Assessment and Management of Patients With Diabetes PDF

Chapter 46 Assessment and Management of Patients With Diabetes By adult nursing team  Outcome 1. Differentiate between the types of diabetes, associated etiologic factors, and pathophysiologic alterations.. 2. Identify the diagnostic and clinical significance of blood glucose test...

Chapter 46 Assessment and Management of Patients With Diabetes By adult nursing team  Outcome 1. Differentiate between the types of diabetes, associated etiologic factors, and pathophysiologic alterations.. 2. Identify the diagnostic and clinical significance of blood glucose test results. 3. Describe the relationships among diet and dietary modifications, exercise, and medication (i.e., insulin or oral antidiabetic agents) for people with diabetes. 4. Describe management strategies for a person with diabetes to use during “sick days.” 5. Outline the major complications of diabetes and the self-care behaviors that are important in their prevention. Copyright © 2018 Wolters Kluwer · All Rights Reserved  Key terms ❖ Diabetic ketoacidosis (DKA): a metabolic derangement in type 1 diabetes that results from a deficiency of insulin; highly acidic ketone bodies are formed, resulting in acidosis ❖ Fasting plasma glucose (FPG): blood glucose determination obtained in the laboratory after fasting for at least 8 hours ❖ Glycated hemoglobin (glycosylated hemoglobin, HgbA1C, or A1C): a measure of glucose control that is a result of glucose molecule attaching to hemoglobin for the life of the red blood cell (120 days). ❖ Nephropathy: a long-term complication of diabetes in which the kidney cells are damaged; characterized by microalbuminuria in early stages and progressing to end-stage kidney disease ❖ Neuropathy: a long-term complication of diabetes resulting from damage to the nerve cell Copyright © 2018 Wolters Kluwer · All Rights Reserved ❖ Retinopathy: a condition that occurs when the small blood vessels that nourish the retina in the eye are damaged ❖ Insulin: a hormone secreted by the beta cells of the islets of Langerhans of the pancreas that is necessary for the metabolism of carbohydrates, proteins, and fats; a deficiency of insulin results in diabetes. ❖ Insulin pump: a continuous subcutaneous insulin infusion device that delivers insulin on a 24-hour basis. Copyright © 2018 Wolters Kluwer · All Rights Reserved  Functions of Insulin ❖ 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 has the following actions 1. Transports and metabolizes glucose for energy 2. Stimulates storage of glucose in the liver and muscle as glycogen 3. Signals the liver to stop the release of glucose 4. Enhances storage of dietary fat in adipose tissue 5. Accelerates transport of amino acids into cells 6. Inhibits the breakdown of stored glucose, protein, and fat Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved  Diabetes ❖ A group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. ❖ Globally, over 382 million people are affected by diabetes , 90% of whom are diagnosed with type 2 ❖ The diabetes prevalence is increasing. ❖ A recent systematic review reported a current type diabetes prevalence of 32.8% in the Kingdom of Saudi Arabia, which was predicted to rise to 40.8% in 2025, and to 45.8% by 2030. Copyright © 2018 Wolters Kluwer · All Rights Reserved  Facts about diabetes ❖ Diabetes is a leading cause of death from MI, stroke, and peripheral vascular disease. ❖ Hospitalization rates for people with diabetes are 2.4 times greater for adults and 5.3 times greater for children than for the general population. ❖ The economic cost of diabetes continues to increase because of increasing health care costs and an aging population. Copyright © 2018 Wolters Kluwer · All Rights Reserved Classifications of Diabetes ❖ Type 1 diabetes ❖ Type 2 diabetes ❖ Latent autoimmune diabetes of adults (LADA) ❖ Gestational diabetes ❖ Diabetes associated with other conditions or syndromes ❖ Refer to Table 46-1 Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved  Type 1 Diabetes ❖Insulin-producing beta cells in the pancreas are destroyed by a combination of genetic, immunologic, and environmental factors ❖Results in decreased insulin production, unchecked glucose production by the liver and fasting hyperglycemia. ❖Affects 5% of adults with diabetes ❖People do not inherit type 1 diabetes itself but rather a genetic predisposition, or tendency, toward the development of type 1 diabetes. Copyright © 2018 Wolters Kluwer · All Rights Reserved  Type 2 Diabetes ❖Insulin resistance and impaired insulin secretion ❖Affects 95% of adults with diabetes, onset over age 30 years, increasing in children r/t obesity ❖Slow, progressive glucose intolerance