T3 New Flashcards
cell destruction leading to absolute insulin deficiency • Autoimmune • Idiopathic
Type 1 Diabetes (T1DM)
• Ranges from insulin resistance with relative insulin deficiency to secretory deficit with insulin resistance
The body does not respond correctly to insulin,
blood sugar can not get into its cells To be stored later for energy,
so a high level of sugar builds up in the blood
Type 2 diabetes
Conditions resulting in hyperglycemia
Infection Cancer Beta cell defects Virus Pancreatitis Trauma
Genetic defects of beta-cell function
• Genetic defects in insulin action • Pancreatic diseases (pancreatitis, trauma, cancer, cystic fibrosis, hemochromatosis)
• Endocrine problems (acromegaly, Cushing’s disease, hyperthyroidism, aldosteronism)
• Drug- or chemical-induced hyperglycemia
• Infections: congenital rubella, cytomegalovirus, human immune deficiency virus
• Genetic syndromes associated with diabetes: Down syndrome, Klinefelter syndrome, Turner syndrome, Huntington disease, and others
Glucose intolerance with onset or first recognition during pregnancy. (All pregnant women should be screened.)
Gestational Diabetes Mellitus (GDM) •
Differentiation of Type 1
and Type 2 Diabetes Features
Type 1 Genetic DKA May occur- ketones Insulin dependent Young with dx Auto immune disease 3 ps Weight loss Pancreases doesn’t release insulin as needed so BS increases (pancreatic beta cell destruction)
Juvenile-onset diabetes- Ketosis-prone diabetes - Insulin-dependent diabetes mellitus (IDDM) Usually younger than 30 yr Abrupt onset, thirst, hunger, increased urine output, weight loss Viral infection, autoimmunity Antibodies Present at diagnosis Non-obese Dependant on insulin Inheritance is complex Pancreatic beta-cell destruction
Type 2 Any age- adults common Sedentary lifestyle Obese Can reduce insulin with exercise and diet Insulin resistance- body doesn’t react to insulin properly to sugar stays in blood and increases BS Dehydrated HHS - common no ketones C-peptide
Adult-onset diabetes Ketosis-resistant diabetes Non–insulin-dependent diabetes mellitus (NIDDM) May occur at any age in adults Frequently none s/s; thirst, fatigue, blurred vision, vascular or neural complications Insulin resistance Dysfunctional pancreatic beta cell Most obese c-peptide present
is the simultaneous presence of metabolic factors known to:
increase risk for developing type 2 DM and cardiovascular disease
Big belly
Increased fasting BS over 100
Increases BP - 130/85
Increased cholesterol over 150
Features of the syndrome include:
• Abdominal obesity: waist circumference of 40 inches (100 cm) or more for men and 35 inches (88 cm) or more for women
• Hyperglycemia: fasting blood glucose level of 100 mg/dL or more or on drug treatment for elevated blood glucose levels
• Hypertension: systolic BP of 130 mm Hg or more or diastolic blood pressure of 85 mg Hg or more or on drug treatment for hypertension
• Hyperlipidemia: triglyceride level of 150 mg/dL or more or on drug treatment for elevated triglycerides; high-density lipoprotein (HDL) cholesterol less than 40 mg/dL for men or less than 50 mg/dL for women
Metabolic syndrome
Risk for type 1 DM is determined by
inheritance of genes
is a low blood glucose level that induces specific symptoms and resolves when blood glucose concentration is raised. Once plasma glucose levels fall below 70 mg/dL (3.88 mmol/L), a sequence of events begins with release of counterregulatory hormones, stimulation of the autonomic nervous system, and production of neurogenic and neuroglycopenic symptoms.
Hypoglycemia
Peripheral autonomic symptoms,.
including sweating, irritability, tremors, anxiety, tachycardia, and hunger, serve as an early warning system and occur before the symptoms of confusion, paralysis, seizure, and coma occur from brain glucose deprivation
Neuroglycopenic symptoms occur when?
S/s
brain glucose gradually declines to a low level:
• Weakness • Fatigue • Difficulty thinking • Confusion • Behavior changes • Emotional instability • Seizures • Loss of consciousness • Brain damage • Death
Neurologic symptoms result from
autonomic nervous activity triggered by a rapid decline in blood glucose:
• Adrenergic: • Shaky/tremulous • Heart pounding • Nervous/anxious • Cholinergic: • Sweaty • Hungry • Tingling
▪ Signs and symptoms
Hypoglycemia s/s:
Skin: Cool, clammy
Dehydration: absent
Resp: no change
Mental status: anxious, nervous, irritable, mental confusion, seizures, coma
Symptoms: weakness, double vision, hunger, high pulse, palpitations
Glucose: less than 70
Urine or blood ketones: negative
▪ Treatment
For mild hypoglycemia:
(hungry, irritable, shaky, weak, headache, fully conscious; blood glucose usually less than 60 mg/dL [3.4 mmol/L]):
• Treat the symptoms of hypoglycemia with 10 to 15 g of carbohydrate. You may use one of these:
• Glucose tablets or glucose gel (dosage is printed on the package)
• cup (120 mL) of fruit juice • cup (120 mL) of regular (nondiet) soft drink
• 8 ounces (240 mL) of skim milk
• 6 to 10 hard candies
• 4 cubes of sugar
• 4 teaspoons of sugar
• 6 saltines
• 3 graham crackers
• 1 tablespoon (15 mL) of honey or syrup
• Retest blood glucose in 15 minutes.
