NURSING Gastrointestinal Disorders Conference 3 Fall 2014

Diabetes Mellitus Conference #3

Jackie Dorsey RN, MS, ANP

Exercise and the Diabetic patient

THERAPEUTIC BENEFITS OF EXERCISE

Decrease

Lower

May decrease need to reach target BG levels

Reduce

Reduce

Improve

BENEFITS SPECIFIC FOR THE TYPE 2 DIABETIC

Decreases

Decreases percentage

May delay onset of Type 2 diabetes

General Guidelines for Exercise

Exercise does not have to be vigorous

Exercise is best done after meals

Exercise plans should be individualized

It is important to monitor blood glucose before, during, and after exercise to determine the effect of exercise on the blood glucose.

General Guidelines for Exercise

Be alert to the possibility of delayed exercise-induced hypoglycemia Effects of exercise on BG level may last up to 48 hours

Stretch for 5-10 minutes before and after exercise

Maintain good posture during exercise

Hydrate before beginning exercise

Wear proper shoes for comfort and injury prevention

When is exercise related hypoglycemia likely to occur?

When insulin or antidiabetic medication is peaking

If exercise is strenuous or prolonged and CHO is not replaced

When would you suggest to a diabetic patient, who takes an antidiabetic agent, the

most appropriate time to exercise?

One hour after eating a meal

After the ingestion of 15 gm of CHO For every 45 minutes of activity the individual

should consume another 15 gm of CHO

What items would constitute 15 Gms of CHO?

17 grapes

8-10 life savers

4-6 oz. of juice

Sport drinks which contain 80-100 calories

from CHO

Why does exercise induced hyperglycemia occur?

Strenuous Activity or Exercise

Perceived by body as stress

Release of counterregulatory hormones (glucagon, epinephrine, growth hormone, cortisol)

Temporary elevation of blood glucose

Hyperglycemia

Type 1 diabetic should avoid exercise if BG level is > 300

mg/dl without urine ketones present or if BG level is > 250

mg/dl with urine ketones present.

INSTRUCTIONS FOR DIABETICS DURING ILLNESS/ SICK DAY GUIDELINES

Medications

Continue as before unless otherwise advised by health care team

Supplemental insulin doses may be required in Type 1 diabetes mellitus


Blood sugar monitoring

Increase frequency to every 4 hour

Assess urine for presence of ketones especially during fevers and when BG is > 240 mg/dl


Intake

Continue CHO intake by substituting regular soda, regular jello, popsicles, or Gatorade

Small, frequent meals

Drink adequate amount of fluids to prevent dehydration


Instruct pt. to keep good written records of BGs & urine ketones as soon as they become sick so that they are prepared to relay this information to the MD.

Contact MD

BG is > 240 mg/dl

Moderate to large amounts of ketones in the urine

unable to keep anything down

Prevention

Seasonal Flu vaccine

Good hand washing

Blood Glucose Monitoring A BG test measures the

amount of sugar (glucose) in a sample of blood

BG monitoring refers to the ongoing measurement of blood sugar (glucose)

Monitoring can be done at any time using a portable device called a glucometer

Blood Glucose Monitoring

The traditional glucose meter comes with test strips, small needles called lancets, and a logbook for recording numbers if the meter is used in the home

In the hospital setting, specific documentation flowsheets are used per agency policy

There are many different kinds of meters, but they all work essentially the same way

Blood Glucose Monitoring

How the Test is Performed

Inform the patient Include slight discomfort

Gather all equipment timing is important

Wash your hands

Clean the area of the finger per agency policy

Avoid using the pads of the finger

Allow area to completely dry before pricking the finger

Provide the patient with a gauze pad for application of slight pressure

How the Test is Performed

Prick finger with lancet

Wipe away the first drop of blood, and then allow a full second drop of blood to fall onto the pad of test strip

The test strip uses a chemical substance to determine the amount of glucose in the blood Newer monitors can use blood from other areas of the body beside the

fingers, reducing discomfort.

