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Chapter 47 Osborn & Wraa: Caring for Patients with DiabetesDiabetes Mellitus Group of metabolic disorders characterized by abnormal fuel metabolism, all of which have hyperglycemia in common.Prevalence of diabetes differs by type of diabetes, race, ethnicity, and geographic location American Diabetes Association ADA have the most recent criteria for diagnosis and classification with periodic updates Types of Diabetes Type 1 Diabetes Mellitus Lacks insulin production caused by autoimmune destruction of insulin-producing pancreatic beta cells Epidemiology and EtiologyFrequently diagnosed BEFORE age 30 Latent autoimmune diabetes in adults LADA5-10% of all diagnosed diabetes Thin, normal weight, abrupt symptom onsetResults from genetics, environment and autoimmunity Risk Factors for Type 1: GeneticsFamilial predispositionHigh chance from father (6%) compared to mom (3%)and monozygotic twins (25-50%) compared to dizygotic twins (6%) Environmental Viral infections, dietary factors, toxins (N-nitroso compounds), congenital rubella syndrome, cow’s milk proteins,Autoimmunity Circulating autoantibodies that target pancreatic beta-cell components: ICAs, IAAs, GAD Presence of 2 or more antibodies, together with alterations in insulin secretion is predictive of type 1 diabetes developmentType 2 Diabetes Mellitus Decreased insulin production by pancreas Increased insulin resistance Epidemiology and Etiology Diagnosed AFTER age 30 90-95% of all diabetes Overweight, obese, strong family hx of disorder Insulin therapy and/or oral medications for hyperglycemia Risk factors for type 2 diabetes: Sedentary Lifestyle and Poor Dietary PatternsFinnish Diabetes Prevention Study: reduced (weight, dietary fat and saturated fat) + increased (dietary fiber and physical activity)= reduced diabetes risk 58% US Diabetes Prevention Program: lifestyle modification program prevalent over metformin medication High carb, high fat, high alcohol and low fat diets contribute to development of type 2 Ethnicity Wide variability in risk of type 1 among racial and ethnic groupsObesity Central obesity: glucose intolerance, hyperinsulinemia, hypertriglyceridemia. Bisceral obesity: weight centered in abdomen Metabolic SyndromeGroup of metabolic abnormalities that predispose individuals to CVD and type 2Abnormalities: insulin resisteance, glucose intolerance, hyperinsulinemia, hypertriglercidemia, and decreased HDL cholesterol, central obesity and HTN. Aka insulin resistance syndrome. Can develop into type 2. Prevention through weight loss, diet, & exercise Risk Factors For Type 2 DiabetesAge, sedentary lifestyle, poor dietary habits, obesity, intrauterine development, familial history, ethnicity, metabolic syndrome, gestational diabetes, prediabetes, high blood pressure, polycystic ovary syndrome (PCOS), HX of previously impaired glucose tolerance, presence of acanthosis nigicans, history of cardiovascular disease, drug induced diabetes, endocrine disorders, genetic diseases, urbanization and soceioeconomic status. On page 1420 Gestational Diabetes MellitusDiabetes onset during pregnancy 2-10% for all pregnancies Risk factors: previous GDM, advanced maternal age, oesity, family hx of diabetes and racial ethnic origin (American: African, Hispanic Latino, Indian) Treatment: diet, oral meds, insulin therapy for hyperglycemia Uncontrolled hyperglycemia= fetal/ maternal complications Other Specific Types of DiabetesMonogenic DiabetesEpidemiology, Etiology and Risk Factors 1-5% of all childhood diabetes From single-gene mutation (type 1,2 is from mult) Neonatal diabetes mellitus= newborn, infantMaturity-onset diabetes of young= adolescence, early adultMedical Management: MODY treated with oral diabetes meds Latent Autoimmune Diabetes in AdultsGenetically linked, hereditary autoimmune disease. 