NR203 Test 1 Diabetes Mellitus

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Long term complications of diabetes: Macrovascular disease-affects large blood vessels and body organs

Microvascular disease
Kidneys (nephropathy)
Eyes (retinopathy)
Nerves (neuropathy)
Macrovascular disease-affects large blood vessels and body organs Microvascular disease Kidneys (nephropathy) Eyes (retinopathy Nerves (neuropathy) Examples of macrovascular disease: Coronary artery disease
Cerebral vascular disease
Peripheral vascular disease
Modifiable risk factors for macrovascular complications: Hyperglycemia
HTN
Dyslipidemia-Increased triglycerides, lowered HDL
Increased platelet adherence
Smoking/tobacco use
Diets high in fat
Obesity and sedentary lifestyle
Metabolic syndrome: Dyslipidemia, insulin resistance, hypertension, central obesity
Diagnosed when any 3 of the following are present:
Abdominal obesity waist >40 inches (men)_ >35 women
Fasting triglycerides >150mg/dL
HDL cholesterol (<40mg/dL men) <50mg/dL-Women
Blood pressure 130/85 mg Hg
Fasting glucose >110 mg/dL
Risk factor: body fat distribution: Apple more susceptible
Microvascular disease: Atherosclerotic changes as with macrovascular
Protein glycosylation-Sugar coating cells⬦Not soft and pliable but stiff-hemoglobin molecule
Neuropathy: Peripheral neuropathy
-Arms, hands, legs, feet
-Pain followed by numbness
-Distal symmetric sensorimotor polyneuropathy (sensory neuropathy or peripheral neuropathy)
Autonomic Neuropathy
Types of autonomic neuropathy: Gastrointestinal neuropathies
Genitourinary neuropathies
Cardiovascular neuropathies
Hypoglycemic unawareness
Long term Complication of Diabetes?: Infection
Decreased ability to kill bacteria
AHS: Increased susceptibility to infection
How does intensive therapy help diabetics: Reduces risk of diabetes related complications
Diagnosing Diabetes: Three ways to diagnose, each must be confirmed on a subsequent day unless unequivocal symptoms of hyperglycemia are present:
Casual plasma glucose 200 mg/dl with symptoms
Fasting plasma glucose 126 mg/dl (no caloric intake for 8 hours)
100-125-pre diabietics
2-h plasma glucose (200 mg/dl) during OGTT
(140-199 pre diabetes)
Additional lab tools to diagnose diabetes: Additional lab tools to diagnose diabetes
A1C
Lipids
-LDL
-Triglycerides
-HDL
Microalbuminuria
Normal <30 micrograms/mg creatinine
Microalbuminuria 30-299
Macroalbuminuria 300
Nursing diagnoses for diabetic patients: 1. Risk for ineffective management of therapeutic regimen related to knowledge of self care skills
2. Imbalanced nutrition: more than body requirements
3. Risk for peripheral vascular dysfunction
4. ineffective protection
5. risk for injury
6. powerlessness
7. ineffective coping
Target Outcomes for the diabetic patient: Blood glucose levels within normal limits a majority of the time without significant hypoglycemia
A1C <7.0%
Preprandial plasma glucose 90-130 mg/dl
Postprandial plasma glucose <180 mg/dl
Blood pressure 130/80
Lipids
LDL <100 mg/dl
Triglycerides <150 mg/dl
HDL >40 mg/dl (50 for women)
Stages for behavior as it relates to diabetes: Precontemplation stage: no intention of taking action in the foreseeable future
Contemplation Stage: intends to take action in the foreseeable future
Preparation Stage
Intends to take action in the immediate future, taking behavioral steps in the direction of change.
Action Stage: Has made a change to the goal level of the behavior in the recent past (6 months)
Maintenance Stage-Has been at goal level for 6 months or longer
Questions to help patients identify the problem: What is it like for you to live with diabetes
What is your greatest concern
Whatâ€™s hardest for you about caring for your diabetes
Whatâ€™s causing you the greatest distress or discomfort?
What do you think makes it so hard for you?
Why do you think that this is happening?
When you think about this problem, what comes to mind?
Has this issue been a problem or concern in the past? Has it been a problem in areas other than your diabetes careâ€¦.
American Association of Diabetes Educators⬦How active are you supposed to be?: A regular physical activity program, adapted to the presence of complications is recommended for all patients with diabetes who are capable of participating
Current recommendation: 150 minutes a week of moderate intensity aerobic physical activity and/or at least 90 minutes per week of vigorous aerobic exercise
Drug therapy to reduce HTN: Multiple drug therapy
Begin with 3 mo. Lifestyle changes
Then:
Ace inhibitors
In type 1, have been shown to delay the progression of nephropathy
In type 2 with microalbuminuria, have been shown to delay progression to macroalbuminuria
Angiotensin receptor blockers ARBs
Have been shown to delay progression of nephropathy