Insert the test strip into glucometer

The meter will display the blood sugar results as a number on a digital display

Sliding Scale Insulin

In order to normalize the blood sugar levels of the patient the MD may prescribe all or part of the patients insulin on a sliding scale basis

The dose or doses are determined on the basis of the patients blood sugar results

Sliding scale is broadly defined as a set of instructions meant to adjust the dose of insulin in accordance with the results of the patients blood sugar levels, activity level and meals


Sliding scale insulin provides for better control of blood glucose since the insulin dosage is matched to the patients current need which is indicated by the blood sugar at that specific time

The RN has a critical responsibility to document the test times, the patients blood sugar results and the amounts and types of insulin administered


Read example 1 & 2 and determine how much insulin to administer to the patient using the sliding scale below.

2 units regular insulin if blood sugar is less than 180

4 units regular insulin if blood sugar is 181-240



ANSWER: 1. 4 units

2. 2 units

Pages 41 and 42 should have been completed as part of your pre-conference

work.

Insulin (high alert medication) Critical Thinking Activities

Case Scenario #1

Determine the sliding scale insulin based on the BG results for listed coverage 0600

2 units

1200

0 units

1800

6 units

2400

0 units/Call MD


Case Scenario #2

Determine and document the amount of Insulin to be given at

0630

6 units

1130

6 units

1630

2 units


Case Scenario #2

Determine how much insulin is needed for the HS dose Regular Sliding Scale Insulin 4 units NPH Insulin 12 units

Draw this amount up and administer to the injection pad

Discard fluid from syringe into Dixie cup

Draw up equivalent amount of air into syringe then administer to injecta pad

(Most agencies require 2 nurses to witness drawing up the insulin and co-sign)

Case Study 1

What assessment data would you document for this patient?

NPO after 6 p.m.

Took her glyburide (high alert medication) today

c/o feeling weak, unsteady and jittery

Case Study 1

Based on your assessment what does the above data indicate?

low BG?

high BG?

Case Study 1

List 2 priority nursing diagnoses with two matching priority outcomes

Risk for unstable blood glucose

Risk for falls

Case Study 1

Priority outcomes for Mrs. Zimmer

Maintain normal blood glucose levels

No falls during hospitalization

Case Study 1

Mrs. Zimmers actual BG was 37. What therapeutic nursing intervention (TNIs) would you implement? List TNIs in priority order.

Notify MD

Anticipate administration of IV Dextrose (D50)

Teach how to prevent incident

Case Study 2

What assessment data would you document for this patient?

Type 1 Diabetic

Strenuous activity hiking

Weak, sweaty

Rapid pulse

Case Study 2


low BG?

high BG?

Case Study 2

List at least 1 priority nursing diagnosis and one matching priority outcome.


Case Study 2

Priority outcomes for Jimmy:

Maintains normal BG levels

Case Study 2

List TNIs in priority order

Simple CHO or oral glucose paste orally if awake

enough to swallow

Do not overtreat

Recheck BG 15 minutes after treatment

Repeat until BG > 60 mg./dl

Case Study 2

List TNIs in priority order

Jimmy should eat regularly scheduled meal/snack to prevent rebound hypoglycemia

If no improvement after 2 or 3 doses of simple CHO or Jimmy becomes unconscious

give Glucagon 1 mg 1M/SC

Have Jimmy eat a complex CHO after recovery

In acute care setting 20-50 ml. D50 IV push

Case Study 3

What assessment data would you document

for this patient?

Type 1 DM

Blurred vision

Polyuria, Polydipsia

Increased stress

Not following her dietary regimen and exercise plan

Case Study 3


low BG?

high BG?

Case Study 3 List 2 priority nursing diagnoses with two

matching priority outcomes for Anne.

Diagnoses:

Risk for fluid volume deficient


Outcomes:

- Maintain urine output 30 mL/hr

- Maintain normal blood glucose levels

Case Study 3

TNIs in priority order

Monitor intake and output

Provide Ann with information on diet and exercise

Case Study 3

What additional teaching would you include?

Reinforce BG monitoring

Pediatric Considerations

Chart on page 49 provides you with important material regarding diabetes and pediatrics. Should have been completed prior to conference. Review on your own.