1.5 diabetes Perceives pancreas as foreign and kills insulin-producing beta cellsCommon AFTER age 30 Risk factors: age, acute symptoms of diabetes, BI <35 kg/m, personal hx of autoimmune disease Clinical Manifestations and PathophysiologySymptoms: age (30-50), lean build, normal-low BMI, no ketoacidosis, no known type 2 relatives, low C peptide levelRequires insulin within 3 years at point of diagnosis LADA pt has less autoantibodies than type 1Medical Management No single optimal treatment. Must distinguish LADA pt from type 2 so drugs are not mistaken Control hyperglycemia Reduced calorie diet, increase physical activity, oral antidiabetic meds. Similar diet to type 1 Secondary Diabetes Pancreas’s inability to produce sufficient amounts of insulin BUT is a reaction to other internal diseases or conditions Epidemiology, Etiology, and PathophysiologyNIDDK: 1-5% of diabetic cases Caused by damage, injury, destroyed pancreas; medications; body’s rxn to surgery involving pancreas Clinical Manifestations, Lab Tests and Medical Management Same manifestations to primary diabetes. Treated like type 2 or destructs insulin making beta cells, resemble tpe 1 treatment and insulin injections Prediabetes People with glucose intolerance and at increased risk for developing diabetes Impaired fasting glucose: fasting blood glucose or HG A1c is higher than normalImpaired glucose tolerance: blood glucose level 2 hours following oral glucose is higher than normal nut not diagnostic of diabetes Increased risk of CVD, stroke, diabetes.Normalize with diet modification, weight loss, physical activity Physiology of Fuel MetabolismPathophysiology of Type 1 DiabetesPathophysiology of Type 2 Diabetes Clinical Manifestations of Type 1 and Type 2 Diabetes Signs and Symptoms of diabetes without metabolic complications (DKA, HHS)Glucosuria, osmotic diuresis, polyuria, nocturia, hypotension, tachycardia, polydipsia, polyphagia, weight loss, fatigue Complications of DiabetesRetinopathy, glaucoma, loss of sensation in foot, skin dryness, cracjing, callus, infections, itching, dermopathy, blisters, poor wound healing, hearing loss, problems with teeth, gums heart disease, PAD, HTN, stroke, gastroparesis, neurogenic bladder, diabetic diarrhea, kidney disease, ketoacidosis, HHNS, neuropathy, charcot deformity, lower extremity ulceration, sexual dysfunction Laboratory Tests and Diagnostic ProceduresBlood Glucose Levels Measured following overnight fast – no food or drink with exception of water for 10-12 hours Used for diagnosis of prediabetes and diabetesOral Glucose Tolerance TestsConfirms diagnosis of diabetes Fast 10 hours prior and intake carbs 150 g/day for 3 days prior Refrain from smoking during test (time between blood draws) Self-Monitoring of Blood Glucose Pt instructed to perform preprandial blood glucose measurements (immediately prior to meal and snack) postprandial blood glucose measurement (approx. 2 hours after meal or snack) or when experiencing symptoms (hypoglycemia) Steps:Strips must be current, properly stored and appropriate temperature Calibrate to correct lot numberMeter must be cleanAdequate blood amount on stripFingertip should be clean and dry pior to puncture Safety Alert: Hospitalized pt eating 4x a da should perform blood glucose before each meal or snack. Calculation prebreakfast dose of rapid acting insulin should be based on glucose made shortly before breakfast (not hours prior). T not eating also should have glucose levels checked 4x a day or every 6 hours depending on insulin regimenContinuous Blood Glucose Monitoring Medtronic measures glucose levels in interstitial fluid every 10 seconds and provides average blood glucose level every 5 minutes. Sensor is small with tubing and small cannula inserted into subcutaneous tissue (abdomen) and results transmit ti insulin pump and read in real time and stored to be downloaded. Pt and health care provider discuss trends on bg patterns and treatment decisions Hemoglobin A1C TestPrimary lab test to monitor long term glucose control. Formed when blood glucose binds irreversibly to hemoglobinUrinary GlucoseSelf-monitoring blood glucose replaced this Urinary and Blood KetonesFor diabetes self management (type 1), pregnancy with preexisting diabetes and gestational diabetes. Type 1 should test urine for ketones during stress or infection, when blood glucose are elvated >300 and DKA symptoms ab pain, n/v. Bedside and self