as well as special care of the affected foot. As always, every opportunity should be taken to educate the patient about diabetes self-management, including daily oral, skin, and foot care. Female patients should also be instructed about measures for the avoidance of vaginal infections, which occur more frequently when blood glucose levels are elevated. Patients often take their cues from nurses and realize the importance of daily personal hygiene if this is emphasized during their hospitalization. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX2deLl%2f4FdfKSHmHSZ7peJYyAcbNSqCsVXJC0jIBoVz… 9/9