NURSING CARE OF THE PATIENTS WITH DIABETES MELLITUS
- Diabetes mellitus, often simply referred to as diabetes, is a group of metabolic diseases characterized by hyperglycemia either because the body does not produce enough insulin,or because cells do not respond to the insulin that is produced.
- Diabetes mellitus is a chronic, progressive disease in which the inability to metabolize,carbohydrates, fats and proteins leads to complications in multiple organ systems.
- This high blood sugar produces the classical symptoms of polyuria (frequent urination),polydipsia (increased thirst) and polyphagia (increased hunger).
Types of diabetes
1. Type 1 diabetes
- Results from the body's failure to produce insulin, and presently requires the person to
inject insulin.
-Also referred to as insulin-dependent diabetes mellitus, IDDM for short, and juvenileonset
diabetes
- Is characterized by destruction of pancreatic beta cells resulting in deficiency of
insulin
- Usually diagnosed before the age of 30
- Usually is more difficult to control and since the onset is often in childhood,
complications may occur earlier than other Type 1
2.Type 2 diabetes
- Results from insulin resistance, a condition in which cells fail to use insulin properly,
sometimes combined with an absolute insulin deficiency.
- Formerly referred to as non-insulin-dependent diabetes mellitus, NIDDM for short,
and adult-onset diabetes.
3. Gestational diabetes
- Occurs in pregnant women, who have never had diabetes before and have a high
blood glucose level during pregnancy.
- It may precede development of type 2 DM
Causes, Risk Factors and Pathophysiology of Diabetes Mellitus
Causes and Risk Factors for Type 1
o Results from an autoimmune reaction which antibodies produced by the body destroy
the beta cells (insulin-producing cells) of the pancreas.
o The cause of the immune attack is not known for sure, but interaction between genes
and environmental factors seems necessary to initiate the disease. factors that may
play a role include
- Viral exposure may trigger autoimmune destruction of beta cells in pancreas
- Family History - Anyone with a parent or sibling with type 1 diabetes has a
slightly increased risk of developing the condition.
- Genetics - The presence of certain genes indicates an increased risk of
developing type 1 diabetes
- Geography - The incidence of type 1 diabetes tends to increase as you travel
away from the equator. People living in Finland and have the highest
incidence of type 1 diabetes - about two to three times higher than rates in the
United States and 400 times that of people living in Venezuela
- Other possible risk factors for type 1 diabetes include: Early introduction of
cow’s milk and drinking water that contains nitrates
Causes and Risk Factors for Type 2
- Inability of cells to use insulin properly leads to hyperglycemia..
- This latter condition affects mostly the cells of muscle and fat tissues, and results in a condition known as insulin resistance.
- There also a steady decline of insulin production of insulin by beta cells that adds to the process of elevated blood sugars. If someone is resistant to insulin, the body can,to some degree, increase production of insulin and try to overcome the level of resistance. After time, if production decreases and insulin cannot be released as vigorously, hyperglycemia develops.
- Predisposing Factors for Type 2include
-A parent, brother, or sister with diabetes
- Gestational diabetes or delivering a baby weighing more than 9 pounds
- Heart disease
- High blood cholesterol level
- Obesity (especially central obesity around waist)
- Not getting enough exercise
- Polycystic ovary disease (in women)
- Previous impaired glucose tolerance
- Some ethnic groups (particularly African Americans, Native Americans, Asians,
Pacific Islanders, and Hispanic Americans)
Pathophysiology of Diabetes
- To understand the pathophysiology of diabetes, it is important to understand the basics of carbohydrate metabolism and insulin action.
- Following the consumption of food, carbohydrates are broken down into glucose molecules in the gut.
- Glucose is absorbed into the bloodstream elevating blood glucose levels o This rise in glycemic (glucose in the blood) stimulates the secretion of insulin fromthe beta cells of the pancreas. Insulin is needed by most cells to allow glucose entry.o Insulin binds to specific cellular receptors and facilitates entry of glucose into the cell,which uses the glucose for energy.
- The increased insulin secretion from the pancreas and the subsequent cellular utilization of glucose results in lowered of blood glucose levels. Lower glucose levels then result in decreased insulin secretion.
