Transcript Chapter 38 Nursing Care of Patients with Disorders of the

Understanding Medical Surgical Nursing, 4th Edition
Nursing Care of Patients with
Disorders of the Endocrine Pancreas
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Pathophysiology
◦ Glucose Intolerance
 Faulty Production of Insulin or
 Tissue Insensitivity to Insulin
◦ Altered CHO, Fat, Protein Metabolism
◦ Long-term Complications
Understanding Medical Surgical Nursing, 4th Edition
Understanding Medical Surgical Nursing, 4th Edition
Understanding Medical Surgical Nursing, 4th Edition
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20.8 Million in U.S. have Diabetes
6.2 Million are Unaware
Cost: $132 Billion per Year
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IDDM, Juvenile (Old Names)
5% to 10% of Diabetes Cases
Some Genetic Component (10%)
Autoimmune Response to Virus
Destruction of Beta Cells
Pancreas Secretes NO Insulin
More Common in Young, Thin Patients
Prone to Ketosis
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NIDDM, Adult Onset (Old Names)
90% to 95% of Diabetes Cases
Large Genetic Component (90%)
Decreased Beta Cell Responsiveness to
Glucose
Reduced Number of Beta Cells
Reduced Tissue Sensitivity to Insulin
Largest Risk Factor is Obesity
Not Ketosis-Prone
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Latent Autoimmune Diabetes of Adulthood
◦ Initial Type 2 Diagnosis
◦ Islet Cell Antibodies Like Type 1
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More Obesity in Children
Type 2 Epidemic
A Nursing Challenge
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Gestational: Pregnancy
Prediabetes: Glucose Intolerance
Secondary Diabetes
◦ Drugs
◦ Pancreatic Trauma
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Elevated Waist Circumference
Elevated Triglycerides
Low HDL Cholesterol
Elevated Blood Pressure
Elevated Fasting Plasma Glucose
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The 3 Ps
◦ Polyuria
◦ Polydipsia
◦ Polyphagia
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Fatigue
Blurred Vision
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Infection Prone
Abdominal Pain
Headache
Ketosis/Acidosis
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Fasting Plasma Glucose ≥ 126 mg/dL
Casual Plasma Glucose ≥ 200 mg/dL
Glucose Tolerance Test > 200 mg/dL
after 2 Hr
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Glycohemoglobin: Normal 4% to 6%
Lipid Profile
Serum Creatinine
Urine Microalbumin
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Lose 5% to 7% Body Weight
30 Minutes of Exercise 5 Days per Week
Reduce Fat and Calories
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Preprandial Glucose 90 to 130 mg/dL
Peak Postprandial Glucose < 180 mg/dL
Blood Pressure < 130/80 Mm Hg
Glycohemoglobin < 7%
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Medical Nutrition Therapy
Exercise
Medication
Monitoring
Education
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ADA Exchange Lists
Carbohydrate Counting
Glycemic Index
REMEMBER CULTURAL DIETARY NEEDS
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Low Fat
Low Sodium
Limit Simple Sugars
Use Complex Carbohydrates
Consistent Day-to-day
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Lowers Glucose up to 24 Hours
Lowers Blood Lipids
Best Done Regularly
Refer to MD or Exercise Physiologist
Avoid Exercise During Acute Hyperglycemia
Carry Fast Sugar
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Insulin for Type 1 or 2
Oral Hypoglycemics for Type 2
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Action
Routes
◦ Subcutaneous
◦ IM
◦ Inhaled
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Insulin pump
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Site Rotation
Timing
◦ Onset
◦ Peak
◦ Duration
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Are Not Insulin
Action Depends on Medication
◦ Stimulate Pancreas
◦ Increase Tissue Sensitivity to Insulin
◦ Slow CHO Digestion and Absorption
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Exenatide (Byetta)
Pramlintide (Symlin)
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Test AC and HS
Record Results
Analyze Meaning of Results
Know Target Glucose Levels
Call Provider if Out of Range
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Understanding Medical Surgical Nursing, 4th Edition
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Glucose
Ketones
◦ If Blood Sugar Greater than 300
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Hyperglycemia
Hypoglycemia = “Insulin Reaction”
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Blood Glucose >126 mg/dL
