Endocrine 3A

Part 3

Long Term Complications of Diabetes

• Macro vascular complications– Arteriosclerosis

• Characterized by thickening and loss of elasticity of the arterial walls “hardening of the arteries”.

– Coronary Artery Disease– Cerebrovascular Disease– Peripheral vascular disease

Coronary/cerebrovascular disease

Changeable risk factors• Weight control• Low-fat diet• Treat hypertension• Treat hyperlipidema• Regular exercise• Control blood glucose levels• Smoking• Diabetes

Unchangeable risk factors• Age• Gender• Family history• Race

Microvascular complications

• Characterized by basement membrane thickening

• Effects smallest blood vessels• Due to hyperglycemia

Diabetic Retinopathy

• Damage to the tiny blood vessels that supply the eye

• Small hemorrhages occur

• Damage is due to hyperglycemia

Prevention

• Control– Glucose– BP

Prevention

• No straining• Use laxatives• Avoid lowering head• Avoid lifting above

shoulders

Retinopathy: Medical Management

• Photocoagulation “laser” treatment

• Control hypertension• Control blood glucose• No smoking

Retinopathy: Nursing Considerations

• Expected• Odds are good• Frequent eye exams• Bilateral but uneven

Other Optic Complications

• Cataracts• Lens Changes• Extraocular muscle

palsy• Glaucoma

Nephropathy

• Damage to the tiny blood vessels within the kidney.

• Due to– Hyperglycemia

Nephropathy: Etiology

• glucose levels– Stress kidney’s

filtration mechanism

• Blood protein leaks into urine

• Pressure in blood vessel of kidney

• Kidney failure

Nephropathy: Pathophysiology

Normally• Kidneys filter blood• Small molecules & waste

squeeze through kidneys urine

• Big stuff (I.e. protein, RBC), stay in blood where they belong

Nephropathy: Pathophysiology

• Diabetes damages the system

• Filters start to leak• Protein and RBC lost in

urine– Microalbuminuria– Macroalbuminuria– Proteinuria

Nephropathy: Pathophysiology

• Filters collapse• Lose of filtering ability– Kidney failure– ESRF / ENRD

• Waste products build up in blood

• Dialysis • Kidney transplant

Nephropathy: S&S / Dx

• Proteinuria / albuminuria

• urine output• Edema• BUN & Creatinine ↑• BP

Nephropathy:Prevention

• Control BG• Control HTN• Tx UTI• No nephrotoxic

substances• Na• Protein

Nephropathy:Management

• Tight glucose control• Anti-hypertensives– Calcium-channel

blockers– Alpha blockers– ACE inhibitor

• Dialysis• Transplant

Neuropathy

• Damage to the Nerves due to hyperglycemia• Most common complication• Various Types of Neuropathies…

Neuropathy

• Sensory-Motor Polyneuropathy– AKA peripheral

neuropathy– Paresthesias: primarily

lower extremities– deep tendon reflexes

Neuropathy

Sensory-motor Numb feet proprioception sensation Unsteady gait risk foot injury

Neuropathy: Management

• Control serum glucose levels

• Pain control– Analgesics (non-

narcotic)– Tri-cyclic

antidepressants– Anticonvulsants

Neuropathy:

• Autonomic neuropathy– Autonomic NS– Can affect almost any

system

Autonomic Neuropathy

• Cardiovascular– Tachycardia– Orthostatic

hypotension– MI

Autonomic Neuropathy

• Gastro-intestinal– Delayed gastric

emptying– Constipation– Diarrhea

Autonomic Neuropathy

• Urinary– Retention– Neurogenic bladder

Autonomic Neuropathy

• Reproductive– Male impotence

Autonomic Neuropathy

• Adrenal Gland– “Hypoglycemic

Unawareness”– Adrenal Medulla– Adrenergic symptoms– No longer feel S&S– Strict BG control &

frequent monitoring

Autonomic Neuropathy

• Sudomotor neuropathy– No sweating– Anhidrosis– dry feet– foot ulcers

Infections

• High risk of foot infections– Neuropathy

• Pain sensation–

• Pressure sensation–

• Dryness–

• Fissures–

Infections

• Peripheral vascular disease– Circulation

• – WBC

• – Oxygen

• – wound healing

• Poor– Antibiotics

• – Gangrene

Infections

• Immuno-compromised– WBC + hyperglycemia =

sluggish WBC’s

Infections

• Once they occur difficult to treat– Poor circulation– Antibiotic not get there– Sluggish WBC’s– Unknown wounds

Infections

• Particular concern– Foot

infections/wounds

Boils: AKA: "furuncles" round, pus-filled

bumps on the skin

D/T: Staphylococcus aureus bacteria

Cellulites• noncontagious

inflammation of the connective tissue of the skin,

• D/T bacterial infection

• Treatment– Antibiotics – Analgesics

Infections of concern

• UTI’s• Yeast Infections• Periodontal disease

Infections of concern

Gangrene• term to describe the

decay or death of an organ or tissue

• d/t blood supply.

Infections of concern (FYI)

• Necrotizing fasciitis – Flesh eating disease

High risk for foot infections

• Duration of diabetes• Age• Smoking• Peripheral pulses• Sensation• Deformities/pressure

areas• Hx of foot ulcers

Progression of events

• Soft tissue injury • Injury not sensed • Infection • Drainage, swelling,

redness • Gangrene

Management of infections

• Bed rest• Antibiotics – Topic vs. IV

• Debridement• Control Glucose levels• ? Amputation

Nursing Management

• Teach foot care– prevention

• Teach wound care

Guideline to Healthy Feet

• Wash daily– Dry between toes– Lubricate dry feet

• Inspect – Mirror– Family– Between toes

Guideline to Healthy Feet

• Avoid activities that circulation– Smoking– Crossing legs– Tight socks

Guideline to Healthy Feet

• Good shoes– Comfortable– Closed toe– No bare feet– New shoes

• Break in slowly

Guideline to Healthy Feet

• Prevent injuries– Wear socks

• Cotton• Light color• No wrinkles

– Check inside of shoe

Guideline to Healthy Feet

• No temperature extremes– Check bath water– No water bottles– No heating pads

Guideline to Healthy Feet

• See doctor regularly– Podiatrist– Trim straight across– Do not cut calluses or

corns

Guideline to Healthy Feet

• Range of Motion

Diabetics & Surgery

BS levels _____ during stress, surgery & illness–

If not controlled (BG) osmotic diuresis dehydration

Diabetics & Surgery

• Risk of _________ if give shot of NPH and then NO surgery or surgery delayed– Hypoglycemia

Diabetics & Surgery

• Management– Check BS before

surgery– No sub-Q– IV

Hospitalized diabetic

• Independence• Sliding scale• Diets– NPO

• Still need insulin

– Clear liquids• Most simple carbs• Low sugar if possible

NCLEX Question

Peripheral vascular disease is most common in patients with

A.an aneurysm.B.viral pneumonia.C.leukemia.D.diabetes mellitus.

NCLEX Question

The nurse is reinforcing the importance of proper foot care to the elderly diabetic. The woman states that they surely must have something more important to discuss. The nurse correctly replies:

A. “Foot care as well as any other type of hygiene is always important.”

B. “We can skip this if you prefer.”C. “All right, just remember that you will be more prone to foot

odor.”D. “Diabetics can easily develop severe foot injury or infection

without knowing it.”