- If insulin production and secretion are altered by disease, blood glucose dynamics willalso change. If insulin production is decreased, glucose entry into cells will be inhibited, resulting in hyperglycemia.
- The same effect will be seen if insulin is secreted from the pancreas but is not used properly by target cells.
- If insulin secretion is increased, blood glucose levels may become very low(hypoglycemia) as large amounts of glucose enter tissue cells and little remains in the bloodstream.
- Following meals, the amount of glucose available from carbohydrate breakdown oftenexceeds the cellular need for glucose.
- Excess glucose is stored in the liver in the form of glycogen, which serves as a readyreservoir for future use. When energy is required, glycogen stores in the liver areconverted into glucose via glycogenolysis, elevating blood glucose levels and providing the needed cellular energy source.
- The liver also produces glucose from fat (fatty acids) and proteins (amino acids)through the process of gluconeogenesis.
- Glycogenolysis and gluconeogenesis both serve to increase blood glucose levels.Thus, glycemia is controlled by a complex interaction between the gastrointestinal tract, the pancreas, and the liver.
- Multiple hormones may affect glycemia. Insulin is the only hormone that lowers blood glucose levels. Hormones such as glucagon, catecholamines, growth hormone,
- thyroid hormone, and glucocorticoids have the opposite effect of insulin and serve allact to increase blood glucose levels, in addition to their other effects.
- Poor glycemic control is clearly a major risk factor for complications, although not allpoorly controlled diabetic patients develop complications and some individuals develop complications despite relatively good glycemic control.
- Hyperglycemia plays a major role in both micro vascular and macro vascular disease.
- Hyperglycemia dramatically alters the function of multiple cell types and their extracellular matrix. Glucose binding (glucation) to proteins, lipids, and nucleic acids, results in structural and functional changes in the affected tissues
Signs and Symptoms of Diabetes Mellitus
Type 1 Diabetes Mellitus
o Usually has an acute onset. Symptoms include:
- Hyperglycemia
- Fatigue
- Increased thirst (polydipsia)
- Increased appetite (polyphagia)
- Increased urination (polyuria)
- Nausea and vomiting
- Weight loss in spite of increased appetite
- Blurred vision
- Muscle cramps
- Tingling or numbness in the hands or feet
- Very dry skin
- Sores that are slow to heal
- More infections than usual
Type 2 Diabetes Mellitus
Type 2 diabetes has a more gradual onset. Often patients are not aware they have the disease until the disease has progressed
o Signs and symptoms of diabetes mellitus type 2 include:
- Mild hyperglycemia
- Fatigue
- Frequent urination
- Darkening of skin especially on shoulders and neck (acanthosis nigrins) with a
velvety texture
- Blurred vision
-Muscle cramps
- Tingling or numbness in the hands or feet
- Very dry skin
- Sores that are slow to heal
- More infections than usual
- Onset of Type 2 is usually subtle and symptoms may be easily missed until
disease has progressed.
Complications Of Diabetic Mellitus and their Specific Signs and
Symptoms
* Complication of Type 1 diabetes mellitus
o Type 1 diabetes is associated with possible emergency complications including:
o Diabetic ketoacidosis
-Occurs when insulin deficiency causes the body to metabolize triglycerides and
muscle instead of glucose for energy.
- As lipids are metabolized, ketones which are acidotic are formed.
- The major ketoacids produced, acetoacetic acid and β-hydroxybutyric acid, are
strong organic acids that create metabolic acidosis.
- Acetone derived from the metabolism of acetoacetic acid accumulates in serum
and is slowly disposed of by respiration. This gives the breath a sweet, fruity odor.
- Hyperglycemia due to insulin deficiency causes an osmotic diuresis that leads to
marked urinary losses of water and electrolytes.
