MEDICAL SURGICAL NURSING II CHAPTER 57

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MEDICAL SURGICAL NURSING IICHAPTER 57

• CARING FOR CLIENTS WITH DIABETES MELLITUS

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Diabetes Mellitus

• Diabetes mellitus is a metabolic disorder of the
  pancreas that affects the metabolism of
  carbohydrates, fats proteins
• Metabolic syndrome central obesity, HTN,
  elevated triglycerides, LDL, blood glucose
  levels a low HDL

• 90-95 cases occur in adulthood
• 2002 stats 18.2 million people in the US have
  diabetes with 5.2 million undiagnosed
• The 6th leading cause of death in the US

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Diabetes Mellitus

• Type I-insulin dependent diabetes mellitus
  (IDDM)/juvenile diabetes the pancreas does not
  produce any insulin. Affects children
  adolescents
• Type II-non-insulin dependent diabetes mellitus
  or NIDDM either a decreased amount of insulin
  produced or insulin resistant usually affects
  adults, but can occur in obese children

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Pre-Diabetes Mellitus

• May lead to Type II diabetes, heart disease
  stroke
• Criteria
• impaired fasting glucose (IFG), FBS of
  100-125mg/dl
• impaired glucose tolerance (IGT), glucose level
  of 140-199mg/dl after glucose tolerance test
  lasting 2 hrs
• Treatment to prevent development of Type II
  diabetes
• weight loss
• increased physical activity

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CAUSES

• TYPE I
• Destruction of islet cells by T-cell lymphocytes
• Autoimmune disease
• No insulin produced

• TYPE 2
• Familial
• Linked to obesity, especially central type
• Insulin is produced but is not effective

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• Main symptoms
• polyuria,
• polydipsia
• polyphagia
• Other symptoms
• wt loss, weakness, fatigue dehydration

• Testing for diabetes
• RBS
• FBS
• Postprandial glucose
• Oral glucose tolerance test
• Glycosylated hemoglobin/Hgb A1C
• Table 57-1 know preparation for each

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MEDICAL MANAGEMENT

• Treatment depends of type of diabetes, presence
  or absence of insulin production
• Diet Wt loss
• Exercise
• Insulin

• Oral antidiabetic meds
• Pancreas transplantation
• Islet cell transplantation

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Diet Wt Loss

• Depends on clients age, sex, height weight,
  activity level, occupation, state of health,
  former dietary habits cultural background
• Diet RX by MD dietician
• Exchange lists
• Type 2 diabetes may be diet-controlled

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EXERCISE

• Helps metabolize carbohydrates
• Improves circulation
• Lowers cholesterol triglyceride levels
• Improves muscle tone
• Must regulate food insulin requirements during
  periods of increased activity

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INSULIN

• Inactivated by GI juices so must be injected.
  See different preparations table 57-2
• insulin administration sites, fig 57-6

• Insulin Pen fig 57-8
• Jet injector fig 57-8
• Insulin pumps fig 57-9 table 57-3

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ORAL ANTIDIABETIC AGENTS

• For clients with type 2 diabetes
• Criteria FBS lt 200mg/dl, insulin requirements lt
  40units/day, No DKA, No renal or hepatic disease
• See Drug table 57-1

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ORAL ANTIDIABETIC AGENTS

• Sulfonyureas Meglitinides
• insulin releasers stimulate the pancreas to
  secrete more insulin
• tend to cause wt gain, hypoglycemic reactions
  secondary failure
• Biguanides Thiazolidinediones
• new type drug insulin sensitizers help tissues
  use available insulin more efficiently
• may cause stomach upset, flatulence diarrhea
• Alpha-Glucosidase Inhibitors
• helps to equalize blood glucose levels
  prevents swings between hyper/hypoglycemia
• if a person develops hypoglycemia while taking
  this, however, will not respond to 1st line
  treatments such as ingestion of orange juice
  must take glucose tablets or by injection

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Surgical Interventions

• Pancreas Transplantation
• Candidates are those with type 1 with renal
  failure
• Requires lifelong immunosuppressive drug therapy

• Islet Cell Transplantation
• Candidates are type 1 diabetics
• Requires 2 pancreases
• Steroids avoided

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Nursing Care for Diabetics

• See care plan 57-1
• Know MD orders
• Teaching points pg 985-989

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DIABETIC KETOACIDOSIS

• DKA is an acute insulin deficiency followed by a
  decrease in glucose in the body cells an
  increased production of glucose by the liver.
  This causes hyperglycemia. The body cells
  cannot use the glucose so breaks down fats to
  use as energy with resulting excessive ketones in
  the blood

