Medical Surgical Nursing Diabetes Mellitus. Endocrine Pancreas Islets of Langerhans Beta cells – Insulin

Medical Surgical Nursing

Diabetes Mellitus

Endocrine Pancreas

• Islets of Langerhans• Beta cells– Insulin

Insulin• Produced and

secreted by…– Beta cells

Insulin• Primary function…– Stimulates the active

transport of glucose– from the blood into

muscle, liver and adipose tissue

– __?__ blood glucose levels•

Glucose Content of Food• Consume food glucose blood stream• *Carbohydrates

– Starch• Simple• Complex

Secretion of Insulin

• Is stimulated by:– What change in homeostasis causes the beta cells

to secrete insulin?– Hyperglycemia

• Glucose levels in the bloodstream regulate the rate of insulin secretion

The major action of insulin

• blood glucose levels• the permeability of target cell membrane to

glucose– Main target cells

• Muscle• Liver• Adipose tissue

Pathophysiology sumamry

• Increased blood glucose levels • Gland

– Pancreas

• B cells • Insulin • Target cells (muscles)

– (insulin pulls glucose from the blood into the muscles)

• Decrease blood glucose levels

Insulin info

• In the absence of insulin, glucose is not able to get into the cells and it is excreted in the urine– Glycouria

• Brain cells are not dependent on insulin for glucose intake

Function of Insulin

• Need insulin for glucose to cross cell membrane

• No insulin no glucose into the cell

• Glucose stays in the blood

• Hyperglycemia

Diagnostic tests

• Blood glucose / Fasting blood glucose

• Glycosylated Hemoglobin Assay

Blood Glucose Fasting blood Glucose

• Measures blood glucose levels after fasting

• Results– Normal – 70-115 mg/dL– Diabetic level > 126 mg/dL– Critical > 400 mg/dL – Critical < 50 mg/dL

Fasting Blood GlucoseNursing Responsibility

• Fast 6-8 hours• Water OK• No insulin or anti-diabetic meds• Exercise will effect results

Glycosylated Hemoglobin Assays (Hgb A1C)

• % of glycosylated hemoglobin– RBC lifecycle • @ 120 days (4 months)

– Glucose slowly binds with Hgb glycosylated– serum glucose level glycosylated Hgb levels

Hgb A1C

• Provides an average blood glucose levels – Past 2-3 months

• Can be taken any time

• Normal levels (non-diabetic)– 4-6%

• Diabetic level (goal)– <8%

Small group questions

1. What are the Islets of Langerhans?2. What cells of the pancreas secrete insulin? 3. What stimulates insulin to be secreted?

What is diabetes mellitus?

• Group of disordered characterized by chronic hyperglycemia

• Due to faulty insulin production• (Not Diabetes Insipidus)

Type 1 – Diabetes Mellitus

• Destruction of the Beta cells• Result in – NO insulin production– Insulin dependent

S&S of Type 1 DM

• Hyperglycemia–↑ blood glucose levels – No insulin – Glucose stays in the blood stream

S&S of Type 1 DM

• Glycosuria– Glucose in the urine

S&S of type 1 DM

• Polyuria• Nocturia

S&S of Type 1 DM

• Polydipsia– Excessive thirst

S&S of Type 1 DM

• Polyphagia– Excessive hunger

S&S of Type 1 DM

• Dehydration– Assessment?• Skin turger• Mucus membranes• Thirst• BUN level

Small Group Questions

1. Why would a person with high glucose levels have polyphagia?

2. Explain why polyuria is a common symptom of diabetes Mellitus Type 1.

3. What is hyperglycemia?4. Why does hyperglycemia happen in Type 1 diabetes

mellitus?


5. What is a normal level for a FBS?6. Define the following terms: Glucose,

Glycosuria.7. What does an Hgb A1c measure? What are

normal values for a diabetic and non-diabetic?