• Repeat this treatment if glucose remains less than 60 mg/dL (3 mmol/L). Symptoms may persist after blood glucose has normalized.
• Eat a small snack of carbohydrate and protein if your next meal is more than an hour away.
Tx For moderate hypoglycemia:
(cold, clammy skin; pale; rapid pulse; rapid, shallow respirations; marked change in mood; drowsiness; blood glucose usually less than 40 mg/dL [2.2 mmol/L]):
• Treat the symptoms of hypoglycemia with 15 to 30 g of rapidly absorbed carbohydrate.
• Retest glucose in 15 minutes. • Repeat treatment if glucose is less than 60 mg/dL (3 mmol/L). • Eat additional food, such as low-fat milk or cheese, after 10 to 15 minutes.
For severe hypoglycemia
(unable to swallow; unconsciousness or convulsions; blood glucose usually less than 20 mg/dL [1.0 mmol/L]):
• Treatment administered by family members: • Give 1 mg of glucagon as intramuscular or subcutaneous injection. • Give a second dose in 10 minutes if the person remains unconscious. • Notify the primary health care provider immediately and follow instructions. • If still unconscious, transport the person to the emergency department. • Give a small meal when the person wakes up and is no longer nauseated.
The most common causes of hypoglycemia are:
- Too much insulin compared with food intake and physical activity
- Insulin injected at the wrong time relative to food intake and physical activity • The wrong type of insulin injected at the wrong time
- Decreased food intake resulting from missed or delayed meals
- Delayed gastric emptying from gastroparesis
- Decreased liver glucose production after alcohol ingestion
- Increased insulin sensitivity as a result of regular exercise and weight loss
- Decreased insulin clearance from progressive kidney failure
o hyperglycemia
▪ signs and symptoms
most people have no symptoms. However, some patients experience headaches, facial flushing (redness), dizziness, or fainting as a result of the elevated blood pressure. Obtain blood pressure readings in both arms. Two or more readings may be taken at each visit (Fig. 36-1). Some patients have high blood pressure due to anxiety associated with visiting a health care provider.
Tests for hyperglycemia
A1c
Fasting blood glucose
Two hour bg
Random bg concentration
Tests that indicate high bs :
1. >6.5%. The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.
- greater than or equal to 126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 hours.
- equal to or greater than 200 mg/dL (11.1 mmol/L) during oral glucose tolerance test. The test should be performed using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.
- In a patient with classic manifestations of hyperglycemia or hyperglycemic crisis, a what????? greater than 200 mg/dL (11.1 mmol/L). Casual is defined as any time of the day without regard to time since last meal.
The classic symptoms of diabetes include??
NOTE: In the absence of unequivocal hyperglycemia, the first three criteria should be confirmed by repeat testing.
A1c
Fasting blood glucose
Two hour bg
Random bg concentration
polyuria, polydipsia, and unexplained weight loss.
Tx for diabetes mellitus
The patient is expected to manage DM and prevent disease progression by maintaining blood glucose levels in his or her target range. Indicators are that the patient consistently demonstrates these behaviors:
- Performs treatment regimen as prescribed
- Follows recommended diet
- Monitors blood glucose using correct testing procedures
- Seeks health care if blood glucose levels fluctuate outside of recommended parameters
- Meets recommended activity levels
- Follows prescribed drug regimen
- Reaches and maintains optimum body weight
- Problem solves about barriers to self-management
When a patient who has had reasonably controlled blood glucose levels in the hospital develops an unexpected rise in blood glucose values, check for ??
wound infection.
Hyperglycemia often occurs before a ?.
Fever
S/s for hyperglycemia
Skin: warm, moist
Dehydration: present
Resp: rapid deep kussmaul type; acetone (fruity breath)
Mental status: varies from alert to stuporous, obtunded, or frank coma
s/s: none specific to DKA, acidosis, hypercapnia, abd cramps, nausea and vomiting. Dehydration, decreased neck vein filling, orthostatic hypotension, tachycardia, and poor skin turgor.
Glucose: 250 or above
Urine blood or ketones: positive (present)
What ? leads to osmotic diuresis with dehydration and electrolyte loss.-DKA
Hyperglycemia
BS normal lab values Lab values Fasting levels- ? Oral glucose tolerance test- A1C- 4-6 Less than 5.7 A1C = 5.7-6.4= 6.5 or over =
Lab values Fasting levels- less than 100 Oral glucose tolerance test- BS every 30 min for 2 hours after fasting for 10-12 hrs. less than 140 A1C- BEST indicator of blood glucose over 3-4 months 4-6 is usually normal range Less than 5.7 A1C = no diabetes 5.7-6.4= prediabetes 6.5 or over = diabetes
Fasting blood glucose?
Or Two-hour blood glucose?
a patient with classic manifestations of hyperglycemia or hyperglycemic crisis, a random blood glucose concentration ??
