Nursing Exam Review Lecture 5 Diabetes Mellitus

Lecture 5 Diabetes Mellitus (DM), Diabetes Insipidus (DI), Insulin Diabetes mellitus = An error in glucose metabolism … Glucose is the body’s primary fuel source • Can be a lack of insulin DM1 • Can be insulin resistance DM2 DIABETES INSIPIDUS = Not a type of DM! … It is insidious, diabetes w/out the glucose element • It is Polyuria, Polydipsia leading to dehydration, due to low ADH. • It is just the fluid part So question is about low urine output or high urine output? … • Similar to DM, DI has a high urine output What is the opposite of Diabetes Insipidus? • It is SIADH = Syndrome of inappropriate ADH (antidiuretic hormone) So, DM has polyuria, polydipsia Therefore, DI also has polyuria, polydipsia However, SIADH is the opposite of the above 2 conditions … • It presents w/ oliguria and no thirst • Decrease urine output • And then, decrease serum specific gravity (due to retention of water) • Increase urine specific gravity (due to decrease urine volume) Nursing Diagnosis? Lots of urine retained, specific gravity is low = SIADH Fluid Volume Deficit = DM, DI Fluid Volume Excess = SIADH Diabetes • Type I—Insulin dependent, Juvenile onset, Ketosis prone • Type II—Non-insulin dependent, Adult onset, Non-ketosis prone • S/Sx of DM o Polyuria—pee a lot o Polydipsia—thirsty o Polyphagia—(eat/swallow a lot) Treatment for DM Type I (if you don’t treat) • They will “DIE” • Diet (calories from carbs, least important) • Insulin (most important) • Exercise Treatment for Type II DM • They are “DOA” • Diet (most important) • Oral hypoglycemic • Activity Diet for DM2 • Primary treatment modality is Calorie restriction • 1200 Cal, 1400 Cal, 1600 Cal • These pts need to eat 6 small feeding per day—smaller more frequent meals—keeps blood sugar more stable Question What is the best dietary action a DM2 should take? a. Restrict calories b. Divide meal into 6 feedings a day Answer: (a) because pt can eat 6 meals but does not limit the Cal with each meal Insulin acts to lower blood sugar 4 types of Insulin are covered here 1. R-Regular insulin—clear solution, IV drip (HESI-intermediate, Rapid, Run IV) • Onset: 1 hour • Peak: 2 hours • Duration: 4 hours … (Audio says 3 hours, but it is 4 hours) • Pattern: 1-2-4 (Pay attention to peak) 2. N-NPH, Intermediate insulin—it is cloudy, N = Not So Clear, Fast (Cloudy = Suspension—it precipitates—can’t give IV drip), N = not so fast, not in the bag • Onset: 6 hours • Peak: 8 to 10 hours • Duration: 12 hours • Pattern: 6-8-10-12 (Hear the even #s and pay attention to peak) Clear = Solution Cloudy = Suspension ! Will precipitate (Not given over IV drip or put in an IV bag) Question How would the board ask question about peak of insulin? For instance, you give 30 units of insulin to a pt at 7 a.m. When do you check for hypoglycemia? • Answer = Add the insulin peak time to the time of insulin administration • For instance, if the pt was given NPH at 7 a.m., add 8 to 10 hours to the time • Answer = Check for hypoglycemia between 3 and 5 p.m. 3. Lispro: (Humalog) • Don’t give it AC (before meal) … Give it with the meal • Onset: 15 min • Peak: 30 min • Duration: 3 hrs • Pattern: 15-30-3 4. Glargine (Lantus) • Long-acting insulin • No Peak • Duration 12 to 24 hrs • Little to no risk for hypoglycemia (only one you can safely give at bedtime) Note: Always check insulin expiration date What action invalidates the manufacturers date? • Opening the package • Once the package is open, the new expiration date is 30 days after that • Open package without an opening or expiration date should be thrown out • Label the package either with o “OPEN” and date package is open or o “EXP” and expiration date • Once the package is