COLEGIO DE DAGUPANArellano Street, Dagupan CityCOLLEGE OF NURSINGDEPARTMENT OF MIDWIFERYPrepared by:Christopher R. Baez, RN, RM, RPT, US-RN, MSN, PhDcAssociate ProfessorCRITICAL CARE NURSINGDIABETOLOGY NURSINGDiabetes mellitus Descriptiona. Chronic disorder of impaired carbohydrate, protein, and lipid metabolism caused by deficiency of insulinb. An absolute or relative deficiency of insulin results in hyperglycemia.c. Type 1 diabetes mellitus is a nearly absolute deficiency of insulin; if insulin is not given, fats are metabolized for energy, resulting in ketonemia (acidosis).d. Type 2 diabetes mellitus is a relative lack of insulin or resistance to the action of insulin; usually, insulin is sufficientto stabilize fat and protein metabolism but not to deal with carbohydrate metabolism (obesity is a major risk factor for type 2 diabetes mellitus).e. Macrovascular complications include coronary artery disease, cardiomyopathy, hypertension, cerebrovascular disease, peripheral vascular disease, and infection.f. Microvascular complications include retinopathy, nephropathy, and neuropathy.Major Types of Diabetes MellitusType 1: Primary beta cell destruction leading to absolute insulin deficiencyType 2: Ranges from insulin resistance with an insulin deficiency to secretory deficit with insulin resistance

Assessmenta. Polyuria, polydipsia, polyphagia (more common in type 1 diabetes mellitus)b. Hyperglycemiac. Weight loss (common in type 1 diabetes mellitus, rare in type 2 diabetes mellitus)d. Blurred visione. Slow wound healingf. Vaginal infectionsg. Weakness and paresthesiash. Signs of inadequate circulation to the feeti. Signs of accelerated atherosclerosis (renal, cerebral, cardiac, peripheral)

Dieta. The total number of calories is individualized based on the client's current or desired weight and the presence of other existing health problems.b. Day to day consistency in timing and amount of food intake helps control the blood glucose level.c. As prescribed by the physician, the client may be advised to follow the food exchange recommendations of the American Diabetic Association diet or U.S. dietary guidelines (MyPyramid) issued by the U.S. Departments of Agriculture and Health and Human Services.d. Carbohydrate counting may be a simpler approach; it focuses on the total grams of carbohydrates eaten per meal. The client may be more compliant with carbohydrate counting, resulting in better glycemic control; it is usually necessary for clients undergoing intense insulin therapy.e. Incorporate diet into individual client needs, lifestyle, and cultural and socioeconomic patterns.

Exercisea. Exercise lowers the blood glucose level, encourages weight loss, reduces cardiovascular risks, improves circulation and muscle tone, decreases total cholesterol and triglyceride levels, and decreases insulin resistance and glucose intolerance.b. Instruct the client in dietary adjustments when exercising; dietary adjustments are individualized.c. Instruct the client to monitor the blood glucose level before exercising; if the client plans to participate in extended periods of exercise, blood glucose levels should be checked before, during, and after the exercise period.d. If the client requires extra food during exercise to prevent hypoglycemia, it need not be deducted from the regular meal plan.e. If the blood glucose level is higher than 250 mg/dL and urinary ketones (type 1 diabetes mellitus) are present, the client is instructed not to exercise until the blood glucose level is closer to normal and urinary ketones are absent.

Oral hypoglycemic medicationsa. Oral medications are prescribed for clients with diabetes mellitus type 2 when diet and weight control therapy have failed to maintain satisfactory blood glucose levels.b. Assess the client's knowledge of diabetes mellitus and the use of oral hypoglycemic agents.c. Assess vital signs and blood glucose levels.d. Assess the medications that the client is currently taking.e. Aspirin, alcohol, sulfonamides, oral contraceptives, and monoamine oxidase inhibitors increase the hypoglycemic effect, causing a decrease in blood glucose levels.f. Glucocorticoids, thiazide diuretics, and estrogen increase blood glucose levels.g. Teach the client to recognize symptoms of hypoglycemia and hyperglycemia.h. Teach the client to avoid over-the-counter medications unless prescribed by the physician.i. Teach the client to avoid alcohol if taking sulfonylureas.j. Inform the client with type 2 diabetes mellitus that insulin may be needed during stress, surgery, or infection.k. Teach the client about the importance of compliance with the prescribed medication.l. Advise the client to wear a Medic-Alert bracelet.

