endocrine disorders

Endocrine Disorder –Diabetes

Miss Hight  Monday 9/29/08

 

Quiz

Function of the pancreas

Name the hormones of the pancreas produced by the Islets of Langerhans

α (alpha) cells produce glucagon which stimulates the liver to convert stored   glycogen

            into glucose and release it into the bloodstream

β (beta) cells produce insulin

Δ  (delta) cells produce somatostatin – neurotransmitter that inhibits production of

            glucagon & insulin

glycogenolysis – breakdown of glycogen into glucose

gluconeogenesis – production of glucose from (non-carb sources): breakdown of fats &

            proteins

 

Prevalence

18.2 million people are affected with diabetes

13 million diagnosed

5.2 are underdiagnosed

Increased prevalence of type 2 diabetes among older adults & minority populations

Type 1 more common in Caucasian than Latino

6^th leading cause of death in U.S.

 

Prevalence and Incidence of DM

8.7% of all non-Hispanic whites aged 20 years or older have diabetes

African-American type II

Diabetes, CHD, strokes, renal end stage disease

 

Prevalence and Incidence of DM

2.5 million Hispanic/Latino Americans have diabetes and are 1.7 times as likely to have diabetes as non-Hispanic whites of similar age

American Indians and Alaska Natives are 2.2 times more likely to have diabetes than non-Hispanic whites

Increasing in older adults between 65-74

 

Food enters body:

Goes to stomach broken down into sugars – glucose main fuel. 

Once glucose enters blood stream blood glucose goes up. Body senses increase in sugar, sends message to pancreas and sends insulin to blood stream, goes to liver, glucose will fall, glucose has to get into cell.

Insulin is key that lets glucose enter cell. Has to unlock cell for glucose to enter

Skeletal, cardiac and adipose require insulin

Brain, liver, intestines renal tubules not require insulin to enter cell

Once insulin unlocks, blood glucose enters cell, blood glucose goes down

 

Low blood sugar ie at 50 pancreas releases glucagon to liver to break down glycogen, thus blood sugar goes up.

 

Pathophysiology

Type I – autoimmune disease

Beta cells gradually destroyed

Eventually fail to produce insulin

Insulin is a hormone that helps the body's cells use glucose for energy.  Blood glucose (or blood sugar) is manufactured from the food we eat (primarily carbohydrates) and by the liver.

 

Patho – cont.

If glucose can't be absorbed by the cells, it builds up in the bloodstream instead, and high blood sugar is the result

Over time high blood glucose levels of uncontrolled diabetes can be toxic to every system of the body.

 

Type I

Closed to entry of glucose*

Total lack of endogenous insulin (within cell)

These type I will need exogenous insulin (medication), Need insulin shots

 

Insulin deficit

↓

Associated risk factors

↓

Glucose production & glucose utilization

↓

Hyperglycemia

↓

Osmotic diuresis

↓

Extracellular dehydration

↔

                    Renal insufficiency                                                   Hypovolemia

                                    ↓                                                                          ↓

Severe hyperosmolarity                                              hypovolemia

                                    ↓                                                                           ↓

                           Fluid shift                                                           tissue hypoxia

                                    ↓                                                                           ↓

Intracellular dehydration                                              lactic acidosis

                                    ↓                                                                            ↓

 

                                                                    Coma

 

 

 

 

Type I

Most often in childhood & adolescent, but can occur at any age

Characterized by hyperglycemia & ketosis*

More prevalent in Caucasian than those in other races

 

Risk factors

Genetic disposition – family hx

Parent or sibling with it 2-6% risk

If both parents highter 10-15%

Sibling with identical twin – increased risk

Viruses:

Coxsackie B-4

Mumps

            Rubella,

Cytomegalovirus

Environmental triggers

Chemical toxins in smoke/ cured meat

 

Clinical manifestations of type I

Polyuruia – hyperosmotic - dehydration

Polydypsia – drink a lot, mouth dry, sense thirst

Polyphagia – not enough energy (cells needs energy)

Weight loss –not gain weight

Malaise – tired all the time

Fatigue

 

