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Chapter 40

Chapter 40. Nursing Care of Patients with Disorders of the Endocrine Pancreas. Diabetes Mellitus. Pathophysiology Glucose Intolerance Faulty Production of Insulin or Tissue Insensitivity to Insulin Altered CHO, Fat, Protein Metabolism Long-term Complications. Blood Glucose Levels.

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Chapter 40

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  1. Chapter 40 Nursing Care of Patients with Disorders of the Endocrine Pancreas

  2. Diabetes Mellitus • Pathophysiology • GlucoseIntolerance • FaultyProductionofInsulinor • TissueInsensitivitytoInsulin • Altered CHO,Fat,Protein Metabolism • Long-term Complications

  3. Blood Glucose Levels

  4. Cell Membranes

  5. CDC Statistics • 20.8 Million in U.S. have Diabetes • 6.2 Million are Unaware • Cost: $132 Billion per Year

  6. Type 1 Diabetes • IDDM,Juvenile(Old Names) • 5%to 10% ofDiabetes Cases • SomeGenetic Component (10%) • AutoimmuneResponsetoVirus • Destruction ofBeta Cells • PancreasSecretesNOInsulin • MoreCommoninYoung, Thin Patients • Prone toKetosis

  7. Type 2 Diabetes • NIDDM,Adult Onset (Old Names) • 90%to 95% ofDiabetes Cases • LargeGenetic Component (90%) • DecreasedBeta Cell Responsiveness toGlucose • ReducedNumberofBeta Cells • ReducedTissue Sensitivity toInsulin • LargestRisk Factor isObesity • NotKetosis-Prone

  8. LADA • Latent Autoimmune Diabetes of Adulthood • Initial Type 2 Diagnosis • Islet Cell Antibodies Like Type 1

  9. Type 2 in Youth • More Obesity in Children • Type 2 Epidemic • A Nursing Challenge

  10. Other Types • Gestational: Pregnancy • Prediabetes: Glucose Intolerance • SecondaryDiabetes • Drugs • PancreaticTrauma

  11. Metabolic Syndrome • ElevatedWaist Circumference • ElevatedTriglycerides • Low HDLCholesterol • ElevatedBlood Pressure • ElevatedFasting Plasma Glucose

  12. SignsandSymptoms • The 3 Ps • Polyuria • Polydipsia • Polyphagia • Fatigue • BlurredVision • InfectionProne • AbdominalPain • Headache • Ketosis/Acidosis

  13. Diagnosing Diabetes • FastingPlasma Glucose≥ 126 mg/dL • CasualPlasma Glucose ≥ 200 mg/dL • GlucoseTolerance Test> 200 mg/dL after2 Hr

  14. Additional Tests • Glycohemoglobin: Normal 4% to 6% • Lipid Profile • Serum Creatinine • Urine Microalbumin

  15. Prevention of Type 2 • Lose 5% to 7% Body Weight • 30 Minutes of Exercise 5 Days per Week • Reduce Fat and Calories

  16. Goals of Treatment • PreprandialGlucose90 to130 mg/dL • PeakPostprandial Glucose < 180 mg/dL • BloodPressure< 130/80 Mm Hg • Glycohemoglobin < 7%

  17. Therapeutic Interventions • MedicalNutrition Therapy • Exercise • Medication • Monitoring • Education

  18. Medical Nutrition Therapy (MNT) • ADAExchange Lists • CarbohydrateCounting • GlycemicIndex • REMEMBER CULTURAL DIETARY NEEDS

  19. GeneralPrinciplesof MNT • LowFat • LowSodium • LimitSimple Sugars • UseComplex Carbohydrates • ConsistentDay-to-day

  20. Exercise • LowersGlucoseup to 24Hours • LowersBlood Lipids • BestDone Regularly • Refer to MD orExercise Physiologist • AvoidExercise During Acute Hyperglycemia • CarryFast Sugar