Fasting blood glucose greater than or equal to 126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 hours.
Or Two-hour blood glucose equal to or greater than 200 mg/dL (11.1 mmol/L) during oral glucose tolerance test. The test should be performed using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.
Or In a patient with classic manifestations of hyperglycemia or hyperglycemic crisis, a random blood glucose concentration greater than 200 mg/dL (11.1 mmol/L). Casual is defined as any time of the day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss. NOTE: In the absence of unequivocal hyperglycemia, the first three criteria should be confirmed by repeat testing.
Normal glucose
70-140
• Assess the patient’s ???what for indications of adherence to prescribed regimens and their effectiveness.
hemoglobin A1C
With insulin deficiency, the body turns to stored fat for energy, releasing free fatty acids. When this stored fat is used for energy, ketone bodies (small acids) provide a backup energy source. Ketone bodies (“ketones”) are abnormal breakdown products that collect in the blood when insulin is not available, leading to the ACID-BASE BALANCE problem of metabolic acidosis.
Guidelines for exercise are based on blood glucose levels and urine ketone levels. Recommend that the patient test blood glucose before exercise, at intervals during exercise, and after exercise to determine if it is safe to exercise and to evaluate the effects of exercise. The absence of urine ketones indicates that enough insulin is available for glucose transport. When urine ketones are present, the patient should not exercise. Ketones indicate that current insulin levels are not adequate and that exercise would elevate blood glucose levels.
Carbohydrate foods should be ingested to raise blood glucose levels above 100 mg/dL (5.6 mmol/L) before engaging in exercise.
Ketone assessment
Teach patients with type 1 DM to perform vigorous exercise only when blood glucose levels are
100 to 250 mg/dL (5.6 to 13.8 mmol/L) and no ketones are present in the urine.
The key feature of DKA ?
And what abg?
elevation in blood ketone concentration (measured as serum β-hydroxybutyrate).
Accumulation of ketoacids results in an increased anion gap metabolic acidosis. A normal anion gap is between 7 and 9 mEq/L (mmol/L); an anion gap greater than 10 to 12 mEq/L (mmol/L) indicates metabolic acidosis.
Electrolyte imbalance common in hyperglycemia ?
Common cause of death in the tx of DKA
Mild-to-moderate hyperkalemia is common in patients with hyperglycemia.
Insulin therapy, correction of acidosis, and volume expansion decrease serum potassium concentration.
To prevent hypokalemia, potassium replacement is initiated after serum levels fall below normal (5.0 mEq/L [mmol/L]). Assess for signs of hypokalemia, including fatigue, malaise, confusion, muscle weakness, shallow respirations, abdominal distention or paralytic ileus, hypotension, and weak pulse.
An ECG shows conduction changes related to alterations in potassium.
Hypokalemia is a common cause of death in the treatment of DKA.
Before giving IV potassium-containing solutions, make sure what?
that the urine output is at least 30 mL/hr.
Teach them to check urine ketone levels when blood glucose levels exceed ?
• Teach patients who exercise to test urine for ketone bodies if blood glucose levels are greater than?
300 mg/dL
250
• Hyperglycemia leads to osmotic diuresis with dehydration and electrolyte loss.
DKA
Dka s/s
- Classic symptoms of DKA include polyuria, polydipsia, polyphagia, a rotting citrus fruit odor to the breath, vomiting, abdominal pain, dehydration, weakness, confusion, shock, and coma.
- Mental status can vary from total alertness to profound coma.
- As ketone levels rise, the pH of the blood decreases, and acidosis occurs.
- Kussmaul respirations (very deep and rapid respirations) cause:
respiratory alkalosis in an attempt to correct metabolic acidosis by exhaling carbon dioxide
- low sodium
- Initial potassium levels depend on how long DKA lasts before treatment.
• After therapy starts,
serum potassium levels drop quickly.
What to assess in dka
- First assess the airway, level of consciousness, hydration status, electrolytes, and blood glucose level of any patient with diabetic ketoacidosis.
- Use blood glucose values to assess therapy effectiveness and determine when to switch from saline to dextrose-containing solutions in a patient with diabetic ketoacidosis.
Dka - average bs values in dka
• BS usually around 300-600 with ketones present
Pathophysiology- how DKA works
Pathophysiology
affects people with diabetes.
It occurs when the body starts breaking down fat at a rate that is much too fast.
The liver processes the fat into a fuel called ketones, which causes the blood to become acidic.
Insulin deficiency, increased insulin counter-regulatory hormones (cortisol, glucagon, growth hormone, and catecholamines) and peripheral insulin resistance lead to hyperglycemia, dehydration, ketosis, and electrolyte imbalance which underlie the pathophysiology of DKA
Tx for DKA
Treatment
Planning: Expected Outcomes.
The patient is expected to have few episodes of hyperglycemia and avoid diabetic ketoacidosis. Indicators include that the patient consistently demonstrates these behaviors:
- Maintains blood glucose levels within the prescribed target range
- Adjusts insulin doses to match eating patterns and blood glucose levels during illness
- Maintains easily digestible liquid diet containing carbohydrate and salt when nauseated
- Describes correct procedure for urine ketone testing
Describes when to seek help from health care professional
- Fluid replacement/ Electrolyte replacement.
