Care of the Client with Diabetes

Care of the Client with Diabetes
Presentation lecture by:Christie M. Candelaria, MA, RN, CCRN.

DIABETES MELLITUS

* Caused by a relative deficit of insulin secretion from the beta cells in the islets of Langerhans or by a lack of response by cells to insulin (insulin resistance)
* Deficient insulin results in abnormal carbohydrate, protein, and fat metabolism due to impaired transport of glucose and amino acids into the cells

Types of Diabetes

* Type I
* Type 2
* Gestational
* Other types include:
o Genetic defect beta cell or insulin
o Disease of exocrine pancreas
o Drug or chemical induced
o Infections
o Others

Pathophysiology: INITIAL STAGE
* Insulin deficit leads to:
o Decreased transportation and use of glucose in many cells of the body
o Blood glucose levels rise (hyperglycemia)
o Excess glucose spills into the urine (glucosuria)
o Glucose in the urine exerts osmotic pressure in the filtrate, resulting in large volume of urine to be excreted (polyuria) with loss of fluids and electrolytes from the body tissues
o Fluid loss through the urine and high blood glucose levels draw water from the cells, resulting in dehydration
o Dehydration causes thirst (polydipsia)
o Lack of nutrients entering the cells stimulates appetite (polyphagia)

PROGRESSIVE EFFECTS

* Lack of glucose in cells results in catabolism of fats and proteins, leading to excessive amounts of fatty acids and their metabolites known as ketones or ketoacids in the blood.
* Some ketoacids are excreted in the urine (ketonuria)

Acute Complications of Diabetes
* Diabetic ketoacidosis
* Hyperglycemic-hyperosmolar-nonketotic syndrome
* Hypoglycemia from too much insulin or too little glucose

Chronic Complications of Diabetes
* Macrovascular complications
o Cardiovascular disease
o Cerebrovascular disease
o Peripheral vascular disease
* Microvascular complications
o Retinopathy (vision) problems
o Diabetic neuropathy
o Diabetic nephropathy
o Male erectile dysfunction
Assessment
* History
* Blood tests
o Fasting blood glucose test: two tests > 126 mg/dL
o Oral glucose tolerance test: blood glucose > 200 mg/dL at 120 minutes
o Glycosylated hemoglobin assays
o Glucosylated serum proteins and albumin

Urine Tests
* Urine testing for ketones
* Urine testing for renal function
* Urine testing for glucose

Drug Therapy
Goal: tight glycemic control
* Drug administration
* Drug selection
* Insulin therapy:
o Insulin analogue
o Short-acting insulin
o Concentrated insulin
o Intermediate
Oral Blood Glucose Lowering Agents

Sulfonylureas

* Appropriate only for clients with pancreatic beta cell function
* Most common serious complication: hypoglycemia
* Side Effects: hematologic reactions
o Allergic skin reactions
o Gastrointestinal effects

Meglitinides
* Repaglinide (Prandin)
* Action and side effects similar to sulfonylureas: hypoglycemia
o GI disturbances
o UR infections
o Arthralgia
o Back pain
o headache

Biguanides

* Metformin (glucophage)
* The only biguanide available in the USA
* Can cause lactic acidosis in clients with renal insufficiency

Alpha-glucosidase inhibitors

* Acarbose (Precose)
* Reduce postprandial hyperglycemia by slowing digestion and absorption of carbohydrate within the intestine
* Side effects: abdominal discomfort related to undigested carbohydrate in the intestinal tract

Thiazolidinedione antidiabetic agents
* Troglitazone
* Enhance insulin action, promoting glucose utilization in peripheral tissues
* Liver function studies should be done at the start of therapy and at regular intervals during therapy

Combination agents
* Combinations from two different classes of medications
* E.g: Glucovance

What’s New

* DDP-4 inhibitors – help lower blood glucose levels by increasing and prolonging the action of GLP-1
o Also called “incretin enhancers”
o How does it work:

When we eat, GLP-1 (glucagonlike peptide-1) is released by the small intestine in response to ingested carbohydrates which

