Medical-Surgical Nursing: Concepts & Practice 3rd edition Chapter 37 Care of Patients with Diabetes and Hypoglycemia Copyright © 2017, Elsevier Inc. All rights reserved.

Diabetes Mellitus Type 1 diabetes mellitus and ketoacidosis Juvenile diabetes and ketosis-prone diabetes Type 2 diabetes and insulin resistance Latent autoimmune diabetes Gestational diabetes

Etiology and Pathophysiology of Diabetes Mellitus Genetic factors Metabolic factors Microbiologic factors Immunologic factors

Clinical Categories of Diabetes Mellitus and Characteristics Type 1 (insulin dependent; IDDM; juvenile diabetes; juvenile onset) Type 2 (non–insulin dependent; NIDDM; adult-onset diabetes; maturity-onset diabetes) Latent autoimmune diabetes (LADA) (slow onset type 1 diabetes or type 1.5 diabetes; type 1 diabetes, according to the World Health Organization) See Table 37-1 on p. 860.

Clinical Categories of Diabetes Mellitus and Characteristics (Cont.) Prediabetes (impaired glucose tolerance and impaired fasting glucose) Gestational diabetes Statistical risk of diabetes

Symptoms of Type 1 Diabetes Very thirsty (polydipsia) Frequent urination (polyuria) Extremely hungry (polyphagia) Rapid loss of weight Irritability Weakness and fatigue Nausea and vomiting See Box 37-1 on p. 860.

Symptoms of Type 2 Diabetes Possibly polydipsia, polyuria, and polyphagia More commonly excessive weight gain Family history of diabetes mellitus Poor healing of scratches, abrasions, and wounds Blurred vision Itching Drowsiness Increased fatigue Tingling or numbness in the feet See Box 37-1 on p. 860.

Signs and Symptoms Classic symptoms of diabetes Fatigue and muscular weakness Weight loss and type 1 diabetes Prone to infection, delayed healing, and vascular diseases

Diagnosis Screening Hemoglobin A1c (A1C or HbA1c), or Fasting plasma glucose (FPG), or 2-Hour 75-g oral glucose tolerance test (OGTT)

Self-Management of Diabetes Mellitus Benefits of tight glycemic control Hypoglycemia or insulin reaction Overall goal of diabetes management Older adult considerations

Self-Management of Diabetes Mellitus (Cont.) Diet is the cornerstone of diabetic treatment. Emphasis on the foods allowed rather than those that are forbidden. Exercise Hypoglycemia and increasing food intake Older adult care considerations Oral hypoglycemic agents, including metformin Insulin therapy

Insulin Therapy Goal of insulin therapy: closely mimic basal insulin Multiple daily injection regimen Insulin-to-carbohydrate ratio Insulin pump Patient teaching and compliance Incretin mimetics Preoperative and postoperative insulin management See Table 37-3 on p. 866. NOTE: One unit of insulin will cover 15 g of carbohydrate for most patients (weight and insulin sensitivity must also be considered).

Rotation Sites for Injection of Insulin See Figure 37-2 on p. 867. Courtesy ACCU-CHEK® is a registered trademark of Roche.

Insulin Pump Courtesy ACCU-CHEK® is a registered trademark of Roche. See Figure 37-3 on p. 868. Courtesy ACCU-CHEK® is a registered trademark of Roche.

Islet Cell Transplantation Two to four donor pancreases are needed. About a third of recipients will develop antibodies. Lifetime immunosuppressive medications are highly nephrotoxic. Ethical issues include (1) two to four donor pancreases are needed for the required number of islet cells, (2) about a third of recipients will develop antibodies that would prohibit any future whole pancreas transplant attempts, and (3) lifetime immunosuppressive medications are highly nephrotoxic. The option may be discussed with patients who have very unstable metabolic control and have frequent life-threatening hypoglycemic episodes (Ruggenenti et al., 2008).

Nursing Management Monitor the trend of blood glucose, hemoglobin A1C, and fructosamine assay. Monitor for hypoglycemia after insulin injections, Monitor for signs of ketoacidosis,

Comparison of Hypoglycemia and Ketoacidosis Etiology Symptoms Treatment Prevention See Table 37-6 on p. 870.

Patient Teaching Foot care What to do on “sick days” Instructions for traveling Working with the older adult who has diabetes

Patient teaching Feet must be inspected daily Apply cream to tops and bottoms of feet, NOT between toes Consult a podiatrist Promptly treat any cuts or wounds On sick days: Monitor glucose closely Consult provider for extra medication if needed

Short-Term Complications Hyperglycemia Hypoglycemia Hyperglycemic hyperosmolar nonketotic syndrome Diabetic ketoacidosis Rebound hyperglycemia (Somogyi effect) Dawn phenomenon

Blood Glucose Monitor Courtesy OneTouch, part of Johnson & Johnson. See Figure 37-4 on p. 873. Courtesy OneTouch, part of Johnson & Johnson.

Nurse Teaching Patient with Diabetes See Figure 37-5 on p. 877.

Long-Term Complications Cardiovascular disease Metabolic syndrome Nephropathy Peripheral vascular disease Retinopathy Diabetic neuropathy

Nursing Management: Assessment A number of questions must be asked to establish a database that indicates whether the patient may have diabetes, has poorly controlled diabetes, or has no signs of diabetes. See Focused Assessment on p. 873.

Hypoglycemia Etiology and pathophysiology Signs and symptoms Functional hypoglycemia Signs and symptoms Diagnosis and treatment Complications

Signs/symptoms and treatment Shakiness, nervousness Sweating Hunger Confusion, dizziness If this happens: Give pt. 4 oz. orange juice, regular milk or regular soda (if conscious) Administer glucagon IM (if unconscious)

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