testing kits too Diabetes Diagnosis National Guidelines for Establishing a Diagnosis of Diabetes:HgA1C 6.5% or higher. C-peptide negative (no insulin)Urine test has glucose and ketones Prediabetes Diagnosis Impaired blood glucose tolerance and often occurs together with metabolic syndrome but not alwaysImpaired glucose tolerance= 2 hour plasma blood glucose level <140 and <200 mg/dL following 75 g oral glucose National Guidelines for Establishing a Diagnosis of Diabetes American Diabetes Associate (ADA)Fasting blood sugar > 126 mg/dL on more than one occasion with or without hyperglycemia symptomsCasual serum blood glucose >200mg/dL along with hyperglycemia symptoms (polydipsia, polyuria)2 hour oral glucose tolerance test of >200mg/dL Medical Management Type 1 (insulin replacement), Type 2 (oral med, insulin), Anti-htn, lipid-lowering drugs, exercise, good nutrition, lifestyle change Goals of Diabetes Management Long term: prevent long term complicationsShort term: prevent severe hypoglycemia, hyperglycemia, DKA, and HHSFrom the DCCT and UKPDS studies, glycemic control is emphasized to manage diabetes, and reduce CVD but did not reach statistical significant. Glycemic goal: A1C <7%, Preprandial blood glucose 90-130 mg/dL, Postprandial blood glucose <180, blood pressure <130/80, Lipid goal: LFL<100, Trigylceride<150, HDL >40 Lifestyle changes (exercise, stop smoke, diet, medication ) Management of Type 1 Diabetes Primary tx: Insulin replacement therapy (injection or pump) Insulin PreparationsCharacterized by onset, peaks and duration of action Insulin secretion is basal or meal stimulated Commercial insulin preparations are rapid, short, intermediate and long acting Rapid Acting InsulinOnset: 15 minutes; Peak: 1-2 hours; Duration 3-4 hours Before meal or snack, OR after meal. Safety Alert: Should be injected as close to meal or nack as soon as possible to avoid hypoglycemia. Nurse role is to be alert for S&S of hypoglycemia and educate about how to prevent/treat hypoglycemic rxn Short Acting InsulinOnset 15 min-1 hour; Peak: 1-5 hours, Duration 6-10 hoursRegular insulin injected 30-45 minutes before meals Regular insulin replaced by rapid-acting insulin analog Intermediate Acting InsulinOnset: 1-2 hours; Peak 6-14 hours, Duration 16-24 hours NPH insulin, provides basal insulin (2 injections a day) Limit NPH because high plasma during peak increases hypoglycemia risk Long-Acting InsulinOnset 1 hour, Peakless, Duration 24 Basal insulin coverage and small peakPremixed InsulinsCombination of rapid or short acting insulin preparations mixed with inetermediate acting insulin. Ex. 70%NPH and 30% regular insulin Not easy to adjust premeal and basal insulin Incretin MimeticsInjectable meds used adjunctive to mealtime therapy to improve glycemic control in type 2. Incretin mimetics enhance glucose dependent insulin secretion from pancreatic beta cells which reducing postprandial glucose levels Side effect: nausea Decrease rate of oral medications so administer them 1 hour before injection of mimetics. Amylin Analog Reduces postprandial blood by slowing gastric emptying, suppress glucagon, promote satiety,. Inject SQ immediately before meal for type 2 glycemic control. Mealtime therapy for type 1 Administer other medications1 hour before or 2 hours after administering pramlintide (amylin analog) because it affects GI motility Insulin Delivery DevicesContinuous subcutaneous insulin infusion CSII –intensive insulin therapy via pump. Pump made out of a pump reservoir (syringe) filled with insulin, small battery operated pump, and a computer chip. Reservoir connects with tubing with a needle or cannula through which insulin is delivered. Cannula inserted SQ in abdomen. Pump delivers 24 hours a day programmed rate specific to patient Designed to mimic basal and meal stimulated patterns Program to infuse differing basal rates thru 24 hour period Insulin Regimes Type 1 insulin therapy goal is to normalize blood glucose levels which is done by using combinations of insulin Twice-Daily Injection RegimenRegular or rapid acting insulin combines with intermediate (NPH) Prior to breakfast and prior