• This can happen even if the client follows the
  prescribed regime, usually to brittle diabetics
  or when a diabetic gets an infection or does not
  follow the treatment plan

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DKA

• S/S weakness, thirst, anorexia, n/v,
  drowsiness, abd pain, flushed cheeks with dry
  mucus membranes, fruity odor breath from acetone
  buildup, Kussmaul respirations, rapid, weak
  pulse, low blood pressure, can lead to coma
  death

• Goals of treatment
• reduce the blood glucose
• correct the fluid electrolyte imbalance
• clear the urine blood of ketones
• Medical treatment
• Usually give IV insulin (regular is used) , check
  blood sugars frequently serum electrolytes
• Nursing regulate the insulin, glucose
  electrolyte monitoring

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Hyperosmolar Hyperglycemic Nonketotic Syndrome or
HHNKS

• Usually happens to older diabetics or in
  nondiabetics with severe burns, renal dialysis or
  on TPN
• Due to persistent hyperglycemia fluid moves from
  the intracellular compartment to the
  extracellular compartments

• Severe diuresis results with loss of K Na
• S/S-hypotension, mental status changes,
  polydipsia, tachycardia fever
• Hyperglycemia, no ketosis electrolyte imbalances
• Treatment give insulin to get blood sugars down,
  correct electrolyte imbalances

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HYPOGLYCEMIA

• When there is too much insulin in the bloodstream
  relative to the amount of available glucose.
• Blood glucose lt 60mg/dl.
• S/S weakness, h/a, nausea, drowsiness,
  nervousness, hunger, tremors, coma, death
• May happen anytime meds for diabetes are
  administered

• Treatment
• conscious-15-20 g simple carbs asap sweetened
  fruit juice, honey, candy, cake frosting, sugar
  or glucose tabs
• unconscious-glucose gel followed by glucagon or
  20-50ml 50 glucose IVP
• Once symptoms relieved give complex carbs
• Nursing care prevention of hypoglycemia

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Peripheral Neuropathy

• generalized changes in nerves resulting from poor
  glucose control
• Motor muscles weaken atrophy joint support
  diminished fig 57-10
• Sensory paresthesias appear total loss of
  feeling
• Autonomic affects internal organs stomach,
  bladder, erectile dysfunction

• S/S pain, edema to feet, digestive, urinary
  sexual dysfunction
• Medical Mgmt blood glucose control non-narcotic
  analgesics or tricyclic antidepressants,
  anticonvulsants
• Nursing teaching!!!

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DIABETIC NEPHROPATHY

• Progressive decrease in renal function due to
  poor glucose control
• Table 57-5
• S/S none in early stages, later edema,
  elevated BP, fatigue

• Medical Mgmt control the glucose BP
• Nursing blood glucose Hgb A1c results,
  teaching

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DIABETIC RETINOPATHY

• Pathologic changes in the retina due to poorly
  controlled blood glucose
• S/S blurred vision, diminished visual acuity
• Refer for ophthalmic evaluation every 3-5 years
• Encourage diabetic control encourage regular
  ophthalmic exams

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VASCULAR DISTURBANCES

• All arteries arterioles are susceptible to
  accelerated atherosclerotic arteriosclerotic
  changes
• Increased incidence of CAD
• Peripheral vascular changes most common
  complication of diabetes
• Extremities pale cool, leg cramps, development
  of gangrene, infection, leg ulcers, AMI
• Treatment good glucose control, use of lipid
  lowering agents

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General Nutritional Considerations

• Nutritional therapy is the cornerstone of
  treatment for all clients with diabetes.
• There is no longer one diabetic diet that is
  appropriate for all clients.
• Consistency in the total amount of carbs consumed
  is considered more important than the type eaten.
• The use of exchange lists simplifies meal planning

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General Pharmalogical Considerations

• Observe the client taking an oral antidiabetic
  agent for s/s of hypoglycemia
• Make sure that the client understands that
  insulin oral antidiabetics agents are used to
  control hyperglycemia, not cure it.
• Use of ETOH with some oral hypoglycemic drugs may
  cause abdominal cramps, nausea, flushing,
  headache, hypoglycemia

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General Gerontologic Considerations

• DM is prevalent among older adults.
• Even if other family members need to be involved
  in the older clients care, be sure to include
  the client as much as possible.
• For those older clients who have difficulty
  self-administering insulin there are many aids
  available, such as a magnifier that fits over the
  syringe.