1. Diabetes- Chapter 49

2. Types of Diabetes
Type 1—insulin-dependent diabetes mellitus (IDDM)
Type 2—non-insulin-dependent diabetes mellitus (NIDDM)

3. Four Pillars of Management of Diabetes
Meal planning referred to as medical nutrition therapy
Activity and exercise
Medication
Self monitoring of blood glucose (SMBG)

4. Insulin
A hormone produced by the beta cells in the pancreas that acts to maintain blood glucose levels within normal limits

5. Insulin
Essential for the use of glucose in cellular metabolism and for proper protein and fat metabolism

6. Insulin Controls the use of glucose, protein, and fat in the body
Lowers blood sugar by inhibiting glucose production by the liver

7. Insulin
Available as purified extracts from beef and pork pancreas (used infrequently)
Synthetic insulins, such a human insulin and insulin analogs; derived from strains of Escherichia coli (recombinant DNA), fewer allergies with this than extracts of beef and pork

8. Insulin (Con’t)
Used to treat diabetes mellitus and control more severe and complicated forms of type 2 diabetes

9. Insulin Injections
Must be injected into the subcutaneous in the legs, arms, stomachs or buttocks. Cannot be taken orally

10. ADMINISTERING INSULIN BY INJECTION
Administered with an insulin syringe

11. Insulin Preparations See handout from Introduction to Pharmacology
Text, page 546

12. Onset, Peak, and Duration of Action
Define onset, peak and duration

13. Insulin Contraindications
Contraindicated if patient has hypersensitivity to any ingredient in the product (older preparations made with beef and pork) and if the patient is hypoglycemic

14. Precautions
Used cautiously with renal and hepatic impairment and during pregnancy and lactation

15. Interactions
See table 49-1 Drugs that Decrease and Increase the Hypoglycemic Effect of Insulin, page 547
Include as nursing considerations

16. Drugs that Decrease the Hypoglycemic Effect of Insulin

17. Drugs that Increase the Hypoglycemic Effect of Insulin

18. MIXING INSULINS

19. Promoting Optimal Response to Insulin Therapy
Will be individualized
Expect adjustments when under stress and with any illness, particularly illnesses resulting in nausea and vomiting

20. Examples of Insulin Administration using a Sliding Scale
Handout from Morton Hospital (use as an example)
Double sided (reverse has how to treat hypoglycemia)
Follow agency protocol

21. Preparing Insulin for Administration
Current insulin bottle at room temperature, except Lantus which is refrigerated

22. Rotating Injection Sites
Rotating sites prevents lipodystrophy (atrophy of subcutaneous fat)
Lipodystrophy interferes with absorption of insulin

23. Body Diagram of Appropriate Sites

24. Methods of Administering Insulin
Parenteral-subcutaneous or intravenous
Insulin Pump

25. Insulin Pumps
Newer technology. Attempts to mimic the body’s normal pancreatic function.
Only regular insulin is used.
Needle inserted subcutaneously and left in place for 1-3 days
Battery operated.
Amount of insulin injected can be adjusted according to blood glucose levels (monitored 4-8 times a day)

26. Monitoring and Managing Adverse Reactions
Must know signs and symptoms of hypoglycemia and hyperglycemia

27. Signs of Hyperglycemia

28. Signs of Hypoglycemia

29. Educating the Patient and Family
Review principles of teaching the adult patient

30. Nursing Diagnoses Anxiety and Fear
Impaired Adjustment, Coping, and Altered Health Maintenance
Acute confusion related to hypoglycemic reaction

31. Oral Drugs Sulfonylureas Biguanides Alpha-glucosidase inhibitors
Meglitinides
Thiazolidinediones
DP-4 Inhibitors- not in textbook (increase insulin secretion and reduce circulating glucagon in a glucose-dependent manner (Januvia)
See Summary of Drugs- pages
Sometimes oral antidiabetic drugs are used in combinations

32. Sulfonylureas
Examples—tolbutamide (Orinase), glipizide (Glucotrol), glyburide (Diabeta, Micronase), glimepiride (Amaryl)
Act to lower blood glucose by stimulating the beta cell to release insulin
Adverse Reactions—
Nursing considerations:
Secondary failure may occur (may lose effectiveness, may prescribe another sulfonylureas or add another oral antidiabetic drug such as metformin

33. Biguanides Example—metformin (Glucophage)
Action—reduces hepatic glucose production and increases insulin sensitivity to muscle and fat cells
Adverse Reactions—
Rare SE: lactic acidosis with kidney failure
Nursing implications; give with meals. Glucophage XR given once daily with evening meal. Glucophage must be stopped 48 hours before and after radiology studies that use iodine

34. Alpha-Glucosidase Inhibitors
Examples—acarbose, miglitol
Action—lower blood sugar by delaying carbohydrate digestion and absorption
Adverse Reactions—
Nursing considerations:

35. Meglitinides Examples—nateglinide (Starlix), repaglinide (Prandin)
Action—stimulate insulin release from the pancreas in response to a glucose load
Adverse Reactions –
Nursing considerations:

36. Thiazolidinediones
Examples—rosiglitazone (Avandia), pioglitazone (Actos)
Action—decrease insulin resistance and increase insulin sensitivity by modifying several processes
Adverse Reactions—
Nursing considerations:

37. Combination Agents Metaglip- glipizide and metformin
Glucovance-glyburide and metformin
Actoplus Met- pioglitazone and metformin
Avandamet- rosiglitazone and metformin
Duetact- Pioglitazone and glimepiride
Avandaryl- rosiglitzone and glimepride

38. Pharmacologic Algorithm for Treating Type 2 Diabetes
See text, page 558

39. Emergency Medications to Elevate Glucose
Glucagon IM (glucagon is a hormone produced by the alpha cells of the pancreas-stimulates the conversion of glycogen to glucose in the liver. . return to consciousness within 5-20 minutes)
IV D50

40. Case Study
Timothy Jones is admitted to your unit with a diagnosis of new onset type 1 diabetes mellitus. His blood sugars have stabilized and he is beginning to ask questions. How would you answer the following questions?
What is diabetes?
Why can’t I be on pills instead of insulin?
Why do I have to test my blood sugars?
What should I do if it is too high or too low?
Does insulin have any side effects? What should I watch for?