1. Nursing Care of Patients with Disorders of the Endocrine Pancreas
Chapter 40
Nursing Care of Patients with Disorders of the Endocrine Pancreas

2. Diabetes Mellitus Pathophysiology Glucose Intolerance
Faulty Production of Insulin or
Tissue Insensitivity to Insulin
Altered CHO, Fat, Protein Metabolism
Long-term Complications

3. Blood Glucose Levels
Maintenance of Blood Glucose Levels A) Normal Physiology-Foods broken down by glucose, B) Type 1 diabetes mellitus, the pancreas does not produce insulin, and C) Type II, insulin production is reduced.

4. Cell Membranes
(A) Cell membrane in normal state, B) cell membrane in Type I, and C) cell membrane in Type II.

5. CDC Statistics 20.8 Million in U.S. have Diabetes
6.2 Million are Unaware
Cost: $132 Billion per Year

6. 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

7. 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

8. LADA Latent Autoimmune Diabetes of Adulthood Initial Type 2 Diagnosis
Islet Cell Antibodies Like Type 1

9. Type 2 in Youth More Obesity in Children Type 2 Epidemic
A Nursing Challenge

10. Other Types Gestational: Pregnancy Prediabetes: Glucose Intolerance
Secondary Diabetes
Drugs
Pancreatic Trauma

11. Metabolic Syndrome Elevated Waist Circumference Elevated Triglycerides
Low HDL Cholesterol
Elevated Blood Pressure
Elevated Fasting Plasma Glucose

12. Signs and Symptoms The 3 Ps Fatigue Blurred Vision Infection Prone
Polyuria
Polydipsia
Polyphagia
Fatigue
Blurred Vision
Infection Prone
Abdominal Pain
Headache
Ketosis/Acidosis

13. Diagnosing Diabetes Fasting Plasma Glucose ≥ 126 mg/dL
Casual Plasma Glucose ≥ 200 mg/dL
Glucose Tolerance Test > 200 mg/dL
after 2 Hr

14. Additional Tests Glycohemoglobin: Normal 4% to 6% Lipid Profile
Serum Creatinine
Urine Microalbumin

15. Prevention of Type 2 Lose 5% to 7% Body Weight
30 Minutes of Exercise 5 Days per Week
Reduce Fat and Calories

16. Goals of Treatment Preprandial Glucose 90 to 130 mg/dL
Peak Postprandial Glucose < 180 mg/dL
Blood Pressure < 130/80 Mm Hg
Glycohemoglobin < 7%

17. Therapeutic Interventions
Medical Nutrition Therapy
Exercise
Medication
Monitoring
Education

18. Medical Nutrition Therapy (MNT)
ADA Exchange Lists
Carbohydrate Counting
Glycemic Index
REMEMBER CULTURAL DIETARY NEEDS

19. General Principles of MNT
Low Fat
Low Sodium
Limit Simple Sugars
Use Complex Carbohydrates
Consistent Day-to-day

20. 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

21. Medication
Insulin for Type 1 or 2
Oral Hypoglycemics for Type 2

22. Insulin
Action
Routes
Subcutaneous IM
Inhaled
Insulin pump

23. Insulin (cont’d)
Site Rotation
Timing
Onset
Peak
Duration

24. Insulin Pump

25. Oral Hypoglycemics Are Not Insulin Action Depends on Medication
Stimulate Pancreas
Increase Tissue Sensitivity to Insulin
Slow CHO Digestion and Absorption

26. New Developments
Exenatide (Byetta)
Pramlintide (Symlin)

27. 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
Please see figure 40.5 on page 863 of the text.

28. Glucose Diary

29. Urine Testing
Glucose
Ketones
If Blood Sugar Greater than 300

30. Alterations in Blood Glucose
Hyperglycemia
Hypoglycemia = “Insulin Reaction”

31. Hyperglycemia Blood Glucose >126 mg/dL Causes Overeating Stress
Illness
Not Enough Medication

32. Symptoms of Hyperglycemia
3 Ps
Blurred Vision
Fatigue, Lethargy
Headache
Abdominal Pain
Ketonuria
Coma

33. 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

34. Hypoglycemia Blood Glucose Greater Than 70 Causes Too Much Insulin
Exercise
Not Enough Food

35. Hypoglycemia Symptoms
Headache
Hunger
Fight or Flight
Shaky
Cold Sweat
Palpitations
Neuroglycopenia
Irritability
Confusion
Seizures, Coma
CAUTION
Autonomic Neuropathy = No Symptoms

36. 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

37. Fast Sugars 4 oz Orange Juice 6 oz Regular (not diet) Soda
Miniature Box of Raisins
Commercial Glucose Tablets
6 to 8 Life Savers

38. Acute Treatment
IV D50
SQ Glucagon

39. Diabetic Ketoacidosis (DKA)
Causes
High Blood Glucose
Most Common in Type 1
Stress
Illness

40. Pathophysiology Insulin Deficiency Cells Starving Fat Breaks Down
Byproduct of Fat Breakdown is Ketones
Ketones are Acidic

41. Signs and Symptoms Flu-like Symptoms Symptoms of Hyperglycemia
Kussmaul’s Respirations
Fruity Breath
Electrolyte Imbalance
Dehydration
Coma
Death

42. Therapeutic Interventions
IV Fluids
IV Insulin Drip
Frequent Glucose Monitoring
Electrolyte Monitoring

43. Prevention Check Ketones if Blood Sugar is Greater Than 300
Drink Fluids
Check Again
Call MD if Still Present
Good Diabetes Control!

44. Hyperosmolar Hyperglycemia
Causes
Hyperglycemia in Type 2 Diabetes
Stress
Illness
Most Common in Elderly

45. Pathophysiology Blood Glucose Elevated Polyuria Profound Dehydration
No Nausea and Vomiting, So Slower to Get Help

46. Signs and Symptoms Extreme Dehydration Lethargy
Blood Glucose may be 1,000 to 1,500 mg/dL
Electrolyte Imbalance
Coma
Death

47. Therapeutic Interventions
IV Fluids
IV Insulin Drip
Frequent Glucose Monitoring
Electrolyte Monitoring

48. Prevention
SMBG
If Glucose Rising
Drink Fluids
Lower Glucose

49. Long-Term Complications
Macrovascular Changes
Stroke MI
Peripheral Vascular Disease

50. Long-Term Complications (cont’d)
Microvascular Changes
Retinopathy
Nephropathy
Neuropathy
Infection
Foot Problems

51. Diabetic Foot Ulcer

52. 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

53. Hope for the Future DCCT UKPDS Tight Control Reduces Complications
HbA1c <7% Reduces Complications

54. Care of Patient Undergoing Surgery
Frequent Glucose Monitoring
Sliding Scale Insulin or Insulin Drip
Maintain Glucose 140 to 180 mg/dL in Critically Ill
Care of Patient Undergoing Surgery

55. Nursing Diagnosis
Risk for Variation in Blood Glucose

56. Diabetes Self-Management Education
Disease Process and Treatment
Nutrition Therapy
Exercise
Medications
SMBG
Acute Complications
Chronic Complications
Psychosocial Adjustment
Health Promotion

57. Reactive Hypoglycemia
Hyper-responsiveness of Pancreas
Low Glucagon Levels
Low Blood Glucose
Sympathetic “Fight Or Flight” Response

58. Therapeutic Interventions
Frequent Small Meals
High-protein, Low-CHO Diet