to supper Gives little flexibility to changing mealtime and NPH peak predisposes hypoglycemia if skipping a meal Three-Times Daily Insulin Injection RegimenRegular or rapid acting insulin combines with NPH Prior to breakfast, regular or rapid acting insulin prior to dinner and NPH prior to bedtimeDifference from twice is that it is at bedtime Two causes Dawn phenomenon- fasting hyperglycemia without prior nocturnal hypoglycemia. Occurs when growth hormone is secreted at night. Pt awake with elevated fast blood glucose. Pregnant women is more exaggerated due to excessive hormones at night.?Somogyi effect- fasting hyperglycemia with prior hypoglycemia. Aka rebound hyperglycemia. Pattern of undetected hypoglycemia followed by hyperglycemia. Happens at night or when too much insulin.?To differentiate between somgyi or dawn, test blood glucose at night. Hypoglycemia at night then somogyi effect. Hypoglycemia not present at night then dawn.? Four-Times Daily Insulin RegimenNPH and rapid or short acting insulin at breakfast time, rapid or short acting insulin before lunch and dinner and just NPH at bedtime. Premeal insulin helps reduce postprandial hypoglycemia. NPH provides basal insulin Other Insulin Regimens Peakless insulins provide better basal insulin coverage. Multiple-dose regimen: long acting insulin is used in combination with rapid acting insulin prior to each meal.Insulin pump- mimics normal insulin secretion because it is programmed Nursing Management 1) Instruct pt in prescribed insulin delivery (pen, syringe, pump)2) Review Insulin delivery techniques 3) Instruct on specific insulin regimen and assess understanding 4) instruct on relationship between glucose monitoring and regimen5)help them understand how prescribed adjustments in insulin affects glycemic control6)help them understand S&S hypo and hyperglycemia Management of Type 2 Diabetes Oral Diabetes Medications SulfonylureasTreats type 2Stimulates insulin from pancreatic beta cells Side effect: hypoglycemia, allergy to sulfa; alcohol causes warmth, flush, headache, n/v, sweat, thirst MeglitinidesTreats type 2 to reduce hyperglycemia with nutrition and exercise Rapid insulin secretion from pancreatic beta cells Give prior to each meal to reduce postprandial hyperglycemiaSide effect: hypoglycemia. Eat within 20 minutes of medication to prevent hypoglycemiaAlpha-Glucosidase Inhibitors Will reduce postprandial glucose levels since postprandial hyperglycemia contributes to diabetes GI effects: softer stools, diarrhea, flatulence and bloating. These can be reduced by titrating slowly up Hypoglycemia can occur so pt must use pure glucose: fruit, juices, glucose tablets to treat and because carb absorption is delayed BiguanidesReduces hepatic glycogenolysis and glucogenolysis results in decreased hepatic glucose and low blood glucose. GI effects: n/v/d, and can be prevented by slow titration. Screen pt who are great risk of lactic acidosis since this is a lifethreatening adverse rxn ThiazolidinedionesDipeptidyl Peptidase-4Inhibitors Combinations of Oral MedicationsWhen a pt fails oral monotherapy, combining drugs of different classes is usually more effective than stopping one and substituting another. When pt requires near-max dose of one med, adding another drug is usually better than increasing dosage of original medicationSecondary failure of two-drug combo in pt wth type 2 is expected eventually. Three-drug combo is useful but adding insulin to existing regimen or insulin alone should be sufficient Insulin Therapy for Type 2 Diabetes Supplements reduction of insulin secretion and overcomes insulin resistance Start off with oral meds but then require insulin treatment for glucose control Insulin in combination with oral medication to suppress hepatic glucose production during the night. (oral meds during day) Nursing Management For oral hypoglycemic therapy is Instruct pt in prescribed oral hypoglycemic medsReview oral hypoglycemic therapy with pt who have been on it prior to visitInstruction pt on relationship between glucose monitoring and oral hypoglycemic medicationsHelp pt understand how prescribed adjustments