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Control of Blood Glucose – Diabetes Mellitus

Control of Blood Glucose – Diabetes Mellitus. Ann MacLeod, RN, BScN, MPH. Objectives. Understand pathophysiology of diabetes Describe the following relating to diabetes Assessment Nursing diagnoses Management. Diabetes Mellitus.

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Control of Blood Glucose – Diabetes Mellitus

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  1. A. MacLeod, 2002 Control of Blood Glucose – Diabetes Mellitus Ann MacLeod, RN, BScN, MPH

  2. Objectives • Understand pathophysiology of diabetes • Describe the following relating to diabetes • Assessment • Nursing diagnoses • Management A. MacLeod, 2002

  3. Diabetes Mellitus • Definition: a metabolic disorder characterized by glucose intolerance • an imbalance between insulin supply and demand • not enough insulin, or insulin isn’t effective A. MacLeod, 2002

  4. Pathophysiology  BS   urine glucose  glycosuria  H20 loss due to hyperosmolarity  polyuria  Usable fat combustion  ketoacidosis resp glucose metab. Acidosis  brain starvation  coma tissue food for bacteria infections glucose serum atherosclerosis  miocardial infarcts cholesterol gangrene ? small vessel disease kidney damage, retinopathy, neuropathy A. MacLeod, 2002

  5. Types of Diabetes • Type 1: IDDM: insulin dependent • Type 2: NIDDM: not insulin dependent • Associated with other conditions: Gestational A. MacLeod, 2002

  6. Type 1 diabetes - IDDM • Diseased pancreatic beta cells not producing insulin • Genetic? Environmental? Autoimmune? • Recall insulin • Inhibits glycogenolysis (breakdown of stored glucose in the liver) • Inhibits gluconeogenesis (making new glucose from nutrients) • Inhibits fatty acid breakdown into glucose(ketones & acid & glucose products) A. MacLeod, 2002

  7. Type II diabetes - NIDDM • Cells receptors not sensitive or resistant to insulin  insulin unable to glucose transport into cell • Insulin still being produced • Risk factors obesity & sedentary A. MacLeod, 2002

  8. Gestational diabetes • Hyperglycemia due to excretion of hormones during pregnancy • Usually return to normal after delivery • At risk for Type II A. MacLeod, 2002

  9. Risk Factors for Diabetes • Heredity: Does someone in the family have the disease? • Black, Aboriginal • Obesity • Age > 45 • Stress • hypertension • HDL < 35 mg/dl • gestational diabetes or large babies • Sex: 3x more women • viral infections of pancreas A. MacLeod, 2002

  10. Diagnostic tests • Random Blood Sugar > 11mmol/l • Fasting Blood Sugar (FBS) > 7 • 2 hr. pc. Blood sugar • Glucose tolerance test • Urine testing for sugar and acetone (diabetic protocol) • HgbA 1c A. MacLeod, 2002

  11. Polydypsia polyuria polyphagia Glucosuria weakness, fatigue Further Assessment A. MacLeod, 2002

  12. Nursing Diagnoses • Risk for fluid volume deficit r/t polyuria • Altered nutrition r/t imbalance of insulin, food and physical activity • Knowledge deficit r/t self-care • Potential self-care deficit r/t blindness neuropathy • Anxiety • Altered coping A. MacLeod, 2002

  13. Diet: based on body wt. And activity: 50-60% CHO, 12-20% protein, 20-30% fat BMI <30 typically 3 meals /day with an eve. snack Monitoring of blood glucose, glucometers oral hypoglycemic agents: stimulate beta cells to produce insulin injectable insulin excercise Collaborative Management A. MacLeod, 2002

  14. Nursing Interventions • Close monitoring for hypoglycemia especially when blood glucose levels are low ie. Fasting for tests, surgery, meal skipping, nausea, vomiting, other short lived illnesses A. MacLeod, 2002

  15. Insulin • Hormone secreted by the pancreas when blood glucose rises. • Needed to transport glucose from the blood into the cells of fat and muscle • most common source is beef/pork • now largely biosynthetic sources ( anything ending with “lin” made with recombinant DNA in a lab A. MacLeod, 2002

  16. Insulins A. MacLeod, 2002

  17. Oral Hypoglycemics • Sulphonylureas eg. glyburide • stimulate b cells to secrete insulin • do not use with renal impairment, no etoh • Alpha-Glucosidase inhibitors • inhibit absorption of Sugars (blocks amylase etc. • Biguanide eg. Metaformin •  liver gluconeogenesis • intestinal absorption of glucose • geriatric risk for DKA, monitor renal function or liver disease A. MacLeod, 2002

  18. Insulin • Various insulin delivery systems are being manufactured, including insulin pens, sq ports, sq infusions, IV infusions A. MacLeod, 2002

