Diabetes & selected medications Medical-surgical Nursing Chapter 64-Iggy-Pg 1300 NUR 152 Mesa Community College

Learning Outcomes  Describe how insulin works in the body and the effects of too little or no insulin production in the body  Differentiate between type 1 and type 2 diabetes mellitus  Explain the complications that can result from diabetes mellitus  Use the nursing process to create nursing care plans for diabetic patients  Administer the prototype drug metformin safely and effectively  Differentiate between rapid, fast, intermediate, and long acting insulin  Review the appropriate steps when mixing insulin  Understand the nursing implications when administering insulin  Review the proper techniques in blood glucose monitoring  Identify diabetic patients in a state of hyperglycemia or hypoglycemia, and those at risk for these conditions  Describe diabetic foot care  Describe managing complications from diabetes

Insulin in the body (Pg 1302)  Insulin is needed to move glucose into body tissues  Absence of insulin makes the body break down fat and protein for energy  Absence of insulin ↑ the levels of other hormones in order to attempt to make glucose from other sources  Resulting in hyperglycemia (high blood glucose levels)  Polyuria  Polydipsia  Polyphagia

Type I Diabetes (DM I) (Pg 1306)  Autoimmune disorder where the beta cells are destroyed in the pancreas leading to no insulin production  Genetically handed down (tissue type HLA-DR or HLA-DQ)  Antibodies exist to work against beta cells and insulin  Usually younger onset

Type II Diabetes (DM II) (Pg 1306) *See pg 761 in Iggy as well  Insulin resistance and decreased insulin production  Most are obese  Hereditary plays a major role  Gene defects may also play a role  *Metabolic Syndrome (any 3)  Abdominal obesity  Hyperglycemia  Hypertension  Hyperlipidemia

Chronic Complications of Diabetes (Pg )  Macrovascular Complications  Cardiovascular Disease  Cerebrovascular Disease  Microvascular Complications  Eye & Vision  Diabetic Neuropathy  Diabetic Nephropathy  Male ED  Cognitive Dysfunction

Nursing Process & Diabetes  Assessment  Health History  Laboratory Results  Screening  Ongoing Assessment  Urine Tests

Nursing Diagnoses  Risk for injury r/t hyperglycemia  Potential for impaired wound healing r/t endocrine and vascular effects of diabetes  Risk for injury r/t diabetic neuropathy  Acute pain r/t diabetic neuropathy  Chronic pain r/t diabetic neuropathy  Risk for injury r/t diabetic retinopathy- reduced vision

Outcomes (Goals)  Performs treatment regimen as prescribed  Follows recommended diet  Monitors blood glucose using correct testing procedure  Manages symptoms of hyper/hypoglycemia  Seeks health care if blood glucose levels go outside of recommended parameters  Meets recommended activity levels  Uses medications as prescribed  Maintains optimum weight

Oral Therapy (Pg Chart 64-2)  Drug Therapy: DM II (Anti-diabetic, oral, Biguanide)  metformin (Glucophage)  Recommended as initial therapy in type 2 diabetes mellitus  Inhibits hepatic glucose production  Increases sensitivity of tissue to insulin  Not given to people with kidney disease or elevated creatinine levels  Look up in SkyScape as well!

Insulin- Where does it come from and why do we need it?  Pancreas - Beta cells in islets of Langerhans - produce:  Insulin - needed for metabolism of carbs, fats, proteins (helps move glucose into cells)  Glucagon - stimulates conversion of glycogen to glucose in the liver  Normal adult blood sugar - 70 to 110 mg/dL

 Insulin  Check blood glucose level before giving insulin  Roll vials between hands instead of shaking them to mix suspensions  Ensure correct storage of insulin vials  Only use insulin syringes, calibrated in units, to measure and give insulin  Ensure correct timing of insulin dose with meals  Insulin order and dosages are second-checked with another nurse Nursing Implications Copyright © 2014 by Mosby, an imprint of Elsevier Inc.12

Insulin (Pg ) Rapid Acting  Novolog (aspart)/Humalog (lispro )  Rapid Acting-Clear  Given right before a meal  Onset: minutes  Peak:  1-3 hrs (aspart)  ½ to 1&1/2 hours (lispro)  Duration:  3-5 hours (aspart)  5 hours (lispro) Short Acting  Regular (Humulin R/Novolin R)  Short Acting-Clear  Given ½ to 1 hour before a meal  Onset: 30 minutes  Peak: 2 to 5 hours  Duration: up to 7-8 hours

Insulin (continued) Intermediate Acting  Humulin N/Novolin N (isophane)-NPH (Neutral Protamine Hagedorn)  Intermediate Acting  Onset: 1&1/2 – 4 hours  Peak: 4-14 hours  Duration: hours  Cloudy

Insulin (continued) Long Acting  Lantus (glargine)  Long Acting  Onset: 2 – 4 hrs  Peak: None  Duration: 24 hrs  Never mixed with another insulin!  Levemir (determir)  Long Acting  Usually given twice a day  Onset: 1 hours  Peak: 6-8 hours  Duration ~ 5 to 24 hours  Never mixed with another insulin!

Mixing Insulin  ATI Skills-  Diabetes Management  Step by Step Viewing  Mixing insulin  Soft Fundies

 Subcutaneous short-acting or regular insulin doses adjusted according to blood glucose test results  Typically used in hospitalized diabetic patients or those on total parenteral nutrition (TPN) or enteral tube feedings  Subcutaneous insulin is ordered in an amount that increases as the blood glucose increases  Disadvantage: delays insulin administration until hyperglycemia occurs; results in large swings in glucose control Sliding-Scale Insulin Dosing Copyright © 2014 by Mosby, an imprint of Elsevier Inc.19

 Regular Insulin sliding scale subcutaneous with meals and at bedtime  = 2 units  = 4 units  = 6 units  = 8 units  =10 units  >400=Call prescriber Sliding scale example

Patient Education  Target goals - Daily sugars  HgbA1C (pg )  Technique  Rotating sites  Timing  Recording  Recognizing and reporting results & problems  Blood Glucose Monitoring

 Oral forms of concentrated glucose  Buccal tablets, semisolid gel  50% dextrose in water (D 50 W)  Glucagon Glucose-Elevating Drugs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.24

Interventions (cont): ( ) Nutrition Therapy  Nutrition Principles  Carbohydrate intake  Dietary fat & cholesterol  Protein  Special considerations Exercise Therapy  Regular Exercise  Diabetic Adjustments  Safety Assessment

Preventing Injury from Peripheral Neuropathy  Preventing foot injuries  Keeping blood sugars in check  Foot inspection (Chart 64-5)  Good fitting shoes  Proper nail trimming  Do not go barefoot!  See your physician immediately for any break in skin  Foot Care (Chart 64-6)

Managing complications Managing Neuropathic Pain  Anticonvulsants  Antidepressants  Creams  Maintain Stable Glucose  Bed cradle Reduced Vision  Blood Glucose control  Regular eye exams  Environmental management  Large print  Low vision aids  Good lighting  Audio tools  Syringe magnifiers