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Nursing Management Diabetes Mellitus

Nursing Management Diabetes Mellitus. Covenant School of Nursing N201 Fall, 2009 Gloria Rodriguez, MSN.RN,CDE. Objectives. By the end of this lecture students should be able to: Differentiate between type 1 and type 2 diabetes mellitus

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Nursing Management Diabetes Mellitus

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  1. Nursing Management Diabetes Mellitus Covenant School of Nursing N201 Fall, 2009 Gloria Rodriguez, MSN.RN,CDE

  2. Objectives • By the end of this lecture students should be able to: • Differentiate between type 1 and type 2 diabetes mellitus – Identify the diagnostic and clinical significance of blood glucose test results – Describe the major complications of DM –Differentiate between DKA and HHNS

  3. Diabetes Mellitus • A chronic multi-system disease related to abnormal insulin production or impaired insulin utilization.

  4. Risk Factors • Family Hx. Of diabetes • Obesity esp. abdominal and viseral adiposity. • BMI> 27% • Race/Ethnicity • GDM or babies > 9 lbs. • Mother is more at risk of developing DM if she has big babies • HTN > 140/90 mm Hg • Triglycerides > 200mg/dL • Prev. impaired glucose tolerance

  5. Causes • Genetics • Autoimmune • Viral • Environmental

  6. Metabolic Processes • Three Metabolic processes are important in ensuring a supply of glucose for body fuel. • 1) Glycolysis-the process through which glucose is broken down into water and carbon dioxide with the release of energy

  7. Metabolic Processes • 2) Glycogenolysis- the breakdown of stored glycogen ( from the liver or skeletal muscles). This action is controlled by 2 hormones: epinephrine-breaks down glycogen in the muscle glucagon-breaks down glycogen in the liver. Glucose from here can be directly released into the blood stream and used by the nervous system

  8. Metabolic Processes • 3) Gluconeogenesis-building of glucose from new sources. • Hormones that stimulate gluconeogensis • Glucagon • Glucocorticoid hormones • Thyroid hormones • Process usually occurs in the liver

  9. Normal Insulin Metabolism • Counterregulatory hormones. They work to oppose the effects of insulin. These hormones work to increase blood glucose levels by stimulating glucose production and output by the liver and decreasing the movt of glucose into the cells. • Glucagons • Epinephrine • Growth hormone • Cortisol

  10. Hormonal Control of Metabolism • Insulin • A hormone secreted by the beta cells in the islet of Langerhans, • Normally released in small increments when food is ingested. • Controls blood glucose levels by regulating glucose production and storage • Insulin is regulated by serum glucose levels. • Consists of 2 polypeptide chains • The amt of insulin a person is secreting can be tested by checking the levels of C peptide • Rise in plasma insulin after a meal stimulates storage of glucose as glycogen in the liver and muscle. It also inhibits gluconeogenisis and enhances fat deposition (enhances fat to be placed/stored in the adipose tissue) in the adipose tissue and increase protein synthesis • The fall in insulin levels during the night when you’re not eating facilitates the release of the stored glucose from the liver, protein from the muscles and fat, and that’s how it kind of compensates for your hypoglycemia

  11. Insulin • Insulin and glucagon are hormones secreted by islet cells within the pancreas • Insulin is normally secreted by the beta cells (a type of islet cells) of the pancreas • Stimulus for insulin is high blood glucose levels

  12. Hormonal Control of Metabolism • Amylin • 2nd beta cell hormone • Effects of Amylin • Amylin and insulin together suppress the secretion of glucagon by the liver • Amylin slows the transfer of nutrients to the intestine

  13. Continued…. • Glucagon • Produced in the alpha cells of the islets of Langerhans in the pancreas • Transported via the portal vein to the liver • Glucagon acts in opposition to insulin • Stimulates the break-down of glycogen and fats to glucose and promotes gluconeogensis from fats and proteins

  14. Continued…. • Catecholamines • Epinephrine and norepinephrine • Help maintain glucose levels during stressful situations by • 1. inhibiting insulin release and decreasing movement of glucose into cells • 2. promoting glycogenolysis by converting muscle and liver glycogen to glucose • 3 Increasing lipid activity, conserving energy. Causes mobilization of fatty acids and conserves glucose. The conservation of blood glucose mediated by these actions is important in the homostatic effect which occurs with hypoglycemia to increase the blood glucose levels

  15. Continued…. • Somatostatin • Produced in the pancreas by the delta cells in the islets of Langerhans • Somatostatin inhibits the secretion of insulin, glucagon and growth hormone.

