Nursing Management of Clients with Stressors of Endocrine Function DIABETES MELLITUS NUR133 Lectures # 12&13 K. Burger, MSEd, MSN, RN, CNE

Nursing Management of Clients with Stressors of Endocrine

FunctionDIABETES MELLITUS

NUR133

Lectures # 12&13

K. Burger, MSEd, MSN, RN, CNE

Definition & Classification

• A group of metabolic diseases characterized by elevated levels of blood glucose resulting from defects in insulin secretion, insulin action, or both

• The disease is further characterized by metabolic abnormalities and by long-term complications to other body systems

• EVERY BODY SYSTEM IS AFFECTED BY DIABETES

Classification

Type 1Diabetes Mellitus

Lack of insulin or production of defective insulin

Age of onset: <20 yrs Often present with DKA Always requires

exogenous insulin Rx

Type 2 Diabetes Mellitus

Reduced ability to respond to insulin and/or secrete sufficient amounts

Age of onset: adults* Obesity = co-factor Rx: variable

DKA versus HHNS

Diabetic Ketoacidosis

Usually preceded by polyuria, polydipsia, polyphagia

BG > 300 Ketosis Fruity breath Lethargy Kussmaul’s Resp

Hyperglycemic-Hyperosmolar

Non-ketotic Syndrome

Gradual Onset BG as high as 800 Hi blood osmolarity No ketosis Dehydration Confusion – Coma Muscle jerking-seizures

Interventions for DKA / HHNS

• Restore fluid volume rapidly to maintain perfusion to vital organs ( NS IV @ 1L/hr)*

• Then continue to balance fluids (1/2 NS @ reduced rate )

• Administer IV insulin

• Administer HCO3 in extreme cases

• Monitor K levels

• Monitor for s/s cerebral edema*

Metabolic Acidosis/AlkalosisThe elevator effect

Metabolic Acidosis

Metabolic Alkalosis

CO2 + H2O = H2CO3 = H + HCO3

PRIOR to LECTURE

• Students are to complete: Winningham & Preusser CASE STUDYEndocrine Disorders – Case Study #4

• BE PREPARED!

• YOU WILL BE CALLED ON IN CLASS TO ANSWER THESE QUESTIONS!

Case Study 4Diabetes Mellitus

Winningham & Pruesser (2005) Elsevier, Inc.

The client, Y.L. has been complaining of chronic fatigue, increased thirst, constantly being hungry, and frequent urination. She denies any pain, burning, or low back pain on urination. She tells you she has a vaginal yeast infection that she has treated numerous times with OTC medication. She admits to starting smoking since going back to work full time as a clerk in a loan company. She also complains of having difficulty reading numbers and reports making frequent mistakes. She says by the time she gets home and makes supper for her family, then puts her child to bed, she is too tired to exercise. She reports her feet hurt; they often “burn or feel like there are pins in them.” She reports that after her delivery, she went back to her traditional eating pattern, which you know is high in carbohydrates Her current weight is 173 lb. Today her BP is 152/97 mm Hg and her plasma glucose is 291 mg/dL.Lab values are as follows: FBG 184 mg/dL, A1c 10.4, UA +glucose, -ketones, cholesterol 256 mg/dL, triglycerides 346 mg/dL, LDL 32 mg/dL, ratio 8.0. Y.L. is diagnosed with type 2 diabetes.The PCP decides to start MDI (multiple dose injection) insulin therapy and have the patient count carbohydrates. Y.L. is scheduled for education classes and is to work with the diabetes team to get her blood sugar under control.



QUESTION #1

Identify the three methods used to diagnose

Diabetes mellitus.



QUESTION #9

What symptoms did YL report that lead you

to believe she has some form of neuropathy?



QUESTION #10

What findings in YLs history place her at

increased risk for the development of other

forms of neuropathy?



QUESTION #11

What are some changes that YL can make

to reduce the risk or slow the progression of

both macrovascular and microvascular

disease?



QUESTION # 8

YLs culture prefers foods high in

carbohydrates. What is carbohydrate counting

and why would this method work well for YL?



QUESTION#12

YL is enrolled in a smoking cessation class.

Why is it so important that she stop smoking?



