Care of Clients with Diabetes Mellitus

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Part 2 - Complications

Somogyi effect

Periods of hypoglycemia followed by rebound hyperglycemia

Hypoglycemia causes some diabetics to release epinephrine

Decrease evening dose or move to bedtime

or increase bedtime snack Diagnose with a 2 or 3 am blood sugar

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Dawn phenomenon

Nocturnal release of growth hormone- leads to an increase in glucose around 4-8 am; normal for everyone

Treat with increase of evening insulin or move supper insulin to bedtime

More severe in adolescence

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Acute complications

Hypoglycemia

Diabetic ketoacidosis: DKA

Hyperosmolar hyperglycemic syndrome: HHS

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Hypoglycemia-causes

Too little food- or delayed

Too much diabetic medicine

Too much exercise without compensation

Alcohol intake without food

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Hypoglycemia- symptoms

Tremors, Nervousness Irritability, personality changes,

abnormal behavior Cool, clammy skin with diaphoresis Increased heart rate Hunger, Headache Unsteady gait, slurred or incoherent

speech Vision changes: double or blurred

vision Seizures, coma

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Hypoglycemia- management

Immediate ingestion of 15 g. of simple CHO 4 oz of juice 4 oz of regular soda 1 tablespoon of honey or syrup 2 tablespoons of raisins 3-4 hard candy Commercial dextrose product: 3-4

tablets 7

Hypoglycemia- management

Repeat tx if no improvement in 15 min.

If not eating a regular meal within the next

1-2 hours follow with additional food that contains protein & CHO 4 oz milk, slice of bread, peanut

butter & crackers8

Hypoglycemia- severe reaction

50% Dextrose: IV 20-50 ml Followed by infusion of D5W

Glucagon: subcutaneous or IM .5- 1 mg Raises the blood glucose level by 20-30

within a few minutes Person should eat as soon as regain

consciousness Causes N/V

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Glucagon

Glucagon can cause vomiting, so be sure to place the person on his or her side prior to injecting so they do not choke. After injecting glucagon, follow with food once the person regains consciousness and is able to swallow.

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Hypoglycemia: severe

Glucose gel or cake icing gel can be put on the cheek inside the mouth

Honey rubbed into gums also has worked

Inform patients to always wear medical alert identification

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Hypoglycemia: severe

15 grams of fast acting CHO will raise blood glucose by approximately 45 points in 10-15 minutes

Do not treat with high-fat foods: chocolate, ice cream

Over treatment is common

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Diabetic ketoacidosis (DKA)- etiology

Too little insulin with increased caloric intake

Physical or emotional stress

Undiagnosed DM

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DKA: Too little insulin

Glucose cannot enter cells & be used for cellular energy

Body releases & breaks down stored fats & proteins to provide needed energy

Free fatty acids from stored triglycerides are released & metabolized in the liver in such large amounts that ketones are formed.

Excess ketones- Acidosis 14

DKA-Pathophysiology

Hyperosmolarity: hyperglycemia (glucose > 250) dehydration (serum osmolarity normal or just above normal)

Fluid & electrolyte imbalance: osmotic diuresis

Metabolic Acidosis PH < 7.30 Norm: 7.35- 7.45 HCO3 < 15 Norm: 22-26 Urinary ketones >3+ Norm: 0

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DKA- symptoms

Develops rapidly over 24 hours

Increased blood glucose- > 250 mg/dlAbdominal pain, N/VKussmaul’s respirationAcetone noted on breath- fruity Hypotension

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DKA- treatment

Insulin: IV infusion of regular insulin

Replacement of fluids to correct hypovolemia NS 10-20 ml/kg of body weight over

first 1-2 hours

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DKA- treatment

Correct electrolyte imbalance Changes in serum potassium,

calcium, magnesium, & phosphate can occur

Hyperkalemic: potassium can’t get into the cells without insulin. When administer insulin the potassium reenters the cell & patient runs a risk for hypokalemia

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DKA: Nursing Interventions Take hourly glucose levels Obtain ABG’s Monitor electrolytes every 1-4 hours Cardiac monitor to watch for

dysrhythmias Assess every 1-4 hours

VS Urine output Neurologic status

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DKA: complication

Cerebral edema Can occur 6-10 hours within start of

treatment Occurs when blood glucose falls too

rapidly: causing fluid to shift into the brain cells

Can also occur with sodium levels dropping too rapidly. Fluid replacement must be monitored carefully 20

DKA

Once the patient’s blood glucose is stable and the patient can have food by mouth or through a feeding tube, subcutaneous insulin can begin

Give first subcutaneous insulin 1-2 hours before you discontinue the insulin infusion

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Sick Day Management

When sick: Always take diabetes medicine Test glucose at least every 4 hours

Call the doctor if: Blood glucose consistently > 250 mg/dl Ketone test is moderate to high Feel sick & vomit Think you might have an infection

Keep well hydrated Replace foods with liquids that

contain CHO 22

Hyperosmolar hyperglycemic syndrome- HHS

Severe hyperglycemia > 600 mg/dl Takes days or weeks to fully develop Type 2 diabetes with diminished

renal function &/or cardiac disease

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HHS

Causes: infection: UTI, pneumonia, sepsis inadequate adherence with insulin regimen new diagnosis of diabetes

Triggers: MI & CVASurgeryPancreatitisMedicationsPregnancy

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HHS- symptoms

Reflect dehydration & altered CHO, fat, & protein metabolism

Thirst Tachycardia Polyuria Fatigue Weight loss Blurred vision Altered mental status Coma

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