- Urinary excretion of ketones obligates additional losses of Na and K. Serum Na
may fall from natriuresis or rise due to excretion of large volumes of free water. If
serum K is not monitored and replaced as needed, life-threatening hypokalemia
may develop.
o Significant hyperglycemia
o Hypoglycemia:
- Usually caused by too much insulin or too little food intake
- May be fatal
o Long term complication for both Type 1 and Type 2 diabetes are largely due to effects
of high blood glucose levels on both large and small blood vessels. Complications are
serious and affect multiple organ systems including:
- Atherosclerosis
- Coronary artery disease
-Diabetic nephropathy
- Diabetic neuropathy
- Diabetic retinopathy
- Erection problems
- Hyperlipidemia
- Hypertension
- Infections of the skin, female urinary tract, and urinary tract
- Peripheral vascular disease
- Stroke
Treatment and Nursing Care of a Patient with Diabetes
*The patient is the most important member of the diabetes care team and full participation
of the patient is necessary to achieve the following aims:
o. Attainment and maintenance of normoglycemia
o. Monitoring of response to therapy
o. Prevention and detection of diabetes- associated complications
o. Facilitation of self- care through education
0.Promotion of social and psychological adjustment
o. The four main therapeutic approaches to this management
-Dietary therapy
- Exercise
- Medication
- Education
Type 1 diabetes
* In type 1 diabetes, insulin is required for survival.
* Diet, exercise and insulin must be carefully balanced in order to prevent hyper or
hypoglycemia.
- Dietary intake raises blood sugar. Both insulin and exercise lower blood sugar.
- Too much insulin, too little food or too much exercise may result in
hypoglycemia, a serious and sometimes fatal condition.
- Conversely, excess food intake, too little insulin or too little exercise may result in hyperglycemia.
*Patients and family must be educated in
- How to measure blood glucose level
- How to adjust insulin dose based on blood glucose level
- How to balance diet, exercise and insulin to maintain optimal blood glucose
levels and avoid complications
- How to recognize hyper and hypoglycemia and take corrective emergency
action
Type 2 Diabetes
* As in Type 1 diabetes, controlling blood glucose is the major goal
- Mild elevations in blood glucose levels are often able to be controlled with diet
and exercise
- If not effective, oral hypoglycemic agents can be added to diet and exercise
regimes
- If blood sugars are still not controlled, insulin may be required.
- Regular exercise, in any form, can help reduce the risk of developing diabetes Activity can also reduce the risk of developing complications of diabetes such as heart disease, stroke, kidney failure, blindness, and leg ulcers.
- As little as 20 minutes of walking three times a week has a proven beneficial
effect. Any exercise is beneficial; no matter how easy or how long, some exercise
is better than no exercise.
Nursing care
* The nurse should educate the patient and family on the following:
o Blood pressure and cholesterol control
o Careful self-testing of blood glucose levels
o Exercise
o Foot care
o Meal planning and weight control
o Medication or insulin use
o Basic diabetes management skills, as listed below, will help prevent the need for
emergency care.
- How to recognize and treat low blood sugar (hypoglycemia) and high blood sugar
(hyperglycemia)
- What to eat and when
- How to take insulin or oral medication
-How to test and record blood glucose
- How to test urine for ketones (type 1 diabetes only)
- How to adjust insulin or food intake when
Diet
- People with type 1 diabetes should eat at about the same times choose. This helps
to prevent blood sugar from becoming extremely high or low.
- People with type 2 diabetes should follow a well-balanced and low-fat diet.
How to Take Medication
- Medications to treat diabetes include insulin and glucose-lowering pills called oral
hypoglycemic drugs.
- People with type 1 diabetes cannot make their own insulin.
- They need daily insulin injections. Insulin does not come in pill form. Injections
are generally needed one to four times per day.
- Some people use an insulin pump. It is worn at all times and delivers a steady
flow of insulin throughout the day. Other people may use inhaled insulin
- Unlike type 1 diabetes, type 2 diabetes may respond to treatment with exercise,
diet, and medicines taken by mouth
- Medications may be switched to insulin during pre.g.nancy and while
breastfeeding.
- Gestational diabetes may be treated with exercise and changes in diet.
Exercise considerations for diabetic patients
- Choose an enjoyable physical activity that is appropriate for the current fitness
level.
- Exercise every day, and at the same time of day, if possible.
- Monitor blood glucose levels before and after exercise.
- Carry food that contains a fast-acting carbohydrate in case you become
hypoglycemic during or after exercise.
- Carry a diabetes identification card and a cell phone in case of emergency.
