Practice nursing care for Clients
with Diabetes Mellitus II
EDUCATION
Diabetes mellitus is a chronic illness requiring a lifetime of special self-management behaviors. Because diet, physical activity, and physical and emotional stress affect diabetic control, patients must learn to balance a multitude of factors. They must learn daily self-care skills to prevent acute fluctuations in blood glucose, and they must also incorporate into their lifestyle many preventive behaviors for avoidance of long-term diabetic complications. Diabetic patients must become knowledgeable about nutrition, medication effects and side effects, exercise, disease progression, prevention strategies, blood glucose monitoring techniques, and medication adjustment. In addition, they must learn the skills associated with monitoring and managing diabetes and must incorporate many new activities into their daily routines. An appreciation for the knowledge and skills that diabetic patients must acquire can help the nurse in providing effective patient education and counseling (Beebe & O’Donnell, 2001).
DEVELOPING A DIABETIC TEACHING PLAN
Changes in the health care delivery system as a whole have had a major
impact on diabetes education and training. Patients with new-onset type 1
diabetes have much shorter hospital stays or may be managed completely on an
outpatient basis; patients with new-onset type 2 diabetes are rarely
hospitalized for initial care. There has been a proliferation of outpatient
diabetes education and training programs, with increasing support of
third-party reimbursement. For some patients, however, exposure to diabetes
education during hospitalization may be the only opportunity for learning
self-management skills and preventing complications. Many hospitals employ nurses who specialize in diabetes education and
management and who are certified by the National Certification Board of
Diabetes Educators as Certified Diabetes Educators. However, because of the
large number of diabetic patients who are admitted to every unit of a hospital
for reasons other than diabetes or its complications, the staff nurse plays a
vital role in identifying diabetic patients, assessing self-care skills,
providing basic education, reinforcing the teaching provided by the specialist,
and referring patients for follow-up care after discharge. Diabetes patient
education programs that have been peerreviewed by the
Organizing Information
There are various strategies for organizing and prioritizing the vast
amount of information that must be taught to diabetic patients. In addition,
many hospitals and outpatient diabetes centers have
devised written guidelines, care plans, and documentation forms (often based on
guidelines from the
TEACHING SURVIVAL SKILLS
This information must be taught to any patient with newly diagnosed type 1 or type 2 diabetes and any patient receiving insulin for the first time. This basic information is literally what the patient must know to survive—that is, to avoid severe hypoglycemic or acute hyperglycemic complications after discharge. An outline of survival information includes:
1. Simple pathophysiology a. Basic definition of diabetes (having a high blood glucose level) b. Normal blood glucose ranges and target blood glucose levels c. Effect of insulin and exercise (decrease glucose) d. Effect of food and stress, including illness and infections (increase glucose) e. Basic treatment approaches
2. Treatment modalities a. Administration of insulin and oral antidiabetes medications b. Diet information (food groups, timing of meals) c. Monitoring of blood glucose and ketones
3. Recognition, treatment, and prevention of acute complications a. Hypoglycemia b. Hyperglycemia
4. Pragmatic information a. Where to buy and store insulin, syringes, and glucose monitoring supplies b. When and how to reach the physician
For patients with newly diagnosed type 2 diabetes, emphasis is initially placed on diet. Patients starting to take oral sulfonylureas or meglitinides need to know about detecting, preventing, and treating hypoglycemia. If diabetes has gone undetected for many years, the patient may already be experiencing some chronic diabetic complications. Thus, for some patients with newly diagnosed type 2 diabetes, the basic diabetes teaching must include information on preventive skills, such as foot care and eye care—for example, planning yearly or more frequent complete (dilated eye) examinations by the ophthalmologist and understanding that retinopathy is largely asymptomatic until the advanced stages. Patients also need to realize that once they master the basic skills and information, further diabetes education must be pursued. Acquiring in-depth and advanced diabetes knowledge occurs throughout the patient’s lifetime, both formally through programs of continuing education and informally through experience and sharing of information with other people with diabetes.
PLANNING IN-DEPTH AND CONTINUING EDUCATION
This involves teaching more detailed information related to survival skills (eg, learning to vary diet and insulin and preparing for travel) as well as learning preventive measures for avoiding longterm diabetic complications. Preventive measures include:
• Foot care
• Eye care
• General hygiene (eg, skin care, oral hygiene)
• Risk factor management (eg, control of blood pressure and blood lipid levels, and normalizing blood glucose levels)
More advanced continuing education may include alternative methods for insulin delivery, such as the insulin pump, and algorithms or rules for evaluating and adjusting insulin doses. For example, patients can be taught to increase or decrease insulin doses based on a several-day pattern of blood glucose levels. The degree of advanced diabetes education to be provided depends on the patient’s interest and ability. However, learning preventive measures (especially foot care and eye care) is mandatory for reducing the occurrence of amputations and blindness in diabetic patients.
Assessing Readiness to Learn
Before initiating diabetes education, the nurse assesses the patient’s (and family’s) readiness to learn (Beebe & O’Donnell, 2001). When patients are first diagnosed with diabetes (or first told of their need for insulin), they often go through various stages of the grieving process. These stages may include shock and denial, anger, depression, negotiation, and acceptance. The amount of time it takes for patients and family members to work through the grieving process varies from patient to patient. They may experience helplessness, guilt, altered body image, loss of self-esteem, and concern about the future. The nurse must assess the patient’s coping strategies and reassure patients and families that feelings of depression and shock are normal. Asking the patient and family about their major concerns or fears is an important way to learn about any misinformation that may be contributing to anxiety. Some common misconceptions regarding diabetes and its treatment are listed in Table. Simple, direct information should be provided to dispel misconceptions. More information can be provided once the patient masters survival skills. After dispelling misconceptions or answering questions that concern the patient the most, the nurse focuses attention on concrete survival skills. Because of the immediate need for multiple new skills, teaching is initiated as soon as possible after diagnosis. Nurses whose patients are in the hospital rarely have the luxury of waiting until the patient feels ready to learn; short hospital stays necessitate initiation of survival skill education as early as possible. This gives the patient the opportunity to practice skills with supervision by the nurse before discharge. Follow-up by home health nurses is often necessary for reinforcement of survival skills. A major goal of patient teaching is an educated consumer, a patient who is informed about the wide variations in the prices of medications and supplies and about the importance of comparing prices.
Determining Teaching Methods
Maintaining flexibility in teaching approaches is important. Teaching skills and information in a logical sequence is not always the most helpful for patients. For example, many patients fear the injection. Before they learn how to draw up, purchase, store, and mix insulins, they should be taught to insert the needle and inject insulin (or practice with saline solution). Numerous demonstrations by the nurse or practice injections before the patient (or family) gives the first injection may actually increase the patient’s anxiety and fear of self-injection. Once patients have actually performed the injection, most are more prepared to hear and to comprehend other information. (If they then want to practice further using a pillow or an orange, that would be appropriate.) Thus, having patients self-inject first or having patients perform a fingerstick for glucose monitoring first may enhance learning to draw up the insulin or to operate the glucose meter. Ample opportunity should be provided for the patient and family to practice skills under supervision (including selfinjection, self-testing, meal selection, verbalization of symptoms, and treatment of hypoglycemia). Once skills have been mastered, participation in ongoing support groups may assist patients in incorporating new habits and maintaining adherence to the treatment regimen. Various tools can be used to complement teaching. Many of the companies that manufacture products for diabetes self-care also provide booklets and videotapes to assist in patient teaching. It is important to use a variety of written handouts that match the patient’s learning needs (including different languages, lowliteracy information, large print). Patients can continue learning about diabetes care by participating in activities sponsored by local hospitals and diabetes organizations. In addition, magazines with information on all aspects of diabetes management are available for people with diabetes.
IMPLEMENTING THE PLAN
Teaching Experienced Diabetic Patients
The nurse should continue to assess the skills of patients who have had diabetes for many years, because it is estimated that up to 50% of patients may make errors in self-care. Assessment of these patients must include direct observation of skills, not just their self-report of self-care behaviors. In addition, these patients must be fully aware of preventive measures related to foot care, eye care, and risk factor management. If patients are experiencing long-term diabetic complications for the first time, they may go through the grieving process again. Some of these patients may have a renewed interest in diabetes self-care in the hope of delaying further complications. Other patients may be overwhelmed by feelings of guilt and depression. The patient is encouraged to discuss feelings and fears related to complications; the nurse meanwhile provides appropriate information regarding diabetic complications.
Teaching Patients to Self-Administer Insulin
Insulin injections are administered into the subcutaneous tissue with the use of special insulin syringes. A variety of syringes and injection-aid devices are available. Chart provides important information to include and evaluate when teaching patients about insulin. Basic information includes explanation of the equipment, insulins, syringes, and mixing insulin.
STORING INSULIN
Cloudy insulins should be thoroughly mixed by
gently inverting the vial or rolling it between the hands before drawing the
solution into a syringe or a pen. Whether insulin is the short- or long-acting
preparation, the vials not in use should be refrigerated and extremes of
temperature should be avoided; insulin should not be allowed to freeze and
should not be kept in direct sunlight or in a hot car. The insulin vial in use
should be kept at room temperature to reduce local irritation at the injection
site, which may occur when cold insulin is injected. If a vial of insulin will
be used up in 1 month, it may be kept at room temperature. Patients should be
instructed to always have a spare vial of the type or types of insulin they use
(
SELECTING SYRINGES
Syringes must be matched with the insulin concentration (eg, U-100). Currently, three sizes of U-100 insulin syringes are available:
• 1-mL (cc) syringes that hold 100 units
• 0.5-mL syringes that hold 50 units
• 0.3-mL syringes that hold 30 units
The concentration of insulin used in the
PREPARING THE INJECTION: MIXING INSULINS
When rapid- or short-acting insulins are to be
given simultaneously with longer-acting insulins,
they are usually mixed together in the same syringe; the longer-acting insulins must be mixed thoroughly before use. There is some
question as to whether the two insulins are stable if
the mixture is kept in the syringe for more than 5 to 15 minutes. This may
depend on the ratio of the insulins as well as the
time between mixing and injecting. When regular insulin is mixed with
long-acting insulin, there is a binding reaction that slows the action of the
regular insulin. This may also occur to a greater degree when mixing regular
insulin with one of the Lente insulins.
Patients are advised to consult their health care provider for advice on this
matter. The most important issue is that patients be consistent in how they
prepare their insulin injections from day to day. While there are varying
opinions regarding which type of insulin (short- or longer-acting) should be
drawn up into the syringe first when they are going to be mixed, the
WITHDRAWING INSULIN
Most (if not all) of the printed materials available on insulin dose preparation instruct patients to inject air into the bottle of insulin equivalent to the number of units of insulin to be withdrawn. The rationale for this is to prevent the formation of a vacuum inside the bottle, which would make it difficult to withdraw the proper amount of insulin. Some nurses who specialize in diabetes report that some patients (who have been taking insulin for many years) have stopped injecting air before withdrawing the insulin. These patients found that the extra step was not necessary for accurately drawing up the insulin dose. Most patients find it easier to withdraw the insulin by eliminating the step and report no difficulty in preparing the proper insulin dose. Eliminating this step (or alternating it by, for instance, injecting a syringe full of air into the vial once per week) facilitates the teaching process for some patients learning to draw up insulin for the first time. Some patients become confused with the sequence of steps involved in injecting air into two separate bottles in two different amounts before drawing up a mixed dose. For many individuals, including elderly ones, simplifying the procedure for preparing insulin injections may help them maintain independence in daily living. As with other variations in insulin injection technique, the most important factors are that the patient maintain consistency in the procedure and that the nurse be flexible when teaching new patients or assessing the skills of experienced patients.
SELECTING AND ROTATING THE INJECTION SITE
The four main areas for injection are the abdomen, arms (posterior
surface), thighs (anterior surface), and hips (Fig. 41-7). Insulin is absorbed
faster in some areas of the body than others. The speed of absorption is
greatest in the abdomen and decreases progressively in the arm, thigh, and hip.
Systematic rotation of injection sites within an anatomic area is recommended
to prevent localized changes in fatty tissue (lipodystrophy).
In addition, to promote consistency in insulin absorption, patients should be
encouraged to use all available injection sites within one area rather than
randomly rotating sites from area to area (
PREPARING THE SKIN
Use of alcohol to cleanse the skin is not recommended, but patients who have learned this technique often continue to use it. They should be cautioned to allow the skin to dry after cleansing with alcohol. If the skin is not allowed to dry before the injection, the alcohol may be carried into the tissues, resulting in a localized reddened area.