in oral meds may affect glycemic controlUnderstand S&S of hypoglycemia and hyperglycemia Nutrition and Diabetes Nutrition and physical activity MNT – medical nutrition therapy- meal planning approaches Micronutrients and Macronutrients in the Diet ADA recommendations for prediabetes, diabetes and diabetes complications Medical Nutrition Therapy No “single” diabetes dietMealplanning can be flexible or not (traditional insulin regimen)ADA Exchange List- foods categorized into groups- bread/starch eat, fruit, veggies, fats) and assigned specific amount based on daily calories Pt instructed to read food labels to determine total amount of CHO in a food item Nutritional Needs of Hospitalized Patients Caloric need met through provision of 25 to 35 kcal/kg body weight Oral route of feeding is preferred. If not, then enteral and parenteral feedingCHO counting is integrated into the diet of the hospital pt in various ways Exercise and Physical Activity Benefits for those already with type 1 and type 2: low blood glucose levels, improved insulin sensitivity, improvements in cardiovascular risks (high lipid and BP levels, improved cardiac conditioning, increased strength, flexibily, personal well being)Best used with calorie restricted diet Fuel mobilization from muscle and liver stores during exercise in individuals with diabetes during exercise may be 20 fold higher than that during sedentary activity to maintain normal blood glucose. Plasma insulin decrease while regulatory hormones increase to maintain glucose homeostasis Safety Alert: Pt with diabetes using pharmacologic therapy are at greater risk for hypoglycemia during the following exercise. Hypoglcemic effect can persist for several hours and pt education about preventing and treating exercise related hypoglycemia is essential** Diabetes individuals can participate in all levels of physical activity. Metabolic response varies depending on plasma glucose levels at time of exercise. Poor metabolic control is at risk for worsening hyperglycemia nd ketosis In type 2, regular exercise plays a key role in improving long term metabolic control positive impact on insulin resistance Guidelines for exercise:Avoid exercise when blood glucose is > 250 mg/dL and ketones present, caution if blood glucose is >300 mg/dL w/o ketosisIf bloog glucose is <100 prior to exercise, ingest CHO food Monitor blood glucose before, after and more frequently during postexercise period Self monitor blood glucose in response to different activitiesMaintain CHO foods readily available after exercise Exercise and Diabetes ComplicationsADA recommends a detailed medical evaluation with appropriate diagnostic studies prior to beginning an exercise programGraded exercise test, pre-exercise assessment- evaluates for PVD, retinal exam, evaluates renal fxn, assess autonomic and peripheral neuropathy. Complications will not disallow participation of exercise but requires medical team attention Exercise Prescriptions Individualized with emphasis on enjoyment 5-10 min warm up, 5-10 minutes of gentle stretching, a period of aerobic activity, and 5-10 minutes of cool down. Type 2 should have minimum of 150 minutes per week of exercise (moderate or higher)Aerobic activities- 10 minute intervals spread throughout week Health PromotionNurse’s role is the primary prevention of type 2 and secondary prevention of the complications of type 1 and 2 Nurse develops individualized programs to reduce risk of type 2 by assessment of pt and family who are obese/overweight Nurse helps both type 1 and type 2 with lifestyle and physical activity changes Complementary and alternative medicine CAMExample: prayer, acupuncture, massage, biofeedback, yoga, plant remedies Nurse must understand that nonpharmalogic meds are supplemental therapy Management of Hospitalized Patients with Diabetes Infection and stress of illness/surgery worsens glycemic control in diabetic pt and precipitates hyperglycemia Hyperglycemia in Acute IllnessHyperglycemia results from stress from illness/ surgery, and increase insulin resistance Hyperglycemia interferes with infection recovery and wound healing Target Glucose