1. Diabetes Manageent
Unit 6
Chapter 59
P. 580

2. Key Points
DM is a group of metabolic diseases characterized by chronic hyperglycemia due to problems with insulin secretion and/or the effectiveness of endogenous insulin ( insulin resistance).
related to:
An endocrine disorder causes Abnormal insulin production
Impaired insulin utilization
Both abnormal production and impaired utilization
Diabetes mellitus is a contributing factor to:
*cardiovascular disease, *HTN
* RF, *blindness, and *CVA

3. Key Points
Hallmark symptoms associated with diabetes mellitus are the 3 P’s
Consistent management of blood glucose levels within the normal range is the goal of Rx
Type 1 DM is: an autoimmune disorder characterized by beta cell destruction.
It occurs in genetically susceptible individuals ,and typical onset is before the age of 30.
Type 2 DM is due to resistance to endogenous insulin and frequently occurs in individuals with a family
disposition who are obese and over the age of 40.

5. Normal and diabetic blood sugar ranges
For the majority of healthy individuals, normal blood sugar levels are as follows:
Between 4.0 to 6.0 mmol/L (72 to 108 mg/dL) when fasting
Up to 7.8 mmol/L (140 mg/dL) 2 hours after eating
For people with diabetes, blood sugar level targets are as follows:
Before meals: 4 to 7 mmol/L for people with type 1 or type 2 diabetes
After meals: under 9 mmol/L for people with type 1 diabetes and under 8.5mmol/L for people with type 2 diabetes

6. Key Points Risk factors for the developing insulin resistance:
Obesity,
physical inactivity,
high triglycerides (> 250 mg/dL), and
hypertension.
Pancreatitis and hyperthyroidism may lead to hyperglycemia
Parenteral nutrition and glucocorticoids may lead to transient iatrogenic hyperglycemia

7. Diagnostic Procedures and Nursing Interventions
Two findings (separate days) of one of the following are required:
Symptoms of diabetes plus casual plasma glucose concentration  200 mg/dL (without regard to time since last meal).
FBS  126 mg/dL (8 hr fasting).
Two-hour glucose  200 mg/dL with an OGTT (10 to 12 hr fasting).

8. Diagnostic Procedures and Nursing Interventions
Fasting blood glucose (FBS):
Client fasts (no food or drink other than water) for the 8 hr prior to the blood draw.
Antidiabetic medications should be postponed until after the level is drawn.
Oral glucose tolerance test
Client consumes a balanced diet for the 3 days prior to the test.
Then the client fasts for the 10 to 12 hr prior to the test.
A fasting blood glucose level is drawn at start of the test.
The client then consumes a specified amount of glucose.
BGL are drawn every 30 min for 2 hr.
Clients must be assessed for hypoglycemia throughout the procedure.

9. Diagnostic Procedures and Nursing Interventions
Glycosylated hemoglobin (HbA1c)
The target is 4 to 6%. HbA1c is the best indicator of average blood glucose level for past 120 days.
Assists in evaluating treatment effectiveness and compliance.
Pre-meal glucose
The target is 90 to 130 mg/dL.
Ensure that the client follows the proper procedure
Supplemental short-acting insulin may be prescribed for elevated pre-meal glucose levels.

10. Assessment Signs and Symptoms by Type of Diabetes
Polyuria, polydipsia, polyphagia
Weight loss
Obesity
Fatigue
Increased frequency of infections
Rapid onset
Gradual onset
Controlled by exogenous insulin
Controlled by oral antidiabetic medications
and insulin

12. Signs and Symptoms by Glucose Alteration
Hypoglycemia (≤ 50 mg/dL)
Hyperglycemia (> 250 mg/dL)
Cool, clammy skin
Hot, dry skin
Diaphoresis
Absence of diaphoresis
Anxiety, irritability, confusion, blurred vision
Alert to coma (varies)
Hunger
Nausea and vomiting, abdominal pain (with
ketoacidosis)
General weakness, seizures (severe
hypoglycemia)
Rapid deep respirations (acetone/fruity odor due
to ketones)

13. Additional appropriate assessments
Blood glucose levels and factors affecting levels
Intake and output, weight.
Skin integrity and healing status of any wounds.
Sensory alterations (tingling, numbness).
Condition of feet and foot care practices.
Dietary practices.
Exercise patterns.
Client’s self monitoring blood glucose skill proficiency.
Client’s self medication administration proficiency.
Pain levels.

