1. Copyright © 2007 Lippincott Williams & Wilkins. Diabetes in my family Slide 1 My grandmother was a Type 2 Diabetic. My husband’s cousin is a Type 1 Diabetic

2. Copyright © 2007 Lippincott Williams & Wilkins. Slide 2 Timby/Smith: Introductory Medical-Surgical Nursing, 9/e Chapter 57: Caring for Clients With Diabetes Mellitus

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5. Copyright © 2007 Lippincott Williams & Wilkins. Slide 5 Diabetes Mellitus Prediabetes Mellitus Can lead to Type 2 diabetes Heart disease Stroke Impaired fasting glucose (IFG) 100 to 125 mg/dL Impaired glucose tolerance (IGT) 140 to 199 mg/dL

6. Copyright © 2007 Lippincott Williams & Wilkins. Slide 6 Diabetes Mellitus Hyperglycemia Associated: Other disorders; their management Pancreatitis; adrenocortical hormones Pathophysiology and Etiology Type 1 diabetes mellitus (IDDM) Juvenile diabetes; no insulin produced Lipolysis; ketones; ketoacidosis Autoimmune disorder Type 2 diabetes mellitus (NIDDM) Insulin resistant; insufficient insulin; inherited

7. Copyright © 2007 Lippincott Williams & Wilkins. Slide 7 Diabetes Mellitus Pathophysiology and Etiology Type 2 diabetes mellitus (NIDDM) (cont’d) Obesity—trigger; glycosuria; impaired renal threshold; ketonemia; Kussmaul respirations Assessment Findings Signs and symptoms Polyuria; polydipsia; polyphagia; weight loss; dehydration; blurred vision; thirst; infections: Skin, urinary tract, vaginal Diagnostic findings Urinary tests; blood tests; glucometer; hemoglobin A1c test

8. Copyright © 2007 Lippincott Williams & Wilkins. Slide 8 Diabetes Mellitus Medical Management Depends on type of diabetes Diet and weight loss: Major component of treatment Exercise Reduces need for insulin Improves blood circulation Insulin Types of insulin Human; beef and pork Alternatives to injection

9. Copyright © 2007 Lippincott Williams & Wilkins. Slide 9 Diabetes Mellitus Medical Management Insulin (cont’d) Administration of insulin Dosage: u-100; type IV; subcutaneous; lipoatrophy; lipohypertrophy Insulin pen Jet injector Insulin pump Figure 57-8 Absorption of Insulin through (A) A needle (B) Jet Injector

10. Copyright © 2007 Lippincott Williams & Wilkins. Slide 10 Diabetes Mellitus Medical Management Oral antidiabetic agents-type 2 1.Sulfonylureas and meglitinides SAM- insulin releaser 2.Biguanides and thiazolidinediones BAT- insulin sensitizer (GI complications) 3.Alpha-glucosidase inhibitors (balancer)- glucose formation is slowed, 15 mintues AC *interferes with conversion of Carbs, can not give juice must give glucose tablets or injection

11. Copyright © 2007 Lippincott Williams & Wilkins. Pancreas transplantation- Life long Immunosuppressant drugs Slide 11

12. Copyright © 2007 Lippincott Williams & Wilkins. Islet Cell Transplantation 2 pancreas, pigs, used in 12hours, no steroids with immunosuppressant drugs Very little Insulin/can eat whatever! Slide 12

13. Copyright © 2007 Lippincott Williams & Wilkins. Slide 13 Diabetes Mellitus Nursing Management History: medical; drug; allergy; family Weight; head-to-toe physical examination; vital signs Observe for physical changes; edema; visual changes Client and family education Diet Treatment: Insulin administration; blood glucose monitoring; urine testing; rotation of injection sites

14. Copyright © 2007 Lippincott Williams & Wilkins. Slide 14 Diabetes Mellitus Nursing Management Client and family education (cont’d) Exercise; weight reduction Drinking adequate water; skin care; foot care Signs and symptoms of hyperglycemia and hypoglycemia Integration of dietary exchange list

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16. Copyright © 2007 Lippincott Williams & Wilkins. Slide 16 Acute Complications of Diabetes Mellitus: Diabetic Ketoacidosis (DKA) Pathophysiology and Etiology Brittle diabetes; noncompliance with treatment; infection Acidotic state; coma Assessment Findings Weakness; thirst; anorexia; vomiting; drowsiness; abdominal pain; Kussmaul respirations; low BP Blood glucose; urine test; laboratory tests; blood pH