- You’ll receive fluids — either by mouth or through a vein (intravenously) — until you’re rehydrated.
Give pt. 5% dextrose in 0.45% saline- This solution helps prevent hypoglycemia and cerebral edema, which can occur when serum osmolarity declines too rapidly.
Insulin therapy. regular insulin by continuous IV infusion is the usual management., – insulin to correct acidosis/hyperkalemia
HHS occurs in who?
Onset?
HHS occurs most often in older/dehydrated patients with type 2 DM, many of whom are unaware they have the disease
Mortality rates in older patients are high.
The onset of HHS is slow and may not be recognized.
The older patient often seeks medical attention later and is sicker than the younger patient.
HHS does not occur in well-hydrated patients.
Older patients are at greater risk for dehydration and HHS because of age-related changes in thirst perception, poor urine-concentrating abilities, and use of diuretics.
Assess all older adults for dehydration, regardless of whether they are known to have DM.
?? is a hyperosmolar (increased blood osmolarity) state caused by hyperglycemia and dehydration
results from a sustained osmotic diuresis.
Kidney impairment in this allows for extremely high blood glucose levels.
As serum concentrations of glucose exceed the renal threshold, the kidney’s capacity to reabsorb glucose is exceeded.
Decreased blood volume, caused by osmotic diuresis, or underlying kidney disease, common in many older patients with DM, results in further reduction of kidney function.
The decreased volume further reduces glomerular filtration rate, causing the glucose level to increase.
Decreased kidney PERFUSION from hypovolemia further impairs kidney function.
Hhs
Difference between HHS and dka
Both HHS and diabetic ketoacidosis (DKA) are caused by hyperglycemia and dehydration.
HHS differs from DKA in that:
ketone levels are absent or low and blood glucose levels are much higher.
Blood glucose levels may exceed 600 mg/dL and blood osmolarity may exceed 320 mOsm/
L. Table 64-13 lists the differences between DKA and HHS.
What to monitor, assess and report in HHS
When you notice changes in the level of consciousness; changes in pupil size, shape, or reaction; or seizures, respond by immediately notifying the primary health care provider.
Continually assess fluid status and level of consciousness in a patient with hyperglycemic-hyperosmolar state (HHS) during the resuscitation period.
• Immediately report indications of cerebral edema (abrupt changes in mental status; changes in level of consciousness; changes in pupil size, shape, or reaction; seizures) in a patient with HHS to the primary health care provider.
Tx in HHS
The first priority for fluid
replacement in HHS is to increase blood volume.
In shock or severe hypotension, normal saline is used. Otherwise half-normal saline is used.
Infuse fluids at 1 L/hr until central venous pressure or pulmonary capillary wedge pressure begins to rise or until..
blood pressure and urine output are adequate.
The rate is then reduced to 100 to 200 mL/hr.
Half of the estimated fluid deficit is replaced in the first 12 hours, and the rest is given over the next 36 hours.
Body weight, urine output, kidney function, and the presence or absence of pulmonary congestion and jugular venous distention determine the rate of fluid infusion.
In patients with heart failure, kidney disease, or acute kidney injury, monitor central venous pressure.
Assess the patient hourly for signs of cerebral edema, abrupt changes in mental status, abnormal neurologic signs, and coma.
Lack of improvement in level of consciousness may indicate inadequate rates of fluid replacement or reduction in plasma osmolarity.
Regression after initial improvement may indicate a too-rapid reduction in plasma osmolarity.
A slow but steady improvement in CNS function is the best evidence that fluid management is satisfactory.
with additional insulin at mealtimes is more effective in controlling blood glucose levels than other schedules.
It allows flexibility in meal timing because, if a meal is skipped, the additional mealtime dose of insulin is not given.
CSII is given by an externally worn pump containing a reservoir of rapid-acting insulin and is connected to the patient by an infusion set.
Teach him or her to adjust the amount of insulin based on data from blood glucose monitoring.
Rapid-acting insulin analogs are used with insulin infusion pumps
Problems with CSII include skin infections that can occur when the infusion site is not cleaned or the infusion set is not changed every 2 to 3 days.
Ketoacidosis may occur more often because of inexperience in pump use, infection, accidental cessation or obstruction of the infusion, or mechanical pump problems.
Stress the importance of testing for ketones when blood glucose levels are greater than 300 mg/dL (16.7 mmol/L).
Patients using CSII need intensive and extensive education
They must be able to operate the pump, adjust the settings, and respond appropriately to alarms.
Removing the pump for any length of time can result in hyperglycemia.
Provide supplemental insulin schedules for times when the pump is not operational.
o Insulin pumps
Continuous subcutaneous infusion of a basal dose of insulin (CSII)
How to draw up and give insulin
Do not mix any other insulin type with long acting- insulin glargine, insulin detemir, or any of the premixed insulin formulations such as Humalog Mix 75/25.