INSERTING THE NEEDLE
There are varying approaches to inserting the needle for insulin injections. The correct technique is based on the need for the insulin to be injected into the subcutaneous tissue. Injection that is too deep (eg, intramuscular) or too shallow may affect the rate of absorption of the insulin. Aspiration (inserting the needle and then pulling back on the plunger to assess for blood being drawn into the syringe) is generally not recommended with self-injection of insulin. Many patients who have been using insulin for an extended period have eliminated this step from their insulin injection routine with no apparent adverse effects.
PROMOTING HOME AND COMMUNITY-BASED CARE
Teaching Patients Self-Care.
Adherence to the therapeutic plan is the most important goal of self-care the patient must master. Patients who are having difficulty adhering to the diabetes treatment plan must be approached with care and understanding. Using scare tactics (such as threats of blindness or amputation if the patient does not adhere to the treatment plan) or making the patient feel guilty is not productive and may interfere with establishing a trusting relationship with the patient. Judgmental actions, such as asking the patient if he or she has “cheated” on the diet, only promote feelings of guilt and low self-esteem. If problems exist with glucose control or with the development of preventable complications, it is important to distinguish among nonadherence, knowledge deficit, and self-care deficit. It should not be assumed that problems with diabetes management are related to nonadherence. The patient may simply have forgotten or never learned certain information. The problem may be correctable simply through providing complete information and ensuring that the patient comprehends the information. Chart 41-8 details how to evaluate the effectiveness of self-injection of insulin. If knowledge deficit is not the problem, certain physical or emotional factors may be impairing the patient’s ability to perform self-care skills. For example, decreased visual acuity may impair the patient’s ability to administer insulin accurately, measure the blood glucose level, or inspect the skin and feet. In addition, decreased joint mobility (especially in the elderly) impairs the ability to inspect the bottom of the feet. Emotional factors such as denial of the diagnosis or depression may impair the patient’s ability to carry out multiple daily self-care measures. In other circumstances, family, personal, or work problems may be of higher priority to the patient. The patient facing competing demands for time and attention may benefit from assistance in establishing priorities. It is also important to assess the patient for infection or emotional stress that may lead to elevated blood glucose levels despite adherence to the treatment regimen. The following approaches by the nurse are helpful for promoting self-care management skills:
• Address any underlying factors (eg, knowledge deficit, selfcare deficit, illness) that may affect diabetic control.
• Simplify the treatment regimen if it is too difficult for the patient to follow.
• Adjust the treatment regimen to meet patient requests (eg, adjust diet or insulin schedule to allow increased flexibility in meal content or timing).
• Establish a specific plan or contract with the patient with simple, measurable goals.
• Provide positive reinforcement of self-care behaviors performed instead of focusing on behaviors that were neglected (eg, positively reinforce blood glucose tests that were performed instead of focusing on the number of missed tests).
• Help the patient to identify personal motivating factors rather than focusing on wanting to please the doctor or nurse.
• Encourage the patient to pursue life goals and interests; discourage an undue focus on diabetes.
Continuing Care.
As discussed, continuing care of the patient with diabetes is critical in managing and preventing complications. The degree to which the client interacts with health care providers to obtain ongoing care depends on many factors. Age, socioeconomic level, existing complications, type of diabetes, and comorbid conditions all may dictate the frequency of follow-up visits. Many patients with diabetes may be seen by home health nurses for diabetic education, wound care, insulin preparation, or assistance with glucose monitoring. Even patients who achieve excellent glucose control and have no complications can expect to see their primary health care provider at least twice a year for ongoing evaluation. In addition to follow-up care with health professionals, participation in support groups is encouraged for those who have had diabetes for many years as well as those who are newly diagnosed. Such participation may assist the patient and family in coping with changes in lifestyle that occur with the onset of diabetes and with its complications. Those who participate in support groups often have an opportunity to share valuable information and experiences and to learn from others. Support groups provide an opportunity for discussion of strategies to deal with diabetes and its management and to clarify and verify information with the nurse or other health care professionals. Participation in support groups may help patients and their families to become more knowledgeable about diabetes and its management and may promote adherence to the management plan. Another very important role of the nurse is to remind the patient about the importance of participating in other health promotion activities and recommended health screening.
Acute Complications of Diabetes
There are three major acute complications of diabetes related to short-term imbalances in blood glucose levels: hypoglycemia, DKA, and HHNS, which is also called hyperglycemic hyperosmolar nonketotic coma or hyperglycemic hyperosmolar syndrome.
HYPOGLYCEMIA (INSULIN REACTIONS)
Hypoglycemia (abnormally low blood glucose level) occurs when the blood glucose falls to less than 50 to 60 mg/dL (2.7 to 3.3 mmol/L). It can be caused by too much insulin or oral hypoglycemic agents, too little food, or excessive physical activity. Hypoglycemia may occur at any time of the day or night. It often occurs before meals, especially if meals are delayed or snacks are omitted. For example, midmorning hypoglycemia may occur when the morning regular insulin is peaking, whereas hypoglycemia that occurs in the late afternoon coincides with the peak of the morning NPH or Lente insulin. Middle-of-the-night hypoglycemia may occur because of peaking evening or predinner NPH or Lente insulins, especially in patients who have not eaten a bedtime snack.
Clinical Manifestations
The clinical manifestations of hypoglycemia may be grouped into two categories: adrenergic symptoms and central nervous system (CNS) symptoms. In mild hypoglycemia, as the blood glucose level falls, the sympathetic nervous system is stimulated, resulting in a surge of epinephrine and norepinephrine. This causes symptoms such as sweating, tremor, tachycardia, palpitation, nervousness, and hunger. In moderate hypoglycemia, the fall in blood glucose level deprives the brain cells of needed fuel for functioning. Signs of impaired function of the CNS may include inability to concentrate, headache, lightheadedness, confusion, memory lapses, numbness of the lips and tongue, slurred speech, impaired coordination, emotional changes, irrational or combative behavior, double vision, and drowsiness. Any combination of these symptoms (in addition to adrenergic symptoms) may occur with moderate hypoglycemia. In severe hypoglycemia, CNS function is so impaired that the patient needs the assistance of another person for treatment of hypoglycemia. Symptoms may include disoriented behavior, seizures, difficulty arousing from sleep, or loss of consciousness
Assessment and Diagnostic Findings
Hypoglycemic symptoms can occur suddenly and unexpectedly. The combination of symptoms varies considerably from person to person. To some degree, this may be related to the actual level to which the blood glucose drops or to the rate at which it is dropping. For example, patients who usually have a blood glucose level in the hyperglycemic range (eg, in the 200s or greater) may feel hypoglycemic (adrenergic) symptoms when their blood glucose quickly drops to 120 mg/dL (6.6 mmol/L) or less. Conversely, patients who frequently have a glucose level in the low range of normal may be asymptomatic when the blood glucose slowly falls to less than 50 mg/dL (2.7 mmol/L). Another factor contributing to altered hypoglycemic symptoms is a decreased hormonal (adrenergic) response to hypoglycemia. This occurs in some patients who have had diabetes for many years. It may be related to one of the chronic diabetic complications, autonomic neuropathy (see the section in this chapter on hypoglycemic unawareness). As the blood glucose level falls, the normal surge in adrenalin does not occur. The patient does not feel the usual adrenergic symptoms, such as sweating and shakiness. The hypoglycemia may not be detected until moderate or severe CNS impairment occurs. These patients must perform SMBG on a frequent regular basis, especially before driving or engaging in other potentially dangerous activities.
Gerontologic Considerations In the elderly diabetic patient, hypoglycemia is a particular concern for many reasons:
• Elderly people frequently live alone and may not recognize the symptoms of hypoglycemia.
• With decreasing renal function, it takes longer for oral hypoglycemic agents to be excreted by the kidneys.
• Skipping meals may occur because of decreased appetite or financial limitations.
• Decreased visual acuity may lead to errors in insulin administration.
Management Immediate treatment must be given when hypoglycemia
occurs. The usual recommendation is for
• Three or four commercially prepared glucose tablets
• 4
to
• 6 to 10 Life Savers or other hard candies
• 2 to 3 teaspoons of sugar or honey
It is not necessary to add sugar to juice, even if it is labeled as unsweetened juice: the fruit sugar in juice contains enough carbohydrate to raise the blood glucose level. Adding table sugar to juice may cause a sharp increase in the blood glucose level, and the patient may experience hyperglycemia for hours after treatment. The blood glucose level should be retested in 15 minutes and retreated if it is less than 70 to 75 mg/dL (3.8 to 4 mmol/L). If the symptoms persist more than 10 to 15 minutes after initial treatment, the treatment is repeated even if blood glucose testing is not possible. Once the symptoms resolve, a snack containing protein and starch (eg, milk or cheese and crackers) is recommended unless the patient plans to eat a regular meal or snack within 30 to 60 minutes.
TEACHING PATIENTS
It is important for patients with diabetes, especially those receiving
insulin, to learn that they must carry some form of simple sugar with them at
all times (
INITIATING EMERGENCY MEASURES
For patients who are unconscious and cannot swallow, an injection of glucagon 1 mg can be administered either subcutaneously or intramuscularly. Glucagon is a hormone produced by the alpha cells of the pancreas that stimulates the liver to release glucose (through the breakdown of glycogen, the stored glucose). Injectable glucagon is packaged as a powder in 1-mg vials and must be mixed with a diluent before being injected. After injection of glucagon, it may take up to 20 minutes for the patient to regain consciousness. A concentrated source of carbohydrate followed by a snack should be given to the patient on awakening to pre vent recurrence of hypoglycemia (because the duration of the action of 1 mg of glucagon is brief [its onset is 8 to 10 minutes and its action lasts 12 to 27 minutes]) and to replenish liver stores of glucose. Some patients experience nausea after the administration of glucagon; if this occurs, the patient should be turned to the side to prevent aspiration. The patient should be instructed to notify the physician after severe hypoglycemia has occurred. Glucagon is sold by prescription only and should be part of the emergency supplies kept available by patients with diabetes who require insulin. Family members, neighbors, or coworkers should be instructed in the use of glucagon. This is especially true for patients who receive little or no warning of hypoglycemic episodes. In the hospital or emergency department, patients who are unconscious or cannot swallow may be treated with 25 to 50 mL 50% dextrose in water (D50W) administered intravenously. The effect is usually seen within minutes. Patients may complain of a headache and of pain at the injection site. Assuring patency of the intravenous (IV) line used for injection of 50% dextrose is essential because hypertonic solutions such as 50% dextrose are very irritating to the vein.
PROMOTING HOME AND COMMUNITY-BASED CARE
Teaching Patients Self-Care.
Hypoglycemia is prevented by a consistent pattern of eating, administering insulin, and exercising. Between-meal and bedtime snacks may be needed to counteract the maximum insulin effect. In general, the patient should cover the time of peak activity of insulin by eating a snack and by taking additional food when physical activity is increased. Routine blood glucose tests are performed so that changing insulin requirements may be anticipated and the dosage adjusted. Because unexpected hypoglycemia may occur, all patients treated with insulin should wear an identification bracelet or tag stating that they have diabetes. Patients and family members must be instructed about the symptoms of hypoglycemia. Family members in particular must be made aware that any subtle (but unusual) change in behavior may be an indication of hypoglycemia. They should be taught to encourage and even insist that the person with diabetes assess blood glucose levels if hypoglycemia is suspected. Some patients (when hypoglycemic) become very resistant to testing or eating and become angry at family members trying to treat the hypoglycemia. Family members must be taught to persevere and to understand that the hypoglycemia can cause irrational behavior. Some patients with autonomic neuropathy or those taking beta blockers such as propranolol to treat hypertension or cardiac dysrhythmias may not experience the typical symptoms of hypoglycemia. It is very important for these patients to perform blood glucose tests on a frequent and regular basis. Patients who have type 2 diabetes and who take oral sulfonylurea agents may also develop hypoglycemia (especially those taking chlorpropamide, a long-lasting oral hypoglycemic agent).
