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DIABETES MELLITUS

is a group of metabolic diseases in which a person has high blood sugar, either because the pancreas does not produce enough insulin, or because cells do not respond to the insulin that is produced.

Type I

●Juvenile onset.

●Very little or no insulin.

●Within the ideal body weight but most are thin.

●Treated with DIET and EXERCISE + INSULIN.

●“Insulin deficiency”.

Type II

●Adult onset.

●Below normal insulin or normal (but higher demand if obese).

●80% is mostly obese or overweight.

●Treated with DIET and EXERCISE + ORAL HYPOGLYCEMICS “insulin resistance”.

Long-term complications

●Atherosclerosis               

●Cardiac complications

●Nephropathy                                     

●Neuropathy   

●Retinopathy

Assessments: Polyuria, polydipsia, polyphagia (common in type I), hyperglycemia, weight loss (common in type I), blurred vision, slow wound healing, vaginal infections, weakness and paresthesia, signs of inadequate circulation to the feet.

DKA

-is a life threatening complication of type 1 diabetes mellitus that develops when a severe insulin deficiency occurs.

Onset: Sudden

Precipitating factors: Infection, stressors, inadequate insulin dose.

Manifestations:

●Ketosis: Kussmaul respiration, “Fruity breath”, nausea, abdominal pain. ●Dehydration or electrolytes loss: polyuria, polydipsia, weight loss, dry skin, sunken eyeballs, lethargy, coma.

Treatment:

●Volume replacement: Treat dehydration with rapid IV infusion of 0.9% or 0.45% normal saline (NS) as ordered. D5 is added in 0.45% saline when blood glucose level reaches 250 – 300 mg/dl. 

●Treat hyperglycemia with regular insulin administered intravenously as prescribed.

●Correct electrolyte imbalances (potassium level may be elevated as a result of dehydration and acidosis). Monitor potassium level.

HHNS

-Extreme hyperglycemia without occurs without ketoacidosis.

-More common in type 2 diabetes mellitus.

Onset: Gradual

Precipitating factors: Infection, stressors, poor fluid intake.

Manifestations:

●Dry mouth and skin, extreme thirst, warm.

●High fever, change in LOC, weakness.

●Dehydration or electrolytes loss: same with DKA.

Treatment:

● Similar to that for DKA: Fluid replacement, correction of electrolytes imbalances, and insulin administration (insulin plays less critical role in the treatment of HHNS) because ketosis and acidosis do not occur; rehydration alone may decrease glucose levels.

●Note: HHNS; enough insulin is present to prevent breakdown of fats for energy, thus preventing ketosis.

Laboratory test:

●Glucose tolerance test: 2 hour post-load glucose level. Higher than 200 mg/dL confirms diagnosis of diabetes.

●Glycosylated hemoglobin (HbA1c): blood bound to hemoglobin – indicates how well blood glucose levels have been controlled for the prior 3-4 months.

Controlling diabetes: 5 M ●Meter: monitoring BG ●Meals: proper diet ●Move: being active (exercise) ●Meds: taking medication ●More: foot care, stress management, smoking cessation, eye exams, and hypoglycemia/hyperglycemia knowledge.

“Rule of 15 for hypoglycemia <4 mmol/L”:

  • Give FAST-ACTING simple carbohydrates (15g, 3 sachet, 15mL) – wait 15 minutes then reassess BG – repeat steps as necessary until BG is normal (>4 mmol/L) & symptoms is resolve. 

  • Once symptoms resolve a snack containing 15g of COMPLEX CARBOHYDRATES (contains proteins or carbohydrates-NEVER GIVE if BG < 4mmol/L -slows digestion thereby hypoglycemia is harder to correct) is recommended unless the client plans to eat a regular meal within 60 minutes.

Fast-acting simple carbohydrates

125 mL of fruit juice, 15mL of sugar, syrup or honey, 3 sachet of sugar dissolved in a glass of water, and 3-5 glucose tablet (depending on the instructions).

Complex carbohydrates

½ turkey sandwich, small bowl of cereal with milk, 1 apple and 2 slices of cheese, 1 glass (250mL) of milk and 4 dry biscuits.

PATIENT TEACHING ON HYPOGLYCEMIA: ●Avoid alcohol intake. ●Do not skip or miss meals. ●Take hypoglycemic medications as prescribed (never increase the dose and take medication on the right time). ●Avoid excessive exercise (especially without eating). ●If patient uses beta-blockers (explain that it can mask S/S of hypoglycemia [except sweating]) TIRED: Tremor. Irritability. Restlessness. Excessive hunger. Diaphoresis.

Insulin: Used to treat type I and type II diabetes mellitus when diet, weight control therapy and oral hypoglycemic has failed. Regular insulin is the only insulin that can be administered intravenously (used in emergency treatment of diabetic ketoacidosis).

