Diabetes Mellitus Nursing Care Plan Notes
Description
- Diabetes is a chronic disease, which occurs when the pancreas does not produce enough insulin, or when the body cannot effectively use the insulin it produces. This leads to an increased concentration of glucose in the blood (hyperglycaemia).
- Type 1 diabetes (previously known as insulin-dependent or childhood-onset diabetes) is characterized by a lack of insulin production.
- Type 2 diabetes (formerly called non-insulin-dependent or adult-onset diabetes) is caused by the body’s ineffective use of insulin. It often results from excess body weight and physical inactivity.
- Gestational diabetes is hyperglycaemia that is first recognized during pregnancy.
Causes
The cause of diabetes depends on the type.
Type 1 diabetes
- Is partly inherited, and then triggered by certain infections, with some evidence pointing at Coxsackie B4 virus. A genetic element in individual susceptibility to some of these triggers has been traced to particular HLA genotypes (i.e., the genetic “self” identifiers relied upon by the immune system). However, even in those who have inherited the susceptibility, type 1 DM seems to require an environmental trigger. The onset of type 1 diabetes is unrelated to lifestyle.
Type 2 diabetes
- is due primarily to lifestyle factors and genetics.
The following is a comprehensive list of other causes of diabetes:
- Genetic defects of β-cell function
- Maturity onset diabetes of the young
- Mitochondrial DNA mutations
- Genetic defects in insulin processing or insulin action
- Defects in proinsulin conversion
- Insulin gene mutations
- Insulin receptor mutations
- Exocrine pancreatic defects
- Chronic pancreatitis
- Pancreatectomy
- Pancreatic neoplasia
- Cystic fibrosis
- Hemochromatosis
- Fibrocalculous pancreatopathy
- Endocrinopathies
- Growth hormone excess (acromegaly)
- Cushing syndrome
- Hyperthyroidism
- Pheochromocytoma
- Glucagonoma
- Infections
- Cytomegalovirus infection
- Coxsackievirus B
- Drugs
- Glucocorticoids
- Thyroid hormone
- β-adrenergic agonists
- Statins
TYPE I VERSUS TYPE 2 DIABETES
| PE I (IDDM) | TYPE 2 (NIDDM) | |
| Age of onset | Usually younger than 40 | Usually older than 40 |
| Body weight | Thin | Usually overweight |
| Symptoms | Sudden onset | Insidious onset |
| Insulin produced | None | Too little, or not effective |
| Insulin requirements | Exogenous insulin required | May require insulin |
Pathophysiology
DM Type I
DM Type II
Signs and symptoms
- The classic symptoms of untreated diabetes are loss of weight, polyuria (frequent urination),polydipsia (increased thirst) and polyphagia (increased hunger).Symptoms may develop rapidly (weeks or months) in type 1 diabetes, while they usually develop much more slowly and may be subtle or absent in type 2 diabetes.
- Prolonged high blood glucose can cause glucose absorption in the lens of the eye, which leads to changes in its shape, resulting in vision changes. Blurred vision is a common complaint leading to a diabetes diagnosis; type 1 should always be suspected in cases of rapid vision change, whereas with type 2 change is generally more gradual, but should still be suspected. A number of skin rashes that can occur in diabetes are collectively known as diabetic dermadromes.
Diabetic emergencies
- People (usually with type 1 diabetes) may also present with diabetic ketoacidosis, a state of metabolic dysregulation characterized by the smell of acetone, a rapid, deep breathing known as Kussmaul breathing, nausea, vomiting and abdominal pain, and altered states of consciousness.
- A rare but equally severe possibility is hyperosmolar nonketotic state, which is more common in type 2 diabetes and is mainly the result of dehydration.