- Drink extra fluids that do not contain sugar before, during, and after exercise.
Foot Care
-People with diabetes are more likely to have foot problems.
- Diabetes can damage blood vessels and nerves and decrease the body's ability to
fight.
- You may not notice a foot injury until an infection develops.
- Death of skin and other tissue can occur.
- If left untreated, the affected foot may need to be amputated.
- Diabetes is the most common condition leading to amputations.
- To prevent injury to the feet, check and care for your feet every day.
Support Groups
- It's important to have support from family, friends and from other people with
diabetes
- Defeat Diabetes by self-empowerment and peer support approach to dealing with
the issue of diabetes.
- With good blood glucose and blood pressure control, many of the complications
of diabetes can be prevented
Nursing care of diabetic patient undergoing surgery
* Close co-operation between medical and nursing staff is essential to the pre- and postoperative
care of patients with diabetes in order to minimise complications and
maximise comfort for the patient.
* A combined approach with sharing of information and findings following the initial
assessment is vital especially in the anxious or distressed patient newly admitted to
hospital.
- Points to consider when making the initial assessment How long has the patient had diabetes?
* What treatment is the patient on to control glucose?
* Insulin alone or insulin and tablets?
* Tablets alone?
* Diet alone?
* How does the patient normally monitor their diabetes?
* Does the patient attend a diabetes clinic in a hospital or is it managed by the GP?
* Is there any evidence of complications of diabetes pre-operatively?
- Heart disease e.g. angina, myocardial infarction.
- Kidney disease e.g. nephropathy, renal artery stenosis, renal failure.
- Eye disease e.g. retinopathy, cataracts.
* Are there any problems directly relating to their diabetes?
- Hyperglycaemia or hypoglycaemia and time of day it tends to occur.
- Recent illness with nausea and vomiting.
- Electrolyte imbalance
- Autonomic neuropathy causing diarrhoea, gastroparesis or postural hypotension.
* Pre-operative investigations – minimum requirements are as follows:
- Urine for ketones
- Urea and electrolytes
- Blood glucose
- Nursing care of hospitalized patient
* Monitor vital signs
Rationale: hypoglycemia and hyperglycemia can be manifested by change in vital
signs
* Monitor blood glucose levels
* Monitor input and output, record the specific gravity of urine.
Rationale: To provide estimates of the need for fluid replacement, renal function, and
effectiveness of the therapy given.
* Provide fluid therapy as indicated.
Rationale: The type and amount of liquid depends on the de.g.ree of lack of fluids and
the response of individual patients.
* Determine the patient's diet and eating patterns and compared with the food available
Rationale: Identify deficiencies and deviations from the therapeutic needs.
* Identify the preferred food/desired according to ethnic/cultural background of the
patient.
Rationale: If the patient's food preferences can be included in meal planning, this
cooperation can be pursued after discharge.
* Involve patients in planning the family meal as indicated.
Rationale: Increase the sense of involvement; provide information on the family to
understand the patient's nutrition.
* Give re.g.ular insulin treatment as indicated.
Rational: re.g.ular insulin has a rapid onset and quickly and therefore can help move
glucose into cells.
* Observe signs of infection and inflammation.
Rationale: Patients may acquired nosocomial infections
* Improve efforts to prevent infection by good hand washing for all people in contact
with patients including the patients themselves.
Rationale: Prevents cross infection.
* Maintain aseptic technique in invasive procedures.
Rationale: high glucose levels in blood is the best medium for the growth of germs
* Encourage the patient to keep his skin clean and intact,
Rationale: the peripheral circulation may be disturbed that puts patients at increased
risk of damage to the skin/skin irritation and infection.
- Key Points
- People with diabetes have high blood sugar.
- In type 1 diabetes this occurs because the pancreas is unable to produce insulin.
- In Type 2 diabetes this is because the amount of insulin may be decreased and muscle, fat, and liver cells do not respond to insulin
- People with diabetes are at risk for serious complication that affect multiple systems.
- Maintaining optimal blood glucose levels can prevent or delay the onset of complication.