B Blockers, diuretics, calcium channel blockers
Lipid lowering agents: Statins
Anti platelet agents: Use aspirin therapy (75-162 mg/day) as a secondary prevention strategy and primary prevention strategy
-over 40 with additional risk factors
Check hx for those who shouldnâ€™t take aspirin
Not for those under 21
Drugs to manage peripheral neuropathy: Goal is pain relief
Anti-depressants
Elavil
Capsaicin (topical)
Newer agents now available
-Cymbalta (duloxetine HCL)
Monitoring blood glucose: Type 1: 3 or more times a day
Type 2 if on insulin, more often than if not on insulin
No real frequencies recommended in standards, go by if reaching goals
Teach how to use the data to adjust food intake, exercise or pharmacological therapy
Professionals need to evaluate patientâ€™s ability regularly
Monitoring blood glucose A1C: A1C 2x/yr
A1C q 3 months if therapy has changed or if not meeting glycemic goals
Correlation between A1C level and mean plasma glucose levels: A1C-6 glucose-135
A1C-7 glucose 170
A1C-8 glucose 205
A1C-9 glucose 240
A1C-10 glucose 275
A1C-11 glucose 345
Signs and symptoms of hypoglycemia: Irritable
Anxious
Weakness, fatigue
Dizziness
Hunger
Fast heartbeat
Shaking
Headache
Impaired vision
Interventions for hypoglycemia: Lantus/Lispro
15 grams of carbohydrates =
-3-4 glucose tabs
-1/2 cup juice
-1 cup skim milk
Recheck BS in 15 minutes
If <70 retreat
If > 3 hrs since insulin, no additional tx
If <3 hrs add 75-100 cal carbohydrate/protein snack

4 dose Regular or split mix
BS>60, tx Carbohydrate and protein mix
<60 tx with 15 grams carbohydrate
Recheck BS in fifteen minutes
If < 70 retreat
Follow with carbohydrate protein snack unless within 30 minutes of meal
Problem solving around blood glucose hiâ€™s and lowâ€™s and sick days hydration, foods to eat: Maintain adequate hydration
-8 oz calorie free fluid q hour while awake
-8 oz bouillon, canned clear soups q 3 hours
If unable to tolerate fluids by mouth, and antiemetics ineffective, ER visit
If unable to tolerate usual foods at meal times
-45-50 g of carbohydrate q 3-4 hours to prevent starvation ketosis
-If regular foods not tolerated, use regular soft drinks, juices, soups, ice cream, etc

Increase frequency of blood glucose monitoring and initiate ketone monitoring
Record results, encourage to call provider

Adjust meds during illness
Continue routine dose of insulin
Metformin should be stopped due to possible lactic acidosis

Supplemental doses of rapid acting or short acting insulin may be required
10% TDD if BS>250
20% TDD if BS > 300 plus ketones
Conditions that require immediate contact with healthcare provider: Vomiting more than once
Diarrhea more than 5 times for longer than 6 hours
Difficulty breathing
BG levels higher than 300 on 2 consecutive measurements that are unresponsive to increased insulin and fluids
Moderate or large ketones
What is the perioperative treatment for a diabetic client: Goals:
Prevention of hypoglycemia, excessive hyperglycemia, lipolysis, protein catabolism, and electrolyte disturbance

