Lecture 2: Nursing Priorities for Adults with DM Types I & II

med-surg notes Lecture 2: January 15 Nursing Priorities for Adults with DM Types I & II Diabetes Mellitus Pathophysiology Health Promotion and Maintenance Common, chronic complex disorder of impaired nutrient metabolism (glucose) 8ocus: Control of diabetes and its complications Glucose regulation and homeostasis Increased activity Vow-calorie diet Absence of insulin >0 min brisk walk after eating BG Acute and chronic complications 7ype 1 Diabetes Autoimmune disorder Implication of viral infections Beta cells destroyed in genetically susceptible Charted as .IDDM. (insulin-dependent DM) or .71DM. 7ype > Diabetes Adult onsetq may occur at any age Incidence and Prevalence Insulin resistance or dysfunctional beta cells American people with diabetes: >→ million Cause is unknown but possibly genetic Many children Charted as .NIDDM. (non-insulin-dependent DM) or .7>DM. American people with undiagnosed diabetes: z↓1 million Insulin Physiology American people with prediabetes: z& million (tripled) Proinsulin is secreted by/stored in the beta cells of the islets of Vangerhans (pancreas) Canadian people with diabetes: >↓> million People of color are more likely to be diagnosed Proinsulin is transformed by the liver into active insulin An underlying condition that increases the chance of severe COUID-1→ illness (immunocompromised) Insulin attaches to receptors on target cells, where it promotes glucose transport into the cells through cell membranes Metabolic Syndrome Simultaneous presence of metabolic factors that increase risk for type > DM Abdominal obesity: ;aist circ T 40 (male) or 35 in (female) Hyperglycemia: 8BG T 100 mg/dV or on drug tx for elevated BG HTN: SBP T 130 or DBP T z5 mmHg OR on medication for H7N Diabetic Screening HLD: 7G T 150 mg/dV OR on drug treatment Clients with a BMI T >5 and one or more of the following: 8irst-degree relative with DM HDV chol L 40 (male) or 50 mg/dV (female) Age 45 or older Know general appearance of patients with metabolic syndrome Sedentary lifestyle H/O vascular disease, PCOS, GDM, or birth to an infant T → lbs (GDM) Absence of Insulin African, Hispanic, Asian, or Indigenous Vack of insulin or cellular insulin action BP consistently T 140/→0 mmHg Hyperglycemia HbA1c T 5↓"2, impaired fasting glucose, or impaired glucose tolerance Polyuria, polydipsia, polyphagia HDV L 35 mg/dV or 7G T >50 mg/dV Screening Method Ketone bodies HgbA1c (gold standard) Hemoconcentration, hypovolemia, hyperviscosity, hypoperfusion, hypoxia Normal: 4-&2 Acidosis: Can cause Kussmaul respirations Diabetic: &↓52 Diabetic target: L "2 Comprehensive Diabetes Medical Evaluation 8GB: Second bestq fast beforehand, then test Assessment OG77: Check in intervals after consuming a sugary drink recogniQing cues risk factors and symptoms Physical Exam Height and weight Blood pressure Eye exam Skin exam Insulin injection sites ;ounds Comprehensive foot exam Uisual inspection Skin integrity Callouses Wlcers 7oenails Screening for PAD Pedal pulses Ankle-brachial index 7emperature and sensation (mono (if on metformin) Serum K (if on ACE inhibitors, ARBS, or diuretics) Planning & Implementation Prevent hyperglycemic injury: Medication (insulin/oral meds) Nutrition and exercise Complications Surgical intervention (transplant) Acute Enhanced surgical recovery Diabetic ketoacidosis (DKA) Hyperglycemia hyperosmolar state (HHS) Prevent injury from peripheral neuropathy Hypoglycemia: More fatal and urgent to get BG back up Manage pain Prevent injury from reduced vision Not enough E for brain function Chronic Reduce risk of renal disease Goals of Care Macrovascular dz: Control DM/ complications and optimiQe 9oV Cardiovascular, cerebrovascular, reduced immunity Microvascular dz: Glucose monitoring and BP cu= use Prevent hypoglycemia Prevent DKA and HHS Nutrition therapy and physical activity Sensory perception Oral anti-hyperglycemic meds Eye and vision complications Insulin therapy and safety Diabetic peripheral neuropathy Education on foot care Diabetic autonomic neuropathy 7obacco cessation Diabetic nephropathy: May be numb or painful (tingling, burning, discomfort while walking) 8eet may be pale, cool to touch, and diminished pulse Sexual dysfunction CU compromised from DM Management of .sick days. Monitor for complications Encourage regular follow-up care Cognitive dysfunction Care Coordination & Transition Management Medication Management Self-management education 7ype 1 DM Home care management Only insulin and food