17. Copyright © 2007 Lippincott Williams & Wilkins. Slide 17 Acute Complications of Diabetes Mellitus: Diabetic Ketoacidosis Medical Management Main goals Reduce the elevated blood glucose Correct fluid and electrolyte imbalances Clear the urine and blood of ketones IV Insulin; glucose Isotonic fluid Potassium replacements

18. Copyright © 2007 Lippincott Williams & Wilkins. Slide 18 Acute Complications of Diabetes Mellitus: Diabetic Ketoacidosis Nursing Management Monitor IV infusions; vital signs; urinary output Check Serum electrolyte findings; blood glucose level Check for Ketones; hyperkalemia

19. Copyright © 2007 Lippincott Williams & Wilkins. Slide 19 Acute Complications of Diabetes Mellitus: Hyperosmolar Hyperglycemic Nonketotic Syndrome Pathophysiology and Etiology Results from serious illness; diuresis; blood glucose >500; pH normal range Assessment Findings Hypotension; mental changes Extreme thirst; dehydration; tachycardia Fever; neurologic signs Physical examination; blood glucose Serum potassium; sodium Serum osmolarity

20. Copyright © 2007 Lippincott Williams & Wilkins. Slide 20 Acute Complications of Diabetes Mellitus: Hyperosmolar Hyperglycemic Nonketotic Syndrome Medical Management Insulin administration; correction of fluid and electrolyte imbalances; CVP Nursing Management Assess for electrolyte imbalances Blood glucose levels Implement medical orders for insulin Evaluate hydration status; skin turgor; vital signs; electrolyte studies Observe neurologic, cognitive symptoms

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22. Copyright © 2007 Lippincott Williams & Wilkins. Slide 22 Long-Term Complications of Diabetes Tissue or Organ Affected What HappensComplications Blood vesselsFatty material (atherosclerotic plaque) builds up and blocks large or medium-sized arteries in the heart, brain, legs, and penis. The walls of small blood vessels are damaged so that the vessels do not transfer oxygen to tissues normally, and the vessels may leak. Poor circulation causes wounds to heal poorly and can lead to heart disorders, strokes, gangrene of the feet and hands, erectile dysfunction (impotence), and infections. EyesThe small blood vessels of the retina are damaged. Decreased vision and, ultimately, blindness occur.

23. Copyright © 2007 Lippincott Williams & Wilkins. Slide 23 KidneyBlood vessels in the kidney thicken. Protein leaks into urine. Blood is not filtered normally. The kidneys malfunction, and ultimately, kidney failure occurs. NervesNerves are damaged because glucose is not metabolized normally and because the blood supply is inadequate. Legs suddenly or gradually weaken. People have reduced sensation, tingling, and pain in their hands and feet. Autonomic nervous system The nerves that control blood pressure and digestive processes are damaged. Swings in blood pressure occur. Swallowing becomes difficult. Digestive function is altered, and sometimes bouts of diarrhea occur. Erectile dysfunction develops. SkinBlood flow to the skin is reduced, and sensation is decreased, resulting in repeated injury. Sores and deep infections (diabetic ulcers) develop. Healing is poor. BloodWhite blood cell function is impaired. People become more susceptible to infections, especially of the urinary tract and skin. Connective tissue Glucose is not metabolized normally, causing tissues to thicken or contract Carpal tunnel syndrome and Dupuytren's contracture develop

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25. Copyright © 2007 Lippincott Williams & Wilkins. Slide 25 Acute Complications of Diabetes Mellitus: Hypoglycemia Pathophysiology and Etiology Hyperinsulinism—blood glucose <60 mg/dL Contributing factors: Diet; exercise; alcohol Assessment Findings Signs and symptoms: Nausea; drowsiness; hunger; malaise; excessive perspiration; confusion; coordination difficulty; personality or behavior changes Diagnostic findings: Symptoms; history; blood glucose levels; glucometer test

26. Copyright © 2007 Lippincott Williams & Wilkins. http://www.youtube.com/watch?v=zLrsCnB vQFo Slide 26

27. Copyright © 2007 Lippincott Williams & Wilkins. Slide 27 Acute Complications of Diabetes Mellitus: Hypoglycemia Medical Management Administration of 15 to 20 g of simple carbohydrate as soon as possible Glucagon; IV administration of 50% glucose Complex carbohydrates Nursing Management Oral source glucose-conscious client Implements medical orders for parenteral medications Monitor blood glucose level Measures to prevent hypoglycemia

28. Copyright © 2007 Lippincott Williams & Wilkins. Slide 28 Chronic Complications of Diabetes Mellitus: Peripheral Neuropathy Pathophysiology and Etiology Poor glucose control; decreased blood circulation to nerve tissue Motor neuropathy; sensory neuropathy; autonomic neuropathy Assessment Findings Signs and symptoms: Pain; swollen feet Figure 57-8 Neuropathic ulcers occur on pressure points