DIABETIC KETOACIDOSIS
DKA is caused by an absence or markedly inadequate amount of insulin. This deficit in available insulin results in disorders in the metabolism of carbohydrate, protein, and fat. The three main clinical features of DKA are:
• Hyperglycemia
• Dehydration and electrolyte loss
• Acidosis
Pathophysiology
Without insulin, the amount of glucose entering the cells is reduced and
the liver increases glucose production. Both factors lead to hyperglycemia. In an attempt to rid the body of the excess
glucose, the kidneys excrete the glucose along with water and electrolytes (eg, sodium and potassium). This osmotic diuresis,
which is characterized by excessive urination (polyuria),
leads to dehydration and marked electrolyte loss. Patients with severe DKA may
lose up to
Clinical Manifestations
The signs and symptoms of DKA are listed in Figure. The hyperglycemia of DKA leads to polyuria
and polydipsia (increased thirst). In addition,
patients may experience blurred vision, weakness, and headache. Patients with
marked intravascular volume depletion may have orthostatic hypotension (drop in
systolic blood pressure of
Assessment and Diagnostic Findings
Blood glucose levels may vary from 300 to 800 mg/dL
(16.6 to 44.4 mmol/L). Some patients have lower
glucose values, and others have values of 1,000 mg/dL
(55.5 mmol/L) or more (usually depending on the
degree of dehydration). The severity of DKA is not necessarily related to the
blood glucose level. Some patients may have severe acidosis with modestly
elevated blood glucose levels, whereas others may have no evidence of DKA
despite blood glucose levels of 400 to 500 mg/dL
(22.2 to 27.7 mmol/L) (Quinn, 2001c). Evidence of ketoacidosis is reflected in low serum bicarbonate (0 to 15
mEq/L) and low pH (6.8 to 7.3) values. A low PCO2
level (10 to
Prevention
For prevention of DKA related to illness, patients must be taught “sick day” rules for managing their diabetes when ill (Chart 41-9). The most important issue to teach patients is not to eliminate insulin doses when nausea and vomiting occur. Rather, they should take their usual insulin dose (or previously prescribed special “sick day” doses) and then attempt to consume frequent small portions of carbohydrates (including foods usually avoided, such as juices, regular sodas, and gelatin). Drinking fluids every hour is important to prevent dehydration. Blood glucose and urine ketones must be assessed every 3 to 4 hours. If the patient cannot take fluids without vomiting, or if elevated glucose or ketone levels persist, the physician must be contacted. Patients are taught to have available foods for use on sick days. In addition, a supply of urine test strips (for ketone testing) and blood glucose test strips should be available. Patients must know how to contact their physician 24 hours a day. Diabetes self-management skills (including insulin administration and blood glucose testing) should be assessed to ensure that an error in insulin administration or blood glucose testing did not occur. Psychological counseling is recommended for patients and family members if an intentional alteration in insulin dosing was the cause of the DKA.
Medical Management
In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis (Quinn, 2001).
REHYDRATION
In dehydrated patients, rehydration is
important for maintaining tissue perfusion. In addition, fluid replacement
enhances the excretion of excessive glucose by the kidneys. Patients may need
up to 6 to
RESTORING ELECTROLYTES
The major electrolyte of concern during treatment of DKA is potassium. Although the initial plasma concentration of potassium may be low, normal, or even high, there is a major loss of potassium from body stores and an intracellular to extracellular shift of potassium. Further, the serum level of potassium drops during the course of treatment of DKA as potassium re-enters the cells; therefore, it must be monitored frequently. Some of the factors related to treating DKA that reduce the serum potassium concentration include:
• Rehydration, which leads to increased plasma volume and subsequent decreases in the concentration of serum potassium. Rehydration also leads to increased urinary excretion of potassium.
• Insulin administration, which enhances the movement of potassium from the extracellular fluid into the cells.
Cautious but timely potassium replacement is vital to avoid dysrhythmias that may occur with hypokalemia. Up to 40 mEq per hour may be needed for several hours. Because extracellular potassium levels drop during DKA treatment, potassium must be infused even if the plasma potassium level is normal. Frequent (every 2 to 4 hours initially) electrocardiograms and laboratory measurements of potassium are necessary during the first 8 hours of treatment. Potassium replacement is withheld only if hyperkalemia is present or if the patient is not urinating.
REVERSING ACIDOSIS
Ketone bodies (acids) accumulate as a result of fat breakdown. The acidosis that occurs in DKA is reversed with insulin, which inhibits fat breakdown, thereby stopping acid buildup. Insulin is usually infused intravenously at a slow, continuous rate (eg, 5 units per hour). Hourly blood glucose values must be measured. IV fluid solutions with higher concentrations of glucose, such as normal saline (NS) solution (eg, D5NS or D50.45NS), are administered when blood glucose levels reach 250 to 300 mg/dL (13.8 to 16.6 mmol/L) to avoid too rapid a drop in the blood glucose level. Various IV mixtures of regular insulin may be used. The nurse must convert hourly rates of insulin infusion (frequently prescribed as “units per hour”) to IV drip rates. For example, if 100 units of regular insulin are mixed in 500 mL 0.9% NS, then 1 unit of insulin equals 5 mL. Thus, an initial insulin infusion rate of 5 units per hour would equal 25 mL per hour. The insulin is often infused separately from the rehydration solutions to allow frequent changes in the rate and content of rehydration solutions. Insulin must be infused continuously until subcutaneous administration of insulin resumes. Any interruption in administration may result in the reaccumulation of ketone bodies and worsening acidosis. Even if blood glucose levels are dropping to normal, the insulin drip must not be stopped; rather, the rate or concentration of the dextrose infusion should be increased. Blood glucose levels are usually corrected before the acidosis is corrected. Thus, IV insulin may be continued for 12 to 24 hours until the serum bicarbonate level improves (to at least 15 to 18 mEq/L) and until the patient can eat. In general, bicarbonate infusion to correct severe acidosis is avoided during treatment of DKA because it precipitates further, sudden (and potentially fatal) decreases in serum potassium levels. Continuous insulin infusion is usually sufficient for reversing DKA.
Nursing Management
Nursing care of the patient with DKA focuses on monitoring fluid and electrolyte status as well as blood glucose levels; administering fluids, insulin, and other medications; and preventing other complications such as fluid overload. Urine output is monitored to ensure adequate renal function before potassium is administered to prevent hyperkalemia. The electrocardiogram is monitored for dysrhythmias indicating abnormal potassium levels. Vital signs, arterial blood gases, and other clinical findings are recorded on a flow sheet. The nurse documents the patient’s laboratory values and the frequent changes in fluids and medications that are prescribed and monitors the patient’s responses. As DKA resolves and the potassium replacement rate is decreased, the nurse makes sure that: • There are no signs of hyperkalemia on the electrocardiogram (tall, peaked [or tented] T waves). • The laboratory values of potassium are normal or low. • The patient is urinating (ie, no renal shutdown). As the patient recovers, the nurse reassesses the factors that may have led to DKA and teaches the patient and family about strategies to prevent its recurrence (Quinn, 2001c). If indicated, the nurse initiates a referral for home care to ensure the patient’s continued recovery.
HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC SYNDROME
HHNS is a serious condition in which hyperosmolarity and hyperglycemia predominate, with alterations of the sensorium (sense of awareness). At the same time, ketosis is minimal or absent. The basic biochemical defect is lack of effective insulin (ie, insulin resistance). The patient’s persistent hyperglycemia causes osmotic diuresis, resulting in losses of water and electrolytes. To maintain osmotic equilibrium, water shifts from the intracellular fluid space to the extracellular fluid space. With glucosuria and dehydration, hypernatremia and increased osmolarity occur. Table 41-8 compares DKA and HHNS. This condition occurs most often in older people (ages 50 to 70) with no known history of diabetes or with mild type 2 diabetes. HHNS can be traced to a precipitating event such as an acute illness (eg, pneumonia or stroke), medications that exacerbate hyperglycemia (thiazides), or treatments, such as dialysis. The history includes days to weeks of polyuria with adequate fluid intake. What distinguishes HHNS from DKA is that ketosis and acidosis do not occur in HHNS partly because of differences in insulin levels. In DKA no insulin is present, and this promotes the breakdown of stored glucose, protein, and fat, which leads to the production of ketone bodies and ketoacidosis. In HHNS the insulin level is too low to prevent hyperglycemia (and subsequent osmotic diuresis), but it is high enough to prevent fat breakdown. Patients with HHNS do not have the ketosisrelated GI symptoms that lead them to seek medical attention. Instead, they may tolerate polyuria and polydipsia until neurologic changes or an underlying illness (or family members or others) prompts them to seek treatment. Because of possible delays in therapy, hyperglycemia, dehydration, and hyperosmolarity may be more severe in HHNS (Quinn, 2001).
Clinical Manifestations
The clinical picture of HHNS is one of hypotension, profound dehydration (dry mucous membranes, poor skin turgor), tachycardia, and variable neurologic signs (eg, alteration of sensorium, seizures, hemiparesis). The mortality rate ranges from 10% to 40%, usually related to an underlying illness.
Assessment and Diagnostic Findings
Diagnostic assessment includes a range of laboratory tests, including
blood glucose, electrolytes, BUN, complete blood count, serum osmolality, and arterial blood gas analysis. The blood
glucose level is usually 600 to 1,200 mg/dL, and the osmolality exceeds 350 mOsm/kg.
Electrolyte and BUN levels are consistent with the clinical picture of severe
dehydration. Mental status changes, focal neurologic
deficits, and hallucinations are common secondary to the cerebral dehydration
that results from extreme hyperosmolality. Postural
hypotension accompanies the dehydration (
Medical Management
The overall approach to the treatment of HHNS is similar to that of DKA:
fluid replacement, correction of electrolyte imbalances, and insulin
administration. Because of the older age of the typical patient with HHNS,
close monitoring of volume and electrolyte status is important for prevention
of fluid overload, heart failure, and cardiac dysrhythmias.
Fluid treatment is started with 0.9% or 0.45% NS, depending on the patient’s
sodium level and the severity of volume depletion. Central venous or arterial
pressure monitoring guides fluid replacement. Potassium is added to IV fluids
when urinary output is adequate and is guided by continuous electrocardiographic
monitoring and frequent laboratory determinations of potassium. Extremely
elevated blood glucose levels drop as the patient is rehydrated.
Insulin plays a less important role in the treatment of HHNS because it is not
needed for reversal of acidosis, as in DKA. Nonetheless, insulin is usually
administered at a continuous low rate to treat hyperglycemia,
and replacement IV fluids with dextrose are administered (as in DKA) when the
glucose level is decreased to the range of 250 to 300 mg/dL
(13.8 to 16.6 mmol/L) (
Nursing Management
Nursing care of the patient with HHNS includes close monitoring of vital signs, fluid status, and laboratory values. In addition, strategies are implemented to maintain safety and prevent injury related to changes in the patient’s sensorium secondary to HHNS. Fluid status and urine output are closely monitored because of the high risk for renal failure secondary to severe dehydration. In addition, the nurse must direct nursing care to the condition that may have precipitated the onset of HHNS. Because HHNS tends to occur in older patients, the physiologic changes that occur with aging make careful assessment of cardiovascular, pulmonary, and renal function important throughout the acute and recovery phases of HHNS (Quinn, 2001c).