Insulina. Insulin is used to treat types 1 and 2 diabetes mellitus when diet, weight control therapy, and oral hypoglycemic agents have failed to maintain satisfactory blood glucose levels.b. Regular insulin is the only insulin that can be administered intravenously (used in the emergency treatment of diabetic ketoacidosis).c. Aspirin, alcohol, oral anticoagulants, oral hypoglycemic medications b-blockers, tricyclic antidepressants, tetracycline, and monoamine oxidase inhibitors increase the hypoglycemic effect of insulin, causing a further decrease in the blood glucose level.d. Glucocorticoids, thiazide diuretics, thyroid agents, oral contraceptives, and estrogen increase the blood glucose level.e. Illness, infection, and stress increase the blood glucose level and the need for insulin; insulin should not be withheld during illness, infection, or stress because hyperglycemia and ketoacidosis can result.f. Instruct the client to recognize symptoms of hypoglycemia and hyperglycemia.g. The peak action time of insulin is important because of the possibility of hypoglycemic reactions occurring during that time.

Complications of insulin therapyLocal allergic reactionsa. Redness, swelling, tenderness, and induration or a wheal at the site of injection may occur 1 to 2 hours after administration.b. Reactions usually occur during the early stages of insulin therapy.c. Instruct the client to cleanse the skin with alcohol before injection.

Insulin lipodystrophya. Lipo atrophy is loss of subcutaneous fat and appears as slight dimpling or more serious pitting of subcutaneous fat; the use of human insulin helps prevent this complication

b. Lipohypertrophy is the development of fibrous fatty masses at the injection site and is caused by repeated use of an injection site.

c. Instruct the client to avoid injecting insulin into affected sites.d. Instruct the client about the importance of rotating insulin injection at one anatomical site. Insulin resistancea. The client receiving insulin develops immune antibodies thatbind the insulin, thereby decreasing the insulin available for use in the body.b. Treatment consists of administering a purer insulin preparation.c. Insulin resistance is also the term used for lack of tissue sensitivity to the insulin from the body, which results in hyperglycemia.

Dawn phenomenona. Dawn phenomenon results from reduced tissue sensitivity to insulin that develops between 5 and 8 am (prebreakfast hyperglycemia occurs); it may be caused by nocturnal release of growth hormone.b. Treatment includes administering an evening dose (or increasing the amount of a current dose) of intermediate-acting insulin at 10 pm.

Somogyi phenomenona. Normal or elevated blood glucose levels are present at bedtime; hypoglycemia occurs at 2 to 3 am, which causes an increase in the production of counter regulatory hormones.b. By 7 am, in response to the counterregulatory hormones, the blood glucose rebounds significantly to the hyperglycemic range.c. Treatment includes decreasing the evening (predinner or bedtime) dose of intermediate-acting insulin or increasing the bedtime snack.

ACUTE COMPLICATIONS OF DIABETES MELLITUS

HypoglycemiaDescriptiona. Hypoglycemia occurs when the blood glucose level falls below 60 mg/dL or when the blood glucose level drops rapidly from an elevated level.b. Hypoglycemia is caused by too much insulin or oral hypoglycemic agents, too little food, or excessive activity.c. The client needs to be instructed always to carry some form of fast-acting simple carbohydrate with him or her.d. If the client has a hypoglycemic reaction and does not have any of the recommended emergency foods available, any available food should be eaten; high-fat foods slow the absorption of glucose and the hypoglycemic symptoms may not resolve quickly.Assessment a. Mild hypoglycemia: The client remains fully awake butdisplays adrenergic symptoms; the blood glucose level is usually lower than 60 mg/dL.b. Moderate hypoglycemia: The client displays symptoms of worsening hypoglycemia; the blood glucose level is usually lower than 40 mg/dL.c. Severe hypoglycemia: The client displays severe neuroglycopenic symptoms; the blood glucose level is usually lower than 20 mg/dL.Interventions: Mild hypoglycemiaa. Give 10 to 15 g of a fast-acting simple carbohydrate b. Retest the blood glucose level in 15 minutes and repeat the treatment if symptoms do not resolve.c. Once symptoms resolve, a snack containing protein and carbohydrates, such as milk or cheese and crackers, is recommended unless the client plans to eat a regular meal within 60 minutes.Interventions: Moderate hypoglycemiaa. Administer 15 to 30 g of a fast-acting simple carbohydrate.b. Administer additional food such as low-fat milk or cheese after 10 to 15 minutes.a. If the client is unconscious and cannot swallow, an injection of glucagon is administered subcutaneously or intramuscularly.b. Administer a second dose in 10 minutes if the client remains unconscious.c. A small meal is given to the client when the client awakens as long as the client is not nauseated.d. The physician is notified if a severe hypoglycemic reaction occurs.e. In the hospital or emergency department, the client may be treated with an IV injection of 25 to 50 mL of 50% dextrose in water.f. Family members need to be instructed about the administration of glucagon.

