Nursing Care of Patients with Disorders of the Endocrine Pancreas 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 Maintenance of Blood Glucose Levels A) Normal Physiology-Foods broken down by glucose, B) Type 1 diabetes mellitus, the pancreas does not produce insulin, and C) Type II, insulin production is reduced.

Cell Membranes (A) Cell membrane in normal state, B) cell membrane in Type I, and C) cell membrane in Type II.

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

Type 1 Diabetes IDDM, Juvenile (Old Names) 5% to 10% of Diabetes Cases Some Genetic Component (10%) Autoimmune Response to Virus Destruction of Beta Cells Pancreas Secretes NO Insulin More Common in Young, Thin Patients Prone to Ketosis

Type 2 Diabetes NIDDM, Adult Onset (Old Names) 90% to 95% of Diabetes Cases Large Genetic Component (90%) Decreased Beta Cell Responsiveness to Glucose Reduced Number of Beta Cells Reduced Tissue Sensitivity to Insulin Largest Risk Factor is Obesity Not Ketosis-Prone

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

Type 2 in Youth More Obesity in Children Type 2 Epidemic A Nursing Challenge

Other Types Gestational: Pregnancy Prediabetes: Glucose Intolerance Secondary Diabetes Drugs Pancreatic Trauma

Metabolic Syndrome Elevated Waist Circumference Elevated Triglycerides Low HDL Cholesterol Elevated Blood Pressure Elevated Fasting Plasma Glucose

Signs and Symptoms The 3 Ps Fatigue Blurred Vision Infection Prone Polyuria Polydipsia Polyphagia Fatigue Blurred Vision Infection Prone Abdominal Pain Headache Ketosis/Acidosis

Diagnosing Diabetes Fasting Plasma Glucose ≥ 126 mg/dL Casual Plasma Glucose ≥ 200 mg/dL Glucose Tolerance Test > 200 mg/dL after 2 Hr

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

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

Goals of Treatment Preprandial Glucose 90 to 130 mg/dL Peak Postprandial Glucose < 180 mg/dL Blood Pressure < 130/80 Mm Hg Glycohemoglobin < 7%

Therapeutic Interventions Medical Nutrition Therapy Exercise Medication Monitoring Education

Medical Nutrition Therapy (MNT) ADA Exchange Lists Carbohydrate Counting Glycemic Index REMEMBER CULTURAL DIETARY NEEDS

General Principles of MNT Low Fat Low Sodium Limit Simple Sugars Use Complex Carbohydrates Consistent Day-to-day

Exercise Lowers Glucose up to 24 Hours Lowers Blood Lipids Best Done Regularly Refer to MD or Exercise Physiologist Avoid Exercise During Acute Hyperglycemia Carry Fast Sugar

Medication Insulin for Type 1 or 2 Oral Hypoglycemics for Type 2

Insulin Action Routes Subcutaneous IM Inhaled Insulin pump

Insulin (cont’d) Site Rotation Timing Onset Peak Duration

Insulin Pump

Oral Hypoglycemics Are Not Insulin Action Depends on Medication Stimulate Pancreas Increase Tissue Sensitivity to Insulin Slow CHO Digestion and Absorption

New Developments Exenatide (Byetta) Pramlintide (Symlin)

Self-Monitoring of Blood Glucose Test AC and HS Record Results Analyze Meaning of Results Know Target Glucose Levels Call Provider if Out of Range Please see figure 40.5 on page 863 of the text.

Glucose Diary

Urine Testing Glucose Ketones If Blood Sugar Greater than 300

Alterations in Blood Glucose Hyperglycemia Hypoglycemia = “Insulin Reaction”

Hyperglycemia Blood Glucose >126 mg/dL Causes Overeating Stress Illness Not Enough Medication

Symptoms of Hyperglycemia 3 Ps Blurred Vision Fatigue, Lethargy Headache Abdominal Pain Ketonuria Coma

Treatment of Hyperglycemia Check Blood Glucose Use Sliding Scale Insulin If Blood Glucose is Greater Than 300, Check Ketones Determine Cause and Eliminate If Blood Glucose is Greater Than 180 for 2 Days, Call MD Call MD if Ill or Vomiting

Hypoglycemia Blood Glucose Greater Than 70 Causes Too Much Insulin Exercise Not Enough Food

Hypoglycemia Symptoms Headache Hunger Fight or Flight Shaky Cold Sweat Palpitations Neuroglycopenia Irritability Confusion Seizures, Coma CAUTION Autonomic Neuropathy = No Symptoms

Hypoglycemia Treatment Check Blood Glucose Administer 15 to 20 G Fast-Acting CHO Recheck in 15 Min Repeat PRN Snack if Greater Than 1 Hr Until Meal

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

Acute Treatment IV D50 SQ Glucagon

Diabetic Ketoacidosis (DKA) Causes High Blood Glucose Most Common in Type 1 Stress Illness

Pathophysiology Insulin Deficiency Cells Starving Fat Breaks Down Byproduct of Fat Breakdown is Ketones Ketones are Acidic

Signs and Symptoms Flu-like Symptoms Symptoms of Hyperglycemia Kussmaul’s Respirations Fruity Breath Electrolyte Imbalance Dehydration Coma Death

Therapeutic Interventions IV Fluids IV Insulin Drip Frequent Glucose Monitoring Electrolyte Monitoring

Prevention Check Ketones if Blood Sugar is Greater Than 300 Drink Fluids Check Again Call MD if Still Present Good Diabetes Control!

Hyperosmolar Hyperglycemia Causes Hyperglycemia in Type 2 Diabetes Stress Illness Most Common in Elderly

Pathophysiology Blood Glucose Elevated Polyuria Profound Dehydration No Nausea and Vomiting, So Slower to Get Help

Signs and Symptoms Extreme Dehydration Lethargy Blood Glucose may be 1,000 to 1,500 mg/dL Electrolyte Imbalance Coma Death

Therapeutic Interventions IV Fluids IV Insulin Drip Frequent Glucose Monitoring Electrolyte Monitoring

Prevention SMBG If Glucose Rising Drink Fluids Lower Glucose

Long-Term Complications Macrovascular Changes Stroke MI Peripheral Vascular Disease

Long-Term Complications (cont’d) Microvascular Changes Retinopathy Nephropathy Neuropathy Infection Foot Problems

Diabetic Foot Ulcer

Foot Care Inspect Feet Daily Wash and Dry Feet Daily Wear Well-Fitting Shoes Protect Feet from Injury Avoid Crossing Legs Use Caution with Nail Care See MD Immediately if Sore Develops

Hope for the Future DCCT UKPDS Tight Control Reduces Complications HbA1c <7% Reduces Complications

Care of Patient Undergoing Surgery Frequent Glucose Monitoring Sliding Scale Insulin or Insulin Drip Maintain Glucose 140 to 180 mg/dL in Critically Ill Care of Patient Undergoing Surgery

Nursing Diagnosis Risk for Variation in Blood Glucose

Diabetes Self-Management Education Disease Process and Treatment Nutrition Therapy Exercise Medications SMBG Acute Complications Chronic Complications Psychosocial Adjustment Health Promotion

Reactive Hypoglycemia Hyper-responsiveness of Pancreas Low Glucagon Levels Low Blood Glucose Sympathetic “Fight Or Flight” Response

Therapeutic Interventions Frequent Small Meals High-protein, Low-CHO Diet