Type II Diabetes

More common in middle age and older adults, but can occur in children and adolescents

Non-ketotic (no ketosis in urine)

Insulin resistance or impaired insulin secretion

Blacks, Amercian Indians, Asian Amercians, Pacific Islanders, Latinos,

 

Cont:

Insulin resistance: takes more insulin to unlock cell (cell membrane closed to sugar entry)

Inability to utilize insulin properly *cellular resistance*

Being overweight affects cellular resistance

Being inactive affects cellular resistance

Obesity BMI > 27

Physical inactivity

Race/ethnicity

Hypertension

Gestational diabetes

Giving birth to baby over 9 lbs.

 

Metabolic syndrome cluster:

            Abdominal obesity

            Lipids – dyslipidemia

            Hypertension

            Fasting blood sugar greater than 110

All of these put diabetic patient at risk for developing cardiovascular disease,

During physical do fasting blood sugar, lipids, blood pressure

May be put on lipid lowering meds

 

Do physical every year. Prevent high sugars

No insurance – physical not done frequently $700-$800 one reason people don't have it done

 

Patho type II

Most people with type II are still able to produce insulin at diagnosis

However, the insulin they produce is unable to perform its primary job, which is helping the body's cells use glucose for energy, and lowering blood sugar levels

 

Have sugar in cell

 

Clinical manifestations type II

Polyuria

Polydypsia

Blurred vision

Fatigue

Frequent skin infections

Problems with sexual function

Polyphagia not often seen (more with type I)

Paresthesia in hands or feet – tingling in hands & feet – circulatory problems

DKA – not common in type II (no have ketones) have enough insulin in cell

Weight loss uncommon

Overweight

 

Gestational diabetes 2-3 trim.

3-8 pregnancies of every 100 in America

Family hx of diabetes

Being overweight

Having prediabetes 100-126?

Risk factors for developing gestational diabetes

Baby over 9lbs

 

 

 

 

 

 

 

Clinical Manifestations of Gestational diabetes 24-28th week (screening done)

Have problems metabolizing blood glucose

Pancreas produces plenty of insulin (the hormone responsible for unlocking cells so that

glucose can enter them and provide energy

Because of insulin resistance, blood glucoe (or blood sugar) builds up in the bloodstream, and gestational diabetes is the result

Watermelon raises blood glucose

 

DM screening tess

Casual plasma glucose (random) – done at any time of day >200

Fasting plasma glucose (FPG) >126mg/dl no caloric intake for 8 hrs = diabetes should be (blood sugar should be 70-110)

Two hour PG – post prandial (after eating) (should not be greater than 200)

 

DM screening cont.

Fasting blood glucose mg/dl 70-110 done in a.m. soon as you go to bathroom,

Glycosylated hemoglobin A1c – shows blood glucose level over 2-3 months previously (July, August, Sept).  depends on hospital 4.1-5.9 at Erlanger

Any value above 7 is bad – not well controlled. 

RBC's recycle every 120 days

First lab will be Hgb A1c – oxyhemoglobin or glycolsylated Hgb

 

Oral glucose tolerance test – 2 hr or 3 hr drink glucose and go back to lab and draw over time,

Test urine for presence of albumin (bad)

Serum cholesterol , triglycerides 50-100, indicator of athlerosclerosis, risk of heart disease

Normal cholesterol level under 200

Lipid breakdown

HDL

LDL

Measure serum electrolytes – measure if in ketosis or hyperosmol state,

Check K, Na, creatinine, BUN, CO2, , if high

If spilling protein in urine will do 24 hr clearance for creatinine get protein count – diabetics prone to end stage renal disease. 

 

Reason for checking kidneys function: if spill protein bad –

GFR – glomerular filtration rate – higher number is better kidney, lower number is bad

African American, non African American

Type I use stick in urine – color coded screening pee on tip compare to chart (used for ketones)

Serum is most accurate for blood sugar

 

 

 

 

Therapeutic management all of these for managing blood glucose

Nutrition/diet/weight control

 

Exercise

 

Glucose monitoring

 

Medication

 

 

 

Nutritional management

Main goal of diet therapy in diabetes is to avoid sharp increase

 

Glycemic index: term used to describe how much a given food raises glucose level to compared to equivalent amount of glucose.