Diabetic ketoacidosis (DKA)Description a. Diabetic ketoacidosis is a life-threatening complication of type 1 diabetes mellitus that develops when a severe insulin deficiency occurs.b. The main clinical manifestations include hyperglycemia, dehydration, ketosis, and acidosis.

Interventionsa. Restore circulating blood volume and protect against cerebral, coronary, or renal hypoperfusion.b. Treat dehydration with rapid IV infusions of 0.9% or 0.45% normal saline (NS) as prescribed;dextrose is added to IV fluids (D5NS, or 5% dextrose in 0.45% saline) when the blood glucose level reaches 250 to 300 mg/dL.c. Treat hyperglycemia with regular insulin administered intravenously as prescribed.d. Correct electrolyte imbalances (potassium level may be elevated as a result of dehydration and acidosis).e. Monitor potassium level closely because when the client receives treatment for the dehydration and acidosis, the serum potassium level will decrease and potassium replacement may be required.Insulin IV administrationa. Use regular insulin only.b. A dose of 5 to 10 units of regular insulin by IV bolus may be prescribed before a continuous infusion is begun.c. Mix the prescribed IV dose of regular insulin for continuous infusion in 0.9% or 0.45% NS as prescribed.d. Flush the insulin solution through the entire intravenous infusion set and discard the first 50 to 100 mL of solution before connecting and administering to the client; insulin molecules adhere to the plastic of IV infusion sets.e. Always place the insulin infusion on an IV infusion controller.f. Insulin is infused continuously until subcutaneous administration resumes.g. Monitor vital signsh. Monitor urinary output and for signs of fluid overload.i. Monitor potassium and glucose levels and for signs of increased intracranial pressure.j. If the blood glucose level falls too far or too fast before the brain has time to equilibrate, water is pulled from the blood to the cerebrospinal fluid and the brain, causing cerebral edema and increased intracranial pressure.k. The potassium level will fall rapidly within the first hour of treatment as the dehydration and the acidosis are treated.l. Potassium is administered intravenously in a diluted solution as prescribed when the potassium reaches a normal level to prevent hypokalemia; ensure adequate renal function before administering potassium.

Client education: Guidelines During Illness Take insulin or oral antidiabetic medications as prescribed. Test blood glucose level and test the urine for ketones every 3 to 4 hours. If the usual meal plan cannot be followed, substitute soft foods six to eight time a day. If vomiting, diarrhea, or fever occurs, consume liquids every 30 to 60 minutes to prevent dehydration and to provide calories. Notify the physician if vomiting, diarrhea, or fever persists, if blood glucose levels are higher than 250 to 300 mg/dL, when ketonuria is present for more than 24 hours, when unable to take food or fluids for a period of 4 hours, or when illness persists for more than 2 days.

Hyperglycemic hyperosmolar nonketotic syndrome (HHNS)Descriptiona. Extreme hyperglycemia occurs without ketosis or acidosis.b. The syndrome occurs most often in individuals with type 2 diabetes mellitus.c. The major difference between HHNS and DKA is that ketosis and acidosis do not occur with HHNS; enough insulin is present with HHNS to prevent breakdown of fats for energy, thus preventing ketosis.Interventionsa. Treatment is similar to that for DKA.b. Treatment includes fluid replacement, correction of electrolyte imbalances, and insulin administration.c. Fluid replacement in the older client must be done very carefully secondary to potential for heart failure.d. Insulin plays a less critical role in the treatment of HHNS than it does for the treatment of DKA because ketosis and acidosis do not occur; rehydration alone may decrease glucose levels.

CHRONIC COMPLICATIONS OF DIABETES MELLITUSDiabetic retinopathyDescriptiona. Chronic and progressive impairment of the retinal circulation that eventually causes hemorrhageb. Permanent vision changes and blindness can occur.c. The client has difficulty with carrying out the daily tasks of blood glucose testing and insulin injections.Assessmenta. A change in vision is caused by the rupture of small microaneurysms in retinal blood vessels.b. Blurred vision results from macular edema.c. Sudden loss of vision results from retinal detachment.d. Cataracts result from lens opacity.Interventionsa. Maintain safety.b. Early prevention via the control of hypertension and blood glucose levelsc. Photocoagulation (laser therapy) removes hemorrhagic tissue to decrease scarring and prevent progression of the disease process.d. Vitrectomy removes vitreous hemorrhages and thus decreases tension on the retina, preventing detachment.e. Cataract removal with lens implantation improves vision.

