MS2 Finals Project DKA

8/14/2019 MS2 Finals Project DKA

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Diabetes Mellitus

Is a chronic disorder of carbohydrate, protein, and lipid metabolism that iscaused by deficiency of insulin

A deficiency of insulin results in hyperglycemia Type I diabetes mellitus is a nearly absolute deficiency of insulin; if insulin is

not given fats are metabolized, resulting in ketonemia (acidosis) Type II diabetes mellitus is a relative lack of insulin or resistance to the

action of insulin; usually insulin is sufficient to stabilized fat and proteinmetabolism but not to deal with carbohydrate metabolism

ASSESSMENT

Polyuria, polydipsia, polyphagia (more common in type I DM)

Hyperglycemia

Weight loss

Blurred visionSlow wound healing

Vaginal infections

Weakness and paresthesias

Sign of inadequate circulation to the feet

Signs of accelerated atherosclerosis

DIET

The total number of calories is individualized based on the clients currentor desired weight and the presence of other existing health problems

EXERCISE

Lowers blood glucose level

Reduces cardiovascular risk

Improves circulation and muscle tone

Decrease total cholesterol and triglyceride levels

Encourages weight loss

Instruct the client to monitor blood glucose level before exercising; if theclients plans to participate in extended period of exercise, blood glucoselevel should be checked before, during and after exercise period

If the blood glucose level is greater than 250mg/dL and urinary ketones(type I DM) are present, the client is instructed not to exercise until theblood glucose is closer to normal and urinary ketones are absent.


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ORAL HYPOGLYCEMIC MEDICATIONS

Oral medications are prescribed with type II DM

Assess vital signs and blood glucose levels

Assess the medications that the client is currently taking

Aspirin, alcohol, sulfonamides, oral contraceptives, and monoamineoxidase inhibitors increase the hypoglycemic effect, causing a decrease inblood glucose levels

Glucocorticoids, thiazide diuretics, and estrogen increase blood glucoselevels

Teach the client to recognize symptoms of hypoglycemia andhyperglycemia

Teach the client to avoid over the counter medications unless prescribed bythe physician

Teach the client to avoid alcohol if taking sulfonylureas

Inform the client with type II DM that insulin may be neede during stress,

surgery or infection.

INSULIN

Insulin is used to treat type I DM and type II DM when diet and weightcontrol therapy have failed to maintain satisfactory blood glucose levels

The peak action time of insulin is important because of the possibility ofhypoglycemic reactions occurring during that time

COMPLICATIONS OF INSULIN THERAPY

Local allergic reactions Redness, swelling, tenderness, and induration or a wheel at the site

of injection may occur 1 to 2 hours after administration

Reactions usually occur during the early stages of insulin therapy

Instruct the client to avoid the use of alcohol to cleanse the skinbefore injection

The physician may prescribe an antihistamine to be taken 1 hourbefore injection

Insulin lipodystrophy

Lipoatrophy is loss of subcutaneous fat and appears as slight

dimpling or more serious pitting of subcutaneous fat; the use ofhuman insulin helps prevent this complication

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

Instruct the client about the importance of rotating insulin injectionsites


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INSULIN ADMINISTRATION

Insulin pens

A device that uses a small, prefilled insulin cartridge that is loaded

into a penlike holder; a disposable needle is attached to the devicefor injection

The clients inserts the needle for injection, and the insulin deliveredby dialing in a dose or pushing a button for every 1 to 2 unitincrement administered

Jet injectors

A device that delivers insulin through the skin under pressure in anextremely fine stream

Insulin administered by this device usually absorbs faster

The injector can cause bruising at the site of insulin delivery

Insulin Pumps

Continuous subcutaneous insulin infusion is administered by anexternally worn device that contains a syringe attached to a long,thin, narrow-lumen tube with a needle or Teflon catheter attached tothe end

The client inserts the needle or Teflon catheter into thesubcutaneous tissue (usually on the abdomen) and secures it withtape or a transparent dressing; the pump is worn on a belt or in apocket, the needle is changed at least every 3 days

Implantable insulin delivery An insulin pump is implanted in the peritoneal cavity, where insulin

can be absorbed in a more physiological manner

Implants are not widely used because of mechanical problemsassociated with the pump, the catheter, and the insulin delivery

Pancreas transplant

The goal of pancreatic transplantation is to halt or reverse thecomplication of diabetes mellitus

Immunosuppressive therapy is prescribed to prevent and treatrejection

COMPLICATIONS OF DIABETEIC MELLITUS

ACUTE COMPLICATIONS:

Hypoglycemia

DIABETIC KETOACIDOSIS

Hyperglycemic hyperosmolar nonketotic syndrome

CHRONIC COMPLICATIONS

Diabetic retinopathy


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Diabetic nephropathy

Diabetic neuropathyDIABETIC KETOACIDOSIS (DKA)

Is a serious complication of diabetes.