Baked potato high – sweet potato is better not raise glycemic index as high

Whole grains lower in glyceminc index,

 

Nutrition

Caloric intake based on individual needs

Follow food pyramid or exchange system form the Amercan Diabetic Assoc.

Weight watchers diet is good – diabetic diet

 

Nutrition

Carbohydrates (CHO)

45-65% (daily diet)

Complex - pasta

Avoid simple sugars candy bar

Saturated fat <10%

Sodium less than 3000mg/day

Protein 15/20%

20-35% fiber  whole grains – blood sugar not rise as quickly, brown rice good, Blood sugar not rise as high, keep food diary,

Eat at same time each day, same amount of CHO's each meal, be consistent

Exercise good to control blood sugar

 

 

 

 

 

 

 

 

 

Nutrition

Sweeteners

FDA approved

Safe in humans

Sugarless

Sugar-free

Dietetic – not necessarily reduced calorie

Nutrasweet, splenda, equal, sunnette

Produce no change in blood sugar

Alcohol – not encouraged nor prohibited -

 

Light beer recommended – may potentiate hypoglycemia, but could cause hyperglycemia in others

Should be consumed with meals

Substituted for fat (1.5 oz eqv. to two fat exchanges)

 

Nutrition

Misleading food labels

Sugarless

Sugar-free

Read labels

Dietetic – not necessarily reduced calorie

Snacks – contain sugar, corn syrup, honey

Healthy snacks – saturated vegetable fats, coconut or palm oil.

 

Nutrition cont.

Greater freedom in food choices – add up get running total.  Meet with registered dietician, do meal planning. Adhere to diet better.

1 cho=15 gms (x 20 carbs) =

Fiber = 5gms - can decrease (subtract) from CHO's total

As the name suggest, carbohydrates counting also called carb counting or carb gram counting involves computing the number of CHO's grams in a given meal or snack

Total carbs are tallied up on a running basis to ensure that the total doesn't exceed a predetermined dietary goal for the meal and/or day.

 

Nutrition

With this method, every 15 grams of CHO's are counted as one CHO choice with a predetermined number of choices allotted daily (as determined by an RD and based on caloric requirements)

Simple carb couting may be preferred by those who like the simplicity of the dietary exchange system but crave added variety in their diet.

 

 

 

 

 

Exercise

Benefits of exercise

Weight control

Improves physical fitness

Improves emotional state

Improves work capacity

For diabetics – improve uptake of glucose by muscle cells

Decreases cholesterol and triglycerides

HDL increased by exercise (over 45 is ideal)

LDL around 130 or less

Reduces the need for insulin

Decreases cholesterol, and triglycerides reducing the risk of cardiovascular disease

576-580 in LeMone**read for Miss Hight

 

Exercise cont

Consult primary care physician before starting exercise program

Start slow, change machines

Assessment of lifestyle before starting

Do you smoke?

            Assess exercise habits, stick with program

Make sure have proper footwear.

Diabetic: inspect feet before and after exercise – wear white socks or get moisture – get medium for athlete's foot

Avoid exercise in extreme cold or hot conditions

All diabetics must wear alert bracelet

If going to exercise, check blood sugar before and after exercise, check for hypoglycemia (not below 70)

           

Exercise habits, living environment

Community programs

Inspect feet before and after exercising

Avoid exercise during period of poor glucose control

 

Exercise for Type 1 diabetic

Glycemic response to exercise varies

Have increase risk for hypoglycemic and hyperglycemic reactions

Avoid prolonged exercise

Do not exercise at peak insulin times –

If check blood sugar and it is over 240, and if have positive ketones, need to postpone exercise, not need to exercise.

If blood sugar low before exercise, eat a CHO

If start to exercise and get chest pain, SOB – call 911

Low impact

Fluid intake

Do not exercise at peak insulin times, eat a carb if insulin also check ketones (if pos), at put off exercise

 

 

Test blood sugar before and after exercise, avoid prolonged exercise, monitor gluclose levels,

Low impact exercise best – walking

 

Exercise for type 2

improves glycemic control

weight loss.