●Increase hypoglycemic effect of insulin: Aspirin, alcohol, oral anticoagulants, oral hypoglycemic medications, beta blockers, Tricyclic antidepressants, tetracycline, MAOI. (Causing further decrease in blood glucose).

●Increase blood glucose level: Glucocorticoids, thiazides diuretics, thyroid agents.

PATIENT TEACHING ON HYPERGLYCEMIA

1. Avoid excessive meal.

2. Do activities as tolerated.

3. Take medication as prescribed (never miss a dose).

4. Avoid stress.

5. Teach proper insulin injection to patient or significant others.

HYPERGLYCEMIA INTERVENTIONS

1. Administer medication as prescribed.

2. Administer O2 by nasal prong or mask.

3. Monitor cardiac status.

4. Open a venous access.

5. Monitor vital signs.

6. Evaluate respiratory system.

7. Monitor blood glucose.

8. Assess for ketonuria (S/S of DKA).

9. Monitor intake and output. 

The PEAK action of insulin is important because of the possibility of hypoglycemic reaction occurring at that time.

Complications of insulin therapy:

  • Local allergic reaction: redness, swelling, tenderness and induration (1-2 hours) – cleanse the skin with alcohol before injection.

  • Lipodystrophy: Avoid injecting insulin to affected part and rotate insulin injection. 

  • Dawn phenomenon:  reduce tissue sensitivity to insulin that develops between 5 and 8 AM (prebreakfast HYPERGLYCEMIA occurs); it may cause by nocturnal release of growth hormone. Treatment: Administering an evening dose (or increasing the amount of current dose) of intermediate-acting insulin at 10 PM.

  • Somogyi phenomenon: Normal or elevated blood glucose levels are present at bedtime; hypoglycemia occurs at 2 to 3 AM, which causes an increase in the production of counteregulatory hormones. By 7 AM, the blood glucose rebounds significantly to hyperglycemic state. Treatment: Increase dose or snack (dinner or bedtime).

Humulin R (fast/short-acting)

Onset: 30 minutes

Peak: 2-4h

Duration: 6-8h

Injection site: Preferable in the abdomen -better convenience during meal. ONLY; insulin appear CLEAR, and can be given IV!

Humulin N (intermediate-acting)

Onset: 1-2h

Peak: 4-12h

Duration: 18-24h

Injection site: Preferable in the thigh and buttocks– slower absorption

Other insulins:

●Lispro (rapid-acting) Onset: 10-15 min. Peak: 1h – Duration: 2-4h

●Ultralente (long-acting) Onset: 6-8h.

Peak: 12-16h – Duration: 20-30h

ORAL HYPOGLYCEMICS AGENTS: If single dose should be taken 30 minutes before breakfast.

1. Sulfonylureas: Directly stimulates the pancreas to secrete insulin. I.e. glipizide (glucotrol), glyburide (micronase, diabeta), tolazimide.

2. Biguanides: Decreasing the amount of sugar produced by the liver. Increasing the amount of sugar absorbed by muscle cells. Decreasing the body's need for insulin. I.e. metformin (glucophage).

3. Alpha-glucosidase inhibitors: Delays absorption of glucose in the intestine. I.e. Acarbose (Precose), Miglitol (glyset).

4. Tiazolidinediones (TZD): Enhance insulin reaction at the receptor site. I.e. Rosiglitazone (Avandia) and Pioglitazone (Actos).

PREVENTIVE FOOT CARE INSTRUCTIONS

  • Provide meticulous skin care and proper foot care.

  • Inspect feet daily and monitor feet for redness, swelling, or break in skin integrity.

  • Notify physician if redness or a break in the skin occurs.

  • Avoid thermal injuries from hot water, heating pads, and baths.

  • Wash feet with warm (not hot) water and dry thoroughly (avoid foot soaks).

  • Do not treat corns, blisters, or ingrown toenails.

  • Do not cross legs or wear tight garments that may constrict blood flow

  • Apply moisturising lotion to the feet but not between the toes.

  • Prevent moisture from accumulating between the toes.

  • Wear loose socks and well-fitting  (not tight) shoes.

  • Do not go barefoot.

  • Wear clean cotton socks to keep the feet warm and change the socks daily.

  • Do not wear the same pair of shoes two days in a row.

  • Do not wear open-toed shoes or shoes with a strap that goes between the toes.

  • Check shoes for cracks or tears in the lining and for foreign objects before putting them on.

  • Break in new shoes gradually.

  • Cut toenails straight across and smooth nails with an emery board.

  • Do not smoke.

HYPERTHYROIDISM

Increase circulating thyroid hormone ↑metabolism.

Risk factor:  Autoimmune, Woman, Stress, Infection, and Overdose of treatment for hypothyroidism.