NURSING PROCESS: THE PATIENT NEWLY DIAGNOSED WITH DIABETES MELLITUS
Assessment
The history and physical assessment focus on the signs and symptoms of prolonged hyperglycemia and on physical, social, and emotional factors that may affect the patient’s ability to learn and perform diabetes self-care activities. The patient is asked to describe symptoms that preceded the diagnosis of diabetes, such as polyuria, polydipsia, polyphagia, skin dryness, blurred vision, weight loss, vaginal itching, and nonhealing ulcers. The blood glucose and, for patients with type 1 diabetes, urine ketone levels are measured. Patients with type 1 diabetes are assessed for signs of DKA, including ketonuria, Kussmaul respirations, orthostatic hypotension, and lethargy. The patient is questioned about symptoms of DKA, such as nausea, vomiting, and abdominal pain. Laboratory values are monitored for metabolic acidosis (ie, decreased pH and decreased bicarbonate level) and for electrolyte imbalance. Patients with type 2 diabetes are assessed for signs of HHNS, including hypotension, altered sensorium, seizures, and decreased skin turgor. Laboratory values are monitored for hyperosmolality and electrolyte imbalance. If the patient exhibits signs and symptoms of DKA or HHNS, nursing care first focuses on treatment of these acute complications, as outlined in previous sections. Once these complications are resolving, nursing care then focuses on long-term management of diabetes, as discussed in this section. Then the patient is assessed for physical factors that may impair his or her ability to learn or perform self-care skills, such as:
• Visual deficits (the patient is asked to read numbers or words on the insulin syringe, menu, newspaper, or written teaching materials)
• Deficits in motor coordination (the patient is observed eating or performing other tasks or handling a syringe or fingerlancing device)
• Neurologic deficits (eg, due to stroke, other neurologic disorders; other disabling conditions) (from history in chart; the patient is assessed for aphasia or decreased ability to follow simple commands)
The nurse evaluates the patient’s social situation for factors that may influence the diabetes treatment and education plan, such as:
• Low literacy level (may be evaluated while assessing for visual deficits by having the patient read from teaching materials)
• Limited financial resources or lack of health insurance
• Presence or absence of family support
• Typical daily schedule (patient is asked about timing and number of usual daily meals, work and exercise schedule, plans for travel)
The patient’s emotional status is assessed by observing general demeanor (eg, withdrawn, anxious) and body language (eg, avoids eye contact). The patient is asked about major concerns and fears about diabetes; this allows the nurse to assess for any misconceptions or misinformation regarding diabetes. Coping skills are assessed by asking how the patient has dealt with difficult situations in the past.
Diagnosis
NURSING DIAGNOSES
Based on the assessment data, the patient’s major nursing diagnoses may include the following:
• Risk for fluid volume deficit related to polyuria and dehydration
• Imbalanced nutrition related to imbalance of insulin, food, and physical activity
• Deficient knowledge about diabetes self-care skills/information
• Potential self-care deficit related to physical impairments or social factors
•Anxiety related to loss of control, fear of inability to manage diabetes, misinformation related to diabetes, fear of diabetes complications
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS
Based on assessment data, potential complications may include:
• Fluid overload, pulmonary edema, heart failure
•Hypokalemia
• Hyperglycemia and ketoacidosis
• Hypoglycemia
• Cerebral edema
Planning and Goals
The major goals for the patient may include maintenance of fluid and electrolyte balance, optimal control of blood glucose levels, reversal of weight loss, ability to perform survival diabetes skills and self-care activities, decreased anxiety, and absence of complications.
Nursing Interventions
MAINTAINING FLUID AND ELECTROLYTE BALANCE
Intake and output are measured. IV fluids and electrolytes are administered as prescribed, and oral fluid intake is encouraged when it is permitted. Laboratory values of serum electrolytes (especially sodium and potassium) are monitored. Vital signs are monitored for signs of dehydration (tachycardia, orthostatic hypotension).
IMPROVING NUTRITIONAL INTAKE
The diet is planned with the control of glucose as the primary goal. It must take into consideration the patient’s lifestyle, cultural background, activity level, and food preferences. An appropriate caloric intake allows the patient to achieve and maintain the desired body weight. The patient is encouraged to eat full meals and snacks as prescribed per the diabetic diet. Arrangements are made with the dietitian for extra snacks before increased physical activity. It is important for the nurse to ensure that insulin orders are altered as needed for delays in eating because of diagnostic and other procedures.
REDUCING ANXIETY
The nurse provides emotional support and sets aside time to talk with the patient who wishes to express feelings, cry, or ask questions about this new diagnosis. Any misconceptions the patient or family may have regarding diabetes are dispelled (see Table 41-7). The patient and family are assisted to focus on learning self-care behaviors. The patient is encouraged to perform the skills that are feared most and must be reassured that once a skill such as selfinjection or lancing a finger for glucose monitoring is performed for the first time, anxiety will decrease. Positive reinforcement is given for the self-care behaviors attempted, even if the technique is not yet completely mastered.
IMPROVING SELF-CARE
Patient teaching (discussed earlier in the Nursing Management section
and below) is the major strategy used to prepare the patient for self-care.
Special equipment may be needed for instruction on diabetes survival skills,
such as a magnifying glass for insulin preparation or an injection-aid device
for insulin injection. Low-literacy information and literature in other
languages can be obtained from the
MONITORING AND MANAGING POTENTIAL COMPLICATIONS
Fluid Overload
Fluid overload can occur because of the administration of a large volume of fluid at a rapid rate that is often required to treat the patient with DKA or HHNS. This risk is increased in elderly patients and in those with preexisting cardiac disease. To avoid fluid overload and resulting congestive heart failure and pulmonary edema, the nurse monitors the patient closely during treatment by measuring vital signs at frequent intervals. Central venous pressure monitoring and hemodynamic monitoring may be initiated to provide additional measures of the fluid status. Physical examination focuses on assessment of cardiac rate and rhythm, breath sounds, venous distention, skin turgor, and urine output. The nurse monitors fluid intake and keeps careful records of IV and other fluid intake, along with urine output measurements.
Hypokalemia
As previously described, hypokalemia is a potential complication during the treatment of DKA as potassium is lost from body stores. Low serum potassium levels may result from rehydration, increased urinary excretion of potassium, and movement of potassium from the extracellular fluid into the cells with insulin administration. Prevention of hypokalemia includes cautious replacement of potassium; before its administration, however, it is important to ensure that the patient’s kidneys are functioning. Because of the adverse effects of hypokalemia on cardiac function, monitoring of the cardiac rate, cardiac rhythm, electrocardiogram, and serum potassium levels is essential.
Hyperglycemia and Ketoacidosis
Although the hyperglycemia and ketoacidosis that may have led to the new diagnosis of diabetes may be resolved, the patient is at risk for their subsequent recurrence. Therefore, blood glucose levels and urine ketones are monitored, and medications (insulin, oral antidiabetic agents) are administered as prescribed. The patient is monitored for signs and symptoms of impending hyperglycemia and ketoacidosis; if they occur, insulin and IV fluids are administered.
Hypoglycemia
Hypoglycemia may occur if the patient skips or delays meals or does not follow the prescribed diet or greatly increases the amount of exercise without modifying diet and insulin. Also, the hospitalized patient or outpatient who fasts in preparation for diagnostic testing is at risk for hypoglycemia. Juice or glucose tablets are used for treatment of hypoglycemia. The patient is encouraged to eat full meals and snacks as prescribed per the diabetic diet. If hypoglycemia is a recurrent problem, the total therapeutic regimen should be re-evaluated. Because of the risk of hypoglycemia, especially with intensive insulin regimens, it is important for the nurse to review with the patient its signs and symptoms, possible causes, and measures to prevent and treat it. The nurse stresses to the patient and family the importance of having information on diabetes at home for reference.
Cerebral Edema
Although the cause of cerebral edema is
unknown, it is thought to be caused by rapid correction of hyperglycemia,
resulting in fluid shifts. Cerebral edema can be
prevented by gradual reduction in the blood glucose level (
PROMOTING HOME AND COMMUNITY-BASED CARE
Teaching Patients Self-Care
The patient is taught survival skills, including simple pathophysiology; treatment modalities (insulin administration, monitoring of blood glucose, and, for type 1 diabetes, urine ketones, and diet); recognition, treatment, and prevention of acute complications (hypoglycemia and hyperglycemia); and practical information (where to obtain supplies, when to call the physician). If the patient has signs of long-term diabetes complications at the time of diagnosis of diabetes, teaching about appropriate preventive behaviors (eg, foot care or eye care) should be included at this time (Chart 41-10).
Continuing Care
Follow-up education is arranged with a home care nurse or an outpatient diabetes education center. This is particularly important for the patient who has had difficulty coping with the diagnosis, the patient who has limitations that may affect his or her ability to learn or to carry out the management plan, or the patient without any family or social supports. Referral to social services and community resources (eg, centers for the visually impaired) may be needed, depending on the patient’s financial circumstances and physical limitations. The importance of selfmonitoring and of monitoring and follow-up by primary health care providers is reinforced, and the patient is reminded about the importance of keeping follow-up appointments. The patient who is newly diagnosed with diabetes is also reminded about the importance of participating in other health promotion activities and health screening. Chart is a checklist of home care skills.
Evaluation
EXPECTED PATIENT OUTCOMES
Expected patient outcomes may include:
1. Achieves fluid and electrolyte balance a. Demonstrates intake and output balance b. Exhibits electrolyte values within normal limits c. Exhibits vital signs that remain stable with resolution of orthostatic hypotension and tachycardia
2. Achieves metabolic balance a. Avoids extremes of glucose levels (hypoglycemia or hyperglycemia) b. Demonstrates rapid resolution of hypoglycemic episodes c. Avoids further weight loss (if applicable) and begins to approach desired weight
3. Demonstrates/verbalizes diabetes survival skills a. Defines diabetes as a condition in which high blood glucose levels are present b. States normal and target blood glucose ranges c. Identifies factors that cause the blood glucose level to fall (insulin, exercise, some oral anti-diabetes medications) d. Identifies factors that cause the blood glucose level to rise (food, illness, stress, and infections) e. Describes the major treatment modalities: diet, exercise, monitoring, medication, education f. Demonstrates proper technique for drawing up and injecting insulin (including mixing two types of insulin if necessary) g. States dose and timing of injections, peak action, duration, and adverse effects of insulin h. Verbalizes plan for rotating insulin injection sites i. States dose, timing, peak action, and duration of prescribed oral agents j. Verbalizes understanding of food group classifications (depending on system used) k. Verbalizes appropriate schedule for eating snacks and meals; orders appropriate foods on menus; identifies foods that may be substituted for one another on the meal plan
4. Demonstrates proper technique for monitoring blood glucose, including
using finger-lancing device; obtaining a drop of blood; applying blood properly
to strip; obtaining value of blood glucose; and recording blood glucose value.
Also, is able to calibrate and clean meter, change batteries, identify alarms
and warnings on meter, and use control solutions to validate strips. m.
Demonstrates proper technique for disposing of lancets and needles used for
blood glucose monitoring and insulin injections (discarding them into hard
plastic container such as empty bleach or detergent container or medical waste
containers) n. Demonstrates proper technique for urine ketone
testing (for patients with type 1 diabetes) and verbalizes appropriate times to
assess for ketones (when ill or when blood glucose
test results are repeatedly and inexplicably more than 250 to 300 mg/dL [13.8 to 16.6 mmol/L]) o.
Identifies community, outpatient resources for obtaining further diabetes
education p. Identifies acute complications (hypoglycemia
and hyperglycemia) q. Verbalizes symptoms of hypoglycemia (shakiness, sweating, headache, hunger,
numbness or tingling of lips or fingers, weakness, fatigue, difficulty
concentrating, change of mood) and dangers of untreated hypoglycemia
(seizures and coma) r. Identifies appropriate treatment of hypoglycemia,
including
Long-Term Complications of Diabetes
There has been a steady decline in the number of deaths of diabetic patients attributable to ketoacidosis and infection, but an alarming rise in the number of deaths from cardiovascular and renal complications. Long-term complications are becoming more common as more people live longer with diabetes. The long-term complications of diabetes can affect almost every organ system of the body. The general categories of chronic diabetic complications are macrovascular disease, microvascular disease, and neuropathy. The specific causes and pathogenesis of each type of complication are still being investigated. It appears, however, that increased levels of blood glucose may play a role in neuropathic disease, microvascular complications, and risk factors contributing to macrovascular complications. Hypertension may also be a major contributing factor, especially in macrovascular and microvascular diseases. Long-term complications are seen in both type 1 and type 2 diabetes but usually do not occur within the first 5 to 10 years of the diagnosis. However, evidence of these complications may be present at the time of diagnosis of type 2 diabetes, as the patient may have had undiagnosed diabetes for many years. Renal (microvascular) disease is more prevalent among patients with type 1 diabetes, and cardiovascular (macrovascular) complications are more prevalent among older patients with type 2 diabetes.
