NURS 210 Care of the Client with Diabetes - PDF

Care of the Client with Diabetes NURS 210 Sarah McArthur RN BSN MN Class Overview - Understanding Diabetes Understanding the Nurse’s Role in the Treatment of Diabetes Insulin Therapy Case Study - Knowledge application Diabetes Mellitus A group of diseases characterized by hyperglycemia that is...

Care of the Client with Diabetes NURS 210 Sarah McArthur RN BSN MN Class Overview - Understanding Diabetes Understanding the Nurse’s Role in the Treatment of Diabetes Insulin Therapy Case Study - Knowledge application Diabetes Mellitus A group of diseases characterized by hyperglycemia that is attributable to defects in insulin secretion, insulin action, or both. Metabolic disorder Affects more than 2 million Canadians Insulin ● ● ● ● Secreted by the beta cells in the pancreas (Islets of Langerhans) When you eat, insulin secretion increases and move glucose from the blood into muscle, liver & fat cells. During fasting periods (between meals & overnight), the pancreas continually releases small amounts of insulin Together, the insulin & glucagon maintain a constant level of glucose in the blood by stimulating the release of glucose from the liver NO Insulin = NO ability to move glucose Functions of Insulin ● ● ● ● ● ● Transports and metabolizes glucose for energy Stimulates storage of glucose in the liver and muscle as glycogen Signals the liver to stop the release of glucose Enhances the storage of dietary fat in adipose tissue Accelerates transport of amino acids into cells Inhibits the breakdown of stored glucose, protein, and fat 1. Classifications of Diabetes 3 MAIN types: ➔ Type 1 Diabetes Often referred to as “juvenile” ➔ Type 2 Diabetes Often referred to as “adult onset” or “late onset” diabetes ➔ Gestational Diabetes Development of diabetes in pregnancy Diagnostic Testing for Diabetes Mellitus ● Fasting plasma glucose - Level greater than or equal to 7mmol/L ● Random plasma glucose- greater than or equal to 11 mmol/L (PLUS classic symptoms of diabetes) ● Oral glucose tolerance test (OGTT) level greater than or equal to 11 mmol/L, using a close load of 75 mg ● Glycosylated Hemoglobin (HgA1c) greater than 6.5% Monitoring Blood Glucose Levels ● Helps the client to make self-management decisions (diet, exercise, medication) ● Should be completed on a schedule (depending on insulin requirements) ALWAYS take a blood glucose level prior to administering insulin- WHY? Risk Factors for Type 2 Diabetes Parent or sibling with diabetes A member of high-risk group (Indigenous, Hispanic, South Asian, Asian, or African descent) History of Gestational Diabetes High Blood Pressure High Cholesterol or other fats in the blood Obesity (especially if the weight is around the abdominal area) Polyuria Polydipsia Polyphagia Testing for Ketones ● ● ● ● ● Ketones are the metabolic end products of fatty acid metabolism Ketones (or ketone bodies) in the urine signal that diabetes control is deteriorating, and the risk of Diabetic Ketoacidosis (DKA) is high When insulin is not available, the body starts to break down stored fat for energy Ketone bodies are by-products of this fat breakdown, and they accumulate in the blood & urine Urine testing is the most common method used for self-testing of ketone bodies Hypoglycemia- “cold & clammy, needs candy” ● Occurs at peak of insulin, during exercise, when too much insulin is taken, or client skips a meal ● Blood glucose LESS than 4 mmol/L (may be higher if client is consistently hyperglycemic) ● Sudden onset of symptoms ● May result in death if left untreated Causes of Hypoglycemia PREDICTABLE (85%) ● ● ● ● ● ● Missed/Delayed Meal Too much insulin Limited understanding of insulin Infrequent BG testing Alcohol use Ignoring or under-treating lows UNPREDICTABLE (15%) ● ● ● Inconsistent action of insulin Menstrual, hormonal changes Delayed stomach emptying Treatment of Hypoglycemia (CONSCIOUS) 1. QUICKLY absorbed Carbohydrate RE-TEST blood glucose level after 15 minutes 1. SLOWLY absorbed Carbohydrate Emergency Measures (if patient unconscious or cannot swallow): Subcutaneous or intramuscular glucagon (1mg) 25-50 ml 50% dextrose solution IV Tip NEVER attempt to put anything in clients mouth if they are unconscious or unable to follow direction Hyperglycemia- “Hot & Dry, Sugar is High” ● Occurs when insulin is absent or ineffective ● Resulting in excess glucose (sugar) circulating in the blood steam and not being absorbed into cells ● Anything greater than 11 mmol/L is considered hyperglycemic ● Left untreated- can lead to DKA (in type 1) or HHNS (in type 2)- both of which can be fatal Causes of Hyperglycemia ● ● ● ● ● ● ● Illness or Infection Corticosteroids Increased glucose intake Minimal or no insulin or diabetes medication Inactivity Emotional or physical stress Poor absorption or lack of insulin Diabetic Ketoacidosis (DKA) ● ● ● ● ● ● ● Life threatening Usually seen in undiagnosed diabetes mellitus type 1 Often in childhood Known type 1 diabetics can have re-occurrences throughout life Caused by an absence of, or inadequate amount of, insulin- resulting in abnormal metabolism of carbohydrates, proteins, and fats Body begins to breakdown fats for fuel- ketones are the end products of fat break down Ketones = Acidic NEW diagnosis of DM Myocardial Infarction Insulin Omission Insulin Pumps Infection or Illness Thyrotoxicosis Trauma Cocaine DKA Treatment ● ● ● ● Rehydration with IV fluids Continuous insulin infusion (titrated to control BG) Reverse acidosis and electrolyte imbalance Monitor: BG & renal function, ECG and electrolyte levels, VS, lung assessments, signs of fluid overload If client is diabetic, take extra care while ill SICK DAY RULES: ● ● ● ● ● ● Drink plenty of extra sugar-free fluids (& water) Avoid caffeine Try to consume 15 grams of carbohydrates per hour Follow usual meal plan If using insulin, continue taking this while sick unless otherwise advised Test BG & Ketone levels every 3 - 4 hours SADMANS - HOLD the following S- Sulfonylureas A- ACE Inhibitors D- Diuretics M- Metformin A- ARB’s N- NSAIDS S- SGLT2 Inhibitors Hyperosmolar Hyperglycemic NonKetotic Syndrome (HHNS or HHNK) ● ● ● ● ● ● Life threatening emergency Develops SLOWLY- result of insufficient circulating insulin Skin flushed, dry, warm Does not affect breathing by results in osmotic diuresis BG levels may rise over 50 mmol/L- may even reach 100 mmol/L Manifests as: HYPOTENSION, PROFOUND DEHYDRATION, TACHYCARDIA, & NEUROLOGICAL CHANGES Sleepiness, Confusion, Hallucinations Dry, Parched Mouth, & Extreme Thirst Warm, dry skin (not sweating) High Fever (>38.5) WARNING SIGNS Loss of Vision Weakness on one side of body Omission of insulin, physiologic stress (infection, surgery, etc.) HHNS While can occur in both, usually occurs in Type 2 (esp. elderly) Physiologic stress (infection, surgery, etc.) Onset Rapid (<24 hours) Slower (over several days) Blood Glucose Levels Usual > 14 mmol/L Usually > 33 mmol/L < 7.3 Normal Present Absent 300-350 >350 Elevated Elevated Occurrence Precipitated by: Arterial pH levels Serum and urine ketones Serum Osmolality BUN and Creatinine levels Mortality Rate DKA While can occur in both, usually occurs in Type 1 < 5% 10-40% BREAK Understanding the Nurse’s Role in the Treatment of Diabetes Nutrition ● ● ● ● Foundation of Diabetes management Complex Multidisciplinary approach Overall goal: prevent wide fluctuations in blood glucose levels ○ Decreasing SERUM LIPID LEVELS - reduces the risk of macrovascular disease Carbohydrates (CHO) ● ● ● ● ● ● Amount and type in a food greatly influences overall glucose control Monitoring total grams of carbohydrate, whether by use of food exchanges or carbohydrate counting is a useful tool Food containing CHO from whole grains, fruits, and vegetables and low-fat dairy products should be emphasized Low CHO diets (“Keto”) are not recommended in the management of diabetes CHO are important sources of fiber, water-soluble vitamins, minerals, and energy The B vitamins- folate, thiamine, riboflavin, niacin, pantothenic acid, biotin, vitamin B6 & B12- and vitamin C are water soluble vitamins FIBER ● ● ● ● ● Fiber is not digested in the stomach or absorbed in the small intestine Has been shown to have large impact on glycemic response A fiber rich diet is processed more slowly, which promotes early satiety, may be less caloric, lower in fat and added sugars, which can combat obesity, and prevent risk of heart disease & colon cancer Recent studies support a 20-30% reduction in the risk of development of Type 2 DM with increased whole grain fiber intake High fiber containing CHO sources (>5g/serving) should be chosen over lower fiber choices Alcohol ● ● ● Alcohol intake greater than in moderation can lead to hypoglycemia Moderation: ○ One drink/day for women ○ Two drinks/day for men One drink is defined as: ○ 12 Oz of Beer ○ 5 Oz of Wine ○ 1.5 Oz of hard liquor Exercise Precautions with Exercise ● ● ● ● ● Muscles need more energy In response, liver increases the amount of glucose it releases into your bloodstream Glucose needs insulin in order to be used by the muscles Not