HCC 2008 Diabetic Complications
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| Diabetic complications can | result in permanent disability and/or death
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| Acute diabetic complications | hypoglycemia, diabetic ketoacidosis(DKA), hyperglycemic hyperosmolar non ketotic syndrome(HHNS), hypoglycemia Insulin reaction, blood glucose<50-60 mg/dl
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| mild symptoms | sweating, tremors, tachycardia, palpation, nervousness, hunger
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| moderate symptoms | inability to concentrate, lightheadedness, confusion, irrational or combative behavior, double vision, drowsiness
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| severe symptoms | disoriented behavior, seizures, difficulty arousing from sleep
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| Treatment of hypoglycemia | aimed at prevention, STAT bloog glucose, 15g of quick acting CHO equivalent to 2-3 tsp of sugar or honey, 6-10 lifesavers, 4-6 o of fruit juice, if unconscious Glucagon 1mg SC or IM of 25-50 ml 50% dextrose in water(D50W)
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| Patient teaching Hypoglycemia | meal pattern, insulin administration, exercise, snacks, routine SBGM, wear ID bracelet, s/s of hypoglycemia instruct client on s/s and treatment, instruct on balancing of exercise and adjusting insulin
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| Concerns in elderly diabetics | skipping meals, decreased visual activity(with too much insulin), living alone, decreased renal function ***should slow functions: dont rid of insulin too fast
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| Diabetic Ketoacidosis(DKA) is also know as a | diabetic coma
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| cause(s) diabetic ketoacidosis | missed dose or too little insulin, illness or infection, undiagnosed and intreated DM
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| symptoms of ketoacidosis | dry skin and mucous membrane, high blood sugar, ketoacidosis-mainly type 1
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| Three key factors of DKA | hyperglycemia, dehydration and electrolyte loss, metabolic acidosis
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| what happens during DKA | bodies cells cannot obtain sufficient fuel glucose, they burn protein and fat for the energy that need which leeds to DKA, the fat burning leads to the formation of highly acidic KETONES
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| difference btw DKA type 1 and type 2 | type 2 diabetics(NIDDM) have enough insulin to prevent the breakdown of fats ad don't produce KETONES
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| Clinical manifestations DKA | blurred vision, WEAKNESS, HEADACHE, dry skin, dry mucous membranes, orthostatic hypotension, dehydrations, anorexia, nausea, vomiting, deep labored(kussmaui resp.), acetone breath, comatose, confused, irritable, tachycardia
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| Assessment and Diagnostic findings of DKA | glucose level>300 (can be>1200)mg/dL, serum bicarbonate low, low pH, PCO2 high or no change, Na & K+ normal or high, high creatinine, BUN, High Hct bc of dehydrated
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| if you are sick particularly vomiting have diarrhea or a fever and diabetic you blood sugar will ___________ | rise; you must call the doctor and still take your insulin
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| when you are sick you must ________ stop your insulin, in fact you might have to give _______insulin | not; more
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| if sick ___________ self monitoring and test ever ___________hrs | increase; 3-4
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| test your urine for _________ Q____hrs | acetone; 3-4
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| when sick try to eat ___________ meals, if vomiting etc you need to drink _______ liters of fluid (water tea juice salty soup) | normal; 2-3
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| remeber if sick report N/V to _______ _________ ____________ | health care provider
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| renal failure causes __________ of ketones and glucose and result is continued acidotic state | retention
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| DKA treatment-Goal | immediate intervention (as nurse start IVs), manage dehydration, restore electrolytes, reverse acidosis
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| Monitoring dehydration with fluid replacement includes | administer .9 Nacl or 0.45% Nacl at a rapid rate, glucose level 250 give D5w, monitor I/O, observe for orthostatic changes in B/P and P, may have to give plasma expanders, observe for fluid overload
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| restoring electrolytes during DKA includes | monitoring e-lytes especially K+, administer insulin( low dose IV), administer potassium
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| Reversing acidosis DKA includes | measuring blood glucose hourly, adminiter insulin at slow rate 5U/hr, hypertonic solutions
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| a patient with DKA would receive solution at what blood glucose level? | 250
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| why would a DKA pt need more then one IV line? | to flush fluids in one arm and insulin in another, can give fluid at a higher rate then insulin