MACROVASCULAR COMPLICATIONS
Diabetic macrovascular complications result from changes in the medium to large blood vessels. Blood vessel walls thicken, sclerose, and become occluded by plaque that adheres to the vessel walls. Eventually, blood flow is blocked. These atherosclerotic changes are indistinguishable from atherosclerotic changes in people without diabetes, but they tend to occur more often and at an earlier age in diabetes. Coronary artery disease, cerebrovascular disease, and peripheral vascular disease are the three main types of macrovascular complications that occur more frequently in the diabetic population. Myocardial infarction is twice as common in diabetic men and three times as common in diabetic women. There is also an increased risk for complications resulting from myocardial infarction and an increased likelihood of a second myocardial infarction. Coronary artery disease may account for 50% to 60% of all deaths in patients with diabetes. One unique feature of coronary artery disease in patients with diabetes is that the typical ischemic symptoms may be absent. Thus, patients may not experience the early warning signs of decreased coronary blood flow and may have “silent” myocardial infarctions. These silent myocardial infarctions may be discovered only as changes on the electrocardiogram. This lack of ischemic symptoms may be secondary to autonomic neuropathy (see below). Cerebral blood vessels are similarly affected by accelerated atherosclerosis. Occlusive changes or the formation of an embolus elsewhere in the vasculature that lodges in a cerebral blood vessel can lead to transient ischemic attacks and strokes. People with diabetes have twice the risk of developing cerebrovascular disease, and studies suggest there may be a greater likelihood of death from cerebrovascular disease in patients with diabetes. In addition, recovery from a stroke may be impaired in patients who have elevated blood glucose levels at the time of and immediately after a stroke. Because symptoms of cerebrovascular disease may be similar to symptoms of acute diabetic complications (HHNS or hypoglycemia), it is very important to rapidly assess the blood glucose level (and treat abnormal levels) in patients reporting these symptoms so that testing and treatment of cerebrovascular disease (stroke) can be initiated if indicated. Atherosclerotic changes in the large blood vessels of the lower extremities are responsible for the increased incidence (two to three times higher than in nondiabetic people) of occlusive peripheral arterial disease in patients with diabetes. Signs and symptoms of peripheral vascular disease include diminished peripheral pulses and intermittent claudication (pain in the buttock, thigh, or calf during walking). The severe form of arterial occlusive disease in the lower extremities is largely responsible for the increased incidence of gangrene and subsequent amputation in diabetic patients. Neuropathy and impairments in wound healing also play a role in diabetic foot disease (see below).
Role of Diabetes in Macrovascular Diseases
Diabetes researchers continue to investigate the relation between diabetes and macrovascular diseases. The main feature unique to diabetes is an elevated blood glucose level; however, a direct link has not been found between hyperglycemia and atherosclerosis. Although it may be tempting to attribute the increased prevalence of macrovascular diseases to the increased prevalence of certain risk factors (eg, obesity, increased triglyceride levels, hypertension) among patients with diabetes, there is a higher-thanexpected rate of macrovascular diseases among patients with diabetes when compared with nondiabetic patients with the same risk factors (ADA, Management of Dyslipidemia in Adults With Diabetes, 2003). Thus, diabetes itself is seen as an independent risk factor for the development of accelerated atherosclerosis. Other potential factors that may play a role in diabetes-related atherosclerosis include platelet and clotting factor abnormalities, decreased flexibility of red blood cells, decreased oxygen release, changes in the arterial wall related to hyperglycemia, and possibly hyperinsulinemia.
Management
Management of macrovascular complications involves prevention and treatment of the commonly accepted risk factors for atherosclerosis. Diet and exercise are important in managing obesity, hypertension, and hyperlipidemia. In addition, the use of medications to control hypertension and hyperlipidemia may be indicated. Smoking cessation is essential. Control of blood glucose levels may reduce triglyceride levels and can significantly reduce the incidence of complications. When macrovascular complications do occur, treatment is the same as with nondiabetic patients. In addition, patients may require increased amounts of insulin or may need to switch from oral antidiabetic agents to insulin during illnesses.
MICROVASCULAR COMPLICATIONS AND DIABETIC RETINOPATHY
Although macrovascular atherosclerotic changes
are seen in both diabetic and nondiabetic patients,
the microvascular changes are unique to diabetes.
Diabetic microvascular disease (or microangiopathy) is characterized by capillary basement
membrane thickening. The basement membrane surrounds the endothelial cells of
the capillary. Researchers believe that increased blood glucose levels react
through a series of biochemical responses to thicken the basement membrane to
several times its normal thickness. Two areas affected by these changes are the
retina and the kidneys. Diabetic retinopathy is the leading cause of blindness
in people between 20 and 74 years of age in the
Clinical Manifestations
Retinopathy is a painless process. In nonproliferative and preproliferative retinopathy, blurry vision secondary to macular edema occurs in some patients, although many patients are asymptomatic. Even patients with a significant degree of proliferative retinopathy and some hemorrhaging may not experience major visual changes. However, symptoms indicative of hemorrhaging include floaters or cobwebs in the visual field, or sudden visual changes including spotty or hazy vision, or complete loss of vision.
Assessment and Diagnostic Findings
Diagnosis is by direct visualization with an ophthalmoscope or with a technique known as fluorescein angiography. Fluorescein angiography can document the type and activity of the retinopathy. Dye is injected into an arm vein and is carried to various parts of the body through the blood, but especially through the vessels of the retina of the eye. This technique allows the ophthalmologist, using special instruments, to see the retinal vessels in bright detail and gives useful information that cannot be obtained with just an ophthalmoscope. Side effects of this diagnostic procedure may include nausea during the dye injection; yellowish, fluorescent discoloration of the skin and urine lasting 12 to 24 hours; and occasional allergic reactions, usually manifested by hives or itching. Generally, however, it is a safe diagnostic procedure. Patient preparation includes explaining:
• The steps of the procedure
• The fact that the procedure is painless
• The potential side effects
• The type of information the technique can provide
• That the flash of the camera may be slightly uncomfortable for a short time
Medical Management
The first focus of management is on primary and secondary prevention.
The results of the DCCT study demonstrated that maintenance of blood glucose to
a normal or near-normal level in type 1 diabetes through intensive insulin
therapy and patient education decreased the risk for development of retinopathy
by 76% when compared with conventional therapy in patients without preexisting retinopathy. The progression of retinopathy was
decreased by 54% in patients with very mild to moderate nonproliferative
retinopathy at the time of initiation of treatment. Similarly, the UKPDS study
demonstrated a reduced risk of retinopathy in type 2 diabetes with better
control of blood glucose levels (
• Control of hypertension
• Control of blood glucose
• Cessation of smoking
Nursing Management
Nursing management of patients with diabetic retinopathy or other eye disorders involves implementing the individual plan of care and providing patient education. Education focuses on prevention through regular ophthalmologic examinations and blood glucose control and self-management of eye care regimens. The effectiveness of early diagnosis and prompt treatment is emphasized in teaching the patient and family. If vision loss occurs, nursing care must also address the patient’s adjustment to impaired vision and use of adaptive devices for diabetes self-care as well as activities of daily living. Nursing care for the patient with low vision or loss of vision is discussed in detail in Chapter.
PROMOTING HOME AND COMMUNITY-BASED CARE
Teaching Patients Self-Care.
In all forms of therapy for retinopathy, something is destroyed in the process of saving vision, and the facts must be presented to the patient and family as honestly as possible. The course of the retinopathy may be long and stressful. In teaching and counseling the patient, it is important to stress the following:
• Retinopathy may appear after many years of diabetes, and its appearance does not necessarily mean that the diabetes is on a downhill course.
• The odds for maintaining vision are in the patient’s favor, especially with adequate control of glucose levels and blood pressure.
• Frequent eye examinations are the best way to preserve vision, because they allow for the detection of any retinopathy. Some additional points to keep in mind when the patient with diabetes has some type of visual impairment include the following:
• Visual impairment can be a shock. The person’s response to vision loss depends on personality, self-concept, and coping mechanisms.
• As in any loss, acceptance of blindness by the patient occurs in stages; some patients may learn to accept blindness in a rather short period, and others may never do so.
• Although retinopathy occurs bilaterally, the severity may differ in the two eyes.
• Many of the chronic complications of diabetes occur simultaneously. For example, a patient who is blind due to diabetic retinopathy may also have peripheral neuropathy and may experience impairment of manual dexterity and tactile sensation.
Continuing Care.
Continuing care for the patient with impaired vision due to diabetic changes depends on the severity of the impairment and the effectiveness of the patient’s coping in response to the impairment. The importance of careful diabetes management is emphasized as one means of slowing the progression of visual changes. The patient is reminded of the need to see the ophthalmologist regularly. If eye changes are progressive and unrelenting, the patient needs to be prepared for inevitable blindness. Therefore, consideration is given to making referrals for teaching the patient Braille and for training with a guide dog. Referral to state agencies should be made to ensure that the patient receives services for the blind. Family members are also taught how to assist the patient to remain as independent as possible despite decreasing visual acuity. Referral for home care may be indicated for some patients, particularly those who live alone, those not coping well, and those who have other health problems or complications of diabetes that may interfere with their ability to perform self-care. During home visits, the nurse can assess the patient’s home environment and ability to manage diabetes despite visual impairments. Medical management and nursing care of patients with visual disturbances are discussed in detail in Chapter 58.
NEPHROPATHY
Nephropathy, or renal disease secondary to diabetic microvascular
changes in the kidney, is a common complication of diabetes. People with
diabetes account for nearly half of new cases of endstage
renal disease (ESRD) each year and about a quarter of those requiring dialysis
or transplantation each year in the
Clinical Manifestations
Most of the signs and symptoms of renal dysfunction in the patient with diabetes are similar to those seen in patients without diabetes. Also, as renal failure progresses, the catabolism (breakdown) of both exogenous and endogenous insulin decreases, and frequent hypoglycemic episodes may result. Insulin needs change as a result of changes in the catabolism of insulin, and also as a result of changes in diet related to the treatment of nephropathy. The stress of renal disease affects self-esteem, family relationships, marital relations, and virtually all aspects of daily life. As renal function decreases, the patient commonly has multiple-system failure (eg, declining visual acuity, impotence, foot ulcerations, heart failure, and nocturnal diarrhea).
Assessment and Diagnostic Findings
One of the most important blood proteins that leaks into the urine is albumin. Small amounts may leak undetected for years. Of patients with microalbuminuria, clinical nephropathy eventually develops in more than 85%. However, if microalbuminuria is not present, nephropathy develops in fewer than 5%. Early microalbuminuria may also be discovered in a 24-hour urine sample. The urine should be checked annually for microalbuminuria. If the microalbuminuria level exceeds 30 mg/24 hours on two consecutive tests, treatment is indicated (see Medical Management section below). When a urine dipstick test reads consistently positive for significant amounts of albumin, serum creatinine and BUN levels are obtained. At this point in the development of renal disease, diagnostic testing for cardiac or other systemic problems may also be required. Some of the tests involve injection of special dyes that are not easily cleared by the damaged kidney, so the value of the diagnostic test must be weighed against the potential risks. Hypertension often develops in patients (both diabetic and nondiabetic) who are in the early stages of renal disease. However, essential hypertension occurs in up to 50% of all individuals with diabetes (for unknown reasons). Thus, it should not be assumed that someone with diabetes who has hypertension also has renal disease; other diagnostic criteria must also be present.
Medical Management
In addition to achieving and maintaining near-normal blood glucose levels, management for all patients with diabetes should include careful attention to the following: • Control of hypertension (the use of angiotensin-converting enzyme [ACE] inhibitors, such as captopril, because control of hypertension may also decrease or delay the onset of early proteinuria)
• Prevention or vigorous treatment of urinary tract infections
• Avoidance of nephrotoxic substances
• Adjustment of medications as renal function changes
• Low-sodium diet
• Low-protein diet
If the patient has already developed microalbuminuria
and its level exceeds 30 mg/24 hours on two consecutive tests, an ACE inhibitor
should be prescribed. ACE inhibitors lower blood pressure and reduce microalbuminuria and therefore protect the kidney.
Alternatively, angiotensin-receptor blocking (ARB)
agents may be prescribed. This preventive strategy should be part of the
standard of care for the person with diabetes. Carefully designed low-protein diets
also appear to reverse early leakage of small amounts of protein from the
kidney (
DIABETIC NEUROPATHIES
Diabetic neuropathy refers to a group of diseases that affect all types of nerves, including peripheral (sensorimotor), autonomic, and spinal nerves. The disorders appear to be clinically diverse and depend on the location of the affected nerve cells. The prevalence increases with the age of the patient and the duration of the disease and may be as high as 50% in patients who have had diabetes for 25 years. Elevated blood glucose levels over a period of years have been implicated in the etiology of neuropathy. The pathogenesis of neuropathy may be attributed to either a vascular or a metabolic mechanism or both, but their relative contributions have yet to be determined. Capillary basement membrane thickening and capillary closure may be present. In addition, there may be demyelinization of the nerves, which is thought to be related to hyperglycemia. Nerve conduction is disrupted when there are aberrations of the myelin sheaths. Control of blood glucose levels to normal or near-normal levels was shown in the DCCT study to decrease the incidence of neuropathy by 60%. The two most common types of diabetic neuropathy are sensorimotor polyneuropathy and autonomic neuropathy. Cranial mononeuropathies, for example, those affecting the oculomotor nerve, also occur in diabetes, especially among the elderly. Sensorimotor polyneuropathy is a diabetic neuropathy also called peripheral neuropathy. It most commonly affects the distal portions of the nerves, especially the nerves of the lower extremities. It affects both sides of the body symmetrically and may spread in a proximal direction.