- The four main therapeutic approaches to this management
o Exercises
o Medication
o Education
Diabetic test
NURSING CARE OF THE PATIENTS WITH DIABETES MELLITUS
- Diabetes mellitus, often simply referred to as diabetes, is a group of metabolic diseases characterized by hyperglycemia either because the body does not produce enough insulin,or because cells do not respond to the insulin that is produced.
- Diabetes mellitus is a chronic, progressive disease in which the inability to metabolize,carbohydrates, fats and proteins leads to complications in multiple organ systems.
- This high blood sugar produces the classical symptoms of polyuria (frequent urination),polydipsia (increased thirst) and polyphagia (increased hunger).
Types of diabetes
1. Type 1 diabetes
- Results from the body's failure to produce insulin, and presently requires the person to
inject insulin.
-Also referred to as insulin-dependent diabetes mellitus, IDDM for short, and juvenileonset
diabetes
- Is characterized by destruction of pancreatic beta cells resulting in deficiency of
insulin
- Usually diagnosed before the age of 30
- Usually is more difficult to control and since the onset is often in childhood,
complications may occur earlier than other Type 1
2.Type 2 diabetes
- Results from insulin resistance, a condition in which cells fail to use insulin properly,
sometimes combined with an absolute insulin deficiency.
- Formerly referred to as non-insulin-dependent diabetes mellitus, NIDDM for short,
and adult-onset diabetes.
3. Gestational diabetes
- Occurs in pregnant women, who have never had diabetes before and have a high
blood glucose level during pregnancy.
- It may precede development of type 2 DM
Causes, Risk Factors and Pathophysiology of Diabetes Mellitus
Causes and Risk Factors for Type 1
o Results from an autoimmune reaction which antibodies produced by the body destroy
the beta cells (insulin-producing cells) of the pancreas.
o The cause of the immune attack is not known for sure, but interaction between genes
and environmental factors seems necessary to initiate the disease. factors that may
play a role include
- Viral exposure may trigger autoimmune destruction of beta cells in pancreas
- Family History - Anyone with a parent or sibling with type 1 diabetes has a
slightly increased risk of developing the condition.
- Genetics - The presence of certain genes indicates an increased risk of
developing type 1 diabetes
- Geography - The incidence of type 1 diabetes tends to increase as you travel
away from the equator. People living in Finland and have the highest
incidence of type 1 diabetes - about two to three times higher than rates in the
United States and 400 times that of people living in Venezuela
- Other possible risk factors for type 1 diabetes include: Early introduction of
cow’s milk and drinking water that contains nitrates
Causes and Risk Factors for Type 2
- Inability of cells to use insulin properly leads to hyperglycemia..
- This latter condition affects mostly the cells of muscle and fat tissues, and results in a condition known as insulin resistance.
- There also a steady decline of insulin production of insulin by beta cells that adds to the process of elevated blood sugars. If someone is resistant to insulin, the body can,to some degree, increase production of insulin and try to overcome the level of resistance. After time, if production decreases and insulin cannot be released as vigorously, hyperglycemia develops.
- Predisposing Factors for Type 2include
-A parent, brother, or sister with diabetes
- Gestational diabetes or delivering a baby weighing more than 9 pounds
- Heart disease
- High blood cholesterol level
- Obesity (especially central obesity around waist)
- Not getting enough exercise
- Polycystic ovary disease (in women)
- Previous impaired glucose tolerance
- Some ethnic groups (particularly African Americans, Native Americans, Asians,
Pacific Islanders, and Hispanic Americans)
Pathophysiology of Diabetes
- To understand the pathophysiology of diabetes, it is important to understand the basics of carbohydrate metabolism and insulin action.
- Following the consumption of food, carbohydrates are broken down into glucose molecules in the gut.
- Glucose is absorbed into the bloodstream elevating blood glucose levels o This rise in glycemic (glucose in the blood) stimulates the secretion of insulin fromthe beta cells of the pancreas. Insulin is needed by most cells to allow glucose entry.o Insulin binds to specific cellular receptors and facilitates entry of glucose into the cell,which uses the glucose for energy.
- The increased insulin secretion from the pancreas and the subsequent cellular utilization of glucose results in lowered of blood glucose levels. Lower glucose levels then result in decreased insulin secretion.