WARNING SIGNS OF DIABETES
| SIGNS AND SYMPTOMSS | LABORATORY FINDINGS |
|
|
Cause: Usually secondary to excess insulin, exercise, or not enough food
Signs and Symptoms
- Nervousness
- Irritability
- Diaphoresis (heavy sweating)
- Hunger
- Weakness
- Tachycardia
- Fatigue
- Hypotension
- Palpitations
- Tachypnea
- Tremors or shaking Pallor
- Blurred or double vision
- Incoherent speech
- Headache Numbness of tongue and lips
- Confusion Coma
- Seizures
Treatment
Provide rapidly absorbed source of glucose:
- Fruit juice or cola
- Graham crackers
- Sugar cubes, sugar packets
- Hard candy
As symptoms improve:
- Provide a meal or source of complex protein or carbohydrates
HYPERGLYCEMIA
Cause: Usually secondary to insufficient insulin, illness, or excess food
Signs and Symptoms
- Confusion
- Nausea
- Irritability
- Vomiting
- Fatigue
- Anorexia
- Weakness
- Abdominal cramping
- Numbness
- Thirst
- Tachycardia
- Lethargy
- Hypotension
- Küssmall breathing
- Decreased level of consciousness
- Increased temperature
- Coma
- Flushed or dry skin
- Fruity breath
- Poor skin turgor
- Dry mucous membranes
Treatment (Requires Hospitalization)
- Restore fluid balance
- Replace electrolytes
- Lower blood glucose with regular insulin
- Monitor: Level of consciousness, vital signs, intake and output, and electrolytes
- Provide emotional support
Diagnostic Procedure
Several blood tests are used to measure blood glucose levels, the primary test for diagnosing diabetes. Additional tests can determine the type of diabetes and its severity.
- Random blood glucose test — for a random blood glucose test, blood can be drawn at any time throughout the day, regardless of when the person last ate. A random blood glucose level of 200 mg/dL (11.1 mmol/L) or higher in persons who have symptoms of high blood glucose suggests a diagnosis of diabetes.
- Fasting blood glucose test — fasting blood glucose testing involves measuring blood glucose after not eating or drinking for 8 to 12 hours (usually overnight). A normal fasting blood glucose level is less than 100 mg/dL. A fasting blood glucose of 126 mg/dL (7.0 mmol/L) or higher indicates diabetes. The test is done by taking a small sample of blood from a vein or fingertip. It must be repeated on another day to confirm that it remains abnormally high .
- Hemoglobin A1C test (A1C) — The A1C blood test measures the average blood glucose level during the past two to three months. It is used to monitor blood glucose control in people with known diabetes, but is not normally used to diagnose diabetes. Normal values for A1C are 4 to 6 percent . The test is done by taking a small sample of blood from a vein or fingertip.
- Oral glucose tolerance test — Oral glucose tolerance testing (OGTT) is the most sensitive test for diagnosing diabetes and pre-diabetes. However, the OGTT is not routinely recommended because it is inconvenient compared to a fasting blood glucose test.
The standard OGTT includes a fasting blood glucose test. The person then drinks a 75 gram liquid glucose solution (which tastes very sweet, and is usually cola or orange-flavored). Two hours later, a second blood glucose level is measured.
Oral glucose tolerance testing is routinely performed at 24 to 28 weeks of pregnancy to screen for gestational diabetes; this requires drinking a 50 gram glucose solution with a blood glucose level drawn one hour later. For women who have an abnormally elevated blood glucose level, a second OGTT is performed on another day after drinking a 100 gram glucose solution. The blood glucose level is measured before, and at one, two, and three hours after drinking the solution.
Medical Management
There is no known cure for DM. Management of the disease focuses on control of the serum glucose level to prevent or delay the development of complications. Individuals with type 1 DM require subcutaneous insulin administration. Insulin may be rapid, intermediate, or slow acting.
Patients with mild DM or those with type 2 DM or GDM may be able to control the disease by diet management alone. A diabetic diet attempts to distribute nutrition and calories throughout the 24-hour period. Daily calories consist of approximately 50% carbohydrates and 30% fat, with the remaining calories consisting of protein. The total calories allowed for an individual within the 24-hour period are based on age, weight, activity level, and medications.