Thorough history and examination
Current S&S including uncontrolled diabetes
Medications: type, dose, timing, OTC
A1C and SBGM records
Current weight and maximum weight
Previous admissions
Allergies
Previous episodes of keoacidosis, HHS, and severe hypoglycemia
-Labs
CBC and electrolyte profile (look for dehydration, fluid overload if the pt. has nephropathy)
WBC for underlying infection
Perioperative treatment: what are the concerns for those with type 1 diabetes: Insulin protocols include alteration of usual insulin dosage and supplying adequate glucose
NS with short acting insulin in NS via pump at 0.5-1.5 units per hour
5-10% glucose solution in separate bag from insulin solution
Hourly capillary BG
Brief surgeries can use sq insulin
Sufficient glucose to prevent hypoglycemia
Electrolytes
Frequent BG and ketone monitoring
Perioperative treatment: what are the concerns for those with type 2 diabetes: May use insulin to manage their diabetes, determined by magnitude of the procedure and the metabolic state of the patient on the day of surgery
Sometimes oral agents are stopped evening before surgery
Discontinue metformin up to two days before surgery. Do not resume postoperatively until patient has resumed a regular diet and has normal renal function
Postoperative care: Diabetic Patient: Assess meal pattern and reasons for varying blood sugars
Small frequent feedings, Lower fat, low fiber
If hypoglycemia is a problem after meals, insuln may be given after the meal per doctorâ€™s orders
Collaborative foot care Amputation/risk factors: Amputation and foot ulceration more common consequences of diabetic neuropathy
Risk factors for amputation
-Peripheral neuropathy with loss of protective sensation
Altered biomechanics
Evidence of increased pressure
Bony deformity
PVD (decreased or absent pedal pulses)
Hx of ulcers or amputation
Severe nail pathology
Collaborative foot care- Foot assessment-how often Visual assessment-how often Initial screening: -Multidisciplinary approach
Foot assessment annually (visual routinely)
Semmes Weinstein monofilament
Tuning fork
Palpatation
Visual examination
-Initial screening
Hx claudication of pedal pulses
Ankle brachial index (AB)
Collaborative foot care-Therapies for decreasing foot pain: Focused on glycemic control, pain management, relief from depression that often accompanies chronic pain, and protecting deformed feet
Nonpharmacological therapies
-Walking to ease leg pains
-Gentle massage
-Stretching exercises
-Avoiding alcohol
-Relaxation exercises
-Biofeedback
-Hypnosis Acupuncture
-Use of percutaneous or transcutaneous nerve stimulation units
-Body stockings or pantyhose to keep clothes away from hypersensitive skin
-Brief cold water foot soaks
-Referral to a pain control clinic
Protecting deformed feet: Lambâ€™s wool padding
Gentle filing of calloused areas
Specially made shoes
Molded insoles or other orthotic devises
Referral to podiatrist or orthotic specialist
DKA, HHS precipitating factors: Infection or illness
-Cause increase in counter-regulatory hormones, all which increase blood sugar
-Glucocorticoids
-Epinephrine
-Cortisol
-Growth hormone
Inadequate insulin dosage
-Expense
-GI symptoms
Psychosocial issues, particularly with adolescents
Signs and symptoms of DKA, HHS: Manifestations of hyperglycemia
Polyuria
Polydipsia
Blurred vision
Polyphagia if long enough
Weakness, lethargy malaise, headache
Signs and symptoms of DKA, HHS GI symptoms (DKA only) Respiratory Symptoms (DKA only) Hypothermia-is it common or uncommon: GI symptoms (DKA)
-N/V, abdominal pain
Respiratory Symptoms (DKA)
-kussmaulâ€™s respiration
-Acetone breath, fruity odor
Hypothermia common
-Due to vasodilation
Signs and symptoms of DKA, HHS Dehydration: Dehydration (intravascular volume depletion)
â€œacute abdomenâ€-only in DKA
-Tenderness to palpation
-Diminished bowel sounds
-Muscle guarding
Mentation changes (alert, obtunded, stuporous, or in frank coma)
-Correlates best with serum osmolality
Hypotonia, uncoordinated ocular movements, and fixed dilated pupils are late signs
Diagnostic Criteria for DKA and HHS: Plasma glucose mild-severe DKA >250, HHS plasma glucose > 600
Arterial pH Mild DKA 7.3-<7 Severe
Arterial pH HHS >7.3
Serum bicarbonate mild DKA 18, severe <10. HHS >15
Urine ketones DKA positive HHS small
Serum ketones DKA positive HHS small
Effective serum osmolality DKA variable HHS >320
Anion Gap DKA >10 or >12 severe,
HHS varable
Alteration in sensorial or mental obtundation: Alert-Mild DKA, Severe DKA stupor/coma, HHS-Stupor, coma
Treatment for DKA/HHS: Dehydration-Give IV fluids, determine hydration status, 0.9% NaCl 1L/hr for hypovolemic shock
Further tx per orders