Peripheral Neuropathy
CLINICAL MANIFESTATIONS
Initial symptoms include paresthesias (prickling, tingling, or heightened sensation) and burning sensations (especially at night). As the neuropathy progresses, the feet become numb. In addition, a decrease in proprioception (awareness of posture and movement of the body and of position and weight of objects in relation to the body) and a decreased sensation of light touch may lead to an unsteady gait. Decreased sensations of pain and temperature place patients with neuropathy at increased risk for injury and undetected foot infections. Deformities of the foot may also occur, with neuropathy-related joint changes producing Charcot joints. These joint deformities result from the abnormal weight distribution on joints due to lack of proprioception. On physical examination, a decrease in deep tendon reflexes and vibratory sensation is found. For patients who have few or no symptoms of neuropathy, these physical findings may be the only indication of neuropathic changes. For patients with signs or symptoms of neuropathy, it is important to rule out other possible neuropathies, including alcohol-induced or vitamin-deficiency neuropathies.
MANAGEMENT
The results of the DCCT study demonstrate that intensive insulin therapy and control of blood glucose levels delay the onset and slow the progression of neuropathy. Pain, particularly of the lower extremities, is a disturbing symptom in some people with neuropathy secondary to diabetes. For some patients, neuropathic pain spontaneously resolves within 6 months. For other patients, pain persists for many years. Various approaches to pain management can be tried. These include analgesics (preferably nonopioid); tricyclic antidepressants; phenytoin, carbamazepine, or gabapentin (antiseizure medications); mexiletine (an antiarrhythmic); or transcutaneous electrical nerve stimulation (TENS). The use of aldose reductase inhibitors is under study to determine whether they block the damaging effects of hyperglycemia. The topical medication capsaicin (Axscain) also has been shown in preliminary reports to decrease lower-extremity neuropathic pain. Studies of the role of this topical medication in neuropathy continue.
Autonomic Neuropathies
Neuropathy of the autonomic nervous system results in a broad range of dysfunctions affecting almost every organ system of the body. Three manifestations of autonomic neuropathy are related to the cardiac, GI, and renal systems Cardiovascular symptoms range from fixed, slightly tachycardic heart rate; orthostatic hypotension; and silent, or painless, myocardial ischemia and infarction. Delayed gastric emptying may occur with the typical symptoms of early satiety, bloating, nausea, and vomiting. In addition, there may be unexplained wide swings in blood glucose levels related to inconsistent absorption of the glucose from ingested foods secondary to the inconsistent gastric emptying. “Diabetic” constipation or diarrhea (especially nocturnal diarrhea) may occur as a result. Urinary retention, a decreased sensation of bladder fullness, and other urinary symptoms of neurogenic bladder result from autonomic neuropathy. Patients with a neurogenic bladder are predisposed to developing urinary tract infections due to inability to completely empty the bladder. This is especially true in patients with poorly controlled diabetes, because hyperglycemia impairs resistance to infection
HYPOGLYCEMIC UNAWARENESS
Autonomic neuropathy of the adrenal medulla is responsible for diminished or absent adrenergic symptoms of hypoglycemia. Patients may report that they no longer feel the typical shakiness, sweating, nervousness, and palpitations associated with hypoglycemia. Strict blood glucose monitoring, including frequent SMBG, is recommended for these patients. Their inability to detect and treat these warning signs of hypoglycemia puts them at risk for developing dangerously low blood glucose levels. Therefore, their goals for blood glucose levels may need to be adjusted to reduce the risk for hypoglycemia. The patient and family need to be taught to recognize subtle signs and symptoms of hypoglycemia (Tkacs, 2002).
SUDOMOTOR NEUROPATHY
This neuropathic condition refers to a decrease or absence of sweating (anhidrosis) of the extremities, with a compensatory increase in upper body sweating. Dryness of the feet increases the risk for the development of foot ulcers.
SEXUAL DYSFUNCTION
Sexual dysfunction, especially impotence in men, is a complication of diabetes. The effects of autonomic neuropathy on female sexual functioning are not well documented. Reduced vaginal lubrication has been mentioned as a possible neuropathic effect; other possible changes in sexual function in women with diabetes include decreased libido and lack of orgasm. Vaginal infection, increased in incidence in women with diabetes, may be associated with decreased lubrication and vaginal itching and tenderness. Urinary tract infections and vaginitis may also affect sexual function (Tilton, 1997). Impotence (inability of the penis to become rigid and sustain an erection adequate for penetration) occurs with greater frequency in diabetic men than in nondiabetic men of the same age. However, diabetic neuropathy is not the only cause of impotence in men with diabetes. Medications such as antihypertensive agents, psychological factors, and other medical conditions (eg, vascular insufficiency) that may affect nondiabetic men also play a role in impotence in diabetic men. Some men with autonomic neuropathy have normal erectile function and can experience orgasm but do not ejaculate. Retrograde ejaculation occurs: seminal fluid is propelled backward through the posterior urethra and into the urinary bladder. Examination of the urine confirms the diagnosis because of the large number of active sperm present. Fertility counseling is necessary for couples attempting conception.
MANAGEMENT
Management strategies depend on the symptoms. There is no treatment for painless cardiac ischemia, and the prognosis is poor. Detection, however, is important so that education about avoiding strenuous exercise can be provided. Orthostatic hypotension may respond to a diet high in sodium, the discontinuation of medications that impede autonomic nervous system responses, the use of sympathomimetics and other agents (eg, caffeine) that stimulate an autonomic response, and the use of lower-body elastic garments that maximize venous return and prevent pooling of blood in the extremities. Treatment of delayed gastric emptying includes a low-fat diet, frequent small meals, close blood glucose control, and use of agents that increase gastric motility (eg, metoclopramide, bethanechol). Treatment of diabetic diarrhea may include bulkforming laxatives or antidiarrheal agents. Constipation is treated with a high-fiber diet and adequate hydration; medications, laxatives, and enemas may be necessary when constipation is severe. Management of the patient with a neurogenic bladder is discussed in Chapter. Treatment of sudomotor dysfunction focuses on education about skin care and heat intolerance. Erectile dysfunction is discussed in Chapter.
FOOT AND LEG PROBLEMS
From 50% to 75% of lower extremity amputations are performed on people
with diabetes. More than 50% of these amputations are thought to be
preventable, provided patients are taught foot care measures and practice them
on a daily basis (
• Neuropathy: Sensory neuropathy leads to loss of pain and pressure sensation, and autonomic neuropathy leads to increased dryness and fissuring of the skin (secondary to decreased sweating). Motor neuropathy results in muscular atrophy, which may lead to changes in the shape of the foot.
• Peripheral vascular disease: Poor circulation of the lower extremities contributes to poor wound healing and the development of angrene.
• Immunocompromise: Hyperglycemia impairs the ability of specialized leukocytes to destroy bacteria.
Thus, in poorly controlled diabetes, there is a lowered resistance to certain infections. The typical sequence of events in the development of a diabetic foot ulcer begins with a soft tissue injury of the foot, formation of a fissure between the toes or in an area of dry skin, or formation of a callus. Injuries are not felt by the patient with an insensitive foot and may be thermal (eg, from using heating pads, walking barefoot on hot concrete, or testing bath water with the foot), chemical (eg, burning the foot while using caustic agents on calluses, corns, or bunions), or traumatic (eg, injuring skin while cutting nails, walking with an undetected foreign object in the shoe, or wearing ill-fitting shoes and socks). If the patient is not in the habit of thoroughly inspecting both feet on a daily basis, the injury or fissure may go unnoticed until a serious infection has developed. Drainage, swelling, redness (from cellulitis) of the leg, or gangrene may be the first sign of foot problems that the patient notices. Treatment of foot ulcers involves bed rest, antibiotics, and dйbridement. In addition, controlling glucose levels, which tend to increase when infections occur, is important for promoting wound healing. In patients with peripheral vascular disease, foot ulcers may not heal because of the decreased ability of oxygen, nutrients, and antibiotics to reach the injured tissue. Amputation may be necessary to prevent the spread of infection. Foot assessment and foot care instructions are most important when caring for patients who are at high risk for developing foot infections. Some of the high-risk characteristics include:
• Duration of diabetes more than 10 years
• Age older than 40 years
• History of smoking
• Decreased peripheral pulses
• Decreased sensation
• Anatomic deformities or pressure areas (eg, bunions, calluses, hammer toes)
• History of previous foot ulcers or amputation
Management
Teaching patients proper foot care is a nursing intervention that can prevent costly, painful, and debilitating complications. Preventive foot care begins with careful daily assessment of the feet. The feet must be inspected on a daily basis for any redness, blisters, fissures, calluses, ulcerations, changes in skin temperature, and the development of foot deformities (ie, hammer toes, bunions). For patients with visual impairment or decreased joint mobility (especially the elderly), use of a mirror to inspect the bottom of the feet or the help of a family member in foot inspection may be necessary. The interior surfaces of shoes should be inspected for any rough spots or foreign objects.
In addition to the daily visual and manual inspection of the feet, the feet should be examined during every health care visit or at least once per year (more often if there is an increase in the patient’s risk) by a podiatrist, physician, or nurse (Fritschi, 2001). Patients with neuropathy should also undergo evaluation of neurologic status using a monofilament device by an experienced examiner. Patients with pressure areas, such as calluses, or thick toenails should see the podiatrist routinely for treatment of calluses and trimming of nails. Additional aspects of preventive foot care that are taught to the patient and family include the following:
• Properly bathing, drying, and lubricating the feet, taking care not to allow moisture (water or lotion) to accumulate between the toes
• Wearing closed-toe shoes that fit well.
Podiatrists can provide patients with inserts (orthotics) to remove pressure from pressure points on the foot. New shoes should be broken in slowly (ie, worn for 1 to 2 hours initially, with gradual increases in the length of time worn) to avoid blister formation. Patients with bony deformities may need extrawide shoes or extra-depth shoes. High-risk behaviors should be avoided, such as walking barefoot, using heating pads on the feet, wearing open-toed shoes, soaking the feet, and shaving calluses.
• Trimming toenails straight across and filing sharp corners to follow the contour of the toe (American Association of Diabetes Educators). If patients have visual deficits or thickened toenails, a podiatrist should cut the nails.
•Reducing risk factors, such as smoking and elevated blood lipids, that contribute to peripheral vascular disease.
• Avoiding home remedies or over-the-counter agents or selfmedicating to treat foot problems (Fritschi, 2001) Blood glucose control is important for avoiding decreased resistance to infections and for preventing diabetic neuropathy. The patient may be referred by the physician to a wound care center for managing persistent wounds of the feet or legs. Many wound care centers provide diabetes education; however, the patient needs to discuss recommendations for treating wounds with his or her own physician, as well as raising any questions about diabetes management.