Rotate injection sites to prevent lipohypertrophy/scaring tissue
Inject 2 inches from belly button at 45-90-degree angle
Not rub site or put heat to site
Draw up clear (shorter acting) before cloudy (long acting) insulin first:
cloudy air first then clear air, clear insulin, then cloudy insulin
Monitor for s/s of hypoglycemia (confusion, diaphoresis, headache, shakiness, blurred vision, and decreased coordination)
Roll don’t shake vial
Refrigerate until open- date for 28 days except toujeo
Subcutaneous Insulin Administration With Vial and Syringe
- Wash your hands.
- Inspect the bottle for the type of insulin and the expiration date.
- Gently roll the bottle of intermediate-acting insulin in the palms of your hands to mix the insulin.
- Clean the rubber stopper with an alcohol swab.
- Remove the needle cover and pull back the plunger to draw air into the syringe. The amount of air should be equal to the insulin dose. Push the needle through the rubber stopper and inject the air into the insulin bottle.
- Turn the bottle upside down and draw the insulin dose into the syringe.
- Remove air bubbles in the syringe by tapping on the syringe or injecting air back into the bottle. Redraw the correct amount.
- Make certain the tip of the plunger is on the line for your dose of insulin. Magnifiers are available to assist in measuring accurate doses of insulin.
- Remove the needle from the bottle. Recap the needle if the insulin is not to be given immediately.
- Select a site within your injection area that has not been used in the past month.
- Clean your skin with an alcohol swab. Lightly grasp an area of skin and insert the needle at a 90-degree angle.
- Push the plunger all the way down. This will push the insulin into your body. Release the pinched skin.
- Pull the needle straight out quickly. Do not rub the place where you gave the shot.
- Dispose of the syringe and needle without recapping in a puncture-proof container. With a Pen Device
- Wash your hands.
- Check the drug label to be sure it is what was prescribed.
- Remove the cap.
- Look at the insulin to be sure it is evenly mixed if it contains NPH and that there is no clumping of particles.
- Wipe the tip of the pen where the needle will attach with an alcohol swab.
- Remove the protective pull tab from the needle and screw it onto the pen until snug. • Remove both the plastic outer cap and inner needle cap.
- Look at the dose window and turn the dosage knob to the appropriate dose.
- Holding the pen with the needle pointing upward, press the button until at least a drop of insulin appears. This is the “cold shot,” “air shot,” or “safety shot.” Repeat this step if needed until a drop appears.
- Dial the number of units needed.
- Hold the pen perpendicular to and against the intended injection site with the thumb on the dosing knob.
- Press the dosing knob slowly all the way to dispense the dose.
- Hold the pen in place for 6-10 seconds; then withdraw from the skin.
- Replace the outer needle cap; unscrew until the needle is removed and dispose of the needle in a hard plastic or metal container.
- Replace the cap on the insulin pen.
The most common source of error of taking bs and insulin
is related to the skill of the user and not to errors of the instrument.
Common errors involve failure to obtain a sufficient blood drop, poor storage of test strips, using expired strips, and not changing the code number on the meter to match the strip bottle code.
Help the patient select a meter based on cost of the meter and strips, ease of use, and availability of repair and servicing.
Provide training, explain and demonstrate procedures, assess visual acuity, and check the patient’s ability to perform the procedure using “teach-back” strategies.
Glucose meters are designed to reduce user error as much as possible.
Patient education
Teach patients who experience Somogyi phenomenon (early morning hyperglycemia)??
Teach patients with peripheral neuropathy to use?
control over blood glucose levels reduces what?.
Teach patients to rotate insulin injection sites within one area rather than to other areas, to prevent what??
Teach patients who exercise to test urine for ketone bodies if blood glucose levels are greater than ??
Instruct all patients with diabetes to avoid becoming dehydrated and to drink at least ?? of water each day unless another medical condition requires fluid restriction.
Refer patients newly diagnosed with diabetes to ??
• Remind patients with diabetes to have yearly ??
Urge patients newly diagnosed with DM to attend diabetes education classes to become a fully engaged partner in management of the disease.
Help patients who have pain from peripheral neuropathy determine which pain-relieving drugs and techniques work best for them
Instruct patients who are taking ?? drugs about an increased risk for hypoglycemic reactions.
• Teach patients who are taking ?? the symptoms of lactic acidosis (fatigue, dizziness, difficulty breathing, stomach discomfort, irregular heartbeat).
Start ??? replacement per the primary health care provider’s prescription or standing protocols immediately on identifying a patient with hypoglycemia.
• Give glucagon how and give what type of IV fluid?? IV to patients identified with hypoglycemia who cannot swallow
Patient education
Teach patients who experience Somogyi phenomenon (early morning hyperglycemia) to ensure an adequate dietary intake at bedtime
Teach patients with peripheral neuropathy to use a bath thermometer to test water for bathing, to avoid walking barefoot, and to inspect their feet daily.
control over blood glucose levels reduces the risk for the vascular complications of diabetes.
Teach patients to rotate insulin injection sites within one area rather than to other areas, to prevent changes in absorption.
Teach patients who exercise to test urine for ketone bodies if blood glucose levels are greater than 250 mg/dL before engaging in strenuous exercise.