Causes
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Overeating
Stress
Illness
Not Enough Medication
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3 Ps
Blurred Vision
Fatigue, Lethargy
Headache
Abdominal Pain
Ketonuria
Coma
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Check Blood Glucose
Use Sliding Scale Insulin
If Blood Glucose is Greater Than 300, Check
Ketones
Determine Cause and Eliminate
If Blood Glucose is Greater Than 180 for 2
Days, Call MD
Call MD if Ill or Vomiting
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Blood Glucose Greater Than 70
Causes
◦ Too Much Insulin
◦ Exercise
◦ Not Enough Food
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Headache
Hunger
Fight or Flight
◦ Shaky
◦ Cold Sweat
◦ Palpitations
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Neuroglycopenia
◦ Irritability
◦ Confusion
◦ Seizures, Coma
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CAUTION
◦ Autonomic
Neuropathy = No
Symptoms
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Check Blood Glucose
Administer 15 to 20 G Fast-Acting CHO
Recheck in 15 Min
Repeat PRN
Snack if Greater Than 1 Hr Until Meal
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4 oz Orange Juice
6 oz Regular (not diet) Soda
Miniature Box of Raisins
Commercial Glucose Tablets
6 to 8 Life Savers
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IV D50
SQ Glucagon
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Causes
◦ High Blood Glucose
 Most Common in Type 1
◦ Stress
◦ Illness
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Insulin Deficiency
Cells Starving
Fat Breaks Down
Byproduct of Fat Breakdown is Ketones
Ketones are Acidic
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Flu-like Symptoms
Symptoms of
Hyperglycemia
Kussmaul’s
Respirations
Fruity Breath
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Electrolyte
Imbalance
Dehydration
Coma
Death
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IV Fluids
IV Insulin Drip
Frequent Glucose Monitoring
Electrolyte Monitoring
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Check Ketones if Blood Sugar is Greater Than
300
◦ Drink Fluids
◦ Check Again
◦ Call MD if Still Present
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Good Diabetes Control!
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Causes
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Hyperglycemia in Type 2 Diabetes
Stress
Illness
Most Common in Elderly
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Blood Glucose Elevated
Polyuria
Profound Dehydration
No Nausea and Vomiting, So Slower to Get
Help
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Extreme Dehydration
Lethargy
Blood Glucose may be 1,000 to 1,500 mg/dL
Electrolyte Imbalance
Coma
Death
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IV Fluids
IV Insulin Drip
Frequent Glucose Monitoring
Electrolyte Monitoring
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SMBG
If Glucose Rising
◦ Drink Fluids
◦ Lower Glucose
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Macrovascular Changes
◦ Stroke
◦ MI
◦ Peripheral Vascular Disease
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Microvascular Changes
◦ Retinopathy
◦ Nephropathy
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Neuropathy
Infection
Foot Problems
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Understanding Medical Surgical Nursing, 4th Edition
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Inspect Feet Daily
Wash and Dry Feet Daily
Wear Well-Fitting Shoes
Protect Feet from Injury
Avoid Crossing Legs
Use Caution with Nail Care
See MD Immediately if Sore Develops
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DCCT
◦ Tight Control Reduces Complications
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UKPDS
◦ HbA1c <7% Reduces Complications
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Frequent Glucose Monitoring
Sliding Scale Insulin or Insulin Drip
Maintain Glucose 140 to 180 mg/dL in
Critically Ill
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Risk for Variation in Blood Glucose
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Disease Process and
Treatment
Nutrition Therapy
Exercise
Medications
SMBG
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Acute Complications
Chronic
Complications
Psychosocial
Adjustment
Health Promotion
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Hyper-responsiveness of Pancreas
Low Glucagon Levels
Low Blood Glucose
Sympathetic “Fight Or Flight” Response
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Frequent Small Meals
High-protein, Low-CHO Diet