Adult Medical-Surgical Nursing Endocrine Module: Acute Complications of Diabetes Mellitus

Acute Complications of Diabetes Mellitus: Classification  Diabetic Ketoacidosis (DKA) (type 1)  Diabetic Hyperglycaemic Hyperosmolar Nonketotic Syndrome (HHNS) (type 2)  Hypoglycaemia

 Diabetic Ketoacidosis (DKA)

Diabetic Ketoacidosis: Aetiology  Undiagnosed DM (type 1)  Missed or ↓ insulin dose (patient error or lack of awareness that must always take)  Illness, stress or infection requiring ↑ insulin  *Illness especially infection may raise blood glucose increasing insulin requirement (should not omit dose)*

Diabetic Ketoacidosis: Pathophysiology  Hyperglycaemia causes osmotic diuresis, dehydration and electrolyte imbalance  Lipolysis: fats → free fatty acids/ glycerol for energy (as glucose unavailable)  Lack of insulin to inhibit the process, uncontrolled  Free fatty acids converted to ketone bodies  Ketones are acid → metabolic acidosis

DKA: Clinical Manifestations  Nausea, vomiting, abdominal pain  Dehydration, dry skin, hypotension  Hyperventilation (aim to correct metabolic acidosis, blowing off CO2)  Ketones on breath and in urine  Reduced level of consciousness → coma

DKA: Diagnosis  Patient/ family history and clinical picture  Elevated blood glucose: m mol/l  Evidence of ketoacidosis (blood/ urine/ on breath) and dehydration: ↑ haematocrit  ABG: metabolic acidosis  Electrolytes: ↓ Na ↓ K  KFT: Increased urea and creatinine  ECG

DKA: Management/ Nursing Considerations  Care in ICU  Rehydration: watch BP/ fluid balance  Correct electrolyte imbalance (replace K+)  IV insulin infusion initially to reverse ketoacidosis with Dextrose/Saline to maintain blood glucose levels  ECG monitoring (related to K+)  Monitor ABG, blood glucose, electrolytes

DKA: Prevention/ Patient Education  Rules for “sick days”:  Take insulin/ oral hypoglycaemics as usual  Test blood and urine glucose frequently  Report ↑ blood glucose, ketonuria to physician (may require extra dose)  Report nausea, vomiting, diarrhoea to physician: may need admission  If tolerated frequent fluids, jelly, carbonated drinks, fruit juice, soup, crackers (not normally allowed)

 Hyperglycaemic Hyperosmolar Nonketotic Syndrome (HHNS)

HHNS: Aetiology  Acute complication of type 2 DM  May be precipitated by acute illness  May be the first recognition of Diabetes when dehydration and neurological symptoms occur causing the patient to seek medical care

HHNS: Pathophysiology  Type 2 Diabetes Mellitus:  Occurs because of insulin resistance  Lack of effective insulin →  Severe hyperglycaemia  Severe osmotic diuresis and dehydration  Hyperosmolarity  No ketosis or acidosis as some insulin

HHNS: Clinical Manifestations  Polyuria and thirst  Dry skin, severe dehydration  Hypotension, tachycardia  Neurological symptoms:  Altered sense of awareness  Convulsions  Hemiparesis (cerebral dehydration)

HHNS: Diagnosis  Patient history and clinical picture (may be the first recognition of the condition of DM type 2)  Very elevated blood glucose level

HHNS: Management  Fluid replacement  Correct electrolyte imbalance  IV insulin infusion and Dextrose/ Saline to restore blood glucose level  Initiate treatment for DM or reassess current medication

HHNS: Nursing Considerations  Patient awareness of condition, importance of regular meals, snacks, medication  No extremes of lifestyle  “Sick Day” rules

 Hypoglycaemia

Hypoglycaemia: Pathophysiology  The brain requires a constant amount of available glucose for cellular metabolism  Hypoglycaemia is a very serious condition which may lead to coma and death

Hypoglycaemia: Aetiology  Low blood glucose (< 4.6 m mol/l) is related to:  Too high dose of insulin or hypoglycaemic medication  Peaking of insulin dose (often early hours)  Increased exercise (used up calories)  Skipped meal

Hypoglycaemia: Clinical Manifestations  Sweating, feeling cold, tremor, hunger  Tachycardia, palpitations  Light-headedness, numbness of lips, slurred speech  Disorientation, confusion → coma

Hypoglycaemia: Management  Diagnosis is made on patient history and clinical picture  Random blood glucose will be assessed  But: EMERGENCY management → immediate response:  If conscious, immediate juice, milk, glucose sweet or drink (don’t wait for tests)  If in coma, requires IV glucose 50%  Then regulate food/ medication dosage

Hypoglycaemia: Nursing Considerations  Patient awareness about:  Causes of hypoglycaemia  Importance of regular meals and snacks  Symptoms of hypoglycaemia  Importance of always carrying a high glucose snack in case of attack  Importance of bedtime snack  Importance of “Sick Day” rules