Acute Complications of Diabetes

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Acute Complications of Diabetes

• Katrina Hamilton RN CDE

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Three Acute Complications

• Diabetic ketoacidosis (DKA)
• Hyperglycaemia
• Hypoglycaemia

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Hyperglycaemia

• Persistant elevation in Blood Glucose levels
• Normal Blood glucose levels are 3.5mmol/l to
  7.8mmol/l
• Untreated hyperglycaemia may lead to DKA or
  Hyperosmolar Nonketotic Syndrome

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Diabetic Ketoacidosis

• Caused by abscence or inadequacy of insulin
• results in disordered metabolism of CHO, fat and
  protein.

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Clinical Features

• Hyperglycaemia
• Dehydration and electrolyte loss
• Acidosis

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Main Causes

• Too little or missed dose of insulin
• Illness or infection
• Undiagnosed diabetes ( commonly is presenting
  feature)

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Clinical Manifestations

• Polyurea, polydipsia and resultant dehydration
• GIT symptoms eg. Abdo pain, anorexia, nausea
• Acetone breath and Kussmaul respirations
• altered mental status depends on severity

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Medical/ Nursing Management

• Aims correct fluid and electrolyte deficits and
  to reverse impaired glucose metabolism to reduce
  hyperglycaemia.
• Fluid replacement usually initially N/Saline 0.5
  to 1l per hour for 5 hours.
• Potassium suppliment added cautiously usually
  5mmol per hour

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Medical /Nursing Management

• IV solution usually changed to D/saline when
  BGLs reach 12-15 mmol/l
• Insulin Infusion usually 50u/s in 50 mls of
  saline. Hourly Blood Glucose levels to titrate
  insulin
• Monitoring of urine output
• Strict Fluid balance chart

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Continued...

• ECG / cardiac monitoring to detect dysrhythmia
  due to Hypokalemia.
• Frequent urea and electrolyte levels, arterial
  blood gases to determine Ph
• Furthure pathology if infection suspected

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Role of RN

• Meticulous documentation and frequent assessment
  of the patient
• co-ordination and ongoing management of the
  patient

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Responsibilities include

• preparation of IV fluids as prescribed
• Monitoring if IV rates as prescribed
• Observations of IV site for inflammation or
  extravasation
• Documentation of ALL fluid input and output
• Observe for signs of overload or electrolyte
  disturbance

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Continued....

• Preparation and administration of insulin
  infusions as per regime
• monitoring of BGLS
• Observe for improving/ deteriorating acidosis
  i.e. Level of mentation, respiratory function ,
  ketonurea

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Sick Day Management Plan

• Continue to take insulin or tablets even if not
  eating
• Increase frequency of Blood Glucose Monitoring to
  at least 4/24 more frequent if vomiting or
  diarrhoea present
• try to maintain normal caloric intake - may need
  to substitute if anorexic

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Sick Day Plan continued

• If BGL 15mmol/l or greater then drink plenty of
  diet soft drinks and water and test urine for
  ketones
• If BGL lt 15mmol/l drink sweetened fluids and
  water
• Aim for 2-3 litres in 24/24 period
• Rest

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Contact Doctor

• if unwell for gt 24-36hrs
• BGL remains gt 15mmol/l
• Diarrhoea and vomiting persist
• if ketones present in urine
• temperature remains elevated
• if there are signs of dehydration

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Hypoglycaemia

• Usually occurs as result of imbalance between
  food intake, medication and exercise
• Rapid drops in blood glucose levels can result in
  symptoms of Hypoglycaemia

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Causes of Hypoglycaemia

• Insufficient CHO intake
• Insulin dose given too early
• Delay in ingestion of food in relation to
  medication
• Exercising when blood glucose levels lt6mmol/l and
  not compensating with CHO

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Causes Continued.

• Failure to adjust insulin/ OHAs dose when insulin
  sensitivity has increased in relation to weight
  loss or exercise
• Ingestion of drugs which potentiate effect of
  OHAs ie.Aspirin, sulphonamide antibiotics
• Ingestion of alcohol suppresses glycogenolysis

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Clinical Manifestations

• Initial symptoms include dizziness, headache,
  tingling around mouth,decreased concentration
• Caused because cerebral tissues sensitive to
  glucose deficit
• Autonomic response symptoms include
  tremor,hunger,tachycardia,cold,clammy,sweating
  and nausea

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Clinical manifestations cont..

• Reasons for autonomic response include
  gluconeogenesis occuring in response to autonomic
  nervous stimulation causing secretion of
  epinephrine and other insulin antagonists
• This response is the bodys way of trying to
  utilise emergency reserves.

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Symptoms of advancing Hypo

• Slurred speech,disorientation,
• Drowsiness,loss of consciousness leading to coma
  and eventually death
• Reason for these symptoms is glucose only can
  cross blood/ brain barrier.
• Brain can not use products of fat and protein
  metabolism.

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Management of Hypoglycaemia

• Immediate treatment required
• Nurse fairly autonomous in treatment
• Medical orders required for Glucagon or
  intravenous glucose
• Preferable to confirm hypoglycaemia prior to
  treatment

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Mild to moderate hypoglycaemia

• Administer 15g CHO
• Follow that with 1 serve of slow acting CHO
• Retest BGL with in 10 minutes to ascertain
  effectivenss of treatment
• If BGL is 3.5mmol/l or higher but patient has
  symptoms just give 1 serve slow CHO

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Examples of 15g fast acting CHO

• 150mls softdrink (not diet)
• 1 small popper
• 100ml Lucozade
• 6-7 jelly beans
• 3 5mg glucose tablets
• 2-3 teaspoons sugar / honey

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Examples of 1 serve slow CHO

• 1 slice of bread
• 1 250ml glass of milk
• 1 piece of fruit
• 2 plain biscuits

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Hypoglycaemia Unawareness

• Lack of warning symptoms of hypo
• Can occur in patients who have autonomic
  neuropathy or those on beta-blockers
• All patients should carry of wear ID stating they
  have diabetes.

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Nursing responsibilities

• Ensure patient is aware of potential for
  hypoglycaemia
• Teach patient how to treat hypo
• Teach patient that they must carry hypo
  treatment at ALL times
• Patients should be warned to refrainf from using
  high fat treatments as they slow the absorption
  of glucose

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Nursing Responsibilities cont..

• If patient taking Arcobose ( glucobay) use
  glucose tablets because the drug inhibits
  absorption of sucrose
• Warning elderly patients the importance of
  regular eating.. No skipping meals

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Severe Hypoglycaemia

• If patient unconscious, put patient on side,
  protect airway
• Administer Glucagon IM, SC or IV
• Family members need to be instucted on its use
• When patient conscious still administer oral hypo
  treatment

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Follow-up

• Patient should be encouraged to contact GP
  especially if no cause found.
• Family need to be aware of symptoms and treatment
  as often patients will be unaware of hypo and not
  very co-operative with treatment.