Hyperglycemia
Insulin-Regular insulin 0.15 units/kg as IV bolus
0.1 units/kg/hr IV regular insulin infusion
Further tx per orders

Electrolyte depletion
Potassium
If initial K is <3.3 mEq/L, hold insulin and give 40 mEq K per hour until K>= 3.3
Further tx per orders

Acidosis
Assess need for HCO3
Further tx per orders
Cautions: switching from IV insulin to sq insulin: Cautions:
When switching from IV insulin to sq insulin, maintain IV infusion for several hours to give sq insulin time to build

Cerebral edema symptoms: deterioration in the level of consciousness with lethargy, decrease in arousal, and headache; seizures, incontinence, papillary changes, bradycardia, and respiratory arrest
-Prevention: gradual replacement of NA and H20 deficits and addition of dextrose to hydrating solution once BS reaches 250 mg/dl
Type 1 diabetes Progression of DKA: Insulin deficiency leads to lowered glucose uptake which leads to hyperglycemia, then osmotic diuresis leads to Electrolyte depletion and hypotonic losses, then finally dehydration
Insulin deficiency also leads to increased Protein Catabolism, then increased gluconeo genesis, then hyperglycemia, which follows the same path as above.
Insulin deficiency leads to increased lipolysis then increased glycerol and increased free fatty acids, then ketogenesis, then increased ketonuria and ketonemia, then acidosis.
Progression of HHS in type 2 diabetics hyperosmolar hyperglycemic state: Insulin deficiency leads to decreased glucose uptake which leads to hyperglycemia, osmotic diuresis which leads to electrolyte depletion and hypotonic losses, and finally dehydration