and may go undetected for years Copyright © 2018 Wolters Kluwer · All Rights Reserved Pathogenesis of Type 2 Diabetes Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved  Latent Autoimmune Diabetes of Adults (LADA) ❖ Subtype of diabetes in which progression of autoimmune beta cell destruction in the pancreas is slower than in types 1 and 2 diabetes ❖ Not insulin dependent in the initial 6 months of disease onset. ❖ Clinical manifestation of LADA shares the features of types 1 and 2 diabetes ❖ Emerging subtype has led some to propose the diabetes classification scheme should be revised to reflect changes in the beta cells in the pancreas Copyright © 2018 Wolters Kluwer · All Rights Reserved  Clinical Manifestations ❖ Depends on the level of hyperglycemia ❖ “Three Ps” o Polyuria o Polydipsia o Polyphagia (from catabolic state induced by insulin deficiency and the breakdown of proteins and fats). ❖ Fatigue, weakness, vision changes, tingling or numbness in hands or feet, dry skin, skin lesions or wounds that are slow to heal, recurrent infections ❖ The onset of type 1 diabetes may also be associated with sudden weight loss or nausea, vomiting, or abdominal pains, change in respiration if DKA has developed. Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved  Assessing the Patient With Diabetes ❖ History o Symptoms related to the diagnosis of diabetes: o Symptoms of hyperglycemia o Symptoms of hypoglycemia ❖ Frequency, timing, severity, and resolution ❖ Results of blood glucose monitoring ❖ Status, symptoms, and management of chronic complications of diabetes: o Eye; kidney; nerve; genitourinary and sexual, bladder, and GI, Cardiac; peripheral vascular; foot complications associated with DM ❖ Adherence to/ability to follow prescribed dietary management plan ❖ Adherence to prescribed exercise regimen ❖ Adherence to/ability to follow prescribed pharmacologic treatment (insulin or oral antidiabetic agents). Copyright © 2018 Wolters Kluwer · All Rights Reserved  Assessing the Patient With Diabetes cont… ❖Use of tobacco, alcohol, and prescribed and over-the-counter medications/drugs ❖Lifestyle, cultural, psychosocial, and economic factors that may affect diabetes treatment ❖Effects of diabetes or its complications on functional status (e.g., mobility, vision) Copyright © 2018 Wolters Kluwer · All Rights Reserved Assessing the Patient With Diabetes cont… ❖ Physical Examination ❖ Blood pressure (sitting and standing to detect orthostatic changes) ❖ Body mass index (height and weight) ❖ Funduscopic examination and visual acuity ❖ Foot examination (lesions, signs of infection, pulses) ❖ Skin examination (lesions and insulin injection sites) ❖ Neurologic examination ❖ Vibratory and sensory examination using monofilament ❖ Deep tendon reflexes ❖ Oral examination Copyright © 2018 Wolters Kluwer · All Rights Reserved Diagnostic Findings ❖ HA1C greater than 6.5 ❖ Fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L). ❖ Fasting is defined as no caloric intake for at least 8 hours. ❖ Casual glucose exceeding 200 mg/dL. ❖ Casual is defined as anytime of day without regard to time since last meal. ❖ Two-hour post load glucose equal to or greater than 200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test. ❖ Refer to Chart 51-2 for ADA diagnostic criteria PP:3855 Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved  Medical Management of Diabetes ❖Main goal is to normalize insulin activity and blood glucose levels to reduce the development of complications. ❖The ADA now recommends HgbA1c less than 7% ❖Diabetes management has five components: o Nutritional therapy o Exercise o Monitoring o Pharmacologic therapy o Education Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Diabetes team Copyright © 2018 Wolters Kluwer · All Rights Reserved  Dietary Management Goals 1# ❖ Control of total caloric intake to attain or maintain a reasonable body weight. ❖ Control of blood glucose levels. ❖ Normalization of lipids and blood pressure to prevent heart disease Copyright © 2018 Wolters Kluwer · All Rights Reserved  Role of the Nurse 1. Be knowledgeable about dietary management 2. Communicate important information to the dietician or other management specialists 3. Reinforce patient understanding 4. Support dietary and lifestyle changes Copyright © 2018 Wolters Kluwer · All Rights Reserved  Meal Planning ❖ Consider food preferences, lifestyle, usual eating times, and cultural and ethnic background ❖ Review diet history and need for weight loss, gain, or maintenance ❖ Caloric requirements and calorie distribution throughout the day; exchange lists o Carbohydrates: 50% to 60% carbohydrates; emphasize whole grains o Fat: 30%, limiting saturated fats to 10% and