14. NANDA Nursing Diagnoses
Risk for injury
Imbalanced nutrition: More than body requirements
Risk for impaired skin integrity
Deficient knowledge
Self-care deficit

16. Nursing Interventions
Comprehensive education in diabetes management.
Provide information regarding the importance of foot care and provide
Instructions for foot care, including:
Inspect feet daily.
Wash feet daily with mild soap and warm water.
Pat feet dry gently, especially between the toes.
Use mild foot powder (powder with cornstarch) on sweaty feet.
Do not use commercial remedies to remove calluses or corns.

17. Nursing Interventions
Cut toenails even with rounded contour of toes.
The best time to cut nails is after a bath/shower.
Separate overlapping toes with cotton or wool.
Avoid open-toe, open-heel shoes. Leather shoes are preferred to plastic ones.
Wear slippers with soles. Do not go barefoot. Shake out shoes before putting them on.
Wear clean, absorbent socks.
Do not use hot water bottles or heating pads to warm feet. Wear socks for warmth.
Avoid prolonged sitting, standing, and crossing of legs.

18. Nursing Interventions
Encourage the client to take measures to reduce risk of injury (wearing shoes, adequate lighting). Cleanse cuts with warm water and mild soap, gently dry and apply a dry dressing.
Instruct clients to monitor healing and to seek intervention promptly.
Refer clients to dieticians for nutritional management of diabetes.
Some guidelines to encourage are:
Count grams of carbohydrates consumed to calculate dose (1 unit/15 g of carbohydrate).
Restrict calories and increase physical activity as appropriate to facilitate
weight loss for clients who are obese or to prevent obesity.
Include fiber in the diet to increase carbohydrate metabolism and to help
control cholesterol levels.
Use artificial sweeteners.

19. Nursing Interventions
Teach the client guidelines to follow when sick:
Monitor blood glucose every 4 hr.
Continue to take insulin or oral antidiabetic agents.
Consume 8 oz of sugar-free non-caffeinated liquid every hour to prevent
dehydration.
Meet carbohydrate needs through solid food if not consume liquids
Test urine for ketones and report if abnormal (should be negative to small).
Rest.

20. Nursing Interventions
Call the primary care provider if:
Blood glucose is higher than 250 mg/dL.
Ketones are moderate or large.
Fever higher than 38.9° C, fever that does not respond to
or lasts more than 12 hr.
Feeling dizzy or confused.
Experiencing Tachypnea.
Vomited more than once.
Diarrhea occurs more than five times or for longer than 24 hr.
Illness lasts longer than 2 days.

21. Nursing Interventions
Teach the client ,in response to hypoglycemia symptoms, to:
Check blood glucose level.
Treat with 15 g carbohydrates.
Recheck blood glucose in 15 min.
If still low, give 15 g more of carbohydrates.
If blood glucose is within normal limits, take 7 g protein (if the next meal is more than an hour away).
15 g of carbohydrates examples: 120 ml orange juice, 60 ml grape juice, 240 milk,
7 g protein: 30 gm of cheese (1 string cheese).
Fluid is more readily absorbed (juice, non-diet soft drink, skim milk).

22. Nursing Interventions
Teach the client ,in response to hyperglycemia, to:
Encourage oral fluid intake.
Administer insulin as prescribed.
Restrict exercise when blood glucose levels are > 250 mg/dL.
Test urine for ketones and report if abnormal.
Consult the primary care provider if symptoms progress.
Know the onset, peak, and duration of administered insulin, plan for administration of prescribed insulin, and monitor client for signs of hypoglycemia

23. Nursing Interventions
Provide information regarding self administration of insulin, following guidelines including:
Rotation of injection sites (prevent lipohypertrophy)
Inject at a 90° angle (45° if thin). Aspiration for blood is not necessary.
When mixing regular with NPH insulin, draw up regular insulin first and then the
NPH.
Observe the client perform self-administration and offer additional instruction as indicated.
Provide information regarding oral antidiabetic medications:
Administer as prescribed (30 min before first main meal).
Monitor renal function.
Monitor liver function
Advise women of childbearing age taking thiazolidinediones that additional contraception methods may be needed since these drugs reduce the blood levels of some oral contraceptives.