Type 2 DM

• Pathophysiology– The pancreas cannot

produce enough insulin for body’s needs

– Impaired insulin secretion

Type 2 DM

• Weakened Beta cells Due to over use

Insulin and Type 2 DM

• Not all clients require insulin–1/3 will at some time• Stress• Illness

Risk Factors for Type 2 DM

• Family history• Obesity• Gestational diabetes or large baby

Type 1 vs. Type 2

• Age of onset– Usually < 30

• Age of onset– Usually > 40

Type 1 vs. Type 2

• Body wt at onset– Normal to thin

• Insulin production– None

• Insulin injections– Always

• Body wt at onset– 80% overweight

• Insulin production– Not enough

• Insulin injections– Sometimes

Type 1 vs. Type 2

• Management– Insulin– Diet– Exercise

• Management– Diet (wt. Loss)– Exercise– Possibly oral

hypoglycemic meds– Possibly insulin

Other specific types of Diabetes Mellitus

• Gestational• Pancreatitis• Drug or chemical induces diabetes (steroids)

S&S of Diabetes Mellitus

• Definition:– A group of disorders characterized by chronic

Hyperglycemia

• 3 P’s– Polydipsia– Polyuria– Polyphagia

S&S of Hyperglycemia

• Neurological– C/O headache– Dull senses– Stupor– Drowsy – Blurred Vision


• Cardiovascular– Tachycardia– Decreased BP– (Dehydration)

• Respiratory– Kussmaul's respirations– Sweet and fruity breath– Acetone breath


• Gastro-intestinal– Polyphagia– N/V– Polydipsia


• Genital-urinary– Polyuria– Glycosuria

• Skeletal-muscular– Weak


• Integumentary– Dry skin– Flushed face


Mr. McMillan is a 50 year old client brough into the ER with extreme fatigue and dehydration. After the MD sees him the nurses asks Mr. McMillan some additional questions. Based on the clients answers the nurse requests that the MD add a glucose level to the lab work. The results are 800mg/dL.

Small group questions

1. What question did the nurse most likely ask?2. Why was Mr. McMillan fatigued?3. Why was he dehydrated?

Medical Management of DM

• No cure• Goal is Control! And prevent complications• Individualized treatment plans– Diet– Exercise– Meds

Dietary management of DMFoundation of Diabetic control

• Goals– Maintain near-normal blood glucose levels– Achieve optimal serum lipid levels– Provide adequate calories for reasonable weight– Prevent & treat acute complications of insulin-

treated diabetes– Improve overall health through optimal nutrition

The exchange system

• Six categories– Starch– Meat– Milk– Vegetable– Fruit– Fat

General guidelines of Dietary Management

• Protein – 20%

• Fat – 20%

• Carbohydrates – 60%

• ADA: American Diabetic Association

Diabetic Meal Plan• Small frequent meals–CONSISTENCY!• Amount of calories• Amount of carbohydrates• Time• Snacks

Diabetic Meal Plan• If the client is obese, the key to treatment is…–Weight loss!

Meal Plan considerations

• Food preferences• Lifestyle• Schedule• Ethnic / Cultural

background

Alcohol and Diabetes

• Increase risk of…– Hypoglycemia– Moderation

Exercise and Diabetes

• blood glucose levels

More Benefits of exercise

• Increases circulation• Improve serum lipid

levels• Improves cardiovascular

status• Assist with wt control• Decreases stress

Rules for the exercising diabetic

• Talk to MD first• Regular vs. sporadic• Correlate exercise and

glucose levels• Don’t exercise when

hypoglycemic• Don’t exercise when

hyperglycemic >250


• Do not exercise when insulin is peaking

• Carry a quick source of sugar

• Best time = 60-90 minutes after a meal


• Proper footwear• May need a pre-

exercise snack• Consistency!

Monitoring Glucose

• Glucometers• FSBS• 2-4 times a day


1. Give signs & symptoms of hyperglycemia by body system (Why do they manifest these symptoms?)

2. A diabetic meal plan’s main goal is to maintain near normal glucose levels. How is this done?

3. The exchange diabetic meal plan is divided into six categories, what are they?


4. What affect does alcohol have on a diabetic?5. What affect does exercise have on a diabetic?6. What council would you give a diabetic

regarding exercise?