  16. Diabetes Classifications • Type 1 • Type 2 • Decreased sensitivity to insulin and impaired beta cell functioning which results in decreased insulin production • Gestational diabetes mellitus • Pre-diabetes • Secondary

  17. Type 1 Diabetes Mellitus • Formerly Known as insulin-dependent • Destruction of their pancreatic cells, genetic, immunologic, and possibly environment • Persons do not inherit Type 1 itself but rather have a genetic predisposition

  18. DCCT Study • Diabetes Control and Complications Trial (DCCT) conducted in 1993 • Results showed that you can prevent the complications of diabetes. • Retinopathy • Nephropathy • Neuropathy “Maintaining blood glucose as close to normal as possible prevents or slows the progression of long-term diabetic complications”

  19. Type 2 Diabetes Mellitus • Most Prevalent • Two main problems • Insulin resistance • Impaired insulin secretion • Inappropriate glucose production by liver • Alteration in the production of hormones and cytokines by adipose tissue.

  20. Gestational Diabetes • Higher risk of C-section • Perinatal death • Neonatal complications • Risk of developing type 2 DM in 5 to 10 years is increased.

  21. Gestational Diabetes • Any degree of glucose intolerance that causes during pregnancy. • Hyperglycemia develops during pregnancy- secretion of placental hormones (which causes insulin resistance)

  22. Gestational Diabetes • High risk women should be screened at 24-28 weeks of gestation • Need oral glucose tolerance test or glucose challenge • A 2 hr. fasting level after 100ml glucose load of 155 would indicate GDM

  23. Secondary Diabetes • Causes • Damage/injury/interference or destruction of pancreas • Conditions • Cushing's • Hyperthyroidism • Recurrent pancreatitis • Use of parenteral nutrition

  24. Secondary Diabetes • Medications • Corticosteroids • Thiazides • Dilantin • Atypical antipsychotics • Resolves when treatment of underlying condition is treated

  25. Clinical Manifestations of Type 1 DM • Frequent urination • Increase in thirst • Weight loss • Increase hunger • Weakness

  26. Clinical Manifestation of Type 2 Diabetes • Type 2 –Non-specific –Gradual Onset Include classic signs of Type 1 • Most common signs of Type 2 • Fatigue • Recurrent infections • Recurrent vaginal yeast infections • Prolonged wound healing • Visual changes- Blurred vision

  27. Diagnostic Studies • Three Methods • Fasting plasma glucose level-> 126 mg-dl- no caloric intake for 8hr • Random or casual plasma glucose > 200mg/dl plus S/S • Two-hour OGTT level- > 200mg/dl using a 75g glucose load

  28. Assessment • History • Signs related to Dx. Of DM • hyperglycemia • hypoglycemia • Monitor frequency, timing, severity and resolution • BS monitoring • Status of symptoms • Adherence to Tx. Regimen • Lifestyle. culture, psychosocial and economic factors • Effects of complications

  29. Assessment • Physical Exam • B/P sitting and lying-(orthostatic chg.) • BMI • Dilated eye exam • Foot exam • Skin exam • Neuro. exam • Oral exam

  30. Continued… • Labs • Hgb A1C • A long-term measure of glucose control that is a result of glucose attaching to hemoglobin for the life of the rbc (120 days). • Fasting lipid profile • Microalbuminuria • Serum Creatine • UA • EKG • Referrals-Opthal., Podiatry, Dietician