intake Self-Monitored Blood Glucose 7ype > DM If on multiple-dose insulin (MDI) or insulin pump therapy Oral antidiabetic agents with diet/exercise At least prior to meals/snacks Biguanides (usually start with metformin) Occasionally post-prandial Second-gen sulfonylureas At bedtime Meglitinides Prior to exercise 7hiaQolidinediones ;hen low BG is suspected Alpha-glucosidase inhibitors After treating low BG until normoglycemic DPP-4 inhibitors Prior to critical tasks (ex↓ driving) Non-Insulin Injectables May be continuous (on disc, info recorded on phone/device) Both amylin and GVP-1 (glucose-like proteins) hormones are released after meals and improve glucose metabolism Insulin may pump may give insulin PRN based on continuous monitor Incretin mimetic: Secreted from the gut (GVP-1) Modulates glucose metabolism working with release of insulin from beta cells Goals of Medical Regimen Inhibits release of glucagon by alpha cells Keep A1C L "↓02, older adults L z↓02 OQempic (injection) and Rybelsus (oral) Amylin mimetic: Co-secreted with insulin from beta cells Keep pre-prandial BG "0-130 mg/dV Inhibits food intake Keep post-prandial BG L 1z0 mg/dV Causes brain to feel satiated Control of DM and its complications Delays gastric emptying May cause constipation and N/U (Qofran) May also cause constant fullness and diarrhea Nutrition Therapy Decreases BG levels ;eight loss recommended for all overweight/obese pts Byetta and Symlin Avoid dehydrationq drink 3V of water %d GVPs may cause muscle wasting if protein intake is inade%uate Vow carb, fat, and calorie diets Meals should be timed with peak insulin Encourage carb counting in pts with complex insulin regimens Consistent timing and intake of carbohydrates Testing Sensation Vimited alcohol intake (e=ects on absorption) Meal Composition Diabetic Foot Care Pt should inspect feet daily Interventions to prevent injury Carbohydrates: 40-502 (1 serving F 15 g) Protein: 15->02 8at: 302 or less May not feel ulcers/injury due to neuropathy Physical Activity OrganiQe consistent regimenq exercise decreases BG levels Exercise after meal with someone present/noti consecutive days w/o exercise In absence of contraindications, adults with DM> should perform resistance training at least twice weekly In older adults, encourage any movement Sick-Day Rules Notify PCP when ill Monitor BG at least %4h 7est urine for ketones if BG T >40 mg/dV (13↓z mmol/V) Continue taking insulin/antidiabetics 7o prevent dehydration, drink z-1> oQ (>40-3&0 mV) of sugar-free li%uids %1h If BG below target, drink ~uids with sugar Continue eating meals at regular times If unable to tolerate solid foods, consume more easily tolerated foods/li%uids e%ual to the carb content of a usual meal Call PCP if: Persistent N/U or inability to intake oral food/~uids Ketonuria BG elevation after > supplemental doses of insulin or BG T >50 unresponsive to meds High temperature (101↓5 8 or 3z↓& C) Increasing fever or fever for more than >4 hours Preventing Hypoglycemia If med regimen changes, check 0300-0400 BG Hold bolus (nutritional) insulin when NPO Replace carbs if meal carbs are not eaten/vomited Give fast-acting insulin within 15 minutes of eating (food should be present) Give bedtime snack as speci days 7reat symptoms as directed and rest Evaluation of Outcomes Achieve BG control Hypoglycemia vs. Hyperglycemia Hypoglycemia S/S: H/A, N/U, cold/clammy skin, sweating, tremors, lethargy, hunger, confusion/irritability, slurred speech, tingling around the mouth, anxiety/nightmares Nursing action: Avoid acute/chronic complications Avoid injury Experience pain relief Maintain optimal vision Maintain urine output in expected range More di6cult to bring BG up than down Have an optimal level of mental status functioning Immediate treatment with complex carbs Have decreased episodes of hypoglycemia or hyperglycemia Rule of 15: Give 15 g carbs every 15 mins, repeat PRN if awake and able to swallow (change BG levels gradually) If unable to swallow or slightly altered VOC: Give glucagon IM S7A7 if not alert to swallow If inpatient, give dextrose IU S7A7 (check peripheral vasculature) May give sublingual dissolvable glucose tab Stop any sources of insulin Check glucose fre%uently Never give oral intake if altered consciousness (risk of aspiration) Hyperglycemia S/S: Polydipsia, polyuria, polyphagia, blurry vision, weakness, weight loss, syncope Nursing action: Encourage water intake Check glucose fre%uently Assess for DKA or HHS Administer IU ~uids or insulin as directed by PCP or protocol