Reduction of cardiovascular

Go to dr before

Exercise 3x week

Monitor glucose before and after exercise

Begin mild and gradually intensify

Include weight training

 

 

 

Glucose monitoring

Allows pt

SMBG -

1. acucheck – why check? Reflects glucose in blood
2. don't want to have reaction – high (hyperglycemic) or low (hypoglycemic)

decrease the danger of hypoglycemia / hyperglycemia

 

urine testing for ketones & color coded strip (not reliable, non invasive, less expensive)

old way of testing

 

 

Pharmacologic therapy

Classified according to:

Source

Onset

Peak

Duration

U100

Concentration 100 units/1 mL

Manufacturer: Eli Lilly & Nova Nordisk

Human insulin – faster onset

Shorter peak

Short duration

Pork or beef insulin – allergic rxn possible, not used a lot

 

 

 

 

Insulin therapy see chart**

Rapid acting

Lispro (humalog)

Usually given to cover meal time

If blood sugar goes up at night – nocturnal hyperglycemia & post prandial

Onset 25 mins.

Peak 1.5 hr

Duration 2-4 hrs

 

Aspart (Novolog)

Onset 25 mon

P40-50 m

3-5 hr duration

 

Glulisine (apidra)

Onset 25 min

Duration 3-5 hr

 

Short acting – regular

Cover meal times - sliding scale

Onset 5-10 min

Peak 2-3 hr

Duration 4-6 hhr

Can give IV only one that can be given IV**

 

Intermediate used to maintain the basal insulin requirements in between meals

NPH – in between meals

onset 2 hr.,

p 6-8,

duration 12-16 rh

Humulin N

 

Insulin cont.

Lantus

Long acting – maintain in between meals

Onset 2 hr

Peak not peak not defined

Duration 24 hr plus, Given at night usually at 2200 (10:00) p.m. to affect day time blood sugar, know when it peaks, ok to give when blood sugar is 98, because it peaks next day. **Very important Do not hold this insulin**

Combination

Administered to mimic pancreatic activity of the pancreas

All these peak in

70/30 onset 5 min, p – 4-8, d= 24

50/50 onset 5 min, p-3 hr. dur 24 hrs

 

 

Route of administration

Only regular insulin may be given IV or in an emergency may be given IM – all insulin drips are regular insulin

Most subcutaneous (fasted from the abdomen) absorbs quicker

Insulin patch

 Inhaled aerosolized insulin (new on market)

 

Alternative methods

 Insulin pens small device (150-300 units)

Prefilled

Good for one type of insulin

Eating out

Very expensive, not refrigerated

 

Jet injectors

Delivers insulin thru the skin under pressure

Very expensive

Requires thorough training

Absorbed faster

Caution pt about peak insulin activity – absorbed faster, not used a lot, easier to have hypoglycemic rxn.

 

Exubera: inhaled insulin

Causes hypoglycemic rxn quickly

 

Methods cont.

Transplantation of the pancreas

Mostly diabetic receiving kidney transplant at same time

Transplant of the pancreatic islet cells

Weighing the risk of anti rejection medication versus the advantage of pancreas transplant

 

Continuous SC insulin infusion CSII insulin pump

Description

Delivers a basal rate of insulin and allows for additional bolus doses of insulin based on requirements (before meals)

Mimics functioning of the normal pancreas

Device is worn

Programmed to deliver before each meal, set up on 24 hr basis

Usually inserted into abdomen, needle into skin

Disadvantage: change needle every 3 days*, be meticulous about cleanliness, may come out, interruption in insulin, line can become kinked, check needle, extension tubing not kinked

Disruption of insulin flow if tubing or needle becomes occluded

Mini-med

Run on battery  - check every week or two

Used on young, brittle ones

 

Complications of insulin therapy

Local reaction

Swelling, tenderness at site,

Systemic reaction

Involved gradual spread to generalized urticaria (hives)

Lipodystrophy or lipoatrophy refers to

Localized reaction occurring at the site of injection

Loss of subcutaneous fat – appear as a dimple, *need to rotate site** of injection

 

Complications cont

Morning hyperglycemia

Dawn phenomena

At 2-3 am. Blood glucose levels rise

From nocturnal surges in growth hormone

Creates a greater need for insulin in early morning hr

Somogyi phenomenon

Normal or elevated blood glucose at bedtime

Results in nocturnal hypoglycemia – followed by rebound hyperglycemia decrease at

2-3 a.m.