Special Issues in Diabetes Care
THE PATIENT WITH DIABETES UNDERGOING SURGERY
During periods of physiologic stress such as surgery, blood glucose levels tend to rise as a result of an increase in the level of stress hormones (epinephrine, norepinephrine, glucagon, cortisol, and growth hormone). If hyperglycemia is not controlled during surgery, the resulting osmotic diuresis may lead to excessive loss of fluids and electrolytes. Patients with type 1 diabetes also risk developing ketoacidosis during periods of stress. Hypoglycemia is also a concern in diabetic patients undergoing surgery. This is especially a concern during the preoperative period if surgery is delayed beyond the morning in a patient who received a morning injection of intermediate-acting insulin. There are various approaches to managing glucose control during the perioperative period. Frequent capillary glucose monitoring is essential throughout the preoperative and postoperative periods, regardless of the method used for glucose control. Examples of these approaches are as follows, although the use of IV insulin and dextrose has become widespread with the increased availability of meters for intraoperative glucose monitoring: • The morning of surgery, all subcutaneous insulin doses are withheld (unless the blood glucose level is elevated—for example, more than 200 mg/dL [11.1 mmol/L], in which case a small dose of subcutaneous regular insulin may be prescribed). The blood glucose level is controlled during surgery with the IV infusion of regular insulin, which is balanced by an infusion of dextrose. The insulin and dextrose infusion rates are adjusted according to frequent (hourly) capillary glucose determinations. After surgery, the insulin infusion may becontinued until the patient can eat. If IV insulin is discontinued, subcutaneous regular insulin may be administered at set intervals (every 4 to 6 hours), or intermediateacting insulin may be administered every 12 hours with supplemental regular insulin as necessary until the patient is eating and the usual pattern of insulin dosing is resumed. The nurse caring for a patient with diabetes who is receiving IV insulin must carefully monitor the insulin infusion rate and blood glucose levels. IV insulin has a much shorter duration of action than subcutaneous insulin. Thus, if the infusion is interrupted or discontinued, hyperglycemia will develop rapidly (within 1 hour in type 1 diabetes and within a few hours in type 2 diabetes). The nurse must ensure that subcutaneous insulin is administered 30 minutes before discontinuing the IV insulin infusion.
• One half to two thirds of the patient’s usual morning dose of insulin (either intermediate-acting insulin alone or both short- and intermediate-acting insulins) is administered subcutaneously in the morning before surgery. The remainder is then administered after surgery.
• The patient’s usual daily dose of subcutaneous insulin is divided into four equal doses of regular insulin. These are then administered at 6-hour intervals. The last two approaches do not provide the control achieved by IV administration of insulin and dextrose.
• Patients with type 2 diabetes who do not usually take insulin may require insulin during the perioperative period to control blood glucose elevations. Patients who are taking chlorpropamide, a long-acting oral antidiabetic agent, may be instructed to discontinue the oral agent 24 to 48 hours before surgery. Some of these patients may resume their usual regimen of diet and oral agent during the recovery period. Other patients (whose diabetes is probably not well controlled with diet and an oral antidiabetic agent before surgery) need to continue with insulin injections after discharge.
• For patients with type 2 diabetes who are undergoing minor surgery but who do not normally take insulin, glucose levels may remain stable provided no dextrose is infused during the surgery. After surgery, they may require small doses of regular insulin until the usual diet and oral agent are resumed. During the postoperative period, diabetic patients must also be closely monitored for cardiovascular complications because of the increased prevalence of atherosclerosis in patients with diabetes, wound infections, and skin breakdown (especially in the patient with decreased pain sensation in the extremities due to neuropathy). Maintaining adequate nutrition and blood glucose control promotes wound healing.
MANAGEMENT OF HOSPITALIZED DIABETIC PATIENTS
At any one time, 10% to 20% of general medical-surgical patients in the hospital have diabetes. This number may increase as elderly patients make up a greater proportion of the population. Although some hospitals may have a specialized diabetic/metabolic unit, typically patients with diabetes are admitted throughout the hospital. Often diabetes is not the primary medical diagnosis, yet problems with the control of diabetes frequently result from changes in the patient’s normal routine or from surgery or illness. Some of the main issues pertinent to nursing care of the hospitalized diabetic patient are presented in the following section.
Self-Care Issues
All patients admitted to the hospital must relinquish control of some aspects of their daily care to the hospital staff. For the patient with diabetes who is actively involved in diabetes selfmanagement (especially insulin dose adjustment), relinquishing control over meal timing, insulin timing, and insulin dosage may be particularly difficult. The patient may fear hypoglycemia and express much concern over possible delays in receiving attention from the nurse if hypoglycemic symptoms occur. It is important for the nurse to acknowledge the patient’s concerns and to involve the patient as much as possible in the plan of care. If the patient disagrees with certain aspects of the nursing or medical care related to diabetes, the nurse must communicate this to other members of the health care team and, where appropriate, make changes in the plan to meet the patient’s needs. The nurse and other health care providers need to pay particular attention to patients who are successful in managing self-care, assess their self-care management skills, and encourage them to continue their self-care management if correct and appropriate.
Hyperglycemia During Hospitalization
Hyperglycemia may occur in the hospitalized patient as a result of the original illness that led to the need for hospitalization. In addition, a number of other factors may contribute to hyperglycemia, such as:
• Changes in the usual treatment regimen (eg, increased food, decreased insulin, decreased activity)
• Medications (eg, glucocorticoids such as prednisone, which are used in the treatment of a variety of inflammatory disorders)
• IV dextrose, which may be part of the maintenance fluids or may be used for the administration of antibiotics and other medications
• Overly vigorous treatment of hypoglycemia
• Mismatched timing of meals and insulin (eg, postmeal hyperglycemia may occur if short-acting insulin is administered immediately before or even after meals)
Nursing actions to correct some of these factors are important for
avoiding hyperglycemia. Assessment of the patient’s
usual home routine is important. The nurse should try to approximate as much as
possible the home schedule of insulin, meals, and activities. Monitoring blood
glucose levels has been identified by the
Hypoglycemia During Hospitalization
Hypoglycemia in a hospitalized patient is usually the result of too much insulin or delays in eating. Specific examples include:
•Overuse of “sliding scale” regular insulin, particularly as a supplement to regularly scheduled, twice-daily short- and intermediate-acting insulins
• Lack of dosage change when dietary intake is changed (eg, in the patient taking nothing by mouth)
• Overly vigorous treatment of hyperglycemia (eg, giving toofrequent successive doses of regular insulin before the time of peak insulin activity is reached) so that there is an accumulated effect
• Delayed meal after administration of lispro or aspart insulin (patient should eat within 15 minutes of administration)
Nurses must assess the pattern of glucose values and avoid giving doses of insulin that repeatedly lead to hypoglycemia. Successive doses of subcutaneous regular insulin should be administered no more frequently than every 3 to 4 hours. For patients receiving NPH or Lente insulin before breakfast and dinner, the nurse must use caution in administering supplemental doses of regular insulin at lunch and bedtime. Hypoglycemia may occur when two insulins peak at similar times (eg, morning NPH peaks with lunchtime regular insulin and may lead to late-afternoon hypoglycemia, and dinnertime NPH peaks with bedtime regular insulin and may lead to nocturnal hypoglycemia). To avoid hypoglycemic reactions caused by delayed food intake, the nurse should arrange for a snack to be given to the patient if meals are going to be delayed because of procedures, physical therapy, or other activities.
Common Alterations in Diet
Dietary modifications common during hospitalization require special consideration when the patient has diabetes.
NPO (NOTHING BY MOUTH)
For the patient who must have nothing by mouth in preparation for diagnostic or surgical procedures, the nurse must ensure that the usual insulin dosage has been changed. These changes may include eliminating the regular insulin and giving a decreased amount (eg, half the usual dose) of intermediate-acting NPH or Lente insulin. Another approach is to use frequent (every 3 to 4 hours) dosing of regular insulin only. IV dextrose may be administered to provide calories and to avoid hypoglycemia. Even when no food is taken, glucose levels may rise as a result of hepatic glucose production, especially in patients with type 1 diabetes and lean patients with type 2 diabetes. Further, in type 1 diabetes, elimination of the insulin dose may lead to the development of DKA. Thus, administering insulin to the patient with type 1 diabetes who is NPO is an important nursing action. For patients with type 2 diabetes who are taking insulin, DKA does not develop when insulin doses are eliminated because the patient’s pancreas produces some insulin. Thus, skipping the insulin dose altogether when the patient has type 2 diabetes (and is receiving IV dextrose) may be safe; however, close monitoring is essential. For patients who are NPO for extended periods, glucose testing and insulin administration should be performed at regular intervals, usually two to four times per day. Insulin regimens for the patient who is NPO for an extended period may include NPH insulin every 12 hours (with regular insulin added to the NPH, depending on the results of glucose testing) or regular insulin only every 4 to 6 hours. These patients should receive dextrose infusions to provide some calories and limit ketosis. To prevent these problems resulting from the need to withhold food, diagnostic tests and procedures and surgery should be scheduled early in the morning if possible.
CLEAR LIQUID DIET
When the diet is advanced to include clear liquids, the diabetic patient will be receiving more simple carbohydrate foods, such as juice and gelatin desserts, than are usually included in the diabetic diet. It is important for hospitalized patients to maintain their nutritional status as much as possible to promote healing. Thus, the use of reduced-calorie substitutes such as diet soda or diet gelatin desserts would not be appropriate when the only source of calories is clear liquids. Simple carbohydrates, when eaten alone, cause a rapid rise in blood glucose levels; thus, it is important to try to match peak times of insulin with peaks in glucose. If a patient was receiving insulin at regular intervals while NPO, the scheduled times for glucose tests and insulin injections must be changed to match meal times.
ENTERAL TUBE FEEDINGS
Tube feeding formulas contain more simple carbohydrates and less protein and fat than the typical diabetic diet. This results in increased levels of glucose in the diabetic patient receiving tube feedings. It is important that insulin doses be administered at regular intervals (eg, NPH every 12 hours or regular insulin every 4 to 6 hours) when tube feedings are administered at a continuous rate. If insulin is administered at routine (prebreakfast and predinner) times, hypoglycemia during the day may result from patients receiving more insulin without more calories, and hyperglycemia may occur during the night when feedings continue but insulin action decreases. A common cause of hypoglycemia in patients receiving continuous tube feedings and insulin is inadvertent or purposeful discontinuation of the feeding. The nurse must discuss with the medical team any plans for temporarily discontinuing the tube feeding (eg, when the patient is away from the unit). Planning ahead may allow alterations to be made in the insulin dose, or it may allow for IV dextrose to be administered. In addition, if problems with the tube feeding develop unexpectedly (eg, the patient pulls out the tube, the tube clogs, or the feeding is discontinued when residual gastric contents are found), the nurse must notify the physician, assess blood glucose levels more frequently, and administer IV dextrose if indicated.
PARENTERAL NUTRITION
The patient with diabetes receiving parenteral nutrition may receive both IV insulin (added to the parenteral nutrition container) and subcutaneous intermediate- or short-acting insulins. If the patient is receiving continuous parenteral nutrition, the blood glucose level should be monitored and insulin administered at regular intervals. If the parenteral nutrition is infused over a limited number of hours, subcutaneous insulin should be administered so that peak times of insulin action coincide with times of parenteral nutrition infusion.
Hygiene
The nurse caring for a hospitalized diabetic patient must focus attention on oral hygiene and skin care. Because diabetic patients are at increased risk for periodontal disease, it is important for the nurse to assist patients with daily dental care. The patient may also require assistance in keeping the skin clean and dry, especially in areas of contact between two skin surfaces (eg, groin, axilla, and, in obese women, under the breasts), where chafing and fungal infections tend to occur. For the bedridden diabetic patient, nursing care must emphasize the prevention of skin breakdown at pressure points. The heels are particularly susceptible to breakdown because of loss of sensation of pain and pressure associated with sensory neuropathy. Feet should be cleaned, dried, lubricated with lotion (but not between the toes), and inspected frequently. If the patient is in the supine position, pressure on the heels can be alleviated by elevating the lower legs on a pillow, with the heels positioned over the edge of the pillow. When the patient is seated in a chair, the feet should be positioned so that pressure is not placed on the heels. If the patient has a foot ulcer, it is important to provide preventive foot care to the unaffected foot as well as to carry out special care of the affected foot. As always, every opportunity should be taken to teach the patient about diabetes self-management, including daily oral, skin, and foot care. Female diabetic patients should also be instructed about measures for the avoidance of vaginal infections, which occur more frequently when blood glucose levels are elevated. Patients often take their cues from the nurse and realize the importance of daily personal hygiene if this is emphasized during their hospitalization.
Stress
As mentioned earlier, physiologic stress, such as infections and surgery, contributes to hyperglycemia and may precipitate DKA or HHNS. Emotional stress may have a negative impact on diabetic control as well. An increase in stress hormones leads to an increase in glucose levels, especially when the intake of food and insulin remains unchanged. In addition, during periods of emotional stress, the person with diabetes may alter the usual pattern of meals, exercise, and medication. This contributes to hyperglycemia or even hypoglycemia (eg, in the patient taking insulin or oral antidiabetic agents who stops eating in response to stress). People who have diabetes must be made aware of the potential deterioration in diabetic control that can accompany emotional stress. They must be encouraged to try to adhere to the diabetes treatment plan as much as possible during times of stress. In addition, learning strategies for minimizing stress and coping with stress when it does occur are important aspects of diabetes education.