  31. Goal • Be an active participant • To experience few or no episodes of acute hyper/hypoglycemia emergencies • Maintain BS levels as close to normal • Prevent, minimize or delay complications • Adjust lifestyle to decrease stress

  32. Diabetes Prevention Program • Obesity # 1 predictor of type 2 DM • DPP showed a modest wt. loss of 5-10% of body wt. with regular exercise-30 min 5X/wk • Dropped the risk of developing type 2 DM up to 58%

  33. Type 2 Diabetes Mellitus • Metabolic Syndrome is increased with Type 2 DM • Characterized by: • Insulin resistance • Elevated insulin levels • High triglycerides • Decreased HDL levels • Increased LDL levels • HTN

  34. Type 2 Diabetes Mellitus • Metabolic Syndrome • Risk Factors • Central obesity • Sedentary lifestyle • Westernization • Certain ethnic groups

  35. Five Components of Diabetes Management • Nutritional management • Exercise • Monitoring • Pharmacologic management • Education

  36. Educators • Certified Diabetes Educators-CDE • Staff Nurses • RN or LVN

  37. DRUG THERAPY

  38. Types of Insulin • Only human insulin is used • Insulin's differ in onset, peak, and duration • Matched to client’s activity

  39. Rapid-Acting Insulin • Humalog or Novolog (LISPRO) (Aspart) (Glulisine) • Onset 10 – 30 min. Peak 1-2 hours. Effects last 2 hrs – 6 hrs • Used to • Rapidly reduce glucose level • Treat postprandial hyperglycemia • Prevent nocturnal hypoglycemia • Usually one shot a day before each meal for a total of 3 shots a day

  40. Short-Acting Insulin • Humilin R, Novolin R, ReliOn R • Onset 30 min. – 1 hr, Peak 2 – 4 hr • Effects last 4 – 6 hrs • Administer 20-30 mins. before eating • If mixing with NPH Regular is always drawn up first.

  41. Intermediate –Acting Insulin • NPH, Novolin N, Humulin N, ReliOn N • Cloudy • Onset 2 – 4 hrs, Peak 4 – 14 hrs • Effects last 16 – 24 hrs • 30 mins before meal

  42. Long-Acting Insulin • Glargine (Lantus) clear • Onset 1-2 hours • Duration 12 - 24 hours • No peak • Cannot mix with other insulins • Cannot Prefill • Normally given once a day • Detemir (levemir) clear • (onset 3-4, peaks in 3-9, duration is 6-23 hours) • Both are for basil gylcemic control, doesn’t control post prandial levels (levels after you eat)

  43. Storing Insulin • Insulin can be stored at room temp. for 30 days • In the refrigerator until expiration date • Pre-filled pens 30 days in refrigerator • Pre-filled pens with insulin mixture are usually good for 30 days

  44. Do’s and Don’ts of Insulin • Keep spare insulin • Inspect for flocculation (frosted whitish coating) before use • Avoid extreme temperatures , do not freeze • Keep out of direct sunlight or in a hot car

  45. Selecting Sites • Recommendations • Do not use same site more than once in 2-3 weeks • Do not inject insulin to limb which will be used to exercise. • Use same anatomic area at the same time of day

  46. Selecting Sites • Abdomen- more stable and radid absorption • Arms- posterior surface • Thighs anterior surface • Hips

  47. Insulin Syringes • Syringes selected should match insulin concentration • 3 types of syringes available • 1 ml-holds 100 units • 0.5ml-holds 50u • 0.3 ml-holds 30u

  48. Complications of insulin Therapy • Local allergic reaction( itching, erythema, and burning around inject. Site • Systemic allergic reactions (urticaria and antiphylactic shock) • Insulin lipodystrophy( atrophy of tissue)

  49. Complications of Insulin Therapy • Dawn Phenomenon-hyperglycemia that is present when awakening from release of counterregulatory hormones in the predawn hours. • More severe when growth hormone is peaking (Adolescence and young adulthood) • Treatment- adjustment in timing of insulin or an increase in insulin

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