Chapter 36: Assessment and management of people with diabetes mellitus

1. Chapter 36:Assessment and management of people with diabetes mellitus

2. Diabetes mellitus • A group of diseases characterised by hyperglycaemia due to defects in insulin secretion, insulin action, or both • Almost 1/3 of cases are undiagnosed • Prevalence is increasing • Minority populations and the elderly are disproportionately affected

3. Functions of insulin • Facilitates glucose entry into cells • Stimulates storage of glucose in the liver and muscle as glycogen • Signals the liver to stop releasing glucose • Enhances storage of dietary fat in adipose tissue • Accelerates transport of amino acids into cells • Inhibits breakdown of stored glucose, protein and fat

4. Classifications of diabetes • Type 1 diabetes • Type 2 diabetes • Gestational diabetes • Diabetes mellitus associated with other conditions or syndromes

5. Type 1 diabetes • Insulin-producing beta cells in the pancreas are destroyed by an autoimmune process • Requires insulin, as little or no insulin is produced • Onset is acute and usually before 30 years of age • Affects 5–10% of persons with diabetes

6. Type 2 diabetes • Reduced sensitivity to insulin (insulin resistance) and impaired beta cell function results in reduced insulin production • Affects 90–95% of persons with diabetes • More common in people over age 30 and those who are obese • Slow, progressive glucose intolerance • Treated initially with diet and exercise • Glucose lowering medicines and insulin usually required

7. Pathogenesis of type 2 diabetes

8. Question • Is the following statement true or false? • Type 1 diabetes is treated initially with diet and exercise

9. Answer • False • Type 2 diabetes, NOT type 1 diabetes, is treated initially with diet and exercise

10. Risk factors • Type 1: not inherited but a genetic predisposition combined with immunological and possibly environmental and epigenetic precipitating factors • Type 2: family history of diabetes, obesity, ethnicity, age over 45 years, previous identified impaired fasting glucose or impaired glucose tolerance, hypertension ≥ 140/90 mmHg, cholesterol <5.5 mmol/L , history of gestational diabetes or babies over 4.5 kilograms

11. Clinical manifestations • ‘Three Ps’ • Polyuria • Polydypsia • Polyphagia • Fatigue, weakness, vision changes, dry skin, skin lesions or wounds that are slow to heal, recurrent infections • Type 1 may have sudden weight loss, nausea, vomiting, and abdominal pain if DKA has developed • Type 2 may not experience symptoms

12. Diagnostic findings • Fasting blood glucose > 7.0 mmol/L (some guidelines state > 6.5 mmol/L • Random glucose > 11.1 mmol/L • Older people may not present with typical symptoms

13. Question • Is the following statement true or false? • The average renal threshold for glucose is 10 to 11.1 mmol/L

14. Answer • True • The average renal threshold for glucose is 10 to 11.1 mmol/L

15. Intensive control dramatically reduces vascular and neuropathic complications But it increases the risk of hypoglycaemia and associated risks Blood glucose targets must be individualised Treatment goal is to normalise blood glucose levels

16. Dietary management — goals • Provide optimal nutrition; all essential food constituents • Meet energy needs • Achieve and maintain a reasonable weight • Prevent wide fluctuations in blood glucose levels • Reduce serum lipids, if elevated • Enjoyment

17. Role of the nurse • Be knowledgeable about dietary management • Communicate important information to the dietician or other management specialists • Reinforce education • Support dietary and lifestyle changes

18. Meal planning • Consider food preferences, lifestyle, usual eating times and cultural background • Review diet history and need for weight loss, gain or maintenance • Caloric requirements and calorie distribution throughout the day • Carbohydrates: 50–60% carbohydrates, emphasise whole grains • Fat: 20–30%, with <10% from saturated fat and <300 mg cholesterol • Fibre

19. Glycaemic index • Describes how much a food increases blood glucose • Combine starchy food with protein and fat containing food slows absorption and glycaemic response • Raw or whole foods tend to have lower response than cooked, chopped or pureed foods • Eat whole fruits rather than juices; decreases glycaemic response due to fibre-slowing absorption • Adding food with sugars may produce lower response if eaten with foods that are more slowly absorbed

20. Other dietary considerations • Alcohol • Nutritive and non-nutritive sweeteners • Reading labels

21. Exercise • Lowers blood glucose • Aids weight loss • Lowers cardiovascular risk • Associated with wellbeing • Helps maintain muscular strength and balance in older people

22. Exercise precautions • Avoid exercising when blood glucose levels are >13 mmol/L and ketones in blood or urine • Insulin secretion usually falls during exercise; people using on exogenous insulin should eat a 15 g carbohydrate snack before moderate exercise to prevent hypoglycaemia • If exercising to control or reduce weight, insulin doses must be adjusted • Potential post-exercise hypoglycaemia • Need to monitor blood glucose levels

23. Exercise recommendations • Encourage regular daily exercise • Gradual, slow increase in exercise duration is encouraged • Modify exercise regimen to individual needs and presence of diabetic complications or potential cardiovascular problems • Exercise stress test for patients older than age 30 who have 2 or more risk factors is recommended

24. Insulin therapy • Blood glucose monitoring • Categories of insulin • Rapid-acting • Short-acting • Intermediate-acting • Very long-acting