Onset – Peak - Duration

• Onset– The time period from

injection to when it begins to take effect

• Peak– When insulin is

working its hardest and therefore blood glucose levels are at their lowest

Onset – Peak - Duration

• Duration– Length of time the

insulin works or lasts

Types of Insulin –Very short acting/ rapid acting

• Lispro (Humalog)• Aspart (Novolog)

• Insulin pumps• Rapid reduction of glucose level

Appearance

Onset Peak Duration

Clear ¼ hour 1 hour 3 hours

Types of Insulin –Short-acting / regular

Appearance

Onset Peak Duration

• Humalog R; Novolin R; Iletin II Regular


Appearance

Onset Peak Duration

Clear



Appearance

Onset Peak Duration

Clear ½ - 1 hr(1 hour)



Appearance

Onset Peak Duration


2-3 hrs(3 hour)



Appearance

Onset Peak Duration


2-3 hrs(3 hour)

4-6 hrs(5 hours)


• Administered 20-30 minutes before meals• IV• Usually given 4 x a day

Types of Insulin –Intermediate-acting

Appearance

Onset Peak Duration

• NPH; Humulin N; Lente: Novolin L; Novolin N


Appearance

Onset Peak Duration

Cloudy



Appearance

Onset Peak Duration

Cloudy 2-4 hrs(2 hrs)



Appearance

Onset Peak Duration


6-12 hrs(12 hrs)



Appearance

Onset Peak Duration


6-12 hrs(12 hrs)

16-20 hrs

(24 hrs)


• Administer after meals• Usually given 2x a day• Eat at onset!

Learning Tip: Even and Odd

• Short-acting think odd – (1-3-5)

• Intermediate-acting think even – (2-12-24)

Regular vs. Intermediate (NPH)

When should insulin be administered

• Short-acting / regular– 30 min before meals (ac)– Do not allow more than 30 min to pass by without eating

• hypoglycemia

• Intermediate acting– After meals (pc)

• If mixed (regular & intermediate)– 30 min before meals

What route is insulin administered

• IV– Regular

• Sub-cutaneous

Syringe Types

• Insulin syringe• 27-29 gauge

Route (Self Administration)

• Subcutaneous tissue– If you can “pinch an inch” • 90 degree angle

– If you can’t “pinch an inch”• 45 degree angle

Area’s of injection

• Abdomen• Arm • Thigh• Hips

Factors affecting absorption rates

• Quickest– Abdomen

What would you do?

Which of the following is frequently best to teach / do first when doing initial diabetic training?

A. How & where to purchase insulinB. Preparation & storage of insulinC. Mixing insulin with return demonstrationD. Self-injection of insulinE. Learning O-P-D of insulin types

Insulin Pumps

• Portable infusion pump• Subcutaneous needle• Continuous/basal rate• Additional bolus if needed• Change site q24-48 hours

Insulin Pumps

• S/E - risks– Hypoglycemia– Infection– Hyperglycemia

Small Group Question

Mrs. Evans is 60 year old women with type 2 DM. She is on Intermediate Acting Insulin [Novolin L (Lente)] every morning. She normally eats her meals at 8:00 AM, 12:00 PM, and 6:00 PM.

1. What time should she take her morning insulin?2. When will this dose onset?3. When will this does peak?4. What does this insulin look like?

Mrs. Sweet Peas takes 13 units of Short-Acting Insulin [Humalog R] q ac. Her meals are B-8:00 AM, L-12:00 PM, D-7:00PM

1. What time should Mrs. Peas take her mid-day (lunch)dose of insulin?

2. When this dose onset?3. When will this dose peak?4. What does this insulin look like?

Mrs. Gumdrop takes 6 units of Intermediate Acting Insulin [NPH] at HS (10PM). She eats

her meals at: B-7AM, L-11AM, D-5PM.

• When will this dose onset?A.9 AMB.7:30 AMC.7 PMD.10:30 PME.12 AM



• When will this dose peak?A.1 AMB.10 PMC.10 AMD.9 PME.None of the above



• What does this insulin look like?A.ClearB.Cloudy

Mr. Chocolate Chip Cookie takes 10 units of Regular Insulin [Novolin R] q AM. His meals are

at : B-7AM, L-11AM, D-5PM.• When should he take his morning does of

insulin? A.6 AMB.6:30 AMC.7 AMD.7:30 AME.None of the above


at : B-7AM, L-11AM, D-5PM.• When will this does peak?A.7:30 AMB.8:30 AMC.9:30 AMD.10:30 AME.None of the above


at : B-7AM, L-11AM, D-5PM.• What does this insulin look like?A.ClearB.Cloudy

Ms. Eng Ewe takes 10 units of Short-Acting Insulin [Iletin II Lente] and 5 units of