Manifestations: #1 answer: Exophthalmos

Tremor

Heart rate and BP up

You feel weak [fatigability]

Restlessness

Oligomenorrhea/amenorrhea

Intolerance to heat, Increase appetite

Diarrhea

Irritability and agitation

Sweating

Muscle wasting & weight loss, fine straight hair

Management:

●High calorie & protein diet (6 meals/day). ●A void stimulants (provide cool and quiet environment, avoid stress). ●Obtain weight daily. ●Protect eyes (eye drops).

●Thyroidectomy. ●Radioactive iodine therapy (radioactive isotope 131) – should sleep alone several nights, flush toilet twice, and monitor s/s of hypothyroidism!

Medications:

1. Propylthiouracil (PTU) – blocks thyroid synthesis. 

2. Methimazole (Tapazole) – inhibit synthesis of thyroid hormone.

3. Beta-blockers (propanolol [Inderal]) – counteracts symptoms of ↑ metabolic rate (tachycardia, tremors, anxiety).

HYPOTHYROIDISM

 Deficiency of circulating thyroid hormone - ↓ BMR. 

Risk factor: Thyroidectomy, Iodine deficiency, Defective hormone synthesis, Woman, Cretinism, Hashimoto’s disease.

Manifestations: 

Tired

Hair loss, Heart rate and BP low

You have facial and eyelid edema

Receding hairline

Obese (weight gain)

Intolerance to cold

Decrease appetite

Inability to pass stool (constipation)

Slow speech/slowness/lethargy

Muscle aches & Myxedema

Management:

●Provide warm. ●Low calorie & high protein diet. ●Increase fiber and fluids (constipation). ●Prevent infection, trauma and stress which precipitate myxedema. ●No narcotics & barbiturates (hypersensitivity). Monitor overdose of thyroid medications: Tachycardia, chest pain, restlessness, nervousness, and insomnia.

Medications: For life!

1. Levothyroxine (Synthroid) – thyroid replacement T4. 

2. Liothyronine (Cytomel) – thyroid replacement T3.

Medications teaching:

  • Radioactive iodine therapy: ●Use disposable utensils ●No kissing.● Avoid close contact/sexual intercourse. ●Keep away from pregnant and children. ●Assess heart rate. ●Have adequate rest. ●NPO before administration (food delays absorption). ●Has at least 6 weeks therapeutic effect. ●24h urine and saliva is slightly radioactive.

  • Propylthiouracil (PTU): ●Assess heart rate. ●Have adequate rest. ●Must be taken round the clock at 8h interval. ●Report sore throat (agranulocytosis). ●Contraindicated in pregnancy.

THYROIDECTOMY

Pre-operative: Achieve euthyroid state by Antithyroid drugs and lugol’s soln. (SSKI- Strong Solution of Potassium Iodide – traps thyroid hormone in the thyroid glands – reducing vasculature of thyroid gland and post-op bleeding, 2-4 weeks before surgery); adequate rest.

Post-operative:

1. Position in semi-fowler’s (reduce edema); limit head movement (sandbag at the side and side pillows: avoids tension on suture line – small pillow avoids hyperextension of the neck. 2. Monitor for: ●Hypocalcemia/tetany (accidental removal of parathyroid):  Check Chvostek’s and Trousseau’s sign. Give CALCIUM GLUCONATE (Make sure that it is available at BEDSIDE after surgery).●Respiratory distress (d/t laryngeal edema): Keep TRACHEOSTOMY set, SUCTION equipment, and oxygen at BEDSIDE. ●Hemorrhage: Assess dressing and slide hands at the back of the head (where blood accumulates). ●Laryngeal nerve damage: as evidenced by respiratory obstruction, dysphonia, high-pitched voice, stridor, dysphagia and restlessness.  Limit patient talking, and assess for level of hoarseness. ●Thyroid storm (d/t thyroid hyperactivity released during surgery): d/t stress, injury and infection. High fever (earliest sign). Exaggerated s/s of hyperthyroidism. Altered LOC. Tachycardia. Priority interventions: ↓ body temperature. Provide a cool environment (use a cooling blanket), Tylenol (non salicylate antipyretics). Medical emergency (notify physician), monitor vital signs and cardiac dysrythmias, administer antithyroid solution as prescribed.

LEVOTHYROXINE (SYNTHROID)

C-Thyroid hormone

H-Give in AM if possible as a single dose to decrease sleeplessness; given at same time of the day.

E-Improved level of T3, T4 by laboratory test.

C-Instruct patient to report excitability, irritability, anxiety, sweating, heat intolerance, chest pain, palpitations which indicate overdose.

-Teach patient that product is not a cure but controls symptoms and treatment is long term.

-Do not take with food absorption will decrease.

-Teach patient to avoid iodine reach food: iodized salt, soybean, tofu, turnips and seafood.