Diabetic nephropathyDescription: Progressive decrease in kidney functionAssessmenta. Microalbuminuriab. Thirstc. Fatigued. Anemiae. Weight lossf. Signs of malnutritiong. Frequent urinary tract infectionsh. Signs of a neurogenic bladderInterventionsa. Early prevention measures include the control of hypertension and blood glucose levels.b. Assess vital signs.c. Monitor intake and output.d. Monitor serum blood urea nitrogen and creatinine and urine albumin levels.e. Restrict dietary protein, sodium, and potassium intake as prescribed.f. Avoid nephrotoxic medications.g. Prepare the client for dialysis procedures as prescribed.h. Prepare the client for kidney transplant as prescribed.i. Prepare the client for pancreas transplant as prescribed.

Diabetic neuropathyDescriptiona. General deterioration of the nervous system throughout the bodyb. Complications include the development of nonhealing ulcers of the feet, gastric paresis, and erectile dysfunction.Classificationsa. Focal neuropathy or mononeuropathy: Involves a single nerve or group of nerves, most frequently cranial nerves III (oculomotor) and VI (abducens), resulting in diplopia; usually resolves spontaneouslyb. Sensory or peripheral neuropathy: Affects distal portion of nerves, most frequently in the lower extremitiesc. Autonomic neuropathy: Symptoms vary according to organ system involvedd. Cardiovascular: Cardiac denervation syndrome (heart rate does not respond to changes in oxygenation needs) and orthostatic hypotension occur.e. Pupillary: Pupil does not dilate in response to decreased light.f. Gastric: Decreased gastric emptying (gastroparesis)g. Urinary: Neurogenic bladderh. Sudomotor: Decreased sweatingi. Adrenal: Hypoglycemic unawarenessj. Impotence (male), painful intercourse (female)Assessmenta. Paresthesiasb. Decreased or absent reflexesc. Decreased sensation to vibration or light touchd. Pain, aching, and burning in the lower extremitiese. Poor peripheral pulsesf. Skin breakdown and signs of infectiong. Weakness or loss of sensation in cranial nerves III (oculomotor),IV (trochlear), V (trigeminal), VI (abducens)h. Dizziness and postural hypotensioni. Nausea and vomitingj. Diarrhea or constipationk. Incontinencel. Dyspareuniam. Impotencen. Hypoglycemic unawarenessInterventionsa. Early prevention measures include the control of hypertension and blood glucose levels.b. Careful foot care is required to prevent trauma.c. Administer medications as prescribed for pain relief.d. Initiate bladder training programs.e. Instruct in the use of estrogen-containing lubricants for women with dyspareunia.f. Prepare the male client with impotence for penile injections or implantable devices as prescribed.

CARE OF THE DIABETIC CLIENT UNDERGOING SURGERYPreoperative care1. Check with physician regarding withholding oral hypoglycemic medications or insulin.2. Some long-acting oral antidiabetic medications are discontinued 24 to 48 hours before surgery.3. Metformin (Glucophage) may need to be discontinued 48 hours before surgery and may not be restarted until renal function is normal postoperatively.4. All other oral antidiabetic medications are stopped the day of surgery.5. Insulin dose may be adjusted or withheld if IV insulin administration during surgery is planned.6. Monitor blood glucose level.7. Administer IV fluids as prescribed.

Intraoperative care1. Monitor blood glucose levels frequently2. Administer IV short- or rapid-acting insulin as prescribed to maintain the blood glucose level lower than 200 mg/dL.

Postoperative care1. Administer IV glucose and regular insulin infusions as prescribed until the client can tolerate oral feedings.2. Administer supplemental short-acting insulin as prescribed based on blood glucose results.3. Monitor blood glucose levels frequently if the client is receiving parenteral nutrition.4. When the client is tolerating food, ensure that the client receives an adequate amount of carbohydrates daily to prevent hypoglycemia and ketosis.5. Client is at higher risk for cardiovascular and renal complications postoperatively.6. Client is also at risk for impaired wound healing.