  19. A. MacLeod, 2002

  20. Complications of Diabetes Diabetic Ketoacidosis: • a life-threatening syndrome • onset: hours>>days • severe hyperglycemia and acidosis resulting from insulin deficiency or absence • associated with failure to take insulin, new Dx., infection • Hyperglycemia acts like an osmotic diuretic and causes severe fld. And electrolyte loss ( K+) A. MacLeod, 2002

  21. Are a result of hyperglycemia and fluid and electrolyte losses alt. LOC kaussmaul resp. tachycardia Dry flushed skin, poor turgor, dry mucous membranes polyuria, polydypsia acetone breath weakness Assessment Diabetic Ketoacidosis A. MacLeod, 2002

  22. Assessment DKA cont’d • Blood work: blood glucose can go as high as 25-80 mm/L • electrolyte imbalances • severe dehydration A. MacLeod, 2002

  23. Fluid replacement rapid acting insulin restore electrolyte levels Treatment of underlying cause Collaborative Management A. MacLeod, 2002

  24. Fluid volume deficit Risk for Injury Altered peripheral tissue perfusion knowledge deficit Nursing Process A. MacLeod, 2002

  25. Hypoglycemia • A lowering of blood glucose caused by excessive insulin or hypoglycemic agent • may also be caused by: skipping meals, ++exercise, vomiting A. MacLeod, 2002

  26. Hypoglycemia • Sudden onset: • typical scenario: hypoglycemia occurs during the time of peak action of insulin or hypoglycemic agent. Especially at night when ct. is asleep, or hasn’t eaten a bed time snack A. MacLeod, 2002

  27. Assessment • For some cts. You will see symptoms when blood glucose drops below 5 • pale, cold, clammy, perspiration • weak, hunger, tachycardia,headache, double vision • confusion, slurred speech, coma A. MacLeod, 2002

  28. Management • Admin. Of rapid acting sugar (fruit juice, cola, hard candy, then follow it with a complex CHO and protein) • 50% dextrose IV works in less than 10 min (25-50 mls) • glucagon A. MacLeod, 2002

  29. Alt. Protection r/t risk of seizure and brain damage knowledge deficit r/t disease process Knowledge deficit r/t diagnostic testing, indicators of hypoglycemia, theraputic regime Nursing Process A. MacLeod, 2002

  30. Hyperosmolar Hyperglycemic, Non ketotic syndrome • Life threatening lack of insulin causing severe hyperglycemia • usually elderly cts. With inadequate Tx. Or undiagnosed DM. • Often have pre-existing cardiac or pulmonary problems A. MacLeod, 2002

  31. Assessment • Same as DKA as well as seizures • resp. shallow with apneic episodes • polyuria, polydypsia, fatigue, weakness • hypotension, increased HR. T. A. MacLeod, 2002

  32. Risk Factors • Undiagnosed DM • gram negative infection • over 50 yrs. In age • cardiac or lung problems A. MacLeod, 2002

  33. Chronic Complications of Diabetes Mellitus • Risk factors: ageing, dietary habits, lack of control of blood sugars, duration of illness, lack of exercise, complicating pre-existing medical conditions, SMOKING A. MacLeod, 2002

  34. Complications of Diabetes • Three main types: • 1) macrovascular • 2) microvascular • 3) neuropathy A. MacLeod, 2002

  35. Macrovascular • Related to degenerative changes in the large blood vessels • MI: r/t coronary artery disease • CVA: r.t cerebral artery disease • PVD: r/t peripheral vasc. Disease • infection d/t vasc. insufficiency A. MacLeod, 2002

  36. Microvascular • Nephropathy: damage to capillaries that supply the glomeruli: early sign is proteinuria, may progress to end stage renal disease • Retinopathy: damage to capillaries of retina>scar tissue>blindness A. MacLeod, 2002

  37. Neuropathy • Most common chronic complication of diabetes • when circulation to axons and dendrites is impeded, transmission of impulses slows • Ax. Parestesia: prickling, tingling,may also be autonomic A. MacLeod, 2002

  38. Ongoing Assessment • Activity • diet • medication • glucose monitoring • eyes ( retinopathy) • skin and mucous membranes • Cardio vascular system BP, tissue perfusion • Genitourinary system - infections, difficulty voiding, • Neuropathies A. MacLeod, 2002

  39. Importance of balance between insulin, diet, exercise more frequent checks of BS during episodes of brief illness, injury or stress Never alter insulin dosage unless advised by a MD. Insulin use:how to give self a SQ injection (begin with simple and work to complex Client Teaching with regards to diabetes A. MacLeod, 2002

  40. Dietary modifications exercise hygiene and safety measures foot care Coping skills, with careful consideration of growth and development techniques for monitoring blood glucose levels Client Teaching A. MacLeod, 2002

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