NUR133 Lectures # 12&13 K. Burger, MSEd, MSN, RN, CNE Nursing Management of Clients with Stressors of Endocrine Function DIABETES MELLITUS NUR133 Lectures # 12&13 K. Burger, MSEd, MSN, RN, CNE

Definition & Classification A group of metabolic diseases characterized by elevated levels of blood glucose resulting from defects in insulin secretion, insulin action, or both The disease is further characterized by metabolic abnormalities and by long-term complications to other body systems EVERY BODY SYSTEM IS AFFECTED BY DIABETES

Type 1Diabetes Mellitus Classification Type 1Diabetes Mellitus Lack of insulin or production of defective insulin Age of onset: <20 yrs Often present with DKA Always requires exogenous insulin Rx Type 2 Diabetes Mellitus Reduced ability to respond to insulin and/or secrete sufficient amounts Age of onset: adults* Obesity = co-factor Rx: variable

Diabetic Ketoacidosis Hyperglycemic-Hyperosmolar DKA versus HHNS Diabetic Ketoacidosis Usually preceded by polyuria, polydipsia, polyphagia BG > 300 Ketosis Fruity breath Lethargy Kussmaul’s Resp Hyperglycemic-Hyperosmolar Non-ketotic Syndrome Gradual Onset BG as high as 800 Hi blood osmolarity No ketosis Dehydration Confusion – Coma Muscle jerking-seizures

Interventions for DKA / HHNS Restore fluid volume rapidly to maintain perfusion to vital organs ( NS IV @ 1L/hr)* Then continue to balance fluids (1/2 NS @ reduced rate ) Administer IV insulin Administer HCO3 in extreme cases Monitor K levels Monitor for s/s cerebral edema*

Metabolic Acidosis/Alkalosis The elevator effect .  . Metabolic Acidosis/Alkalosis The elevator effect Metabolic Acidosis Metabolic Alkalosis CO2 + H2O = H2CO3 = H + HCO3

PRIOR to LECTURE Students are to complete: Winningham & Preusser CASE STUDY Endocrine Disorders – Case Study #4 BE PREPARED! YOU WILL BE CALLED ON IN CLASS TO ANSWER THESE QUESTIONS!

Case Study 4 Diabetes Mellitus Winningham & Pruesser (2005) Elsevier, Inc. The client, Y.L. has been complaining of chronic fatigue, increased thirst, constantly being hungry, and frequent urination. She denies any pain, burning, or low back pain on urination. She tells you she has a vaginal yeast infection that she has treated numerous times with OTC medication. She admits to starting smoking since going back to work full time as a clerk in a loan company. She also complains of having difficulty reading numbers and reports making frequent mistakes. She says by the time she gets home and makes supper for her family, then puts her child to bed, she is too tired to exercise. She reports her feet hurt; they often “burn or feel like there are pins in them.” She reports that after her delivery, she went back to her traditional eating pattern, which you know is high in carbohydrates Her current weight is 173 lb. Today her BP is 152/97 mm Hg and her plasma glucose is 291 mg/dL.Lab values are as follows: FBG 184 mg/dL, A1c 10.4, UA +glucose, -ketones, cholesterol 256 mg/dL, triglycerides 346 mg/dL, LDL 32 mg/dL, ratio 8.0. Y.L. is diagnosed with type 2 diabetes. The PCP decides to start MDI (multiple dose injection) insulin therapy and have the patient count carbohydrates. Y.L. is scheduled for education classes and is to work with the diabetes team to get her blood sugar under control. ALSO FYI: Pt has history of gestational diabetes

Case Study 4 Diabetes Mellitus Winningham & Pruesser (2005) Elsevier, Inc. QUESTION #1 Identify the three methods used to diagnose Diabetes mellitus.

Case Study 4 Diabetes Mellitus Winningham & Pruesser (2005) Elsevier, Inc. QUESTION #9 What symptoms did YL report that lead you to believe she has some form of neuropathy?

Case Study 4 Diabetes Mellitus Winningham & Pruesser (2005) Elsevier, Inc. QUESTION #10 What findings in YLs history place her at increased risk for the development of other forms of neuropathy?

Case Study 4 Diabetes Mellitus Winningham & Pruesser (2005) Elsevier, Inc. QUESTION #11 What are some changes that YL can make to reduce the risk or slow the progression of both macrovascular and microvascular disease?

Case Study 4 Diabetes Mellitus Winningham & Pruesser (2005) Elsevier, Inc. QUESTION # 8 YLs culture prefers foods high in carbohydrates. What is carbohydrate counting and why would this method work well for YL?

Case Study 4 Diabetes Mellitus Winningham & Pruesser (2005) Elsevier, Inc. QUESTION#12 YL is enrolled in a smoking cessation class. Why is it so important that she stop smoking?