25. Normal pancreatic insulin release

26. One injection per day

27. Two injections per day-mixed

28. Three or four injections per day

29. Insulin pump

30. Educating patients about insulin self-management • Use and action of insulin • Symptoms of hypoglycaemia and hyperglycaemia • Required actions • Blood glucose monitoring • Self-injection of insulin • Insulin pump use

31. Question • Which insulin is rapid acting? • Humalog • Detemir • Humalog R • NovoRapid • Glargine (Lantus)

32. Answer • A and D

33. Glucose-lowering medicines (GLMs) • Used for people with type 2 diabetes who do not achieve optimal blood glucose using diet and exercise alone • Combinations of medicine may be used and some GLMs are often combined with insulin • Nurses and people with diabetes should be familiar with the side effects of the GLMs they are using • Nursing interventions: monitor blood glucose and other potential side effects • Patient education

34. Sites of action of GLMs

35. Acute complications of diabetes • Hypoglycaemia • Diabetic ketoacidosis (DKA) • Hyperglycaemic hyperosmolar states (HHS)

36. Hypoglycaemia Abnormally low blood glucose level (< 2.7–3.3 mmol/L) Causes include too much insulin or GLM, too little food and excess physical activity Manifestations Adrenergic symptoms: sweating, tremors, tachycardia, palpitations, nervousness, hunger Central nervous system symptoms: inability to concentrate, headache, confusion, memory lapses, slurred speech, numbness of lips and tongue, irrational or combative behaviour, double vision, drowsiness Severe hypoglycaemia may cause disorientation, seizures and loss of consciousness

37. Assessment • Onset is abrupt and may be unexpected (not so with oral GLMs) • Symptoms vary from person-to-person • Symptoms also vary related to the rate at which the blood glucose falls and usual blood glucose range • Reduced adrenergic response affects symptom recognition in people who had diabetes for many years due to a number of factors including autonomic neuropathy

38. Managing hypoglycaemia • Treatment must be immediate • Give 15 g of fast-acting, concentrated carbohydrate • 3 or 4 glucose tablets • 60–120 mL of juice or regular soft drink (not diet) • 2–3 teaspoons of honey • Retest blood glucose in 15 minutes, retreat if >3.8 mmol/L or if symptoms persist more than 10–15 minutes and testing is not possible • Provide a snack with protein and carbohydrate unless the person plans to eat a meal within 30–60 minutes • Consider the factors that led to hypo and revise care plan to prevent future hypos, if necessary

39. Emergency measures • If the person cannot swallow or is unconscious: • Protect the airway • Subcutaneous or intramuscular glucagon 1 mg • As a last resort 25–50 mL 50% glucose solution IV

40. Diabetic ketoacidosis (DKA) • Caused by an absence of or inadequate insulin resulting in abnormal metabolism of carbohydrate, protein and fat • Clinical features • Hyperglycaemia • Dehydration • Acidosis • Manifestations include polyuria, polydipsia, blurred vision, weakness, headache, anorexia, abdominal pain, nausea vomiting, acetone breath, hyperventilation with Kussmaul respirations (in the early stages) and mental changes

41. Pathophysiology of DKA • Refer to Figure 36-7

42. Assessing DKA • Blood glucose levels range between 17 mmol/L and 44 mmol/L • Severity of DKA is not related to blood glucose level • Ketoacidosis is reflected in low serum bicarbonate and low pH; low PCO2 reflects respiratory compensation • Ketone bodies in blood and urine • Electrolytes vary according to water loss and level of hydration

43. Prevention • Develop a ‘sick day management plan’ • Assess for underlying causes • Diagnose and optimal diabetes management

44. Treating DKA • Rehydrate with IV fluid • IV continuous infusion using regular insulin • Reverse acidosis and restore electrolyte balance • Note: rehydration leads to increased plasma volume and decreased K+, insulin enhances the movement of K+ from extracellular fluid into the cells • Monitor • Blood glucose and renal function/UO • EKG and electrolyte levels—potassium • VS, lung assessments, signs of fluid overload

45. Hyperglycaemic hyperosmolar states • Hyperosmolality and hyperglycaemia occur due to lack of effective insulin • Ketosis is minimal or absent • Hyperglycaemia causes osmotic diuresis with loss of water and electrolytes; hypernatraemia and increased osmolality • Manifestations include hypotension, profound dehydration, tachycardia and variable neurological signs due to cerebral dehydration • High mortality

46. Treatment of HHS • Rehydration • Insulin administration • Monitor fluid volume and electrolyte status • Prevention • BGSM • Diagnosis and management of diabetes • Assess and promote self-care management skills

47. Long-term complications of diabetes • Macrovascular complications • Accelerated atherosclerotic changes • Coronary artery disease, cerebrovascular disease and peripheral vascular disease • Microvascular complications • Diabetic retinopathy, nephropathy • Neuropathic changes • Peripheral neuropathy, autonomic neuropathies, hypoglycaemic unawareness, neuropathy, sexual dysfunction

48. Diabetic retinopathy

49. Neuropathic ulcers

50. Nursing process: care of the person with diabetes — assessment • Assess the primary presenting problem • In addition, assess needs related to diabetes • Patient knowledge of diabetes and diabetes care skills • Blood glucose levels • Skin assessment • Preventive health measures