Levels for Hospitalized PatientsTarget glucose levels vary for critically ill and non critically ill pt Critically ill pt: insulin therapy for hyperglycemia- no greater than 180mg/dLNon-critically ill pt: no clear evidence for specific blood glucose goals. Blood glucose should be 140-180 mg/dLNon-critically ill: schedules SQ insulin injections with basal, nutritional and supplemental insulin correction doses Insulin Protocols Designed to Meet Treatment Goals in Hospitalized Patients Evidence supports IV insulin infusions in ICU for hyperglycemic critically ill Protocol to infuse glucose to prevent hypoglycemia Insulin infusions are effective with NPO, parenteral nutrition and enteral tube feedings. Allows for greater flexibility in changing insulin dosage and preventing hypoglycemia Can transition from IB infusion to SQ insulin. Oremeal insulin, basal insulin dose and correction factor. Correction factor is an additional amount of insulin provided with each meal based on the premeal blood glucose. Diabetic KetoacidosisLife threatening complication precipitated by acute or deficiency in insulin secretion. Characteristics: disturbance in metabolism of CHO, fat and protein Treated in ICUPt care: severe dehydration, insulin deficiency, metabolic acidosis from ketosis and lactic acidosis, depletion of electrolytes from osmotic diuresis, Hyperosmolar Hyperglycemic Syndromelife threatening complication characterized by serum hyperosmolarity, dehydration and hyperglycemia Cannot recognize thirst or express need for water Excessive unreplaced fluid losses, secondary to massiv glycosuric diuresis, following gi fluid losses and limited fluid intake HypoglycemiaHypoglycemia Unawareness Loss of autonomic nervous system responses to low blood glucose Symptoms: tachycardia, sweating, palpitations prompts pt to eat to prevent hypoglycemia but unawareness is results deficient glucagon and epinephrine response to hypoglycemia Chronic Complications of Diabetes and Associated Medical Treatment Diseases of the Heart and Blood VesselsCoronary heart disease, PBD and stroke Diabetics with heart disease are at risk for death 2 times more than those without diabetes Risk for stroke is higher in diabetic pt Kidney DiseaseDiabetes is the leading cause of chronic kidney disease Diabetic nephropathy- asymptomatic and detected from routine lab tests. Increased GFR, to ESRD characterized by proteinuria, decreasing GFR and increasing creatinine. Signs are microalbuminuria. National Guidelines: microalbuminuria annual tests, glycemic control, regular bp check, treatment of hypertension with meds, weight loss and sodium restriction, increased risk of infection and report S&S infection symptoms to health care provider. Pt with progressive diabetic nephropathy need to explore options like dialysis and transplantationBlindness and Other Visual DisordersDiabetes is leading cause of blindness Causes: cataracts, macular degeneration and glaucoma. Naional Guidelines for Diabetic Retinopathy: Report visual signs promptly, instruct pt about relationship between hyperglycemia, hypertension and diabetic retinopathy, inform pt about importance of annual dilated exam, inform pt with isometric exercise to raise intraocular pressure (but can worse proliferative retinopathy_, inform pt about support programs and community services Neuropathy60-70% diabetes pt have mild/severe nervous system damage Peripheral neuropathy, autonomic neuropathyAutonomic neuropathy: gastroparesis, neurogenic bladder, diabetic diarrhea, impaired CV reflex (orthostatic hypotension and tachycardia and impotence) Neurogenic bladder: frequent small voiding, incontinence leading to urinary retention Cardiovascular autonomic neuropathy: resting tachycardia and orthostasis Diabetic perpheraly neuropathy- seen in legs, feet and hands DPN pain first felt in the lower legs and worsens at night. Perisstent or intermittent pain over periods of weeks or months- aching or burning. Primary treatment for neuropathy is pain management Vascular and Neuropathic Complications Leading to Lower Extremity AmputationsLow extremity amputations result from combination of