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DIABETES MELLITUS

DIABETES MELLITUS . STATE UNIVERSITY OF NEW YORK AT STONY BROOK 1 YEAR NURSING PROGRAM SUMMER 2008 HNI 364. The story of patient S.S. Case Study: Diabetes Mellitus. Who is S.S.?: Case History. White female, 5’ tall, 87 lbs. Active, thin 14 year-old

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DIABETES MELLITUS

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  1. DIABETES MELLITUS STATE UNIVERSITY OF NEW YORK AT STONY BROOK 1 YEAR NURSING PROGRAM SUMMER 2008 HNI 364

  2. The story of patient S.S. Case Study: Diabetes Mellitus

  3. Who is S.S.?: Case History • White female, 5’ tall, 87 lbs. • Active, thin 14 year-old • General good health, occasional cold/flu • Never been hospitalized • Family history: maternal grandmother has hyperthyroidism

  4. History of Present Illness (HPI) • Late fall, Mrs. S. noticed that S.S. was pale and less active • S.S. felt tired and began to avoid friends and activities (wanted to resign from cheerleading!) • S.S. was constantly hungry, but still thin. • S.S. noticed she had to use the bathroom after almost every class. • S.S. was irritable, had difficulty concentrating • Due to these symptoms, Mrs. S. took S.S. to family physicians

  5. S.S.’s current status • S.S. has lost 7 lbs in last week, despite eating 5-6 meals /day. • Skin is pale and dry • VS are within normal limits, but respirations and ulse rates are higher than on previous physical exams. • Voiding lg. amounts of urine q 1-2 hrs • Constantly hungry, thirsty, fatigued • Fasting glucose level = 396 mg/dl • Urine acetone +

  6. S.S. is diagnosed with Type 1 diabetes and hospitalized to regulate her insulin!

  7. Conclusions • S.S. and her family demonstrated technical competence and understanding in: • Blood glucose monitoring • Urine testing • Diet activity • Sick day management • Reason for urine testing

  8. S.S. released from hospital!!

  9. Question 1A: What was the most likely cause of S.S.’s polyuria and weight loss before her hospitalization?

  10. No insulin formed by pancreas Diabetes Type 1 Accumulation of glucose in bloodstream (Hyperglycemia) No uptake of glucose by body’s cells Increased solute concentration in blood due to excess glucose Polyuria H20 moves from high to low solute concentration: from cells to intravascular space Body excretes excess H20, glucose, and electrolytes in urine Cell dehydration

  11. Why did S.S. lose weight? When your body cannot utilize glucose for energy it will begin to breakdown adipose tissue or fat and use that for energy, which explains the weight loss.

  12. Question 1B: What are normal blood glucose levels?

  13. Normal blood glucose Normal blood glucose levels, before meals, should be less than 100 mg/l. Normal blood glucose levels, 2 hours after meals, should be less than 140 mg/l. Realistic target levels for people on medication is 70 – 140 before meals and less than 180 after meals.

  14. Question 2: Compare and contrast the signs and symptoms of diabetic ketoacidosis and insulin shock. Explain why each occurs.

  15. The DIFFERENCES betweenketoacidosis &insulin shock

  16. Lab tests Ketoacidosis High blood glucose levels (> 250 mg/dL) Accumulation of ketones in urine and blood Insulin shock Low blood glucose levels (< 45 mg/dL)

  17. Symptoms Ketoacidosis Extreme thirst Dehydration Dry mouth Frequent urination Fatigue Nausea/Vomiting Difficulty breathing Difficulty concentrating Insulin shock Confusion Difficulty concentrating Irritability Weakness Tremors Anxiety Hunger

  18. Hyperglycemia

  19. What’s the deal with ketoacidosis? When the body cannot use glucose for energy due to the lack of insulin, the glucose is converted into fat for energy. Excess fat is broken down by the liver and produces ketone bodies, which end up in the urine (ketouria). Polyuria further increases the concentration of ketone bodies in the urine. Breakdown of protein in the body also produces ketone bodies, contributing to ketoacidosis.

  20. What causes insulin shock? Too much insulin in the blood due to overdose during an insulin shot. Since insulin is responsible for uptake of glucose into body’s cells, too much insulin results in too little blood glucose. Immediate intake of sugar will counteract insulin shock.

  21. Similarities between ketoacidosis & insulin shock Both ketoacidosis and insulin shock are severe, emergency situations. If left unaddressed they can both lead to coma. The best way to prevent either one is to constantly monitor blood glucose levels.

  22. Question 3: Why must insulin be injected? Discuss the various types of insulin, their time of onset, peak of action and duration of action. Do persons with Type II diabetes ever require insulin injections? If so, when and why?

  23. Why must insulin be injected? • Insulin is a protein made up of two peptide chains linked together by disulfide bonds. • Proteins are broken down and digested by proteases (i.e. pepsin in the stomach & trypsin in the small intestines) • If taken orally, insulin will therefore be broken down and deactivated, never reaching the blood stream • Insulin must be injected SQ to provide a more direct route of entry into the blood stream

  24. Types of Insulin • Rapid (Quick-acting) -Insulin Lispro • Short Acting -Regular (R) • Intermediate-Acting -NPH (N) or Lente (L) • Long-Acting -Ultralente (U) • Pre-mixed

  25. Rapid Insulin Onset: 5-15 minutes Peak of Action: 1 hour after injection Duration of Action: 3-4 hours

  26. Short-Acting (Regular) Insulin Onset: 30-45 minutes Peak of Action: 2-3 hours after injection Duration of Action: 5-8 hours

  27. Intermediate-Acting Insulin Onset: 2-4 hours Peak of Action: 4-10 hours after injection Duration of Action: 10-16 hours

  28. Long-acting Insulin Onset: 6-10 hours Peak of Action: has a peak, but top speed looks like its normal speed Duration of Action: 20 + hours

  29. Pre-mixed Insulin Onset: 30 minutes Duration: 16-24 hours

  30. Figure 2. Onset of action, peak, and duration of action of exogenous insulin preparations. (Neutral protamine Hagedorn = NPH) Reprinted with permission from the American Diabetes Association's Clinical Education Program "Insulin Therapy for the 21st Century."