Preventive Foot Care Instructions Provide meticulous skin care and proper foot care. Inspect feet daily and monitor feet for redness, swelling, or break in skin integrity. Notify the physician if redness or a break in the skin occurs. Avoid thermal injuries from hot water, heating pads, and baths. Wash feet with warm (not hot) water and dry thoroughly (avoid foot soaks). Do not treat corns, blisters, or ingrown toenails. Do not cross legs or wear tight garments that may constrict blood flow. Apply moisturizing lotion to the feet but not between the toes. Prevent moisture from accumulating between the toes. Wear loose socks and well-fitting (not tight) shoes, and instruct the client not to go barefoot. Wear clean cotton socks to keep the feet warm and change the socks daily. Do not wear the same pair of shoes 2 days in a row. Do not wear open-toed shoes or shoes with a strap that goes between the toes. Check shoes for cracks or tears in the lining and for foreign objects before putting them on. Break in new shoes gradually. Cut toenails straight across and smooth nails with an emery board. Do not smoke.

DIABETES INSPIDUS Also known as ADH deficiency. The major disorder of the posterior lobe Passes excessive amount of urine highly diluted and contains no glucose A disorder in which there is an abnormal increase in urine output, fluid intake and often thirst Urine output is increased because it is not concentrated normally A condition that results from insufficient production of the Antidiuretic hormone, a hormone that helps the kidneys and body conserve the correct amount of water ADH is secreted to decrease the amount of urine output so that dehydration does not occur. Diabetes insipidus, however, causes excessive production of much diluted urine and excessive thirst.It causes symptom such as:1. Urinary frequency, nocturia (frequent awakening at night) or enuresis (involuntary urination during sleep or bedwetting2. Excessive thrist3. Dehydration

Etiology1. Vasopressin/ ADH deficiencya. There is abnormalities in the hypothalamus and pituitary gland; familial/ idiopathic b. Destruction of the gland by:a. Tumor in the hypothalamus and pituitary glandb. Traumac. Infectious processd. Vascular accidents e. Metastatic tumors from the breast/ the lungsc. Medication such as:a. Phenytoinb. Alcoholc. Lithium Carbonate- interfere with the synthesize of ADH2. Nephrogenic Diabetes Insipidusa. Kidney tubules cannot reabdorb waterb. May develop secondary potassium depletion/ pyelonephritis

Assessment1. Arise slowly or appear suddenly following injury/ infectious process2. 2 major manifestations:a. Polyuriab. Polydipsia

Diagnostic Test Water deprivation test-Instruct client not to drink Urine specific gravity: 1.003-1.030 Diluted urine: 1.001-1.006 Drink almost continually to prevent severe dehydration

Interventions1. Administration of benzothiazide diuretics2. Sulfonylurea chlorpropamide (antidiuretic)3. Injection of Vasopressin (aqueous Pitressin) or Vasopressin tannate (pitressin tannate) Assess for water intoxication which can lead to cerebral edema, which can later result to seizure Fluid overload- cerebral edema-seizure4. Synthesized polypeptide DDAVP (desmopression Acetate)b. For long term treatment in severe form of diabetes insipidus

II. SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE (SIADH) Exact opposite of diabetic insipidus May water of intoxication due to fluid retention Consist of hyponatremia, inappropriate elevated urine osmolality (>200 mOsm/kg), excessive urine sodium excretion (UNa >30 mEg/L), and decreased serum osmolality Iappropriate secretion of the antidiuretic hormone (ADH), also known as vasopressin, due to any case interferes with renal excretion of water and results in production of concentrated urine and hyponatremiaa. SIADH occurs when excessive levels of antidiuretic hormones (hormones that help the kidneys, and body, conserve the correct amount if water) are produced. The syndrome causes the body to retain water and certain levels of electrolyte in blood to fall (such as sodium)DiagnosisPresence of hypovolemia with normal or expanded plasma volume Diminished GI function Complicated by a need of fluid restriction Do not administer tap/saline solution fluid Only Distilled Water

InterventionsMedical1. Fluid restriction2. Accurate assessment and fluid balance3. Weighing the person daily4. Careful and frequent assessment of neurologic status5. Replacement of NACl6. Diuretics7. Demeclocycline: a tetracycline derivative that induces drug-induced diabetes insipidus by impairing generation and action of cyclic AMP. Onset of action may be delayed by over a week, thus not indicated for emergency management of symptomatic hyponatremia8. Proper positioning: head is flat or no more than that of 5 degrees

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