open, refrigeration is optional o However, unopened bottle must be kept refrigerated o Although it is good practice to teach pt to refrigerate insulin at home Exercise potentiates insulin action • Exercise is like another shot of insulin • Therefore, if a student is schedule to play soccer (exercise) this afternoon … It is necessary to decrease the dosage of insulin • In addition, the school nurse must give the student rapidly metabolized carbohydrates— snacks or juice Sick Days … Pt has a fever or the flu, and so on • Serum glucose levels go up • Need their insulin even though pt is eating • Take sips of water because they get dehydrated • Any sick diabetic pt has 2 problems o Hyperglycemia and Dehydration Acute complications of Diabetes • Low blood glucose—a.k.a. Hypoglycemia or Hypoglycemic shock or Insulin shock/reaction • Why are some of the causes o Not enough food o Too much insulin (#1 cause, can lead to permanent brain damage) o Too much exercise What does hypoglycemia look like? • Think of Drunk pt in Shock • Drunk o Staggering gait o Slurred speech o Cerebral impairment (labile) o Slow reaction time o Decrease social inhibition • Shock—Vasomotor collapse o Tachycardia, tachypnea, Low BP o Cold/clammy, mottled skin Treatment • Give pt sugars or Rapidly metabolizable carbohydrate such as o Juice (any), candy, regular soda, milk (lactose), honey, icing, jelly, jam • Boards want sugar + starch or protein o For example, apple juice + turkey, Milk is sugar/protein—1/2 cup Skim milk • Bad answer o Candy + Soda—1 sugar is good, 2 sugars are bad o 5 packs of sugar emptied into a glass of orange juice • Unconscious pts—pay attention to location • Glucagon IM if the mother is on the phone • Dextrose IV (D10, D50) if in the ER DKA—High Glucose in a Type I (keto is the clue!) Causes • Too much food • Not enough insulin • Not enough exercise • #1 cause acute viral Upper Respiratory Infection within last 2 weeks S/Sx of DKA is “DKA” • Dehydration (dry, poor skin elasticity and turgor, warm) … Water is a coolant (you overheat) • Ketones in serum, Kussmauls, High K+ • Acidosis, Acetone breath, Anorexia due to nausea Note: Ketone in urine does not necessarily means DKA Treatment • Insulin IV (Regular!) • IV fluid! 200 mL/hr (some of the fastest rate) HHNK or HHS or HHNS • High blood sugar in a Type 2 • These pts don’t burn ketones, no acid • Whenever you see HHNK, think dehydration • Severe Dehydration! o Skin is dry, flushed, decreased turgor, increased HR o #1 Nursing diagnosis: fluid volume deficit (same as dehydration) o #1 Nursing intervention: Rehydration! o Outcomes in successful treatment: Increase urine output, Moist mucous membrane, etc. o Long-term complications: Poor perfusion, Peripheral neuropathy Between DKA and HHNK • Which one is more dependent on insulin? o DKA pt is more dependent on insulin o HHNK pt needs to be rehydrated • Which one has a higher mortality rate? o More pts die HHNK • Which is a higher priority? o DKA is a more acute condition and responds very quickly to insulin o HHN pts show up late in the emergency room and do not readily respond to treatment Long-term complication of diabetes • Related to o Poor tissue perfusion or o Peripheral neuropathy • Examples of long-term complications: Renal failure, Gangrene, Heart failure, Urinary incontinence, Pt can’t feel a burn on the foot • For instance o Renal failure is a cause of poor perfusion o Urinary incontinence is a cause of peripheral neuropathy Which lab test is the best indicator of long-term blood glucose level? • Hb A1C, a.k.a. glycosated Hb or glycosylated Hb o Average blood sugar over last 90 days • (Hb = Hemoglobin) • Hb < 6 is normal • Hb > 8 is out of control • Hb 7 Borderline—have pt come in for evaluation