Instruct all patients with diabetes to avoid becoming dehydrated and to drink at least 2 L of water each day unless another medical condition requires fluid restriction.
Refer patients newly diagnosed with diabetes to local resources and support groups.
• Remind patients with diabetes to have yearly eye examinations by an ophthalmologist.
Urge patients newly diagnosed with DM to attend diabetes education classes to become a fully engaged partner in management of the disease.
Help patients who have pain from peripheral neuropathy determine which pain-relieving drugs and techniques work best for them
Instruct patients who are taking sulfonylurea drugs about an increased risk for hypoglycemic reactions.
• Teach patients who are taking metformin the symptoms of lactic acidosis (fatigue, dizziness, difficulty breathing, stomach discomfort, irregular heartbeat).
Start carbohydrate replacement per the primary health care provider’s prescription or standing protocols immediately on identifying a patient with hypoglycemia.
• Give glucagon subcutaneously or IM and 50% dextrose IV to patients identified with hypoglycemia who cannot swallow
Outcome Criteria for Diabetes Teaching
Before self-management begins to home, the patient with diabetes or the significant other should be able to:
• Tell why insulin or a noninsulin antidiabetic drug is being prescribed
• Name which insulin or noninsulin antidiabetic drug is being prescribed, and name the dosage and frequency of administration
• Discuss the relationship between mealtime and the action of insulin or the other antidiabetic agent
• Discuss plans to follow diabetic diet instructions
• Prepare and administer insulin accurately
• Test blood for glucose or state plans for having blood glucose levels monitored
• Test urine for ketones and state when this test should be done
• Describe how to store insulin
• List symptoms that indicate a hypoglycemic reaction
• Tell which carbohydrate sources are used to treat hypoglycemic reactions
• Tell which symptoms indicate hyperglycemia • Tell which dietary changes are needed during illness
• State when to call the primary health care provider or the nurse (frequent episodes of hypoglycemia, symptoms of hyperglycemia)
• Describe the procedures for proper foot care
Exercise With diabetes education?
Teach the patient about the relationship between regularly scheduled exercise and blood glucose levels, blood lipid levels, and complications of diabetes.
- Reinforce the level of exercise recommended for the patient based on his or her physical health.
- Instruct the patient to wear appropriate footwear designed for exercise.
- Remind the patient to examine his or her feet daily and after exercising.
- Remind the patient to stay hydrated and not to exercise in extreme heat or cold.
- Warn the patient not to exercise within 1 hour of insulin injection or near the time of peak insulin action.
- Teach patients how to prevent hypoglycemia during exercise:
- Do not exercise unless blood glucose level is at least 80 and less than 250 mg/dL.
- Have a carbohydrate snack before exercising if 1 hour has passed since the last meal or if the planned exercise is high intensity.
- Carry a simple sugar to eat during exercise if symptoms of hypoglycemia occur.
- Ensure that identification information about diabetes is carried during exercise.
• Remind the patient to check blood glucose levels more frequently on days in which exercise is performed and that extra carbohydrate and less insulin may be needed during the 24-hour period after extensive exercise.
Teach patients with type 1 DM to:
perform vigorous exercise only when blood glucose levels are 100 to 250 mg/dL and no ketones are present in the urine.
-Because of the potential for alcohol-induced delayed hypoglycemia, instruct the patient with DM to ingest alcohol only with or shortly after meals.
Teach Desired Outcomes of Nutrition Therapy for the Patient With Diabetes
- Achieving and maintaining blood glucose levels in the normal range or as close to normal as is safely possible
- Achieving and maintaining a blood lipid profile that reduces the risk for vascular disease
- Achieving blood pressure levels in the normal range or as close to normal as is safely possible
- Preventing or slowing the rate of development of the chronic complications of diabetes by modifying nutrient intake and lifestyle
- Addressing patient NUTRITION needs, taking into account personal and cultural preferences and willingness to change
- Maintaining the pleasure of eating by limiting food choices only when indicated by scientific evidence
- Meeting the NUTRITION needs of unique times of the life cycle, particularly for pregnant and lactating women and for older adults with diabetes
- Providing self-management training for patients treated with insulin or insulin stimulators (secretagogues) for exercising safely, including the prevention and treatment of hypoglycemia and managing diabetes during acute illness
Teach patients with a history of hypoglycemic unawareness not to ??
Test at alternative sites.
Assessment of blood glucose levels is very important for these situations/teach patient when to take:
Symptoms of hypoglycemia/hyperglycemia • Hypoglycemic unawareness • Periods of illness • Before and after exercise • Gastroparesis • Adjustment of antidiabetes drugs • Evaluation of other drug therapies (e.g., steroids) • Preconception planning • Pregnancy
Education of insulin
Teach patients to refrigerate insulin that is not in use to maintain potency, prevent exposure to sunlight, and inhibit bacterial growth.
Insulin in use may be kept at room temperature for up to 28 days to reduce injection site irritation from cold insulin.
To prevent loss of drug potency, teach the patient to avoid exposing insulin to temperatures below 36° F (2.2° C) or above 86 F° (30° C),
avoid excessive shaking, and to protect insulin from direct heat and light.