  21. Medication • Insulin for Type 1 or 2 • OralHypoglycemicsfor Type 2

  22. Insulin • Action • Routes • Subcutaneous • IM • Inhaled • Insulinpump

  23. Insulin(cont’d) • SiteRotation • Timing • Onset • Peak • Duration

  24. Insulin Pump

  25. Oral Hypoglycemics • AreNot Insulin • ActionDependsonMedication • StimulatePancreas • IncreaseTissue Sensitivity toInsulin • Slow CHODigestionandAbsorption

  26. New Developments • Exenatide (Byetta) • Pramlintide (Symlin)

  27. Self-Monitoring of Blood Glucose • Test AC and HS • RecordResults • AnalyzeMeaningofResults • KnowTarget Glucose Levels • CallProviderifOutofRange

  28. Glucose Diary

  29. UrineTesting • Glucose • Ketones • IfBlood Sugar Greater than 300

  30. Alterations in Blood Glucose • Hyperglycemia • Hypoglycemia = “Insulin Reaction”

  31. Hyperglycemia • Blood Glucose>126 mg/dL • Causes • Overeating • Stress • Illness • NotEnough Medication

  32. Symptoms of Hyperglycemia • 3 Ps • BlurredVision • Fatigue,Lethargy • Headache • AbdominalPain • Ketonuria • Coma

  33. Treatment of Hyperglycemia • CheckBlood Glucose • Use Sliding Scale Insulin • IfBlood Glucose is Greater Than 300,Check Ketones • DetermineCauseandEliminate • If Blood Glucose is Greater Than 180 for2 Days, Call MD • Call MD ifIllorVomiting

  34. Hypoglycemia • Blood Glucose Greater Than70 • Causes • TooMuch Insulin • Exercise • NotEnough Food

  35. Hypoglycemia Symptoms • Headache • Hunger • Fight orFlight • Shaky • ColdSweat • Palpitations • Neuroglycopenia • Irritability • Confusion • Seizures,Coma • CAUTION • AutonomicNeuropathy=No Symptoms

  36. Hypoglycemia Treatment • CheckBlood Glucose • Administer15 to 20GFast-ActingCHO • Recheck in 15 Min • RepeatPRN • Snack ifGreater Than 1Hr Until Meal

  37. Fast Sugars • 4 oz Orange Juice • 6 oz Regular (not diet) Soda • Miniature Box of Raisins • Commercial Glucose Tablets • 6 to 8 Life Savers

  38. Acute Treatment • IV D50 • SQGlucagon

  39. Diabetic Ketoacidosis (DKA) • Causes • HighBlood Glucose • Most Common in Type 1 • Stress • Illness

  40. Pathophysiology • InsulinDeficiency • CellsStarving • FatBreaks Down • Byproduct ofFat Breakdown isKetones • Ketones areAcidic

  41. Signs and Symptoms • Flu-likeSymptoms • Symptoms ofHyperglycemia • Kussmaul’sRespirations • FruityBreath • ElectrolyteImbalance • Dehydration • Coma • Death

  42. Therapeutic Interventions • IVFluids • IVInsulin Drip • FrequentGlucose Monitoring • ElectrolyteMonitoring

  43. Prevention • CheckKetonesifBlood Sugar is Greater Than 300 • DrinkFluids • CheckAgain • Call MD ifStill Present • GoodDiabetes Control!

  44. Hyperosmolar Hyperglycemia • Causes • Hyperglycemia inType2Diabetes • Stress • Illness • MostCommoninElderly

  45. Pathophysiology • BloodGlucose Elevated • Polyuria • ProfoundDehydration • NoNauseaandVomiting, SoSlowertoGet Help

  46. Signs and Symptoms • ExtremeDehydration • Lethargy • BloodGlucosemay be1,000 to 1,500 mg/dL • ElectrolyteImbalance • Coma • Death

  47. Therapeutic Interventions • IVFluids • IVInsulin Drip • FrequentGlucose Monitoring • ElectrolyteMonitoring

  48. Prevention • SMBG • IfGlucose Rising • DrinkFluids • LowerGlucose

  49. Long-Term Complications • MacrovascularChanges • Stroke • MI • PeripheralVascular Disease

  50. Long-Term Complications(cont’d) • MicrovascularChanges • Retinopathy • Nephropathy • Neuropathy • Infection • FootProblems

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