enough insulin available- blood glucose levels can actually increase right after exercise End result: glucose backs up into the bloodstream, causing higher BG readings 1. Check BG BEFORE exercise 2. Carry simple carbohydrates 3. Check BG AFTER exercise INSULIN Therapy Type 1 diabetics require exogenous insulin for life Type 2 diabetics may require exogenous insulin IF diet/oral agents fail 3 main characteristics: - - Time course of Action Species (source) Manufacturer. Time Course of Action ● Categories based on: ○ ○ ○ ● ● ● ● Onset Peak Duration of action Human insulin preparations have a shorter duration of action than insulin from animal sources RAPID and SHORT acting insulins are expected to cover the rise in glucose levels (with meals) INTERMEDIATE acting insulins are expected to cover subsequent meals LONG acting insulins provide constant levels of insulin BASAL Insulin ● ● ● Provides insulin in the non-fed state (overnight/between meals) Prevents glucose production from the liver Usually about 50% of Total Daily Dose (TDD) of insulin ● WHO NEEDS EXOGENOUS BASAL INSULIN BOLUS Insulin ● ● ● ● ● Used to cover rise in blood glucose from carbohydrates Use to correct high blood glucose levels Absorbed quickly once injected 50-60% of TDD 1 unit of insulin covers about 10 grams of carbohydrates CORRECTION Insulin ● ● To make a correction for an unpredictable high glucose (usually before a meal) Added to the pre meal bolus dose EKRH Current Policy on SC Insulin Administration ● ● ● ● ● ● ● System using insulin PENS (1 per patient) Pens are multidose (change needle each time) Reduces insulin error Reduces blood borne contamination More accurate dosing Patient teaching opportunities for self-administration Reduces needle stick injuries WHY IS THIS IMPORTANT KEY CHANGES: Insulin PPOs • 4 types of Insulin Pre-Filled pens will be available LONG Acting Insulin glargine (Lantus® SoloSTAR) RAPID Acting Insulin aspart (NovoRapid®) COMBINATION Insulin (MIX 25 HumaLOG®) Lispro 25%+lispro protamine 75% Nursing Considerations with Insulin Therapy Careful monitoring ● BG levels ● Ketone testing (if indicated) ● Potassium levels Know onset, peak, and duration of insulin therapies HOLD insulin if patient is fasting for tests/procedures Client education is central! Client Education ● ● ● MOST important nursing intervention Goal: self-care and administration for the client Providing education requires one to KNOW about diabetes and insulin SITE SELECTION ● ● ● ● Abdomen- more stable and rapid absorption Arms- Posterior surface (tricep) Thigh- Anterior surface Hips Long Term Complications Complications of Diabetes Mellitus MICROVASCULAR ● ● ● ● ● Specific to diabetes Thickening of vessel membranes in arterioles Results from chronic hyperglycemia Retinopathy, nephropathy, neuropathy, dermopathy Clinical manifestations may not appear for 10-20 years after onset MACROVASCULAR ● ● ● ● Diseases of the large & medium vessels Coronary artery disease Cerebrovascular disease Peripheral vascular disease Diabetic Retinopathy Damage to small blood vessels that supply glomeruli of the kidney Pressure in blood vessels of the kidney’s increase Leading cause of end stage renal disease Significant reduction when near-normal blood glucose control was achieved and maintained Autonomic Neuropathy: Sexual Dysfunction ● ● ● ● ● Decreased libido in women Anorgasmia Erectile Dysfunction in men UTI and vaginitis Retrograde ejaculations Peripheral Vascular Disease & Foot Ulcers Ulcers may not heal due to the decreased ability of oxygen, nutrients, and antibiotics to reach the injured tissue Amputation may be necessary to prevent spread of infection INFECTIONS ➔ More susceptible to infections ➔ Defect in the mobilization of inflammatory cells and an impairment of phagocytosis ➔ Treatment must be prompt and aggressive Diabetes & Surgery ● During stress (such as surgery) blood glucose levels rise as a result of an increase in the level of stress hormones ● If hyperglycemia is not controlled- osmotic diuresis may lead to excessive loss of fluids & electrolytes ● Risk of hypoglycemia : withhold insulin morning of surgery Special Considerations/Issues HYPERGLYCEMIA in hospital ● ● ● ● ● ● Increased Food Decreased Insulin Steroids IV Dextrose Overly vigorous treatment of hypoglycemia Inappropriate holding of insulin HYPOGLYCEMIA in hospital ● ● ● ● ● Overuse of sliding scale Lack of insulin - dietary intake withheld Over-treatment of hyperglycemia Delayed meals after insulin given Alterations in diet- enteral, PN, clear liquid diets QUESTIONS?