- If insulin production and secretion are altered by disease, blood glucose dynamics willalso change. If insulin production is decreased, glucose entry into cells will be inhibited, resulting in hyperglycemia.
- The same effect will be seen if insulin is secreted from the pancreas but is not used properly by target cells.
- If insulin secretion is increased, blood glucose levels may become very low(hypoglycemia) as large amounts of glucose enter tissue cells and little remains in the bloodstream.
- Following meals, the amount of glucose available from carbohydrate breakdown oftenexceeds the cellular need for glucose.
- Excess glucose is stored in the liver in the form of glycogen, which serves as a readyreservoir for future use. When energy is required, glycogen stores in the liver areconverted into glucose via glycogenolysis, elevating blood glucose levels and providing the needed cellular energy source.
- The liver also produces glucose from fat (fatty acids) and proteins (amino acids)through the process of gluconeogenesis.
- Glycogenolysis and gluconeogenesis both serve to increase blood glucose levels.Thus, glycemia is controlled by a complex interaction between the gastrointestinal tract, the pancreas, and the liver.
- Multiple hormones may affect glycemia. Insulin is the only hormone that lowers blood glucose levels. Hormones such as glucagon, catecholamines, growth hormone,
- thyroid hormone, and glucocorticoids have the opposite effect of insulin and serve allact to increase blood glucose levels, in addition to their other effects.
- Poor glycemic control is clearly a major risk factor for complications, although not allpoorly controlled diabetic patients develop complications and some individuals develop complications despite relatively good glycemic control.
- Hyperglycemia plays a major role in both micro vascular and macro vascular disease.
- Hyperglycemia dramatically alters the function of multiple cell types and their extracellular matrix. Glucose binding (glucation) to proteins, lipids, and nucleic acids, results in structural and functional changes in the affected tissues
Signs and Symptoms of Diabetes Mellitus
Type 1 Diabetes Mellitus
o Usually has an acute onset. Symptoms include:
- Hyperglycemia
- Fatigue
- Increased thirst (polydipsia)
- Increased appetite (polyphagia)
- Increased urination (polyuria)
- Nausea and vomiting
- Weight loss in spite of increased appetite
- Blurred vision
- Muscle cramps
- Tingling or numbness in the hands or feet
- Very dry skin
- Sores that are slow to heal
- More infections than usual
Type 2 Diabetes Mellitus
Type 2 diabetes has a more gradual onset. Often patients are not aware they have the disease until the disease has progressed
o Signs and symptoms of diabetes mellitus type 2 include:
- Mild hyperglycemia
- Fatigue
- Frequent urination
- Darkening of skin especially on shoulders and neck (acanthosis nigrins) with a
velvety texture
- Blurred vision
-Muscle cramps
- Tingling or numbness in the hands or feet
- Very dry skin
- Sores that are slow to heal
- More infections than usual
- Onset of Type 2 is usually subtle and symptoms may be easily missed until
disease has progressed.
Complications Of Diabetic Mellitus and their Specific Signs and
Symptoms
* Complication of Type 1 diabetes mellitus
o Type 1 diabetes is associated with possible emergency complications including:
o Diabetic ketoacidosis
-Occurs when insulin deficiency causes the body to metabolize triglycerides and
muscle instead of glucose for energy.
- As lipids are metabolized, ketones which are acidotic are formed.
- The major ketoacids produced, acetoacetic acid and β-hydroxybutyric acid, are
strong organic acids that create metabolic acidosis.
- Acetone derived from the metabolism of acetoacetic acid accumulates in serum
and is slowly disposed of by respiration. This gives the breath a sweet, fruity odor.
- Hyperglycemia due to insulin deficiency causes an osmotic diuresis that leads to
marked urinary losses of water and electrolytes.