Case Study 4 Diabetes Mellitus Winningham & Pruesser (2005) Elsevier, Inc. QUESTION # 2 Identify (3) functions of insulin

Case Study 4 Diabetes Mellitus Winningham & Pruesser (2005) Elsevier, Inc. QUESTION #3 Insulin’s main action is to lower blood sugar levels. Several hormones produced in the body inhibit the effects of insulin. Identify (3)

ANTIDIABETIC AGENTS ORAL Sulfonylurea Agents Biguanides Alpha-glucosidase Inhibitors Thiazolidinediones Meglitinides INSULINS Rapid Acting Short Acting Intermediate Acting Long Acting Combination

ORAL ANTIDIABETICS Sulfonylureas Chlorpropamide ( Diabinese ) 1st generation Glipizide ( Glucotrol ) 2nd generation Glyburide ( Micronase ) 2nd generation Work best in early stages of disease Stimulate beta cells to secrete insulin Also have some effect on glucose absorption & storage in tissues Most commonly prescribed type oral rx

Sulfonylurea Drugs Nursing Implications Hypoglycemia is most common side-effect Can also cause blood dyscrasias Geriatric clients and anyone with decreased organ function more susceptible to above Cross allergies to loop diuretics and sulfonamides Diabinase and other 1st generation sulfonylureas should not be taken with alcohol; potential severe reaction Glucotrol has most rapid onset and shorter duration Usually taken 30 minutes before meals

Biguanides Metformin ( Glucophage ) Reduces the production of glucose Decreases intestinal absorption of glucose Increases the uptake of glucose Does NOT produce hypoglycemia Often given in combination with other orals

Biguanides Nursing Implications Onset within 1 hr, duration 24 hrs Hold med temporarily if pt going for diagnostic studies involving iodinated contrast materials Should not be used in renal impaired client Side effects are mostly GI related but usually transient: Abdominal bloating Nausea Diarrhea

Alpha –glucosidase Inhibitors Miglitol ( Glyset ) Delays glucose absorption after a meal Taken with first bite of each meal GI side effects: abd pain, diarrhea, flatus usually lessen over time Contraindicated for persons with inflammatory bowel disease

Thiazolidinediones Rosiglitazone ( Avandia ) Decrease insulin resistance Stimulate peripheral glucose uptake Inhibit glucose production in the liver Side effects: weight gain, edema, anemia Potential for hepatic toxicity; liver enzymes need to be monitored

Meglitinides Repaglinide ( Prandin ) Nateglinide ( Starlix ) Rapidly increases release of insulin from pancreas Must be taken with meals 0-30min ac Meal must have adequate CHO

Insulin Therapy Rapid - Lispro Short - Regular Intermediate -NPH Long - Lantus

Case Study 4 Diabetes Mellitus Winningham & Pruesser (2005) Elsevier, Inc. QUESTION #4 YL was started on lispro (Humalog) and glargine (Lantus) insulin. What is the most important point to make when teaching the patient about glargine?

Case Study 4 Diabetes Mellitus Winningham & Pruesser (2005) Elsevier, Inc. QUESTION #5 Because YL has been on regular insulin in the past, you want to make sure she understands the difference between regular and lispro. What is the most significant difference between these two insulins?

Case Study 4 Diabetes Mellitus Winningham & Pruesser (2005) Elsevier, Inc. QUESTION #6 What is the peak time and duration for lispro insulin?

Case Study 4 Diabetes Mellitus Winningham & Pruesser (2005) Elsevier, Inc. QUESTION #7 YL wants to know why she can’t take NPH and regular insulin. She is more familiar with them and has taken them in the past. Explain why the MD chose lispro and glargine insulin over NPH and regular insulin.

Insulin Rx Considerations Rotation within one anatomic site is preferred to moving from site to site. Abdomen provides best absorption Be alert to Dawn and/or Somagyi Phenomena Refrigerate unused insulin Insulin in use can be left out up to 28 days Do not re-use needles. Dispose properly

Alternative Methods of Insulin Administration External pumps Internal pumps Injection devices Inhaled ( under development )

Common Nursing Implications for Antidiabetic Medications Monitor for hypo/hyperglycemia Many drug interactions; both agonist and antagonist Use cautiously in geriatric clients and those with organ impairment Monitor A1c levels q2-3months Monitor BG levels daily Patient teaching is KEY!!!

Self-Study Hypoglycemia versus Hyperglycemia Signs & Symptoms _______________ Hyperglycemia _______________

Self-Study Insulin Comparison Action / Onset / Duration Agent Onset Peak Duration LISPRO REGULAR NPH LANTUS