-Avoid OTC drugs unless approved by prescriber.

-Product may be d/c after giving birth; thyroid panel will be evaluated.

-Hyperthyroid child will show almost immediate behavior or personality change; hair loss will occur in the child but temporary.

K- Assess for signs and symptoms of overdose usually in 1-3 weeks of treatment. (Withhold treatment for 1 week; acute overdose: gastric lavaged or induced emesis activated charcoal; provide supportive treatment to control symptoms.)

-Determine if the patient is taking anticoagulants (monitor prothrombin time), antidiabetic agents; document on the chart.

-Take BP, pulse before each dose; monitor I and O ratio and weight every day in light clothing, using same scale, at same time of the day.

-Monitor height, weight, psychomotor development, and growth rate if given to a child.

-Assess cardiac status and signs and symptoms of depression.

-Give crushed and mixed with water, nonsoy formula, or breast milk for infants.

PROPYLTHIOURACIL (PTU)

C-Thyroid hormone antagonist.

H-Give with meals to decrease GI upset. Given at the same time of the day.

E-Decreased T3, T4 levels, and hyperthyroid symptoms.

C-Advise patient to abstain from breastfeeding after delivery; product appears in breast milk.

-Teach patient to take pulse daily and keep graph of weight, pulse, and mood.

-Advise patient to report redness, swelling, sore throat, mouth lesions, which indicate blood dyscrasias.

-Avoid OTC products.

-Do not d/c abruptly; thyroid crisis may occur.

-Teach patient that response may take months if thyroid is large.

-Teach patient s/s of overdose: periorbital edema, cold intolerance, mental depression. Notify prescriber at once.

K-Monitor pulse, BP, temp.; I and O, check for edema (puffy hands, feet, and periorbits) indicates hypothyroidism.

-Check weight daily.

-Monitor T3, T4 which are increased. TSH decreased. Discontinue product 3-4 weeks before radioactive iodine uptake test.

-Monitor blood test: CBC for blood dyscrasias (leukopenia, thrombocytopenia, agranulocytosis; liver function test.

-Monitor clinical response: after 3 weeks (it can also be seen in 1-2 weeks) should include increased weight, decreased pulse, decreased T4.

-Assess for bone marrow depression: sore throat, fever, and fatigue.

ADDISON’S DISEASE

-Hyposecretion of adrenal cortex hormone (glucocorticoids and mineralocorticoids)

Manifestations:

Lethargy, fatigue, and muscle weakness. Gastrointestinal disturbances. Weight loss. Menstrual changes in women, impotence in men. Hypoglycemia, hyponatremia, hyperkalemia, hypercalcemia. Postural hypotension. Hyperpigmentation of the skin (bronzed).

Management:

●Replace fluids and glucocorticoids. ●Reduce stress. ●Promote adequate nutrition: high sodium and low potassium. ●Lifelong exogenous replacement of glucocorticoids.

CUSHING’S DISEASE

-Hypersecretion of glucocorticoids from the adrenal cortex.

-Excessive production of cortisol by the adrenal cortex or by the administration of glucocorticoids in large doses for several weeks.

Manifestations:

Generalized muscle wasting and weakness. Moon face, buffalo hump.

Truncal obesity with thin extremities, supraclavicular fat pads, weight gain. Hirsutism. Hyperglycemia, hypernatremia, hypokalemia, hypocalcemia. Hypertension. Fragile skin. Reddish-purple straiae on the abdomen and upper thigh.

Management:

●Provide comfort: protect from trauma (pathologic fracture is common). ●Monitor BP, labs., weight and I&O. ●Prevent infections.

●Increase protein, ↑K but ↓ calories and sodium.

●Surgery: Adrenalectomy.

METABOLIC SYNDROME is a term used to describe a group of conditions that puts people at higher risk of developing type II diabetes and heart diseases. ●Possible cause: may be related to insulin resistance. Genetics, older age and lifestyle - including a high-fat diet and inactivity. ●Must have 3 or more to consider metabolic syndrome: 1. High FBS. 2. High BP. 3. High level of triglycerides. 4. Low level of HDL. 5. Abdominal obesity.

●Teachings: 1. Follow a healthy diet. 2. Exercise regularly. 3. Maintain a healthy weight. 4. Have his/her blood glucose, blood pressure and cholesterol levels tested regularly.

REFERENCES:

 

Preparation guide for professional examination of the OIIQ, PRN comprendre pour intervenir guide d'evaluation, de surveillance clinique, et d'intervention infermieres, Fundamentals of nursing potter-perry, Ultimate learning guide nursing review, The ABC's of passing philippine nursing exam, Medical-surgical nursing assessment and management of clinical problem, Saunders Comprehensive review for the NCLEX-RN examination, Mosby drug guide for nurses, Critical thinking in nursing Winningham & Pressure

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