- Urinary excretion of ketones obligates additional losses of Na and K. Serum Na
may fall from natriuresis or rise due to excretion of large volumes of free water. If
serum K is not monitored and replaced as needed, life-threatening hypokalemia
may develop.
o Significant hyperglycemia
o Hypoglycemia:
- Usually caused by too much insulin or too little food intake
- May be fatal
o Long term complication for both Type 1 and Type 2 diabetes are largely due to effects
of high blood glucose levels on both large and small blood vessels. Complications are
serious and affect multiple organ systems including:
- Atherosclerosis
- Coronary artery disease
-Diabetic nephropathy
- Diabetic neuropathy
- Diabetic retinopathy
- Erection problems
- Hyperlipidemia
- Hypertension
- Infections of the skin, female urinary tract, and urinary tract
- Peripheral vascular disease
- Stroke
Treatment and Nursing Care of a Patient with Diabetes
*The patient is the most important member of the diabetes care team and full participation
of the patient is necessary to achieve the following aims:
o. Attainment and maintenance of normoglycemia
o. Monitoring of response to therapy
o. Prevention and detection of diabetes- associated complications
o. Facilitation of self- care through education
0.Promotion of social and psychological adjustment
o. The four main therapeutic approaches to this management
-Dietary therapy
- Exercise
- Medication
- Education
Type 1 diabetes
* In type 1 diabetes, insulin is required for survival.
* Diet, exercise and insulin must be carefully balanced in order to prevent hyper or
hypoglycemia.
- Dietary intake raises blood sugar. Both insulin and exercise lower blood sugar.
- Too much insulin, too little food or too much exercise may result in
hypoglycemia, a serious and sometimes fatal condition.
- Conversely, excess food intake, too little insulin or too little exercise may result in hyperglycemia.
*Patients and family must be educated in
- How to measure blood glucose level
- How to adjust insulin dose based on blood glucose level
- How to balance diet, exercise and insulin to maintain optimal blood glucose
levels and avoid complications
- How to recognize hyper and hypoglycemia and take corrective emergency
action
Type 2 Diabetes
* As in Type 1 diabetes, controlling blood glucose is the major goal
- Mild elevations in blood glucose levels are often able to be controlled with diet
and exercise
- If not effective, oral hypoglycemic agents can be added to diet and exercise
regimes
- If blood sugars are still not controlled, insulin may be required.
- Regular exercise, in any form, can help reduce the risk of developing diabetes Activity can also reduce the risk of developing complications of diabetes such as heart disease, stroke, kidney failure, blindness, and leg ulcers.
- As little as 20 minutes of walking three times a week has a proven beneficial
effect. Any exercise is beneficial; no matter how easy or how long, some exercise
is better than no exercise.
Nursing care
* The nurse should educate the patient and family on the following:
o Blood pressure and cholesterol control
o Careful self-testing of blood glucose levels
o Exercise
o Foot care
o Meal planning and weight control
o Medication or insulin use
o Basic diabetes management skills, as listed below, will help prevent the need for
emergency care.
- How to recognize and treat low blood sugar (hypoglycemia) and high blood sugar
(hyperglycemia)
- What to eat and when
- How to take insulin or oral medication
-How to test and record blood glucose
- How to test urine for ketones (type 1 diabetes only)
- How to adjust insulin or food intake when
Diet
- People with type 1 diabetes should eat at about the same times choose. This helps
to prevent blood sugar from becoming extremely high or low.
- People with type 2 diabetes should follow a well-balanced and low-fat diet.
How to Take Medication
- Medications to treat diabetes include insulin and glucose-lowering pills called oral
hypoglycemic drugs.
- People with type 1 diabetes cannot make their own insulin.
- They need daily insulin injections. Insulin does not come in pill form. Injections
are generally needed one to four times per day.
- Some people use an insulin pump. It is worn at all times and delivers a steady
flow of insulin throughout the day. Other people may use inhaled insulin
- Unlike type 1 diabetes, type 2 diabetes may respond to treatment with exercise,
diet, and medicines taken by mouth
- Medications may be switched to insulin during pre.g.nancy and while
breastfeeding.
- Gestational diabetes may be treated with exercise and changes in diet.
Exercise considerations for diabetic patients
- Choose an enjoyable physical activity that is appropriate for the current fitness
level.
- Exercise every day, and at the same time of day, if possible.
- Monitor blood glucose levels before and after exercise.
- Carry food that contains a fast-acting carbohydrate in case you become
hypoglycemic during or after exercise.
- Carry a diabetes identification card and a cell phone in case of emergency.