pathologic events working in tandem. Testing for sensory changes in the feet of diabetic patients is done with a Semmes-Weinstein monofilament close eyes, monofilament applied to plantar surface of toes, and give a verbal cue on where it is felt. Inability means loss of protective sensation Vibratory perception threshold BPT- technique to measure sensory neuropathy. Pt indicates when he stops feeling vinbration of tuning fork. Unable to feel vibration means at risk for ulcerationConditions related to feet that are associate with higher risk for amputations: peripheral neuropathy with loss of protective sensation, altered biomechanics in presence of neuropathy, evidence of increased pressures, bony deformity, PVD, history of ulcers or amputation, severe nail pathology. Charcot DeformityDistal symmetric polyneuropathy and peripheral autonomic neuropathy leads to charcot deformity. Autonomic neuropathy damages sympathetic nerves in small bv and lower extremities= loss of constrictive tone, vasodilation and increased peripheral perfusion and expedited bone resorption and osteopenia Gastrointestinal DisturbancesGastroparesis- syndrome, impaired transit of food from stomach to duodenum in absence of mechanical obstruction Early satiety, n/v, abdonimcal discomfort Fluctuations in blood glucose levels due to delayed gastric emptying or retention of food. Hypoglycemia results from insulin peak during delayed gastric emptying. Hyperglycemia due to food absorption while insulin actions are waning Gastroparesis treatment- relies on diet and meds, nutritional support Diabetic DiarrheaFrequent after meals and during night Alternating diarrhea and constipation Treatment: empirical, antdiarrheal agents Oral/Dental Problems Receding gums, gym disease, periodontal disease, diminished saliva production, elevated blood sugar= cavitiesHave good oral hygiene: brushing, flossing and rinsing Complications of PregnancyElevated glucose levels in type 1 women can cause birth defects and spontaneous abortions. Chronic hyperglucemia in second and third trimester= macrosomia (excessively large barbies)Gestational diabetes- requires dietary treatment and possible insulin therapy for hyperglycemia. Uncontrolled hyperglycemia= fetal and maternal complications. Increases risk for type 2 diabetes Foot Problems Diabetics have high incidence of amputations of feet Patient education for foot care Inspection: Check feet daily Daily Care: Wash feet with warm soapy water and dried thoroughly. Soaking not advised. Lotion applied daily but not between toes Footwear: Never go barefoot. Correct size. Decreased sensation in neuropathy causes unnoticed injury. Avoid garters because they restrict blood flow Special care: Do NOT use OTC chemical agents to remove corns and warts. Irritation causes ulceration and sharp instruments shouldn’t be used to self treat ingrown toenails. Notify healthcare provider if any problem arises (cut, blister, wound, infection, redness, swelling) Health Promotion for foot problems ADA recommends diabetic pt receive annual thorough foot examHealthcare provider should assist pt in change modifiable risk factors: smoking, home foot care, activity levels and glycemic control. Do not walk without shoes, walk with ill-fitting shoes, decrease attention to daily inspection and cutting toenails if vision is too poor. Activities= jogging on concrete sidewalks are contraindicated Poor glycemic control= pour wound healing and infection Nursing ManagementOutpatient Management of DiabetesNurse’s role: assess insulin regimens, medication, nutrition, physical activity, adherence to guidelines and changes in health status Pt needs to have testing of A1c 2-4 times per year, ongoing MNT therapy evaluation, annual eye exam, foot exam 1-2 times per year by health care provider and daily by pt, annual nephropathy screening, regular blood pressure assessment, annual lipid profile and serum creatinine and influenza and pneumococcal immunixations. Diagnose pt needs and develop plan that includes education or referral. Ex. Nurse educates about insulin injection but refers pt for MNT. Nurse implements plan, evaluates