Linda S. Williams / Paula D. Hopper Copyright © F.A. Davis Company Understanding Medical Surgical Nursing, 4th Edition Chapter 40 Nursing Care of Patients with Disorders of the Endocrine Pancreas

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Diabetes Mellitus  Pathophysiology  Glucose Intolerance  Faulty Production of Insulin or  Tissue Insensitivity to Insulin  Altered CHO, Fat, Protein Metabolism  Long-term Complications

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Blood Glucose Levels

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Cell Membranes

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition CDC Statistics  20.8 Million in U.S. have Diabetes  6.2 Million are Unaware  Cost: $132 Billion per Year

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition 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

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition 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

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition LADA  Latent Autoimmune Diabetes of Adulthood  Initial Type 2 Diagnosis  Islet Cell Antibodies Like Type 1

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Type 2 in Youth  More Obesity in Children  Type 2 Epidemic  A Nursing Challenge

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Other Types  Gestational: Pregnancy  Prediabetes: Glucose Intolerance  Secondary Diabetes  Drugs  Pancreatic Trauma

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Metabolic Syndrome  Elevated Waist Circumference  Elevated Triglycerides  Low HDL Cholesterol  Elevated Blood Pressure  Elevated Fasting Plasma Glucose

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Signs and Symptoms  The 3 Ps  Polyuria  Polydipsia  Polyphagia  Fatigue  Blurred Vision  Infection Prone  Abdominal Pain  Headache  Ketosis/Acidosis

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Diagnosing Diabetes  Fasting Plasma Glucose ≥ 126 mg/dL  Casual Plasma Glucose ≥ 200 mg/dL  Glucose Tolerance Test > 200 mg/dL after 2 Hr

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Additional Tests  Glycohemoglobin: Normal 4% to 6%  Lipid Profile  Serum Creatinine  Urine Microalbumin

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Prevention of Type 2  Lose 5% to 7% Body Weight  30 Minutes of Exercise 5 Days per Week  Reduce Fat and Calories

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Goals of Treatment  Preprandial Glucose 90 to 130 mg/dL  Peak Postprandial Glucose < 180 mg/dL  Blood Pressure < 130/80 Mm Hg  Glycohemoglobin < 7%

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Therapeutic Interventions  Medical Nutrition Therapy  Exercise  Medication  Monitoring  Education

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Medical Nutrition Therapy (MNT)  ADA Exchange Lists  Carbohydrate Counting  Glycemic Index  REMEMBER CULTURAL DIETARY NEEDS

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition General Principles of MNT  Low Fat  Low Sodium  Limit Simple Sugars  Use Complex Carbohydrates  Consistent Day-to-day

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition 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

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Medication  Insulin for Type 1 or 2  Oral Hypoglycemics for Type 2

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Insulin  Action  Routes  Subcutaneous  IM  Inhaled  Insulin pump

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Insulin (cont ’ d)  Site Rotation  Timing  Onset  Peak  Duration

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Insulin Pump

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Oral Hypoglycemics  Are Not Insulin  Action Depends on Medication  Stimulate Pancreas  Increase Tissue Sensitivity to Insulin  Slow CHO Digestion and Absorption

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition New Developments  Exenatide (Byetta)  Pramlintide (Symlin)

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition 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

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Glucose Diary

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Urine Testing  Glucose  Ketones  If Blood Sugar Greater than 300

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Alterations in Blood Glucose  Hyperglycemia  Hypoglycemia = “ Insulin Reaction ”

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Hyperglycemia  Blood Glucose >126 mg/dL  Causes  Overeating  Stress  Illness  Not Enough Medication

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Symptoms of Hyperglycemia  3 Ps  Blurred Vision  Fatigue, Lethargy  Headache  Abdominal Pain  Ketonuria  Coma

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition 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

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Hypoglycemia  Blood Glucose Greater Than 70  Causes  Too Much Insulin  Exercise  Not Enough Food

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Hypoglycemia Symptoms  Headache  Hunger  Fight or Flight  Shaky  Cold Sweat  Palpitations  Neuroglycopenia  Irritability  Confusion  Seizures, Coma  CAUTION  Autonomic Neuropathy = No Symptoms

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition 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

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Fast Sugars  4 oz Orange Juice  6 oz Regular (not diet) Soda  Miniature Box of Raisins  Commercial Glucose Tablets  6 to 8 Life Savers

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Acute Treatment  IV D50  SQ Glucagon

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Diabetic Ketoacidosis (DKA)  Causes  High Blood Glucose  Most Common in Type 1  Stress  Illness

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Pathophysiology  Insulin Deficiency  Cells Starving  Fat Breaks Down  Byproduct of Fat Breakdown is Ketones  Ketones are Acidic

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Signs and Symptoms  Flu-like Symptoms  Symptoms of Hyperglycemia  Kussmaul ’ s Respirations  Fruity Breath  Electrolyte Imbalance  Dehydration  Coma  Death

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Therapeutic Interventions  IV Fluids  IV Insulin Drip  Frequent Glucose Monitoring  Electrolyte Monitoring

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Prevention  Check Ketones if Blood Sugar is Greater Than 300  Drink Fluids  Check Again  Call MD if Still Present  Good Diabetes Control!

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Hyperosmolar Hyperglycemia  Causes  Hyperglycemia in Type 2 Diabetes  Stress  Illness  Most Common in Elderly

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Pathophysiology  Blood Glucose Elevated  Polyuria  Profound Dehydration  No Nausea and Vomiting, So Slower to Get Help

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Signs and Symptoms  Extreme Dehydration  Lethargy  Blood Glucose may be 1,000 to 1,500 mg/dL  Electrolyte Imbalance  Coma  Death

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Therapeutic Interventions  IV Fluids  IV Insulin Drip  Frequent Glucose Monitoring  Electrolyte Monitoring

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Prevention  SMBG  If Glucose Rising  Drink Fluids  Lower Glucose

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Long-Term Complications  Macrovascular Changes  Stroke  MI  Peripheral Vascular Disease

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Long-Term Complications (cont’d)  Microvascular Changes  Retinopathy  Nephropathy  Neuropathy  Infection  Foot Problems

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Diabetic Foot Ulcer

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition 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

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Hope for the Future  DCCT  Tight Control Reduces Complications  UKPDS  HbA1c <7% Reduces Complications

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Care of Patient Undergoing Surgery  Frequent Glucose Monitoring  Sliding Scale Insulin or Insulin Drip  Maintain Glucose 140 to 180 mg/dL in Critically Ill

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Nursing Diagnosis  Risk for Variation in Blood Glucose

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Diabetes Self-Management Education  Disease Process and Treatment  Nutrition Therapy  Exercise  Medications  SMBG  Acute Complications  Chronic Complications  Psychosocial Adjustment  Health Promotion

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Reactive Hypoglycemia  Hyper-responsiveness of Pancreas  Low Glucagon Levels  Low Blood Glucose  Sympathetic “ Fight Or Flight ” Response

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Therapeutic Interventions  Frequent Small Meals  High-protein, Low-CHO Diet