Nursing Care and Interventions in Managing Type II Diabetes Mellitus

1. Nursing Care and Interventions in Managing Type II Diabetes Mellitus Keith Rischer, RN, MA, CEN

3. Objectives for Today… Describe the onset, clinical manifestations, laboratory findings and pathologic mechanisms of type 2 diabetes. Identify clients at risk for type 2 diabetes Differentiate between macro & microvascular complications of chronic diabetes. Compare the mechanisms of action, side effects and nursing considerations of the oral antidiabetic medications for type 2 diabetes. Compare the time action profile, and nursing considerations of insulin to control type 2 diabetes. Identify nursing care priorities to treat and prevent complications of chronic diabetes.

4. Background • 90-95% of all diabetes • Family history 2-4x risk developing • Obesity • Increased resistance to insulin • Impaired suppression of glucose production by liver

5. Patho of Type II Diabetes • Pancreas secretes less insulin • Beta cells of pancreas • Insulin resistance • Initial increase in insulin • Leads to beta cell exhaustion & failure • Increased glucose production by liver • Metabolic syndrome • Insulin resistance • Abd. Obesity • HTN-high cholesterol • High triglycerides, CRP, low LDL, atherosclerotic changes

6. Those at Highest Risk… Overweight Abd obesity >age 40 Inactivity Hypertension High cholesterol Parents with type II DM Gender & Ethnic influences

7. Clinical Manifestations Asymptomatic Same as Type 1 Fatigue Polyuria Polydipsia Vaginal yeast infections Wounds that do not heal

8. Laboratory Diagnosis for Type 2 Symptoms of DM plus casual ^ 200 mg/dL Fasting ^ 126 2-hr ^ 200 Urine Albumin Ketones Protein Glucose

9. Macrovascular Complications Cardiovascular disease (most common) 2-3 X greater than non-DM, Women more MI leading cause of death Cerebrovascular disease ^ glucose levels lead to greater brain injury

10. Microvascular Complications Eye and vision complications Retinopathy which is leading cause of new blindness linked to fasting BG >129 Cataracts, glaucoma, macular degeneration Diabetic Nephropathy Leading cause of ESRD Early sign… microalbuminuria Neurontin or Amitriptyline to manage pain

11. Diabetic Neuropathy Clinical Manifestations Loss of sensation, pain, weakness Late complication foot ulcers/deformaties (Charcot’s joints), amputations CV GI GU

12. Male Erectile Dysfunction Occurs at higher rate and earlier age as compared to general population Affects 50% of males Treatments penile implants medications counseling

13. Medications: Sulfonylurea Agents p.1512-1515 Mechanism Require some beta-cell function Stimulates pancreas to secrete more insulin Increases insulin sensitivity Hypoglycemia most common SE Glipizide (Glucatrol)-30” before meals Glyburide (Diabeta)-with first meal Adverse effects Hypoglycemia Impaired renal-liver function elevates levels Onset 15-30”…peak 1-2h…duration 24 hours

14. Oral Therapy Biguanides (Metformin or Glucophage) Decreases liver glucose release and decreases cellular insulin resistance Should not cause hypoglycemia Avoid those with renal disease (causes lactic acidosis in those with renal, liver, CHF or ETOH) Withhold 48 hours before using contrast media and surgery requiring anesthesia Avoid ETOH…causes lactic acidosis

15. Oral Therapy Thiazolidine-diones (Avandia, Actos) Enhance insulin action Decreasing insulin resistance Can be used with insulin or sulfonylurea Need periodic liver tests to assess for damage Cause weight gain Due to fluid retention Elevates HDL as well as LDL & triglycerides

16. Oral Therapy Combination meds Combine with insulin Orals combined with other orals Drug Selection Based on cost, age, client’s ability to manage, response to meds Body’s response to oral DM meds decreases, so clients may have to go on insulin

17. Insulin Needed for type 1 and often for type 2 Assess elderly’s ability to give insulin Types of insulin Rapid Short Intermediate Long acting Know the onset, peak, and duration

18. Foot Assessment & Care Do not smoke Inspect feet daily No bare feet Trim toenails Use lotion Report non-healing breaks Complete foot assessment with provider at least 4 times a year.

19. Foot Assessment & Care Without sensation, risk for injury Peripheral sensation management - monofilament Footwear - protective shoes Wound Care - elimination of pressure: contact cast Wound Care clinics Growth hormones Debridement

20. Treatment: Chronic Pain Maintain normal BG levels Anticonvulsants - Neurontin Antidepressants - Amitriptyline Capsaicin cream Pain Clinics and specialty services

21. Treatment: Visual Disturbances Many times loss of central vision Assistive devices special insulin devices: magnifier on bottle talking glucometers coding objects: wrap rubber band around bottle Fluorescent lighting above object Society for the blind - large print Treatment: Laser (photocoagulation) Vitrectomy (aspiration of blood, membranes, fibers)

22. Diabetic Glomerulosclerosis (CKD) • Glomeruli changes • Capillary basement thickening • Patho • Glucose incorporated into noncellular components • Influenced by high glucose levels • HTN and smoking accelerate progression • Albumin-protein in urine reflect progression of disease

23. Treatment: Renal Tight blood glucose control Random urine test for albumin/creatinine Control of BP - low sodium diet Aggressively treat UTI If nephropathy - restrict protein Avoid dehydration - careful use of diuretics Dialysis Avoid drugs that injure kidney, if IV dye - give fluids prior

24. Exercise Therapy Essential part of treatment Also increases well-being Can produce hypoglycemia or hyperglycemia Low intensity aerobic best - walk, swim 20 to 40 minutes performed 4 to 7 days/week Keep logs to note progress

25. Exercise Therapy Complete physical check up before exercise program initiated Exercise with a friend Always carry a simple sugar Always carry ID Athletes who are diabetic - extra planning Monitor BG levels to determine effects on their body

26. Diet 15 - 20% protein, 80% COH, <10% saturated fat Moderate to high dietary fiber - gradual. If a food has 5 or > GM/ fiber can deduct from COH Alcohol - 2/day for men, 1 for women Food labels vital Individual meal plans Consistent meals and snacks Type 2 - may be on calorie restriction for wt loss

27. Physical & Emotional Needs Entire family affected - stress of diagnosis Prepare same meals for family - “not special” Group education classes - cooking classes Most is one to one education to tailor to client Assess individual educational needs considering lifestyle, attitude, goals, ethnic, home, background Wealth of teaching materials - printed, electronic

28. Non-Compliance Sometimes lack of knowledge, lack of power: Role of nurse to empower Peer pressure Lack of motivation - unaware of consequences Poor family history of previous members Inadequate finances Unfamiliar with health care system Lack of advocate History of obesity

29. Community Resources Home care for post hospital teaching Out patient diabetic education Contact for emergency Assistance with shopping or cooking Referrals to local resources - Traveling clinics, senior citizens American Diabetes Association

30. Hyperglycemic-Hyperosmolar Nonketotic Syndrome and Coma Caused by hyperglycemia Increased insulin resistance & CHO intake Absence of ketones & higher glucose levels (BG >800) than keto-acidosis High blood osmolarity (>350 mOsm/L) Pulls water out of body cells including brain Mortality 50% Gradual onset Coma, confusion, decreased Glasgow, Seizures Treatment: IV fluids 6 to 20 liters in 24 hours IV insulin