1. 1 Nursing Care and Interventions in Managing Type II Diabetes Mellitus Keith Rischer, RN, MA, CEN

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3. 3 Objectives for Today…  Describe the onset, clinical manifestations, laboratory findings and pathologic mechanisms of type 2 diabetes.  Identify clients at risk for type 2 diabetes  Differentiate between macro & microvascular complications of chronic diabetes.  Compare the mechanisms of action, side effects and nursing considerations of the oral antidiabetic medications for type 2 diabetes.  Compare the time action profile, and nursing considerations of insulin to control type 2 diabetes.  Identify nursing care priorities to treat and prevent complications of chronic diabetes.

4. 4 Background  90-95% of all diabetes  Family history 2-4x risk developing  Obesity  Increased resistance to insulin  Impaired suppression of glucose production by liver

5. 5 Patho of Type II Diabetes  Pancreas secretes less insulin  Beta cells of pancreas  Insulin resistance  Initial increase in insulin  Leads to beta cell exhaustion & failure  Increased glucose production by liver  Metabolic syndrome  Insulin resistance  Abd. Obesity  HTN-high cholesterol  High triglycerides, CRP, low LDL, atherosclerotic changes

6. 6 Those at Highest Risk…  Overweight  Abd obesity  >age 40  Inactivity  Hypertension  High cholesterol  Parents with type II DM  Gender & Ethnic influences

7. 7 Clinical Manifestations  Asymptomatic  Same as Type 1  Fatigue  Polyuria  Polydipsia  Vaginal yeast infections  Wounds that do not heal

8. 8 Laboratory Diagnosis for Type 2  Symptoms of DM plus casual ^ 200 mg/dL  Fasting ^ 126  2-hr ^ 200  Urine  Albumin  Ketones  Protein  Glucose

9. 9 Macrovascular Complications  Cardiovascular disease (most common)  2-3 X greater than non-DM, Women more  MI leading cause of death  Cerebrovascular disease  ^ glucose levels lead to greater brain injury

10. 10 Microvascular Complications Eye and vision complications  Retinopathy which is leading cause of new blindness  linked to fasting BG >129  Cataracts, glaucoma, macular degeneration Diabetic Nephropathy  Leading cause of ESRD  Early sign… microalbuminuria  Neurontin or Amitriptyline to manage pain

11. 11 Diabetic Neuropathy  Clinical Manifestations  Loss of sensation, pain, weakness  Late complication foot ulcers/deformaties (Charcot’s joints), amputations  CV  GI  GU

12. 12 Male Erectile Dysfunction  Occurs at higher rate and earlier age as compared to general population  Affects 50% of males  Treatments  penile implants  medications  counseling

13. 13 Medications: Sulfonylurea Agents p.1512-1515  Mechanism  Require some beta-cell function Stimulates pancreas to secrete more insulin Increases insulin sensitivity  Hypoglycemia most common SE Glipizide (Glucatrol)-30” before meals Glyburide (Diabeta)-with first meal  Adverse effects  Hypoglycemia Impaired renal-liver function elevates levels  Onset 15-30”…peak 1-2h…duration 24 hours

14. 14 Oral Therapy  Biguanides (Metformin or Glucophage)  Decreases liver glucose release and decreases cellular insulin resistance  Should not cause hypoglycemia  Avoid those with renal disease (causes lactic acidosis in those with renal, liver, CHF or ETOH)  Withhold 48 hours before using contrast media and surgery requiring anesthesia  Avoid ETOH…causes lactic acidosis

15. 15 Oral Therapy  Thiazolidine-diones (Avandia, Actos)  Enhance insulin action  Decreasing insulin resistance  Can be used with insulin or sulfonylurea  Need periodic liver tests to assess for damage  Cause weight gain  Due to fluid retention  Elevates HDL as well as LDL & triglycerides

16. 16 Oral Therapy  Combination meds  Combine with insulin  Orals combined with other orals  Drug Selection  Based on cost, age, client’s ability to manage, response to meds  Body’s response to oral DM meds decreases, so clients may have to go on insulin

17. 17 Insulin  Needed for type 1 and often for type 2  Assess elderly’s ability to give insulin  Types of insulin  Rapid  Short  Intermediate  Long acting  Know the onset, peak, and duration

18. 18 Foot Assessment & Care  Do not smoke  Inspect feet daily  No bare feet  Trim toenails  Use lotion  Report non-healing breaks  Complete foot assessment with provider at least 4 times a year.