Helps to know what to give in a.m.

 

Client teaching about insulin

Store in cool place away from sunlight

**replace every 4 weeks**

Cold insulin causes subcutaneous atrophy or hypertrophy alters insulin absorption

Note date of expiration  must have a date and time

Avoid alcohol lowers blood glucose

Do not shake, roll non regular insulin

Monitor for hypoglycemia

When travel take extra insulin, with carry on, do not pack in suitcase, need to have with you for in case of rxn, take two bottles of insulin

Rotate the site

Do not inject in an area that will be involved in exercise increases absorption

Increase absorption, risk of hypoglycemia

 

Rotating sites

Arms

Abdomen

Back

Legs

 

 

 

Oral hypoglycemic agents ** see chart**

 Sulfonylureas – stimulate pancreastic

Amaryl

Glucotrol

Tollinse

Orinase

1^st genation

 Old drugs

 

Action

Side effects

Cause hypoglycemia

 

 

Drugs Cont

Biguanindes

Metformin (Glucophage)

Reduce overproduction of glucose by liver, making insulin more effective for peripheral tissues, reduce fasting blood sugar in the morning

Side effects**lactic acidosis*

If on constrast dye suspend 48 hrs

Must do liver enzymes if on this drug – metformin

Check every 2-3 months

 

Drugs cont.

Meglitinindes

Prandin

Action: Lower blood glucose by stimulating release of insulin from the pancreatic islet cells

new class, tx type 2

Decreases spikes in glucose following meals, evens it out

d-phenylalanine (amino acid derivative)

starlix

prandin

 

Drugs cont.

Alpha glucoside inhibitors

Acarbose – work in small intestine to delay glucose absorption

Side effect: gas and bloating

 

 

 

 

 

 

 

Drugs cont.

Thazolidinediones

Avandia –

Actose

Action: Sensitizes peripheral tissue to insulin, Allows your own insulin or the insulin you take to work more effectively

Side effects – not give to people with CHF

Weight gain, edema

**Good for insulin resistance – drug of choice**

 

Drugs cont.

Aspirin therapy

Given to reduce atherosclerosis in clients with vascular disease

81 mg or 325 mg if Enteric Coated

Daily

Diabetics 4x more likely to die of cardiovascular complications / disease

Contraindicated with clients with aspirin allergy

 

Incretin Mimetics

Byetta

Incretin mimetic is used in type 2 diabetic

Predialed pen

Last 30 days

Mimics many of the action of naturally occurring hormones form the intestines

Helps body make more of own insulin

Action: Insulin production signals the pancreas to make the right amount

Inject 2x day morning afternoon, dose 5 mg,

Sugar production helps prevent the liver from making too much insulin

Side effect: nausea (made from snake spit)

Food breakdown helps to slow down the rate in which the food leaves the stomach

Control weight

Should be stored in fridge at 37 celsius

After in fridge can be at room temp at 77 degrees, screw needle on

 

Nursing Interventions

Education

Develop diabetic teaching plan

Teaching survival

Assessing readiness to learn

Determining teaching methods

 

 

 

 

 

 

Complications

DKA – life threatening metabolic acidosis, Ketones in blood

Onset <24 hrs

Cause: Decreased insulin, Infection

CNS depression, coma

 

Clinical manifestation

Metabolic acidosis (from ketosis)

thirst

Weakness

Warm, dry skin with poor turgor

Malaise

Soft eyeballs

Rapid, weak pulse

Hypotension

Dry mucus membranes

 