View Video

Diabetic Emergencies: Hyperglycemia and Ketoacidosis

VHS-193A (10 min.)

Notetaking Guide Provided on page 50

Acute Complications: Hyperglycemia & DKA

Definition

Precipitating Factors

Assessment Data

Treatment


Prevention

Teach patient:

to take antidiabetic medications as prescribed

proper technique to draw up and administer insulin with return demonstration

maintain target blood glucose range

to monitor blood glucose as ordered


Prevention

Teach patient:

lifestyle changes that may be required to control disease (exercise plan, adherence to diet)

S/S and how to treat

wear or carrying medical alert identification

ways to prevent hypo/hyperglycemia since activity chances can effect insulin needs

Diabetic Ketoacidosis Case Study

Diabetic Ketoacidosis Case Study Group Activity

pp. 54-57

Faculty may choose to do some or all of this

pre-conference activity if time allows.

Diabetic Ketoacidosis Case Study p 55

1. Briefly explain the pathophysiology of the development of diabetic ketoacidosis (DKA) in this patient.

Answer

Diabetic ketoacidosis (DKA), also referred to as diabetic acidosis and diabetic coma, can develop quickly or over several days or weeks

For Mr. John, DKA developed as a result of too little insulin accompanied by increased physical stress (the flu), which increases the demand of the body for insulin


2. What clinical manifestation(s) of DKA does this patient exhibit?

Answer:

Breathing deep and rapid, acetone smell on breath, skin flushed and dry


3. What factors precipitated this patients DKA?

Answer: Flu x 1 week

Vomiting and anorexia resulted in decreased caloric intake

Stopped taking his insulin

When insulin supply is inadequate, glucose cannot be properly used for cellular energy

In response to cellular starvation, the boy releases and breaks down stored fats and protein to provide the needed energy


What factors precipitated this patients DKA?

Answer:

Free fatty acids from stored triglycerides are released & metabolized in the liver in such large quantities that ketones are formed (ketonemia)

Excess ketones alter pH balance & acidosis develops

More H2O is lost as ketones are excreted (ketonuria) in an attempt to balance the pH



Answer:

Gluconeogenesis from protein is the last resource used by the body as a compensatory response to provide a cellular energy source

Result is increase in BG and nitrogen levels

Due to prevailing insulin deficiency, this glucose resource cannot be used and the BG level rises further, adding to the osmotic diuresis



Answer:

Dehydration and loss of electrolytes, particularly potassium

Patients skin becomes dry and loose, and

Eyeballs become soft and sunken

Hypotension with a weak, rapid pulse may also develop


4. What teaching should be done with this patient and his family?

Answer: Food intake is important during illness because the

body requires extra energy to deal with the stress

When he has a minor illness, such as a cold or the flu, continue drug therapy and food intake A carbohydrate liquid substitution, such as regular soft

drinks, gelatin dessert, or beverages such as Gatorade, may be necessary


What teaching should be done with this patient and his family?

Answer: Extra insulin may be necessary to meet the extra energy

demand and prevent DKA

BG monitoring should be done every 1 to 2 hours by either John or a person who can assume responsibility for care during the illness

Urine output ,presence & degree of ketonuria should be monitored, particularly when fever is present


What teaching should be done with this patient and his family?

Answer: Fluid intake should be increased to prevent

dehydration, with a minimum of 4 oz per hour for an adult

Mr. John should be instructed to contact the health care provider when BG is > 250 mg/dl (13.9 mmol/L), fever, ketonuria, & N/V occurs


5. What role should Mr. Johns wife have in the management of his diabetes?

Answer:

If Mr. John is not able to effectively manage his DM his wife can assist by

Frequent monitoring of BG levels

Encouraging fluids and food intake

Reporting abnormal BGs to MD as prescribed


6. Appropriate nursing diagnoses

Answer:

Deficient fluid volume



Collaborative problems/Potential complications

Answer:

Diabetic ketoacidosis

Hyperglycemia

Diabetes Mellitus Conference #3

Please review post conference

activities and the Diabetes

Mellitus Comprehensive review

Documents

NURSING Gastrointestinal Disorders Conference 3 Fall 2014