19. 19 Foot Assessment & Care  Without sensation, risk for injury  Peripheral sensation management - monofilament  Footwear - protective shoes  Wound Care -  elimination of pressure: contact cast  Wound Care clinics  Growth hormones  Debridement

20. 20 Treatment: Chronic Pain  Maintain normal BG levels  Anticonvulsants - Neurontin  Antidepressants - Amitriptyline  Capsaicin cream  Pain Clinics and specialty services

21. 21 Treatment: Visual Disturbances  Many times loss of central vision  Assistive devices  special insulin devices: magnifier on bottle  talking glucometers  coding objects: wrap rubber band around bottle  Fluorescent lighting above object  Society for the blind - large print  Treatment: Laser (photocoagulation) Vitrectomy (aspiration of blood, membranes, fibers)

22. 22 Diabetic Glomerulosclerosis (CKD)  Glomeruli changes  Capillary basement thickening  Patho  Glucose incorporated into noncellular components  Influenced by high glucose levels  HTN and smoking accelerate progression  Albumin-protein in urine reflect progression of disease

23. 23 Treatment: Renal  Tight blood glucose control  Random urine test for albumin/creatinine  Control of BP - low sodium diet  Aggressively treat UTI  If nephropathy - restrict protein  Avoid dehydration - careful use of diuretics  Dialysis  Avoid drugs that injure kidney, if IV dye - give fluids prior

24. 24 Exercise Therapy  Essential part of treatment  Also increases well-being  Can produce hypoglycemia or hyperglycemia  Low intensity aerobic best - walk, swim  20 to 40 minutes performed 4 to 7 days/week  Keep logs to note progress

25. 25 Exercise Therapy  Complete physical check up before exercise program initiated  Exercise with a friend  Always carry a simple sugar  Always carry ID  Athletes who are diabetic - extra planning Monitor BG levels to determine effects on their body

26. 26 Diet  15 - 20% protein, 80% COH, <10% saturated fat  Moderate to high dietary fiber - gradual. If a food has 5 or > GM/ fiber can deduct from COH  Alcohol - 2/day for men, 1 for women  Food labels vital  Individual meal plans  Consistent meals and snacks  Type 2 - may be on calorie restriction for wt loss

27. 27 Physical & Emotional Needs  Entire family affected - stress of diagnosis  Prepare same meals for family - “not special”  Group education classes - cooking classes  Most is one to one education to tailor to client  Assess individual educational needs considering lifestyle, attitude, goals, ethnic, home, background  Wealth of teaching materials - printed, electronic

28. 28 Non-Compliance  Sometimes lack of knowledge, lack of power: Role of nurse to empower  Peer pressure  Lack of motivation - unaware of consequences  Poor family history of previous members  Inadequate finances  Unfamiliar with health care system  Lack of advocate  History of obesity

29. 29 Community Resources  Home care for post hospital teaching  Out patient diabetic education  Contact for emergency  Assistance with shopping or cooking  Referrals to local resources - Traveling clinics, senior citizens  American Diabetes Association

30. 30 Hyperglycemic-Hyperosmolar Nonketotic Syndrome and Coma  Caused by hyperglycemia  Increased insulin resistance & CHO intake  Absence of ketones & higher glucose levels (BG >800) than keto-acidosis  High blood osmolarity (>350 mOsm/L)  Pulls water out of body cells including brain  Mortality 50%  Gradual onset  Coma, confusion, decreased Glasgow, Seizures  Treatment:  IV fluids 6 to 20 liters in 24 hours  IV insulin