Insulin deficiency also leads to increased protein catabolism, increased glucconeo genesis, then hyperglycemia, and so on.
As the shift begins, you are assigned these patients. Which patient should you assess first? 1. A 38 year old patient with Graveâ€™s disease and a heart rate of 94/minute 2. A 63 year old patient with type 2 diabetes and a fingerstick glucose o: Answer 3. Although patients with hypothyroidism often have cardiac problems that include bradycardia, a heart rate of 48/minute may have significant implications for cardiac output and hemodynamic stability. Patients with gravesâ€™ disease usually have a rapid heart rate, but 94/minute is within normal limits. The diabetic patient may need sliding scale insulin. This is important but not urgent. Patientâ€™s with Cushingâ€™s disease frequently have dependent edema.
Which patientâ€™s nursing care would be most appropriate for the charge nurse to assign to the LPN, under the supervision of the RN team leader 1. A 51 year-old patient with bilateral adrenalectomy just returned from the post-op anesthesia care unit: Answer: 2-83 year old has no complicating factors at the moment. Providing care for stable and uncomplicated patients is within the LPNâ€™s educational preparation and scope of practice, with the care always being provided under the supervision and direction of the RN. The RN should assess the newly post-operative patient and the new admission. The patient who is preparing for discharge after MI may need some complex teaching.
You are preparing to review a teaching plan for a patient with type 2 diabetes. What will you check to determine the patient's level of compliance with his diabetic regimen? 1. Patient's fasting glucose level 2. Patient's oral glucose toleran: Answer 3. the higher the blood glucose level is over time, the more elevated the glycosylated hemoglobin becomes. Glycosylted hemoglobin is a good indicator of average blood glucose level over the previous 120 days. Fasting glucose and oral glucose tolerance tests are important diagnostic tests. Fingerstick blood glucose monitoring provides information that allows for adjustment of patientsâ€™ therapeutic regimen
The patient has newly diagnosed type 2 diabetes. Which task should you delegate to the nursing assistant? 1. Arrange consult with the dietitian for patient. 2. Verify patient's insulin injection technique. 3. Teach patient to use glucom: Answer 4
The nursing assistantâ€™s role includes reminding patients about interventions that are already part of the plan of care. Arranging for a diet consult is appropriate to delegate to the unit clerk. Teaching and assessing require additional education and should be completed by licensed nurses.
A nursing diagnosis for the newly diagnosed diabetic patient is Risk for Injury related to sensory alterations. Which key points should you include in the teaching plan for this patient? (Choose all that apply.) 1. Clean and inspect your feet every: 1,2,5
Sensory alterations are the major cause of foot complications in diabetic patients, and patients should be taught to examine their feet on a daily basis. Properly fitted shoes protect the patient from foot complications. Broken skin increases the risk of infection. Cotton socks are recommended to absorb moisture. Patientâ€™s, family, or health care providers may trim toenails.
The diabetic patient has all of these assessment findings. Which will you instruct the LPN/LVN to report immediately? 1. Fingerstick glucose of 185 mg/dL 2. Numbness and tingling in both feet 3. Profuse perspiration 4. Bunion on l: Answer 3. Profuse perspiration is a symptom of hypoglycemia, a complication of diabetes that needs urgent treatment. A glucose level of 185 will need coverage with sliding scale insulin, but this is not urgent. Numbness, tingling, and bunions are related to the chronic nature of diabetes and are not urgent.
The plan of care for the diabetic patient includes all of the following interventions. Which intervention could you delegate to the nursing assistant? 1. Check to make sure that the patient's bath water is not too hot. 2. Discuss community re: Answer 1: Checking the bath water temperature is part of assisting with activities of daily living and is within the educational scope of the nursing assistant. Discussion of community resources and teaching and assessing require a higher level of education and are appropriate to the scope of practice of licensed nurses
You are precepting a nurse who has recently graduated and passed the NCLEX examination. The new nurse has been on the unit for only 2 days. Which patient should you assign to the new nurse? 1. A 68-year-old diabetic who is experiencing signs of hyp: Answer: 2. The new nurse is still orienting to the unit. Appropriate patient assignments at this time include those who are stable and not complex.
In the emergency department, during initial assessment of a new admission with diabetes, you discover all of the following. Which information should you immediately report to the physician? 1. Hammertoe of the left second metatarsophalangeal joint: Answer 2. Rapid, deep respirations (Kussmaul) are symptomatic of DKA. Hammertoe, as well as numbness and tingling, are chronic complications associated with diabetes. Decreased sensitivity and swelling (lipohypertrophy) occur at a site of repeated insulin injections, and treatment involves teaching the patient to rotate injection sites
You are caring for a diabetic patient who is developing DKA. Which delegated task is most appropriate? 1. Ask the unit clerk to page the physician to come to the unit. 2. Ask the LPN/LVN to administer IV insulin according to the sliding scale: Answer 1. The nurse should not leave the patient. The scope of the unit clerkâ€™s job includes calling and paging physicians. LPN/LVNs generally do not administer IV push medication. IV fluid administration is not within the scope of nursing assistants. Patients with DKA already have a high glucose level and do not need orange juice.
A diabetic patient presents with hot and dry skin, rapid and deep respirations, and a fruity odor to his breath. As charge nurse, you observe the new graduate RN accomplishing all these patient tasks. Which one requires that you intervene immediately?: Answer 2. the signs and symptoms the patient is exhibiting are consistent with hyperglycemia. The nurse should not give the patient additional glucose. All of the other interventions are appropriate for this patient. The RN should also notify the physician at this time.

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