Intermediate Acting Insulin [NPH] q AM. Her meals are B-8AM, L-12PM, D-7PM

• When should she take her insulin injection?A. 7:00 AMB. 8:00 AMC. 9:00 AMD.10:00 AME. None of the above

Ms. Eng Ewe takes 10 units of Short-Acting Insulin [Iletin II Lente] and 5 units of

Intermediate Acting Insulin [NPH] q AM. Her meals are B-8AM, L-12PM, D-7PM

1. When will her insulin onset2. When will her insulin peak

Mixing Insulin – How to

#1 Assemble equipment• Insulin• Syringe• Alcohol swab• MD order

Mixing insulin – How to

#2 Check MD order for dose and types

Mixing insulin – How it

#3 Roll the bottle of intermediate acting insulin (DO NOT SHAKE)


#4 Wipe the top of both vials with alcohol swab


#5 Draw up and inject an amount of air equal to the dose of intermediate acting insulin into the cloudy vial. Then remove syringe from the vial


#6 Draw up and inject an amount of air equal to the amount of short-acting insulin into the clear vial. *Leave syringe in the vial


#7 Draw up the correct amount of clear/regular insulin.


#8 Double check with another nurse if this is the institutions policy.


#9 Remove the syringe and insert into the cloudy vial. Carefully draw up the correct amount of insulin.


#10 Double check with another nurse before removing the syringe from the vial

What do you do if you draw up too much intermediate acting insulin with mixing?

A. Push it back into the vial and re-draw up the correct amount.

B. Waste the med and start over with the same syringe.

C. Waste the med and start over with a clean syringe.

D. Who cares, a little extra never hurt anyone! Just give it to the patient.

What do you do if you draw up too much Regular/clear insulin when mixing?

A. Push it back into the vial and re-draw up the correct amount.

B. Waste the med and start over with the same syringe.

C. Waste the med and start over with a clean syringe.

D. Who cares, a little extra never hurt anyone! Just give it to the patient.

How would you do it?

Give 8u Humulin R and 12u NPH sub-q, qAM.

Sliding Scale

• Used during– Surgery– Illness– Stress

• Determines insulin dose based on FSBG• FSBS check usually every 4-6 hrs• Usually regular insulin is used

Sample Sliding Scale

• Check FSBS before meals and at HS (2200)• 4u Humulin R insulin for glucose 151-200 mg/dL• 6u Humulin R insulin for glucose 201-250 mg/dL• 8u Humulin R insulin for glucose 251-300 mg/dL• 10u Humulin R insulin for glucose 301-350 mg/dL• Call MD for glucose >350 mg/dL

Questions for sliding scale

• Check FSBS before meals and at HS (2200)

• 4u Humulin R insulin for glucose 151-200 mg/dL




• Call MD for glucose >350 mg/dL

• If FSBS 189 how much insulin would you give?

A. NoneB. 4 unitsC. 6 unitsD. 8 unitsE. 10 units




























Pre-mixed insulin

• NPH + Regular• Novolin 70/30– 70% NPH– 30% regular

Insulin Storage

• Vial NOT being used refrigerate

• Vial in use room temperature

• Storage life un-refrigerated = 1 month

Insulin Therapy Complications

• Hypoglycemia• Causes– Too much insulin– Too little food– Extreme exercise

S&S of Hypoglycemia

• Neuro– Dizzy / faint– Nervous / Irritability– Blurred vision– Numb tongue or lips

S&S of Hypoglycemia

• Cardiovascular– Full bounding pulse

• Respiratory– Shallow breathing

• Gastro-intestinal– Polyphagia

S&S of Hypoglycemia

• Genital-urinary– No polydipsia– No polyuria

• Skeletal/muscular– Weak– Trembling / tremor

• Integumentary– Perspiring/ Moist– Pale

Small group Questions

1. When is a sliding scale commonly used?2. A tuberculin syringe is also calibrated in units. Is

it OK to use a TB syringe to draw up insulin?3. What route is insulin administered?4. Compare the signs and symptoms of hyper and

hypoglycemia

– How come they are not all opposite signs and symptoms?

– Why are some so similar?– Which symptoms can you look for to tell the

difference between hyper and hypoglycemia? (*)

– What is the biggest risk factor in using an insulin pump?