Insulin should not be allowed to freeze.
Insulin glargine (Lantus) should be stored in a refrigerator (36° to 46° F [2.2° to 7.8° C]) even when in use.
Teach patients to discard any unused insulin after 28 days.
Teach patients to always have a spare supply of each type of insulin used.
A slight loss in potency may occur for bottles in use for more than 30 days, even when the expiration date has not passed.
Prefilled syringes are stable up to 30 days when refrigerated.
Store prefilled syringes in the upright position, with the needle pointing upward or flat, so insulin particles do not clog it.
Teach patients to roll prefilled syringes between the hands before using. Proper dose preparation is critical for insulin effectiveness and patient safety.
Teach patients that the person giving the insulin needs to inspect the vial before each use for changes (e.g., clumping, frosting, precipitation, or change in clarity or color) that may indicate loss in potency.
Preparations containing NPH insulin are uniformly cloudy after gently rolling the vial between the hands.
Other insulins should be clear when inspected in good lighting.
If potency is questionable, another vial or pen of the same insulin type should be used.
Syringes may be used to administer insulin. The standard insulin syringes are marked in insulin units. They are available in 1-mL (100-U)
Insulin and diabetic education
Education on insulin:
Before self-management begins to home, the patient with diabetes or the significant other should be able to:
• Tell why insulin or a noninsulin antidiabetic drug is being prescribed
• Name which insulin or noninsulin antidiabetic drug is being prescribed, and name the dosage and frequency of administration
• Discuss the relationship between mealtime and the action of insulin or the other antidiabetic agent
• Discuss plans to follow diabetic diet instructions
• Prepare and administer insulin accurately
• Test blood for glucose or state plans for having blood glucose levels monitored
• Test urine for ketones and state when this test should be done
• Describe how to store insulin
• List symptoms that indicate a hypoglycemic reaction
• Tell which carbohydrate sources are used to treat hypoglycemic reactions
• Tell which symptoms indicate hyperglycemia
• Tell which dietary changes are needed during illness
• State when to call the primary health care provider or the nurse (frequent episodes of hypoglycemia, symptoms of hyperglycemia)
• Describe the procedures for proper foot care
Patient and Family Education on Preparing for Self-Management Sick-Day Rules
- Notify your primary health care provider that you are ill.
- Monitor your blood glucose at least every 4 hours.
- Test your urine for ketones when your blood glucose level is greater than 240 mg/dL (13.8 mmol/L).
- Continue to take insulin or other antidiabetic agents.
- To prevent dehydration, drink 8 to 12 ounces (240 to 360 mL) of sugar-free liquids every hour that you are awake. If your blood glucose level is below your target range, drink fluids that contain sugar.
- Continue to eat meals at regular times.
- If unable to tolerate solid food because of nausea, consume more easily tolerated foods or liquids equal to the carbohydrate content of your usual meal.
- Call your primary health care provider for any of these danger signals:
- Persistent nausea and vomiting
- Moderate or large ketones
- Blood glucose elevation after two supplemental doses of insulin
- High (101.5° F [38.6° C]) temperature or increasing fever; fever for more than 24 hours
- Treat symptoms (e.g., diarrhea, nausea, vomiting, fever) as directed by your primary health care provider.
- Get plenty of rest.
Preparing for Self-Management Foot Care Instructions
- Notify your primary health care provider that you are ill.
- Monitor your blood glucose at least every 4 hours.
- Test your urine for ketones when your blood glucose level is greater than 240 mg/dL (13.8 mmol/L).
- Continue to take insulin or other antidiabetic agents.
- To prevent dehydration, drink 8 to 12 ounces (240 to 360 mL) of sugar-free liquids every hour that you are awake. If your blood glucose level is below your target range, drink fluids that contain sugar.
- Continue to eat meals at regular times.
- If unable to tolerate solid food because of nausea, consume more easily tolerated foods or liquids equal to the carbohydrate content of your usual meal.
- Call your primary health care provider for any of these danger signals:
- Persistent nausea and vomiting
- Moderate or large ketones
- Blood glucose elevation after two supplemental doses of insulin
- High (101.5° F [38.6° C]) temperature or increasing fever; fever for more than 24 hours
- Treat symptoms (e.g., diarrhea, nausea, vomiting, fever) as directed by your primary health care provider.
- Get plenty of rest.
• Glaucoma
o Pathophysiology
How does it occur?
Increase in IOP due to issue with optic nerve-leading cause of blindness.
the level of intraocular pressure is related to retinal ganglion cell death. Intraocular pressure can cause mechanical stress and strain on the posterior structures of the eye, notably the lamina cribrosa and adjacent tissues
Glaucoma is a group of eye disorders resulting in increased intraocular pressure (IOP). As described in Chapter 46, the eye is a hollow organ.
For proper eye function, the gel in the posterior segment (vitreous humor) and the fluid in the anterior segment (aqueous humor) must be present in set amounts that apply pressure inside the eye to keep it ball shaped.
Usually about 1 mL of aqueous humor is always present, but it is continuously made and reabsorbed at a rate of about 5 mL daily
A normal IOP requires a balance between production and outflow of aqueous humor
If the IOP becomes too high, the extra pressure compresses retinal blood vessels and photoreceptors and their synapsing nerve fibers.