In addition to strict dietary adherence to control blood glucose, obese patients with type 2 DM also need weight reduction. The dietitian selects an appropriate calorie allotment depending on the patient’s age, body size, and activity level. A useful adjunct to the management of DM is exercise. Physical activity increases the cellular sensitivity to insulin, improves tolerance to glucose, and encourages weight loss. Exercise also increases the patient’s sense of well-being concerning his or her health.
Pharmacological Highlights
When diet, exercise and maintaining a healthy weight aren’t enough, you may need the help of medication. Medications used to treat diabetes include insulin. Everyone with type 1 diabetes and some people with type 2 diabetes must take insulin every day to replace what their pancreas is unable to produce. Unfortunately, insulin can’t be taken in pill form because enzymes in your stomach break it down so that it becomes ineffective. For that reason, many people inject themselves with insulin using a syringe or an insulin pen injector,a device that looks like a pen, except the cartridge is filled with insulin. Others may use an insulin pump, which provides a continuous supply of insulin, eliminating the need for daily shots.
The most widely used form of insulin is synthetic human insulin, which is chemically identical to human insulin but manufactured in a laboratory. Unfortunately, synthetic human insulin isn’t perfect. One of its chief failings is that it doesn’t mimic the way natural insulin is secreted. But newer types of insulin, known as insulin analogs, more closely resemble the way natural insulin acts in your body. Among these are lispro (Humalog), insulin aspart (NovoLog) and glargine (Lantus).
A number of drug options exist for treating type 2 diabetes, including:
- Sulfonylurea drugs. These medications stimulate your pancreas to produce and release more insulin. For them to be effective, your pancreas must produce some insulin on its own. Second-generation sulfonylureas such as glipizide (Glucotrol, Glucotrol XL), glyburide (DiaBeta, Glynase PresTab, Micronase) and glimepiride (Amaryl) are prescribed most often. The most common side effect of sulfonylureas is low blood sugar, especially during the first four months of therapy. You’re at much greater risk of low blood sugar if you have impaired liver or kidney function.
- Meglitinides. These medications, such as repaglinide (Prandin), have effects similar to sulfonylureas, but you’re not as likely to develop low blood sugar. Meglitinides work quickly, and the results fade rapidly.
- Biguanides. Metformin (Glucophage, Glucophage XR) is the only drug in this class available in the United States. It works by inhibiting the production and release of glucose from your liver, which means you need less insulin to transport blood sugar into your cells. One advantage of metformin is that is tends to cause less weight gain than do other diabetes medications. Possible side effects include a metallic taste in your mouth, loss of appetite, nausea or vomiting, abdominal bloating, or pain, gas and diarrhea. These effects usually decrease over time and are less likely to occur if you take the medication with food. A rare but serious side effect is lactic acidosis, which results when lactic acid builds up in your body. Symptoms include tiredness, weakness, muscle aches, dizziness and drowsiness. Lactic acidosis is especially likely to occur if you mix this medication with alcohol or have impaired kidney function.
- Alpha-glucosidase inhibitors. These drugs block the action of enzymes in your digestive tract that break down carbohydrates. That means sugar is absorbed into your bloodstream more slowly, which helps prevent the rapid rise in blood sugar that usually occurs right after a meal. Drugs in this class include acarbose (Precose) and miglitol (Glyset). Although safe and effective, alpha-glucosidase inhibitors can cause abdominal bloating, gas and diarrhea. If taken in high doses, they may also cause reversible liver damage.