effectiveness and modifiesInpatient Nursing Management of Diabetes Ongoing attention to subjective and objective changes in diabetes status (type 1 and type 2) regardless of their admitting diagnosis. Nurse assesses improvement or deterioration of blood glucose Nurse needs to be aware of discharge needs Collaborative Management Mutlidisciplinary approach: monitor blood glucose levels, make changes to medications and nutrition therapies and assess response to those changes Interdisciplinary team must communicate opening Interdisciplinary team: Nurse, dietitian, physical therapist, health care workerHealth Promotion, Diabetes Education and Cultural Implications Educate the patient for diabetes self-management Pathophysiology of diabetes and treatments Nutritional management and physical activity into lifestyleUse diabetes medications safely Monitor blood glucose and interpret to make self-management decisionsPrevent, detect and treat acute/chronic complicationsDevelop personal strategies to address psychosocial issues and concerns to promote health and behavior changes Culture and religious background influences values, beliefs, behaviors, attitudes, self care habits and relationships with healthcare providersCultural Considerations: Related to Diet for Patients with Diabetes p 1457African Americans, Asian Americans, Hispanics Gerontological Considerations Manage hyperglycemia, hypoglycemia and risk factors. Hypoglycemia, hypotension and drug interactions due to polypharmacy are of great concern. Special ConsiderationsComes from poor socioeconomic situationExperience greater social isolation and lonelinessHigher frequency of depressive illness or cognitive impairmentNursing home Relies on caregiversPolypharmacyFrail and limited life expectancyComorbidities that limit ability to self medicate and recognize/ deal with hypoglycemia Factors addressed: nutrition, diet management, exercise, medication and testing, functional impairment, cognitive impairment, emotional distress and education Nutrition and Diet ManagementOlder adults are undernourished. Modify diet: change nutritent composition or density, food consistency or using supplements Environmental factors need to be changed like where food is prepared, eaten, willingness to prepare food to comply with dietary restrictions ExerciseReduces cardiac risk and improves insulin sensitivity, improves body composition and arthritic pain, reduces falls and depression, increases strength and balance, enhances life quality and improves survival Medications and TestingPt and caregiver must know medication dose, route and side effects. Assess physical ability to administer an insulin syringe Goal is to maintain targeted glycemic control Oral or multiple oral medications HgA1c lab testing or home monitoring Functional ImpairmentAffects ability to care for self and manage diabetes Participation in activities should be encouraged and pt should be referred to an appropriate rehab program Cognitive ImpairmentIn older pt with type 2 Have difficulty performing self management and following complicated treatment regimensWhen there is nonadherance with therapy, frequent episodes of hypoglycemia and less glycemic control= assess cognitive fxn Emotional Distress (Depression) Associated with poor glycemic control and accelerated rates of coronary heart diseaseEarly identification and treatment may help achieve better glycemic control EducationExplain disease process and treatment plan, meds (type, route, administration and seide effects), importance of physical activity and exercise, changes in mood and behavior and knowledge of potential complications and actions to be taken Determine glycemic control and evaluate conformity Prevent hypoglycemia, which may lead to impaired cognition and functionProvide individualized counseling regarding lifestyle modification, including med nutrition evaluation tailored to meet medical, lifestyle and personal factors ResearchTransplantation of cells responsible for insulin production and using stem cells to regenerate pt ability to produce insulin ................
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