This compression results in poorly oxygenated photoreceptors and nerve fibers.
These sensitive nerve tissues become ischemic and die. When too many have died, vision is lost permanently. Tissue damage starts in the periphery and moves inward toward the fovea centralis. Untreated, glaucoma can lead to complete loss of visual SENSORY PERCEPTION. Glaucoma is usually painless, and the patient may be unaware of gradual vision reduction.
In some cases of diabetic retinopathy, blood vessels on the retina are damaged
Open angle
Closed angle:
Normal IOP range:
Open angle is most common- aqueous humor outflow is decreased which results in increased in IOP and loss of peripheral vision
Closed angle: less common angle between iris and sclera closes completely- increase in IOP
Normal IOP range: 10-21 mmHg- Measure using tonometry. Measure drainage angle with gonioscopy.
??is one of the leading causes of blindness for people over the age of 60
Glaucoma
Common Causes of Glaucoma Primary Glaucoma
Aging • Heredity Associated Glaucoma • Diabetes mellitus • Hypertension • Severe myopia • Retinal detachment
Secondary Glaucoma
• Uveitis • Iritis • Neovascular disorders • Trauma • Ocular tumors • Degenerative disease • Eye surgery • Central retinal vein occlusion Risk is higher in African Americans over 40 and Hispanics or anyone over 60 years old.
o Prevention
Of glaucoma
Teach the patient that loss of visual SENSORY PERCEPTION from glaucoma can be prevented by early detection, lifelong treatment, and close monitoring.
Use of ophthalmic drugs that reduce ocular pressure can delay or prevent damage.
Chart 47-3 lists ways to help the older-adult patient with reduced visual SENSORY PERCEPTION to remain as independent as possible,
Chart 47-4 provides a list of interventions to care for any patient who has reduced vision.
These interventions can be very helpful when you care for hospitalized patients who have other disorders, yet also have sight problems.
Nursing Focus on the Older Adult Promote Independent Living in Patients With Impaired Vision Drugs
- Having a neighbor, relative, friend, or visiting nurse visit once a week to measure the proper drugs for each day may be helpful.
- If the patient is to take drugs more than once each day, it is helpful to use a container of a different shape (with a lid) each time. For example, if the patient is to take drugs at 9 AM, 1 PM, and 9 PM, the 9 AM drugs would be placed in a round container, the 1 PM drugs in a square container, and the 9 PM drugs in a triangular container.
- It is helpful to place each day’s drug containers in a separate box with raised letters on the side of the box spelling out the day.
- “Talking clocks” are available for the patient with low vision.
• Some drug boxes have alarms that can be set for different times. Communication
•
Telephones with large, raised block numbers may be helpful. The best models are those with black numbers on a white phone or white numbers on a black phone.
•
Telephones that have a programmable automatic dialing feature (“speed dial”) are very helpful. Programmed numbers should include those for the fire department, police, relatives, friends, neighbors, and 911. Safety
•
It is best to leave furniture the way the patient wants it and not move it.
• Throw rugs are best eliminated.
•
Appliance cords should be short and kept out of walkways.
• Lounge-style chairs with built-in footrests are preferable to footstools.
•
Nonbreakable dishes, cups, and glasses are preferable to breakable ones.
•
Cleansers and other toxic agents should be labeled with large, raised letters.
•
Hook-and-loop (Velcro) strips at hand level may help mark the locations of switches and electrical outlets. Food Preparation
•
Meals on Wheels is a service that many older adults find helpful. This service brings meals at mealtime, cooked and ready to eat. The cost of this service varies, depending on the patient’s
ability to pay.
•
Many grocery stores offer a “shop by telephone” service. The patient can either complete a computer booklet indicating types, amounts, and brands of items desired; or the store will complete this booklet over the telephone by asking the patient specific information. The store then delivers groceries to the patient’s door (many stores also offer a “put-away” service) and charges the patient’s bank card.
- A microwave oven is a safer means of cooking than a standard stove, although many older patients are afraid of microwave ovens. If the patient has and will use a microwave oven, others can prepare meals ahead of time, label them, and freeze them for later use. Also, many microwavable complete frozen dinners that comply with a variety of dietary restrictions are available.
- Friends or relatives may be able to help with food preparation. Often relatives do not know what to give an older person for birthdays or other gift-giving occasions. One suggestion is a homemade prepackaged frozen dinner that the patient enjoys. Personal Care
- Handgrips should be installed in bathrooms.
- The tub floor should have a nonskid surface.
- Male patients should use an electric shaver rather than a razor.
- Choosing a hairstyle that is becoming but easy to care for (avoiding parts) helps in independent living.
- Home hair-care services may be available. Diversional Activity
- Some patients can read large-print books, newspapers, and magazines (available through local libraries and vision services).
- Books, magazines, and some newspapers are available on audiotapes or discs.
- Patients experienced in knitting or crocheting may be able to create items fashioned from straight pieces such as afghans.
- Card games, dominoes, and some board games that are available in large, high-contrast print may be helpful for patients with low vision.