- Thiazolidinediones. These drugs make your body tissues more sensitive to insulin and keep your liver from overproducing glucose. Side effects of thiazolidinediones, such as rosiglitazone (Avandia) and pioglitazone hydrochloride (Actos), include swelling, weight gain and fatigue. A far more serious potential side effect is liver damage. The thiazolidinedione troglitzeone (Rezulin) was taken off the market in March 2000 because it caused liver failure. If your doctor prescribes these drugs, it’s important to have your liver checked every two months during the first year of therapy. Contact your doctor immediately if you experience any of the signs and symptoms of liver damage, such as nausea and vomiting, abdominal pain, loss of appetite, dark urine, or yellowing of your skin and the whites of your eyes (jaundice). These may not always be related to diabetes medications, but your doctor will need to investigate all possible causes.
- Drug combinations. By combining drugs from different classes, you may be able to control your blood sugar in several different ways. Each class of oral medication can be combined with drugs from any other class. Most doctors prescribe two drugs in combination, although sometimes three drugs may be prescribed. Newer medications, such as Glucovance, which contains both glyburide and metformin, combine different oral drugs in a single tablet.
Nursing Intervention
- Advice patient about the importance of an individualized meal plan in meeting weekly weight loss goals and assist with compliance.
- Assess patients for cognitive or sensory impairments, which may interfere with the ability to accurately administer insulin.
- Demonstrate and explain thoroughly the procedure for insulin self-injection. Help patient to achieve mastery of technique by taking step by step approach.
- Review dosage and time of injections in relation to meals, activity, and bedtime based on patients individualized insulin regimen.
- Instruct patient in the importance of accuracy of insulin preparation and meal timing to avoid hypoglycemia.
- Explain the importance of exercise in maintaining or reducing weight.
- Advise patient to assess blood glucose level before strenuous activity and to eat carbohydrate snack before exercising to avoid hypoglycemia.
- Assess feet and legs for skin temperature, sensation, soft tissues injuries, corns, calluses, dryness, hair distribution, pulses and deep tendon reflexes.
- Maintain skin integrity by protecting feet from breakdown.
- Advice patient who smokes to stop smoking or reduce if possible, to reduce vasoconstriction and enhance peripheral flow.
DOCUMENTATION GUIDELINES
- Results of urine and blood tests for glucose
- Physical findings: Visual problems, skin problems or lesions, changes in sensation or circulation to the extremities
- Patient teaching, return demonstrations, patient’s understanding of teaching
- Response to insulin
DISCHARGE AND HOME HEALTHCARE GUIDELINES
- Diet. Explain how to calculate the American Diabetic Association exchange list to develop a satisfactory diet within the prescribed calories. Emphasize the importance of adjusting diet during illness, growth periods, stress, and pregnancy. Encourage patients to avoid alcohol and refined sugars and to distribute nutrients to maintain a balanced blood sugar throughout the 24-hour period.
- Insulin. Patients need to understand the type of insulin prescribed. Instructions should include onset, peak, and duration of action. Stress proper timing of meals and planning snacks for the time when insulin is at its peak, and recommend an evening snack for those on long-acting insulins. Reinforce that patients cannot miss a dosage and there may be a need for increasing dosages during times of stress or illness. Teaching regarding the proper preparation of insulin, how to administer, and the importance of rotating sites is necessary.
- Urine and Blood Testing. Teach patients the appropriate technique for testing blood and urine and how to interpret the results. Patients need to know when to notify the physician and increase testing during times of illness.
- Skin Care. Stress the importance of close attention to even minor skin injuries. Emphasize foot care, including the importance of properly fitting shoes with clean, nonconstricting socks; daily washing and thorough drying of the feet; and inspection of the toes, with special attention paid to the areas between the toes. Encourage the patient to contact a podiatrist as needed. Because of sensory loss in the lower extremities, teach the patient to test the bath water to prevent skin trauma from water that is too hot and to avoid using heating pads.
- Circulation. Because of the atherosclerotic changes that occur with DM, encourage patients to stop smoking. In addition, teach patients to avoid crossing their legs when sitting and to begin a regular exercise program.