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| nursing management of DKA | monitor: electrolytes, blood glucose, I/O administer: fluids, insulin, and other meds, prevent fluid overload, assess renal function before administering K+
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| HHNS, HHS occur when | occurs when there is not enough insulin to prevent hyperglycemia, osmotic diuresis and extracellular fluid depletion but enough insulin to prevent DKA
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| HHNS, HHS occurs most often in | patients with indiagnosied diabetes or patient with mild type II diabetes, may be precipitated by stress or other illness, older adults, certain medications
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| Symptoms of HHNS | profound dehydration, hypotension, tachycardia and neurologic signs such as... high urine volume with causes dehydration and hyperosmolar blood + fruity odor in mouth
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| Assessment and Diagnostic findings in HHNS | BG 600-1200 mg/dL, serum osmolarity> 350mOsm/L, mental status changes, focal neurological deficits- aphasia hemiparesis, ataxia, hallucinations, postural hypotension, dehydration
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| Differences btw DKA and HHNS | DKA more common in type 1 HHNS more common in type 2, DKA has a rapid onset and HHNS is slower, glucose level for DKA is >250 HHNS is typically >600, DKA pH 7.3 HHNS pH is normal, ketones are present in DKA not in HHNS
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| medical management of HHNS | rapid IV infusion of 0.9 NS or 0.45 NS(initially) then dextrose, monitor and replace electrolytes, regular insulin IV
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| Nursing Implications of HHNS | cardiopulmonary monitoring, I&Os, frequent VS, fluid status, laboratory values, maintain safety/prevent injury, treat underlying precipitating condition
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| In summary collaborative care of DKA includes | diagnostic tests, blood glucose, CBC, ketones(blood and urine), pH, e-lytes, BUN, serum osmolality, IV insulin, IV fluids> HHNS, e-lye replacement, mental status, glucose monitoring, I/O, blood and urine, ketones, EKG monitoring, CV and resp monitoring
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| In summary collaborative care of HHNS includes | diagnostic tests, blood glucose, CBC, ketone, pH-normal, BUN, serum osmolality >350, IV insulin IV fluids, e-lytes replacement, mental status, glucose monitoring, I/O, blood & urine, ketone(usually no ketoacidosis), EKG monitoring, CV & Resp monitoring
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| nursing planning and implementation or macrovascular complications includes | prevention and treatment of risk factors of atherosclerosis, diet and excercise to manage obesity, hypertension and dyslipidemia, smoking cessation, control blood glucose, knowing s/s, cut alcohol, regular eye and dental exams, hemoglobin A1C
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| Microvascular Long term complications includes | diabetic retinopathy, microvascular damage to retina due to chronic hyperglycemia, almost always present in pts with type 1 diabetes btw the ages of 10-15 yrs, leading cause of blindness in ages 24-74
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| other ocular complications include | cataracts, lens changes, extrocular muscle palsy, glaucoma
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| clinical manifestations of microvascular complications and retinopathy | blurred vision- red or black spots, muscular edema, hemorrhage, complete loss of vision
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| Assessment and Diagnostic findings of microvascular complications and retinopathy | flouicein angiography- use of dye to examine retinal vessels; manage with laser photocoagulation or vitrectomy
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| nursing planning and implementation of microvascular complications | tight control of blood glucose, control of ypertension with ACE inhibitors, prevent and.or treat UTIs early, avoid nephrotoxic drugs, low sodium, low protein diets, smoking cessation, regular eye exams and renal screenings, refer to low-vision centers
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| Neuropathy | decreased pain and pressure sensation, increased dryness and fissuring leas to risk for injury and infection
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| Peripheral vascular disease | poor circulation contributes to poor wound healing and gangrene---loss on sensation
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| Immunocompromised | hyperglycemia impaire the ability to leukocytes to destroy bacteria. Therefore there is a lowered resistance to infection
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| Diabetic foot care---how to prevent complications? | inspect feet when you take off socks, look for small injuries and redness, wash feet everyday in luke warm water, dont soak no water higher the 37C, keep feet clean and dry, check shoes b4 putting them on, never walk barefoot
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| Diabetic foot care---more ways to prevent complications? | not hot water bottles or devices to warm feet, if you have an injury call doctor, if skin is dry use neutral creams, if humid use powder, file nails instead of cutting
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| Management of Diabetes---goals | to normalize activity and blood glucose levels, reduce the development of complications, maintain as normal a lifestyle as possible
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