Oral Hypoglycemic Agents

SulfonylureaCholpropamide (Diabanese)Glipizide (Glucotrol)Glimepride (Amaryl)Glyburide (Diabeta, Micronase)


BiguanidesMetformin (Glucophage)Glucovance

Sulfonyurea+Biguanide


• Oral hypoglycemic meds are not Insulin• Oral hypoglycemic meds require some production of

insulin• Oral hypoglycemic agents are used in the treatment

of type ___DM– Type 2

• Oral hypoglycemic meds are meant to supplement diet and exercise, not replace them


• Oral hypoglycemic meds cannot be used during pregnancy

• Oral hypoglycemic meds may need to be held temporarily and insulin prescribed if BS levels rise due to stress or illness etc.

• Action varies so effect may be enhanced by use of multiple meds

Sulfonylureas

• Sulfonylurea’s work primarily by the secretion of insulin by directly stimulating the pancreas

Sulfonylurea

• Side-effects of Sulfonylurea– Hypoglycemia– GI upset

Biguanides

• Biguanides work primarily by aiding insulin’s action on peripheral receptor sites (target cells)

• Biguanides are NOT associated with episodes of hypoglycemia

• Biguanides + sulfonylurea may the glucose lowering effect

Biguanides

• Major side effects of Metformin are:– Anorexia/ wt. Loss

• Metformin is contraindicated in patients with Renal impairment

Can diabetes pills help me?

• Only Type 2 DM• Results vary• Effectiveness wears off• Insulin may still need to be taken occasionally• Pregnant…


It’s your turn!


1. A type 1 DM asks you “Why do I have to have insulin injections, why can’t I just take the Insulin pills?” How would you answer him?

2. Mrs. Murdock is a Type 2 DM. She was taking Glucatrol 20 mg BID. The MD changed her meds today to Micronase 5 mg PO BID and Glucophage 500 mg PO BID. Mrs. Murdock asks you why she is taking two medications now, instead of just increasing the dose of Glucatrol?

Hypoglycemia

• Definition: When blood glucose levels fall below 70mg/dL

• < 50mg/dL = severe

Hypoglycemia: Etiology

• Any time– Usually: Before meals or a night

• Too much insulin or oral hypoglycemic meds• Too little food• Excessive exercise

Hypoglycemia: Dx & Assessment

• Signs & Symptoms• Can occur suddenly!• If pt is a long time

diabetic

• No early S&S

Hypoglycemia: Dx & Assessment

• #1 Dx tool– Lab Values

• FSBS

Hypoglycemia can result:

• When a patients baseline blood glucose level is 100mg/dL – Drops to 60 mg/dL

• When a patients baseline blood glucose level is 200mg/dL – Drops to 120 mg/dL

Hypoglycemia: Medical Management

• Assess for S&S• blood sugar level• Admin. fast sugar

Hypoglycemic Protocol: Sample

• For BG <60 mg/dL– If patient can take PO, give 15g of fast acting

carbohydrate. – Check FSBG q 15 minutes and repeat above if

BG<80.

Glucose Fast!

• 15 g fast acting carbohydrate–4-6 oz. Juice/soda

Rules to remember

• Do not add sugar to OJ• Recheck FSBS q 15 min until WNL• Avoid high fat slows absorption of glucose• Instruct: carry fast sugar• NPO if “unconscious” or confused• If meal is >1 hr away, follow with a protein

and complex carbohydrate

Hypoglycemia treatmentUnconscious

• Position: side lying

HypoglycemiaGerontological Consideration

• Cognitive deficits – not recognize S&S

• Decreased renal function – oral hypoglycemic meds stay in body longer

• More likely to _________a meal– Skip

• Vision problems – inaccurate insulin draws

HypoglycemiaNursing measures

• Follow protocol• Teach– Carry simple sugar at all times– S&S or hypoglycemia– How to prevent Hypoglycemia– Check FSBS if you suspect NOW!

Treating Hyperglycemia

• Assess for – S&S

• Check – FSBS

• Administer – insulin per MD order

Medical Management/treatment

• Monitor Fluid and electrolytes– Especially K+

– Push fluids

Documents

Medical Surgical Nursing Diabetes Mellitus. Endocrine Pancreas Islets of Langerhans Beta cells – Insulin