  31. Do persons with Type II Diabetes ever require insulin injections? If so, when & why? • Type II diabetes occurs when the body produces enough insulin, but the ability to process & use this insulin is lost (the body becomes resistant)

  32. Type II Diabetes Insulin Requirements Injections of insulin should mimic normal release patterns of the body Long-acting insulin is usually injected 1-2x a day In addition, short-acting or rapid-acting insulin is injected at mealtimes

  33. Question #4Goal for a nutrition program for children with Type 1 Diabetes • Maintain blood glucose levels without causing excessive hypoglycemia • When hypoglycemia occurs bring levels up to 80 mg/dl • Foods low on glycemic index do not produce drastic changes in blood glucose levels; i.e. whole grains, oranges and peanuts

  34. DIET: - > 50% calories from carbohydrates (1300 kcal/day) - 10-15% calories from protein (260-390 kcal/day) - 30-35% calories from fats (780-910 kcal/day)

  35. Tips to help when eating out • keep a count of calorie intake • eat slowly • eat same portions as you would at home • order foods that are not breaded or fried • choose healthy alternatives • carry diabetes kit with you. • if rapid acting insulin is taken, try to delay injection until meal is served • talk to doctor about how to adjust insulin regimen when eating out

  36. #5A How do you prepare the injection? Why? •NPH (intermediate-acting) and regular (shortacting) are commonly mixed to produce differently-timed pharmacologic actions with a single injection. •The regular insulin is prepared first to prevent it from becoming contaminated with the intermediate-acting insulin (NPH).

  37. Steps To Preparing Injection • •Carefully verify insulin labels. • •Roll the NPH vial between hands to resuspend the insulin preparation. • •If vial did not have cap on top, wipe off with an alcohol swab. • •Verify dosage a second time. •Check the patient's name, medication, dosage, route and time of administration.

  38. Steps To Preparing Injection (Cont.) •With the same syringe inject air equal to the dose of insulin to be withdrawn from the short-acting (regular) insulin. • Take insulin syringe and aspirate volume of air equivalent to the dose of insulin to be withdrawn from the intermediate-acting (NPH) insulin first. • DO NOT LET THE TIP OF NEEDLE TOUCH THE INSULIN. • Remove syringe from vial without aspirating the insulin.

  39. Steps To Preparing Injection (Cont.) • Withdraw the correct dose into the syringe (10 units of regular). Verify again that the correct dose has been withdrawn. • Place the needle of the syringe back into the NPH vial and withdraw the correct dose (10 units). Verify that the correct dose has been withdrawn. • The total amount of insulin in the syringe should be the sum of the two types (20 units). • Because short acting insulin was mixed with intermediate-acting insulin, which reduces the action of the faster-acting insulin, administer the mixture within 5 minutes of preparation.

  40. What Type of Syringe would you use? Since the total amount to be given is 20 units, a low dose 50 unit syringe is appropriate, but a 100 unit syringe may also be used. • A 50 or 100 unit Insulin syringe would be used • Insulin is measured in units (check the insulin bottle) * syringe measuring cc's or mL's cannot be used*

  41. What sites could you use for the injection? • Insulin should be administered subcutaneously • There are 4 main sites: abdomen, posterior arms, anterior and lateral thighs and posterior hips • The insulin is absorbed faster in the abdomen and the rate of absorption decreases in the arms, thighs and hips

  42. Education Teach the patient what treatments are used, how the treatments work and how to administer the drugs The patient should be aware of the effects of continuously injecting into the same site They should know that it is important to rotate the injection site They shouldn’t inject into a limb that is to be exercised because it will be absorbed faster and may result in hypoglycemia.

  43. Question #5: Lipodystrophy and What are some of the long term complications of diabetes and why do they occur? Researchers: J Strasheim & M. Valerio Ppt. Preparer: Stefany Cimino Presenter: Nancy Yang

  44. Lipodystrophy: Localized Disturbance of Fat Metabolism Below Skin Surface Causes: Not Rotating Insulin Injection Sites 2 Forms: • Lipoatrophy • Lipohypertrophy

  45. Lipoatrophy: Loss of Subcutaneous Fat Under the Skin Surface Resulting in Small Dents • Appears as Slight Dimpling • Appears as Pitting (more serious)

  46. Lip hypertrophy: Buildup of Fat Below the Skin Surface Causing lumps • Appears as Fibro-Fatty Masses. • Absorption is Delayed at these Sites. • Avoid these Sites Until Hypertrophy Disappears.

  47. Question 5d: • What are Some of the Long Term Complications of Diabetes and Why Do They Occur?

  48. Diabetes: Long Term Complications • Affects the Metabolism of Every Cell in the Body • Adversely Affects the Body’s Blood Supply • Can Lead to Life-Threatening and Disabling Complications Over Time • Therapeutic Management can Prevent or Delay the Onset of Various Complications

  49. 3 General Categories of Long Term Diabetes Complications • Macrovascular Disease • Microvascular Disease • Neuropathy

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