29. Copyright © 2007 Lippincott Williams & Wilkins. Slide 29 Chronic Complications of Diabetes Mellitus: Peripheral Neuropathy Assessment Findings Signs and symptoms: Disturbing sensations; digestive, urinary, and sexual dysfunction; dizziness; smaller skeletal muscles Diagnostic findings: Neurologic examination; screening test; electromyography Medical Management Diet; exercise; pain relief measures Drug therapy; antibiotic therapy Drugs to reverse diabetic neuropathies

30. Copyright © 2007 Lippincott Williams & Wilkins. Slide 30 Chronic Complications of Diabetes Mellitus: Peripheral Neuropathy Nursing Management Teaching plan: Management; potential complications Foot care Precautions for autonomic neuropathy, digestive problems Compliance with prescribed medications and dosage Referral to urologist

31. Copyright © 2007 Lippincott Williams & Wilkins. Slide 31 Chronic Complications of Diabetes Mellitus: Diabetic Nephropathy Pathophysiology and Etiology Glomerular deterioration; five stages Assessment Findings Swollen feet and hands Gradually increasing BP Tiredness Weakness Urinalysis Serum creatinine test Renal creatinine clearance test

32. Copyright © 2007 Lippincott Williams & Wilkins. Slide 32 Chronic Complications of Diabetes Mellitus: Diabetic Nephropathy Medical Management Control blood glucose levels, hypertension Drug therapy; Dietary protein reduction; smoking cessation Nursing Management Monitor blood glucose and hemoglobin A1c results Check for albuminuria Smoking cessation measures Explain the therapeutic regimen

33. Copyright © 2007 Lippincott Williams & Wilkins. Slide 33 Chronic Complications of Diabetes Mellitus: Diabetic Retinopathy Pathophysiology and Etiology Vascular changes in retina Types Nonproliferative Proliferative—blindness Assessment Findings Diminished visual acuity Opthalmic examination; fluorescein angiography Figure 57-11 Top: In the normal eye Bottom: In diabetic retinopathy

34. Copyright © 2007 Lippincott Williams & Wilkins. Slide 34 Chronic Complications of Diabetes Mellitus: Diabetic Retinopathy Medical Management Laser photocoagulation; vitrectomy; ACE inhibitor Nursing Management Encourage therapeutic regimen for tight glucose control Client education Complications of diabetes Regular ophthalmic examinations Medication

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36. Copyright © 2007 Lippincott Williams & Wilkins. Slide 36 Chronic Complications of Diabetes Mellitus: Vascular Disturbances Pathophysiology and Etiology Thickening of arterial walls; coronary artery disease Insensitivity to leptin; hyperlipidemia Assessment Findings Cool extremities; leg cramps Gangrene; skin ulcers; myocardial infarctions Laboratory tests; angiography Doppler ultrasonic flow studies

37. Copyright © 2007 Lippincott Williams & Wilkins. Slide 37 Chronic Complications of Diabetes Mellitus: Vascular Disturbances Medical and Surgical Management Lipid-lowering measures; vasodilators Platelet aggregation reduction drugs Amputation Insulin; antidiabetic drugs Nursing Management Related to Type of vascular disturbance Client’s signs and symptoms

38. Copyright © 2007 Lippincott Williams & Wilkins. Slide 38 General Considerations Nutritional Considerations Nutrition therapy: Cornerstone of treatment Diet depends on the type of diabetes Individualized meal plans Exchange lists to simplify meal planning Consistency in the total amount of carbohydrate consumed influences blood glucose level

39. Copyright © 2007 Lippincott Williams & Wilkins. Slide 39 General Considerations Pharmacologic Considerations Properties of insulin: Onset; peak; duration Clients may be sensitive to minute insulin dose changes Insulin; oral antidiabetic drugs: Control hyperglycemia, but do not cure diabetes Oral antidiabetic drugs along with insulin therapy decreases the incidence of hypoglycemia (with IDDM)

40. Copyright © 2007 Lippincott Williams & Wilkins. Slide 40 General Considerations Gerontologic Considerations Provide sufficient time, instruction, and assistance to learn self-care Active involvement of client and family Plan meals and treatment based on eating and sleeping habits of older adults Emphasize foot care Review all drugs for any that may interact with oral antidiabetic drugs

41. Copyright © 2007 Lippincott Williams & Wilkins. Slide 41 End of Presentation