1. helps regulate the synthesis and release of insulin from the pancreatic beta cells
2. initiates neuropeptide reactions that reduce hepatic glucose (glucagon) production after meals
3. induce satiety by crossing the blood-brain barrier to reduce appetite
4. slows down gastric emptying
5. may also play a role in beta-cell regrowth and repair known as its “pancreatic-sparing effect”
* Sitagliptin (Januvia) – first in the market
o Can be used alone or in combination with other oral medications like metformin or thiazolidinediones
o Available in 25 mg, 50 mg, 100 mg tabs.
o Typically administered as a 100-mg dose once daily with or without food; can be titrated down depending on patient’s renal status
o Weight-neutral drug; neither promoting weight loss or weight gain
o Approved only for adults
o Adverse reactions: URTI, nasopharyngitis, diarrhea, headache
* Vildagliptin (Galvus) – in the final stages of FDA approval

Insulin Regimens

* Single daily injection protocol
* Two-dose protocol
* Three-dose protocol
* Four-dose protocol
* Combination therapy
* Intensified therapy regimens

Drug Therapy

o Fixed-combination
o Long-acting
o Buffered insulins

Complications of Insulin Therapy

* Hypoglycemia
* Lipoatrophy
* Dawn phenomenon
* Somogyi's phenomenon

Alternative Methods of Insulin Administration

* Continuous subcutaneous infusion of insulin
* Implanted insulin pumps
* Injection devices
* New technology includes:
o Inhaled insulin
o Transdermal patch (being tested)

Client Education

* Storage and dose preparation
* Syringes
* Blood glucose monitoring
* Interpretation of results
* Frequency of testing
* Blood glucose therapy goals

Diet Therapy
* Goals of diet therapy
* Principles of nutrition in diabetes
o Protein, fats and carbohydrates, fiber, sweeteners, fat replacers
o Alcohol
o Food labeling
o Exchange system, carbohydrate counting
o Special considerations for type 1 and type 2 diabetes

Exercise Therapy

* Benefits of exercise
* Risks related to exercise
* Screening before starting exercise program
* Guidelines for exercise
* Exercise promotion

Whole-Pancreas Transplantation
* Operative procedure
* Rejection management
* Long-term effects
* Complications
* Islet cell transplantation hindered by limited supply of beta cells and problems caused by antirejection drugs

Nursing Diagnoses
Risk for Injury Related to Sensory Alterations
* Interventions and foot care practices:
o Cleanse and inspect the feet daily.
o Wear properly fitting shoes.
o Avoid walking barefoot.
o Trim toenails properly.
o Report nonhealing breaks in the skin.

Wound Care

* Wound environment
* Debridement
* Elimination of pressure on infected area
* Growth factors applied to wounds

Chronic Pain

* Interventions include:
o Maintenance of normal blood glucose levels
o Anticonvulsants
o Antidepressants
o Capsaicin cream

Risk for Injury Related to Disturbed Sensory Perception: Visual
* Interventions include:
o Blood glucose control
o Environmental management
+ Incandescent lamp
+ Coding objects
+ Syringes with magnifiers
+ Use of adaptive devices

Ineffective Tissue Perfusion: Renal
* Interventions include:
o Control of blood glucose levels
o Yearly evaluation of kidney function
o Control of blood pressure levels
o Prompt treatment of UTIs
o Avoidance of nephrotoxic drugs
o Diet therapy
o Fluid and electrolyte management

Potential for Hypoglycemia

* Blood glucose level < 70 mg/dL
* Diet therapy: carbohydrate replacement
* Drug therapy: glucagon, 50% dextrose, diazoxide, octreotide
* Prevention strategies for:
o Insulin excess
o Deficient food intake
o Exercise
o Alcohol

Potential for Diabetic Ketoacidosis
* Interventions include:
o Monitoring for manifestations
o Assessment of airway, level of consciousness, hydration status, blood glucose level
o Management of fluid and electrolytes
o Drug therapy goal: to lower serum glucose by 75 to 150 mg/dL/hr
o Management of acidosis
o Client education and prevention

Potential for Hyperglycemic-Hyperosmolar Nonketotic Syndrome and Coma

* Interventions include:
o Monitoring
o Fluid therapy: to rehydrate the client and restore normal blood glucose levels within 36 to 72 hr
o Continuing therapy with IV regular insulin at 10 units/hr often needed to reduce blood glucose levels


Health Teaching

* Assessing learning needs
* Assessing physical, cognitive, and emotional limitations
* Explaining survival skills
* Counseling
* Psychosocial preparation
* Home care management
* Health care resources

Care of the Client with Diabetes.ppt