Manifestations of diabetic ketoacidosis

Nausea vomiting

Lethargy

Fruity breath

Coma

Other manifestations

Abdominal pain (cause unknown)

Kussmaul's respirations  - increased rate and deep, longer expiration – blow off CO2 trying to decrease ph

 

DKA cont

Risk factors

Triggered by emotional stress

Infections

Trauma

Insufficienct insulin administration

**Must be given on time**

 

DKA cont

Lab

Serum >250

Plasma <7.35

Ketones +

Serum osmol: 300-350

Urine ketones+

NA, Cl, K abnormal

Treatment: Insulin 1^st 12 hrs require 8-10 liters of fluid NS 200 cc/hr

Intravenous fluid & Electrolytes

usually on floor

if blood sugar high, run NS (1st 12 hrs maybe 2000 cc), after blood sugar, give D5w to prevent hypoglycemia (can get cerebral edema),

 

Hyperosmolar Hyperglycemic State

Metabolic problem

Occurs in type 2 diabetes

Characterized by serum osmo of 340 mOsm/l or greater

Elevated glucose 600 mg/dL

Higher mortality rate than DKA if uncontrolled

Onset: Can occur in type 1 or 2 but is more prevalent in type 2

Slow onset several days

Causes: Decrease in insulin

Older age

 

HHS cont.

Risk facts

Trauma

Surgery, dialysis

Dehydration

Illness

Medication

Assessment

Flushed skin red

Thirst

Decrease in BP

Increased pulse

Level of conscious decreased

Seizures

Abdominal pain

 

Lab finding

Glucose >600

Ketones normal

Urine glucose increased

K, NA, CL abnormal

Serum osmol >340

Treatment: Administer insulin, On insulin drip check q 1hr

Intravenous fluids:

Correcting fluid and electrolyte protocol – standing orders

Replace K+

Admitted to ICU

 

 

 

 

 

Hypoglycemia "insulin shock or insulin rxn" mainly type 1

Description

Low blood glucose levels

Onset rapid

Increase in insulin

Omitting meals

Error in insulin dose – too much insulin given **do not round up on insulin**

Common in type 1

Occasionally occurs in type 2

Onset: rapid

Causes: Increased insulin

 

Manifestations of hypoglyemcia

Hunger

Shakiness

Nausea

Irritable

Anxiety

Sweating

Pale cool skin

Decrease in BP

Rapid pulse

Increased anxiety

 

Hypoglycemia cont.

Risk factors

surgery

alcohol intake

trauma

lipodystrophy – not getting absorbed

Exercise

 

Hypoglycemia

Lab finding

Serum Glucose less than 50 some below 70 treat below 70

Urine glucose normal

Na, K, Cl normal

Serum osmol normal

Ketones –absent

Serum osmo normal

Treatment: Glucagon, Rapid acting carbohydrates, **Give apple juice** brings it up faster than OJ

**Check blood sugar first* then treat,

If continue to go down, glucagon can give IM if drops below 50 can seizure, give 10 minutes, check treat again.

If they can talk can take glucagon orally give soft stuff

Rapid acting carbohydrate, candy, crackers, honey, peanut butter

Give at least 15 grams of carbohydrates

If below 70 give D50 use syringe in blue box only give IV (not all pts have IV)

Hard to push in

 

T.I.R.E.D.

Tired/tachycardia

Irritability

Restless

Excessive hunger

Diaphoresis/depression

Cold and clammy means you need some candy

Hot and dry means your sugar is high

 

Sick day management

Taking your meds

Test blood glucose

Stay hydrated

Are all parts of managing your diabetes while sick

 

Sick Day plan

Monitor blood glucose 4x day

Usual insulin dose or oral

8-12 oz drink per hour

Substitute easily digested liquid or soft foods if solid food no tolerated– of carbohydrate equivalent

Replace small carbohydrates

Call MD if client is unable to eat for 24 hrs

If B/S >240 for 24 hrs or >350 at any time

May be nauseated can get hypoglycemia

Stress to body makes blood sugar go up

So if blood sugar high, interpret as stress,

Surgery puts stress on body

Trauma, check blood sugar, sliding scale on insulin

 