QUESTION # 2

Identify (3) functions of insulin



QUESTION #3

Insulin’s main action is to lower blood sugar

levels. Several hormones produced in the

body inhibit the effects of insulin. Identify (3)

ANTIDIABETIC AGENTS

ORAL

Sulfonylurea Agents Biguanides Alpha-glucosidase

Inhibitors Thiazolidinediones• Meglitinides

INSULINS

Rapid Acting Short Acting Intermediate Acting Long Acting Combination

ORAL ANTIDIABETICSSulfonylureas

• Chlorpropamide ( Diabinese ) 1st generation

• Glipizide ( Glucotrol ) 2nd generation

• Glyburide ( Micronase ) 2nd generation

• Work best in early stages of disease• Stimulate beta cells to secrete insulin• Also have some effect on glucose

absorption & storage in tissues• Most commonly prescribed type oral rx

Sulfonylurea DrugsNursing Implications

• Hypoglycemia is most common side-effect

• Can also cause blood dyscrasias

• Geriatric clients and anyone with decreased organ function more susceptible to above

• Cross allergies to loop diuretics and sulfonamides

• Diabinase and other 1st generation sulfonylureas should not be taken with alcohol; potential severe reaction

• Glucotrol has most rapid onset and shorter duration

• Usually taken 30 minutes before meals

Biguanides

• Metformin ( Glucophage )

• Reduces the production of glucose

• Decreases intestinal absorption of glucose

• Increases the uptake of glucose

• Does NOT produce hypoglycemia

• Often given in combination with other orals

BiguanidesNursing Implications

• Onset within 1 hr, duration 24 hrs

• Hold med temporarily if pt going for diagnostic studies involving iodinated contrast materials

• Should not be used in renal impaired client

• Side effects are mostly GI related but usually transient:– Abdominal bloating– Nausea– Diarrhea

Alpha –glucosidase Inhibitors

• Miglitol ( Glyset )

• Delays glucose absorption after a meal

• Taken with first bite of each meal

• GI side effects: abd pain, diarrhea, flatususually lessen over time

• Contraindicated for persons with inflammatory bowel disease

Thiazolidinediones

• Rosiglitazone ( Avandia )

• Decrease insulin resistance• Stimulate peripheral glucose uptake• Inhibit glucose production in the liver• Side effects: weight gain, edema, anemia• Potential for hepatic toxicity; liver enzymes

need to be monitored

Meglitinides

• Repaglinide ( Prandin )

• Nateglinide ( Starlix )

• Rapidly increases release of insulin from pancreas

• Must be taken with meals 0-30min ac

• Meal must have adequate CHO

Insulin Therapy

• Rapid - Lispro

• Short - Regular• Intermediate -NPH

• Long - Lantus



QUESTION #4

YL was started on lispro (Humalog) and

glargine (Lantus) insulin. What is the most

important point to make when teaching the

patient about glargine?



QUESTION #5

Because YL has been on regular insulin in the

past, you want to make sure she understands the

difference between regular and lispro. What is the

most significant difference between these two

insulins?



QUESTION #6

What is the peak time and duration for lispro

insulin?



QUESTION #7YL wants to know why she can’t take NPH and

regular insulin. She is more familiar with them and has taken them in the past. Explain why the MD chose lispro and glargine insulin over NPH and regular insulin.

Insulin Rx Considerations

• Rotation within one anatomic site is preferred to moving from site to site.

• Abdomen provides best absorption

• Be alert to Dawn and/or Somagyi Phenomena

• Refrigerate unused insulin

• Insulin in use can be left out up to 28 days

• Do not re-use needles. Dispose properly

Alternative Methods of Insulin Administration

• External pumps

• Internal pumps

• Injection devices

• Inhaled ( under development )

Common Nursing Implications for Antidiabetic Medications

• Monitor for hypo/hyperglycemia

• Many drug interactions; both agonist and antagonist

• Use cautiously in geriatric clients and those with organ impairment

• Monitor A1c levels q2-3months

• Monitor BG levels daily

• Patient teaching is KEY!!!

Self-StudyHypoglycemia versus Hyperglycemia

Signs & SymptomsHypoglycemia

_______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________

Hyperglycemia _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________

Self-StudyInsulin Comparison

Action / Onset / Duration

Agent Onset Peak Duration

LISPRO

REGULAR

NPH

LANTUS

Documents

Nursing Management of Clients with Stressors of Endocrine Function DIABETES MELLITUS NUR133 Lectures # 12&13 K. Burger, MSEd, MSN, RN, CNE