1. Medical-Surgical Nursing: Concepts & Practice
3rd edition
Chapter 37
Care of Patients with Diabetes and Hypoglycemia
Copyright © 2017, Elsevier Inc. All rights reserved.

2. Diabetes Mellitus Type 1 diabetes mellitus and ketoacidosis
Juvenile diabetes and ketosis-prone diabetes
Type 2 diabetes and insulin resistance
Latent autoimmune diabetes
Gestational diabetes

3. Etiology and Pathophysiology of Diabetes Mellitus
Genetic factors
Metabolic factors
Microbiologic factors
Immunologic factors

4. Clinical Categories of Diabetes Mellitus and Characteristics
Type 1 (insulin dependent; IDDM; juvenile diabetes; juvenile onset)
Type 2 (non–insulin dependent; NIDDM; adult-onset diabetes; maturity-onset diabetes)
Latent autoimmune diabetes (LADA) (slow onset type 1 diabetes or type 1.5 diabetes; type 1 diabetes, according to the World Health Organization)
See Table 37-1 on p. 860.

5. Clinical Categories of Diabetes Mellitus and Characteristics (Cont.)
Prediabetes (impaired glucose tolerance and impaired fasting glucose)
Gestational diabetes
Statistical risk of diabetes

6. Symptoms of Type 1 Diabetes
Very thirsty (polydipsia)
Frequent urination (polyuria)
Extremely hungry (polyphagia)
Rapid loss of weight
Irritability
Weakness and fatigue
Nausea and vomiting
See Box 37-1 on p. 860.

8. Symptoms of Type 2 Diabetes
Possibly polydipsia, polyuria, and polyphagia
More commonly excessive weight gain
Family history of diabetes mellitus
Poor healing of scratches, abrasions, and wounds
Blurred vision
Itching
Drowsiness
Increased fatigue
Tingling or numbness in the feet
See Box 37-1 on p. 860.

10. Signs and Symptoms Classic symptoms of diabetes
Fatigue and muscular weakness
Weight loss and type 1 diabetes
Prone to infection, delayed healing, and vascular diseases

11. Diagnosis Screening Hemoglobin A1c (A1C or HbA1c), or
Fasting plasma glucose (FPG), or
2-Hour 75-g oral glucose tolerance test (OGTT)

12. Self-Management of Diabetes Mellitus
Benefits of tight glycemic control
Hypoglycemia or insulin reaction
Overall goal of diabetes management
Older adult considerations

13. Self-Management of Diabetes Mellitus (Cont.)
Diet is the cornerstone of diabetic treatment.
Emphasis on the foods allowed rather than those that are forbidden.
Exercise
Hypoglycemia and increasing food intake
Older adult care considerations
Oral hypoglycemic agents, including metformin
Insulin therapy

15. Insulin Therapy Goal of insulin therapy: closely mimic basal insulin
Multiple daily injection regimen
Insulin-to-carbohydrate ratio
Insulin pump
Patient teaching and compliance
Incretin mimetics
Preoperative and postoperative insulin management
See Table 37-3 on p. 866.
NOTE: One unit of insulin will cover 15 g of carbohydrate for most patients (weight and insulin sensitivity must also be considered).

16. Rotation Sites for Injection of Insulin
See Figure 37-2 on p. 867.
Courtesy ACCU-CHEK® is a registered trademark of Roche.

17. Insulin Pump Courtesy ACCU-CHEK® is a registered trademark of Roche.
See Figure 37-3 on p. 868.
Courtesy ACCU-CHEK® is a registered trademark of Roche.

18. Islet Cell Transplantation
Two to four donor pancreases are needed.
About a third of recipients will develop antibodies.
Lifetime immunosuppressive medications are highly nephrotoxic.
Ethical issues include (1) two to four donor pancreases are needed for the required number of islet cells, (2) about a third of recipients will develop antibodies that would prohibit any future whole pancreas transplant attempts, and (3) lifetime immunosuppressive medications are highly nephrotoxic. The option may be discussed with patients who have very unstable metabolic control and have frequent life-threatening hypoglycemic episodes (Ruggenenti et al., 2008).

19. Nursing Management
Monitor the trend of blood glucose, hemoglobin A1C, and fructosamine assay.
Monitor for hypoglycemia after insulin injections,
Monitor for signs of ketoacidosis,

20. Comparison of Hypoglycemia and Ketoacidosis
Etiology
Symptoms
Treatment
Prevention
See Table 37-6 on p. 870.

21. Patient Teaching Foot care What to do on “sick days”
Instructions for traveling
Working with the older adult who has diabetes

22. Patient teaching Feet must be inspected daily
Apply cream to tops and bottoms of feet, NOT between toes
Consult a podiatrist
Promptly treat any cuts or wounds
On sick days:
Monitor glucose closely
Consult provider for extra medication if needed

23. Short-Term Complications
Hyperglycemia
Hypoglycemia
Hyperglycemic hyperosmolar nonketotic syndrome
Diabetic ketoacidosis
Rebound hyperglycemia (Somogyi effect)
Dawn phenomenon

24. Blood Glucose Monitor Courtesy OneTouch, part of Johnson & Johnson.
See Figure 37-4 on p. 873.
Courtesy OneTouch, part of Johnson & Johnson.

26. Nurse Teaching Patient with Diabetes
See Figure 37-5 on p. 877.

27. Long-Term Complications
Cardiovascular disease
Metabolic syndrome
Nephropathy
Peripheral vascular disease
Retinopathy
Diabetic neuropathy

28. Nursing Management: Assessment
A number of questions must be asked to establish a database that indicates whether the patient may have diabetes, has poorly controlled diabetes, or has no signs of diabetes.
See Focused Assessment on p. 873.

29. Hypoglycemia Etiology and pathophysiology Signs and symptoms
Functional hypoglycemia
Signs and symptoms
Diagnosis and treatment
Complications

30. Signs/symptoms and treatment
Shakiness, nervousness
Sweating
Hunger
Confusion, dizziness
If this happens:
Give pt. 4 oz. orange juice, regular milk or regular soda (if conscious)
Administer glucagon IM (if unconscious)

32. Community Care Healthy People 2020 Home Care
Patient education programs
Long-term care