Develops when you have too little insulin in your body.Without enough insulin, sugar (glucose) can't enter your cells for energy.Your blood sugar level rises and your body begins to break down fat forenergy. This produces toxic acids known as ketones.

most common in people who have type 1 diabetes, but people whohave type 2 diabetes may develop diabetic ketoacidosis, too.

In fact, in a few cases diabetic ketoacidosis is the first sign that aperson has diabetes.

PATHOPHYSIOLOGY

Progressive hyperglycemia occurs due to inadequate circulating

insulin, preventing cellular uptake of glucose leading to a state of'cellular starvation'

This induces pancreatic glucagon secretion and release of other

stress hormones such as catecholamine, corticol and GHThese humoral factors encourage glycogenolysis and

gluconeogenesis, further raising plasma glucoseThe stress response encourages proteolysis and lipolysis, forming

free fatty acids, which are then converted to the ketoacidsacetoacetate, beta-hydroxybutyrate and acetone, (due to absence ofintracellular glucose required for their metabolic conversion) leadingto acidosisThe very high glucose levels cause a huge osmotic diuresis and

gross dehydrationDehydration may reduce tissue perfusion and further derange

metabolism by causing lactic acidosisA vicious cycle of progressive metabolic disruption is set in train,

continuing until rehydration and insulin therapy are given
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SIGNS AND SYMPTOMS

Diabetic ketoacidosis symptoms often develop quickly, sometimes within 24 hours.You may notice:

Excessive thirst

Frequent urination

Nausea and vomiting

Abdominal pain

Loss of appetite

Weakness or fatigue

Shortness of breath

Fruity-scented breath

Confusion

More specific signs of diabetic ketoacidosis which can be detected throughhome blood and urine testing kits include:

High blood sugar level High ketone level in your urine

CAUSES

Diabetic ketoacidosis is usually triggered by:

An infection or other illness can cause your body to producecertain hormones, such as adrenaline. Unfortunately, thesehormones work against insulin sometimes triggering anepisode of diabetic ketoacidosis

A problem with insulin therapy missed insulin treatments orinadequate insulin therapy can leave you with too little insulin inyour system, triggering an episode of diabetic ketoacidosis.

Other possible triggers of diabetic ketoacidosis may include:

Stress

Physical or emotional trauma

High fever

Surgery

Heart attack

Stroke


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Alcohol or drug abuse

RISK FACTOR

Those who have type I diabetic mellitus

Younger than age of 19

WHEN TO SEEK MEDICAL ADVICE

Contact your doctor if:

You're vomiting and unable to tolerate any food or liquid

Your blood sugar level is higher than your target range anddoesn't respond to home treatment

Your urine ketone level is moderate or high

Seek emergency care if:

Your blood sugar level is consistently higher than 300milligrams per deciliter (mg/dL) or 16.5 millimoles per liter(mmol/L)

You have excess ketones in your urine

You have multiple symptoms of diabetic ketoacidosis excessive thirst or urination, nausea and vomiting,abdominal pain, loss of appetite, shortness of breath, fruity-

scented breath, confusion

SCREENING AND DIAGNOSIS

Blood sugar level if there isn't enough insulin in your body toallow sugar to enter your cells, your blood sugar level will rise(hyperglycemia). As your body breaks down fat and protein forenergy, your blood sugar level will continue to rise.

Ketone level when your body breaks down fat and protein forenergy, toxic acids known as ketones enter your bloodstream.

Blood acidity If you have excess ketones in your blood, yourblood will become acidic (acidosis). This can damage organsthroughout your body.


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COMPLICATIONS

Low blood sugar (hypoglycemia) insulin allows sugar to enter yourcells. This causes your blood sugar level to drop. If your blood sugar leveldrops too quickly, you may develop low blood sugar.

Low potassium (hypokalemia) the fluids used to treat diabeticketoacidosis may cause your potassium level to drop too low. A lowpotassium level can impair the activities of your heart, muscles andnerves.

Swelling in the brain (cerebral edema) adjusting your blood sugarlevel too quickly can produce swelling in your brain. This complicationappears to be more common in children, especially those who havenewly diagnosed diabetes.

TREATMENT

Fluid replacement will replace those you've lost through excessiveurination, as well as help dilute the excess sugar in your blood.

Electrolyte replacement you'll receive electrolytes through your veinsto help keep your heart, muscles and nerve cells functioning normally.

Insulin therapy Insulin reverses the processes that cause diabeticketoacidosis. Along with fluids and electrolytes, you'll receive insulintherapy usually through a vein. When your blood sugar level fallsbelow 250 mg/dL (14 mmol/L) and your blood is no longer acidic, youmay be able to stop intravenous insulin therapy and resume yournormal insulin therapy.


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MS2 Finals Project DKA