- Drink extra fluids that do not contain sugar before, during, and after exercise.
Foot Care
-People with diabetes are more likely to have foot problems.
- Diabetes can damage blood vessels and nerves and decrease the body's ability to
fight.
- You may not notice a foot injury until an infection develops.
- Death of skin and other tissue can occur.
- If left untreated, the affected foot may need to be amputated.
- Diabetes is the most common condition leading to amputations.
- To prevent injury to the feet, check and care for your feet every day.
Support Groups
- It's important to have support from family, friends and from other people with
diabetes
- Defeat Diabetes by self-empowerment and peer support approach to dealing with
the issue of diabetes.
- With good blood glucose and blood pressure control, many of the complications
of diabetes can be prevented
Nursing care of diabetic patient undergoing surgery
* Close co-operation between medical and nursing staff is essential to the pre- and postoperative
care of patients with diabetes in order to minimise complications and
maximise comfort for the patient.
* A combined approach with sharing of information and findings following the initial
assessment is vital especially in the anxious or distressed patient newly admitted to
hospital.
- Points to consider when making the initial assessment How long has the patient had diabetes?
* What treatment is the patient on to control glucose?
* Insulin alone or insulin and tablets?
* Tablets alone?
* Diet alone?
* How does the patient normally monitor their diabetes?
* Does the patient attend a diabetes clinic in a hospital or is it managed by the GP?
* Is there any evidence of complications of diabetes pre-operatively?
- Heart disease e.g. angina, myocardial infarction.
- Kidney disease e.g. nephropathy, renal artery stenosis, renal failure.
- Eye disease e.g. retinopathy, cataracts.
* Are there any problems directly relating to their diabetes?
- Hyperglycaemia or hypoglycaemia and time of day it tends to occur.
- Recent illness with nausea and vomiting.
- Electrolyte imbalance
- Autonomic neuropathy causing diarrhoea, gastroparesis or postural hypotension.
* Pre-operative investigations – minimum requirements are as follows:
- Urine for ketones
- Urea and electrolytes
- Blood glucose
- Nursing care of hospitalized patient
* Monitor vital signs
Rationale: hypoglycemia and hyperglycemia can be manifested by change in vital
signs
* Monitor blood glucose levels
* Monitor input and output, record the specific gravity of urine.
Rationale: To provide estimates of the need for fluid replacement, renal function, and
effectiveness of the therapy given.
* Provide fluid therapy as indicated.
Rationale: The type and amount of liquid depends on the de.g.ree of lack of fluids and
the response of individual patients.
* Determine the patient's diet and eating patterns and compared with the food available
Rationale: Identify deficiencies and deviations from the therapeutic needs.
* Identify the preferred food/desired according to ethnic/cultural background of the
patient.
Rationale: If the patient's food preferences can be included in meal planning, this
cooperation can be pursued after discharge.
* Involve patients in planning the family meal as indicated.
Rationale: Increase the sense of involvement; provide information on the family to
understand the patient's nutrition.
* Give re.g.ular insulin treatment as indicated.
Rational: re.g.ular insulin has a rapid onset and quickly and therefore can help move
glucose into cells.
* Observe signs of infection and inflammation.
Rationale: Patients may acquired nosocomial infections
* Improve efforts to prevent infection by good hand washing for all people in contact
with patients including the patients themselves.
Rationale: Prevents cross infection.
* Maintain aseptic technique in invasive procedures.
Rationale: high glucose levels in blood is the best medium for the growth of germs
* Encourage the patient to keep his skin clean and intact,
Rationale: the peripheral circulation may be disturbed that puts patients at increased
* risk of damage to the skin/skin irritation and infection.
- Key Points
- People with diabetes have high blood sugar.
- In type 1 diabetes this occurs because the pancreas is unable to produce insulin.
- In Type 2 diabetes this is because the amount of insulin may be decreased and muscle, fat, and liver cells do not respond to insulin
- People with diabetes are at risk for serious complication that affect multiple systems.
- Maintaining optimal blood glucose levels can prevent or delay the onset of complication.
- The four main therapeutic approaches to this management
o Exercises
o Medication
o Education
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