Gerontologic Considerations
People with diabetes are living longer; therefore, both type 1 and type 2 diabetes are seen more frequently in the elderly population. Regardless of the type or duration of diabetes, the goals of diabetes treatment may need to be altered when caring for the elderly. The focus is on quality of life issues, such as maintaining independent functioning and promoting general well-being. Although striving for strict blood glucose control may not be safe or appropriate, prolonged symptomatic hyperglycemia should be avoided. Some elderly patients cannot manage a detailed diabetes treatment plan, but the nurse must not assume that all patients older than a certain age can adhere only to the simplest regimen. Although the goal may be simply to avoid hypoglycemia and symptomatic hyperglycemia, certain patients may prefer more complex regimens that allow more flexibility in meals and daily schedule. As with all people with diabetes, individualization of the treatment plan with frequent follow-up by the health care team is important. Some of the barriers to learning and self-care that may be seen in the elderly include decreased vision, hearing loss, memory deficits, decreased mobility and fine motor coordination, increased tremors, depression and loneliness, decreased financial resources, and limitations related to other medical illnesses. Assessing patients for these barriers as well as discussing any misconceptions or folk beliefs regarding the cause and treatment of diabetes is important in setting up a diabetes treatment plan and educational activities. Presenting brief, simplified instructions with ample opportunity for practice of skills is important. The use of special devices such as a magnifier for the insulin syringe, an insulin pen, or a mirror for foot inspection is helpful. If necessary, family members and other community resources are called on to assist with diabetes survival skills. It is preferable to teach patients or family members to test blood glucose at home; the choice of meter should be tailored to the patient’s visual and cognitive status and dexterity. Frequent evaluation of self-care skills (insulin administration, blood glucose monitoring, foot care, diet planning) is essential, especially in patients with deteriorating vision and memory. Dietary adherence is difficult for some elderly patients because of decreased appetite, poor dentition, and decreased physical and financial ability to prepare meals. In addition, patients may be unwilling to change long-standing dietary habits. Altering the meal plan to incorporate these eating habits or other limitations may be necessary.
NURSING PROCESS: THE PATIENT WITH DIABETES AS A SECONDARY DIAGNOSIS
People with diabetes frequently seek medical attention for problems not directly related to blood glucose control. However, during the course of treatment for the primary medical diagnosis, blood glucose control may worsen. In addition, the only opportunity for some patients with diabetes to update their knowledge about diabetes self-care and prevention of complications is during hospitalization. Therefore, it is important for the nurse caring for the patient with diabetes to focus attention on diabetes, regardless of the primary problem. Further, control of blood glucose levels is important because hyperglycemia impairs resistance to certain infections and impedes wound healing.
Assessment
Assessment of the patient with diabetes with a primary problem such as cardiac disease, renal disease, cerebrovascular disease, peripheral vascular disease, surgery, or any other type of illness is the same as that for a nondiabetic patient and is described in other chapters. In addition to nursing assessment for the primary problem, assessment of the patient with diabetes must also focus on hypoglycemia and hyperglycemia, skin breakdown, and diabetes self-care skills, including survival skills and measures for prevention of long-term complications. In addition, the patient is asked about use of alternative or complementary therapies; studies have demonstrated that patients with diabetes are twice as likely as other patients to use these therapies, and some may be harmful (Egede et al., 2002). The patient is assessed for hypoglycemia and hyperglycemia with frequent blood glucose monitoring (usually prescribed before meals and at bedtime) and with monitoring for signs and symptoms of hypoglycemia or prolonged hyperglycemia (including DKA or HHNS), as described in previous sections. Careful assessment of the skin, especially at pressure points and on the lower extremities, is important. The skin is assessed for dryness, cracks, skin breakdown, and redness. The patient is asked about symptoms of neuropathy, such as tingling and pain or numbness of the feet. Deep tendon reflexes are assessed. Assessment of diabetes self-care skills is performed as early as possible to determine whether the patient requires further diabetes teaching. The nurse observes the patient preparing and injecting the insulin, monitoring blood glucose, and performing foot care. (Simply questioning the patient about these skills without actually observing performance of the skills is not sufficient.) Knowledge about diet can be assessed with the help of the dietitian through direct questioning and review of patient choices on the menu. The patient is questioned regarding signs, treatment, and prevention of hypoglycemia and hyperglycemia. The patient’s knowledge of risk factors for macrovascular disease, including hypertension, increased lipids, and smoking, is assessed. The patient is asked the date of the last eye examination (including dilation of the pupil). It is also important to assess the patient’s use of preventive health measures: annual influenza vaccination (flu shot), date of last pneumonia vaccine (ADA, Immunization and the Prevention of Influenza and Pneumococcal Disease in People With Diabetes, 2003), daily dose of aspirin (unless contraindicated) (ADA, Aspirin Therapy in Diabetes, 2003), and smoking cessation (ADA, Smoking and Diabetes, 2003).
Diagnosis
NURSING DIAGNOSES
Based on the assessment data, the patient’s major nursing diagnoses may include:
• Imbalanced nutrition related to increase in stress hormones (caused by primary medical problem) and imbalances in insulin, food, and physical activity
• Risk for impaired skin integrity related to immobility and lack of sensation (caused by neuropathy)
• Deficient knowledge about diabetes self-care skills (caused by lack of basic diabetes education or lack of continuing indepth diabetes education)
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS
Based on the assessment data, potential complications may include: • Inadequate control of blood glucose levels (hyperglycemia, hypoglycemia) • DKA and HNNS
Planning and Goals
The major goals for the patient may include improved nutritional status, maintenance of skin integrity, ability to perform basic diabetes self-care skills as well as preventive care for the avoidance of chronic diabetes complications, and absence of complications.
Nursing Interventions
IMPROVING NUTRITIONAL STATUS
The patient’s diet is planned with the primary goal of glucose control; however, the dietary prescription must also consider the patient’s primary health problem in addition to lifestyle, cultural background, activity level, and food preferences. If alterations are needed in the patient’s diet because of the primary health problem (eg, GI problems), alternative strategies to ensure adequate nutritional intake must be implemented. The patient’s nutritional intake is monitored carefully along with blood glucose, urine ketones, and daily weight. Blood glucose records are assessed for patterns of hypoglycemia and hyperglycemia at the same time of day, and findings are reported to the physician for alteration in insulin orders. In the patient with elevated blood glucose levels that are prolonged, laboratory values and the patient’s physical condition are monitored for signs of DKA or HHNS.
MAINTAINING SKIN CARE
The skin is assessed daily for dryness or breaks. The feet are cleaned with warm water and soap. Excessive soaking of the feet is avoided. The feet are dried thoroughly, especially between the toes, and lotion is applied to the entire foot except between the toes. For bedridden patients (especially those with a history of neuropathy), the heels are elevated off the bed with a pillow placed under the lower legs and the heels resting over the edge of the pillow. Dermal ulcers are treated as indicated and prescribed. The nurse promotes optimal blood glucose control in patients with skin breakdown.
ADDRESSING KNOWLEDGE DEFICITS
Hospital admission of the patient with diabetes provides an ideal opportunity for the nurse to assess the patient’s level of knowledge about diabetes and its management. The nurse uses this opportunity to assess the patient’s understanding of diabetes management, including blood glucose monitoring, administration of medications (ie, insulin, oral agents), dietary requirements, exercise, and strategies to prevent long- and short-term complications of diabetes. The nurse also assesses the adjustment of the patient and family to diabetes and its management and identifies any misconceptions they have.
MONITORING AND MANAGING POTENTIAL COMPLICATIONS
Inadequate control of blood glucose levels may hinder recovery from the immediate health problem. Blood glucose levels are monitored, and insulin is administered as prescribed. It is important for the nurse to ensure that insulin prescribed is modified as needed to compensate for changes in the patient’s schedule or eating pattern. Treatment is given for hypoglycemia (with oral glucose) or hyperglycemia (with supplemental regular insulin no more often than every 3 to 4 hours). Blood glucose records are assessed for patterns of hypoglycemia and hyperglycemia at the same time of day, and findings are reported to the physician for modification in insulin orders. In the patient with elevated blood glucose levels that are prolonged, laboratory values and the patient’s physical condition are monitored for signs of DKA or HHNS. Development of acute complications of diabetes secondary to inadequate control of blood glucose levels may be associated with other health care problems because of changes in activity level and diet and physiologic alterations related to the primary health problem itself. Therefore, the patient must be monitored for acute complications (hyperglycemia, hypoglycemia) and measures must be implemented for their prevention and early treatment.
PROMOTING HOME AND COMMUNITY-BASED CARE
Teaching Patients Self-Care
Even if the patient has had diabetes for many years, it is important to assess his or her knowledge and adherence to the plan of care. It may be necessary to plan and implement a teaching plan that includes basic information about diabetes, its cause and symptoms, and acute and chronic complications and their treatment. The nurse asks the patient to give repeated return demonstrations of skills that were not performed correctly during the initial assessment. The patient is taught self-care activities for the prevention of long-term complications, including foot care, eye care, and risk factor management. The nurse also reminds the patient and family about the importance of health promotion activities and recommended health screening.
Continuing Care
The patient who is hospitalized for another health problem may require referral for home care for that problem or if gaps in knowledge about self-care are uncovered. In either case, the home care nurse can use this opportunity to assess the patient’s knowledge about diabetes management and the patient’s and family’s ability to carry out that management. Teaching provided in the hospital, clinic, office, or diabetes education center is reinforced by the nurse. The home care environment is assessed to determine its adequacy for self-care and safety. During home care visits, the nurse assesses the patient for signs and symptoms of long-term complications and assesses the patient’s and family’s techniques in blood glucose monitoring, insulin administration, and food selection. In addition, the patient and family are reminded of the importance of participating in health promotion activities as well as recommended health screening.
Evaluation
EXPECTED PATIENT OUTCOMES
Expected patient outcomes may include:
1. Achieves optimal control of blood glucose a. Avoids extremes of hypoglycemia and hyperglycemia b. Takes steps to resolve rapidly any hypoglycemic episodes
2. Maintains skin integrity a. Demonstrates intact skin without dryness and cracking b. Avoids ulcers caused by pressure and neuropathy
3. Demonstrates/verbalizes diabetes survival skills and preventive care
4. Understands treatment modalities a. Demonstrates proper technique for administering insulin or oral antidiabetic medications and assessing blood glucose b. Demonstrates appropriate knowledge of diet through proper menu selections and identification of pattern used for selecting foods at home c. Verbalizes signs, appropriate treatment, and prevention of hypoglycemia and hyperglycemia
5. Demonstrate proper foot care a. Inspects feet (using mirror if necessary to see bottom of foot), including inspection for cracks or fungal infections between toes b. Washes feet with warm water and soap; dries feet thoroughly c. Applies lotion to entire foot except between toes d. Verbalizes behaviors that decrease the risk of foot ulcers, including wearing shoes at all times; using hand or elbow, not foot, to test temperature of bath water; avoiding use of heating pad on feet; avoiding constrictive shoes; wearing new shoes for brief periods; avoiding home remedies for treatment of corns and calluses; having feet examined at every appointment with the physician; and consulting a podiatrist for regular nail care if necessary
6. Takes steps to prevent eye disease a. Verbalizes need for yearly or more frequent thorough dilated eye examinations by an ophthalmologist (starting at 5 years after diagnosis for type 1 diabetes or the year of diagnosis for type 2 diabetes) b. Verbalizes that retinopathy usually does not cause change in vision until serious damage to the retina has occurred c. States that early laser treatment along with good control of blood glucose and blood pressure may prevent visual loss from retinopathy d. Identifies hypoglycemia and hyperglycemia as two causes of temporary blurred vision
7. States measures to control macrovascular risk factors a. Smoking cessation b. Limitation of fats and cholesterol c. Control of hypertension d. Exercise e. Regular monitoring of renal function
8. Reports absence of acute complications a. Maintains blood glucose and urine ketones within normal limits b. Experiences no signs or symptoms of hypoglycemia or hyperglycemia c. Identifies signs and symptoms of hypoglycemia or hyperglycemia d. Reports appearance of symptoms so that treatment can be initiated