Chronic complications

macrovascular complications results

From changes in the medium to large blood vessels

Blood walls thicken scleroses

50-60% of CAD

Cerebral vascular disease

Peripheral vascular disease – amputation is a possibility

Stroke

Myocardial infarction twice as common

 

 

 

Mainfestations caused by impaired cerebral function

Strange unusual feeling CVA

Slurred speech

Blurred vision

Difficulty thinking – decreased LOC

Change in emotional behavior

Inability to concentrate

seizures

Coma

 

Diabetic retinopathy

Microvascular changes affecting retina

Deterioration of small blood vessels which nourishes the retina

Sx painless blurry vision, Macular edema

Leading cause of blindness

Treatment: A yearly opthalmology visit

 

Diabetic Nephropathy

Secondary to Microvascular in the kidney

Diabetic accounts for half of new cases of end stage renal diseases each year in the USA

Hypertension

Protein in urine spilled bad – messing up kidney

Treatment:

Achieving and maintaining near normal glucose levels

Control hypertension –

use ACE inhibitor – protect kidney

Prevent UTI

Avoidance of nephrotoxic substances

If  GFR  is High, this is good, this means good filtration, healthy kidney

If GFR value is low, this is bad, unhealthy kidney

Protein in urine – decrease in renal function

 

Diabetic neuropathies

Description

A group of diseases that affects all types of nerves including peripheral and spinal

Peripheral neuropathy

Lower extremities

Manifestations

Feet becomes

Numb especially at night

Deformities Of charcot joint abnormal joint distribution on joint due to lack of proprioception

Give neurontin, lot of amputations

Take care of lower extremities, Pulse hard to find, pulses of 1, & Decreased tendon reflexes; Joint distribution uneven on joint due to lack of proprioception

 

Pharmacologic  Management

Analgesic

Elevil – tricyclic antidepressant

Phenytoin –dilantin

Mexeletine (anti-arrhythmic)

TENS unit

 

Autonomic neuropathies

Related to gastrointestinal delayed gastric emptying

Gastral paresis

Renal urinary retention

Cardio tachycardia

Orthostatic hypotension

Silent MI – pain not know about chest pain

Sexual dysfunction can use penile pump

Impotence in men

In women decrease lubrication and decrease libido

Lack of orgasm

 

Foot and Leg problems

Foot and leg problems

50-75 % of lower extremity amputations are performed on people with diabetes

50% are preventable

If diabetic are educated about foot care measures and practice them on a daily basis

Client teaching

Inspect daily for redness blisters changes in temp

Properly bathe and dry feet

Wear closed toe shoes

Wear shower shoes

Shoes that fit

Trim toe nails straight across

Avoid walking barefoot

Not wear flip-flops in summer

Bring own equipment for pedicure so not get infection in salon, could get amputation

Consult podiatrist yearly for food exam

Wear socks

 

 

 

 

 

 

 

 

 

Nursing Interventions

Maintaining blood glucose

Definitions of normal blood glucose levels vary in clinical practice, depending on the laboratory that performs the assay

Pharmacologic treatment for diabetes mellitus depends on the type of diabetes

Dietary management for adults for adults with diabetes, based on guidelines established by the ADA

The ability to maintain an exercise program is affected by many different factors

 

Nursing interventions

Insulin

Monitor storage and expiration of insulin

Montor blood glucose reading

Monitor food intake

Oral hypoglycemics

Administer with food

Assess diet and exercise

Monitor for hypo/hyperglycemia

Assess for side effects

 

 

Self management of DM

Maintain prescribed diet & exercise

Insulin needs are increased if you have surgery, trauma, fever, or infection

Monitor blood glucose

Undergo periodic lab evaluations

Take medications as prescribed

Some medications (oral) may interfere with oral contraceptives

Report any illness side effects to health care provider

Avoid alcohol

Get a flu shot yearly and pneumonia shot every 5 yrs.

 

Nursing diagnoses

Health promotion

Assessment

Risk for impaired skin integrity

Risk for infection

Risk for injury

Sexual dysfunction

Ineffective coping