Khadije dehghaniKhadije dehghani

Faculty member of nursing andFaculty member of nursing and

midwifery college ,yazdmidwifery college ,yazd

Nursing Care Plan Of Nursing Care Plan Of The Patient With The Patient With

Diabetes Mellitus ( Type I ) Diabetes Mellitus ( Type I )

Assessment • Physical assessment • Family history• Health history• Signs as fallows: • Polyphagia• Polyuria• Polydipsia• Weight Loss• Bed wetting• Irritability• Shortened attention span• Temper tantrum in young children • Over tired • Dry Skin

Cont,d• Blurred vision• Poor wound healing• Flushed Skin• Headache• Frequent infection• Hyperglycemia• Glucosuria• Ketonuria• Dehydration• Electolyte imbalance• Acidosis• Progress to coma , death• Hypoglycemia• Diet, Exercise , drugs • Life style• Psychosocial state• Chronic complications

Assist with diagnostic procedures test : • FBS , Urine ketons , BG, HbAIC , PH , Na , K , Hco3 , BuN , Cr , Ca , ECG ,

Microalbuminuria test.

Nursing Diagnosis:

1- Risk for injury related to insulin deficiency

• Hyperglycemia

• Diabetes Ketoacidosis ( DKA)

• Dehydration , Hyper or Hypokalemila

• Cerebral Edema

Nursing Care :

• Recognize Hyperglycemia( polyuria , Polydipsia , polyphagia , Fatigue, blurred Vision , headache , paresthesia, dehydration )

• Assist patient in stress management

• Regulate in diet , activity , insulin

• Blood glucose monitor dose of insulin

• Administer insulin as prescribed

• Proper insulin injection a preparation techniques

• Rotate sites to enhance absorption

• Encourage appropriate activity as tolerated ( avoid if BS > 300 g/ dl or ketonuria)

Cont,d

• Recognize DKA ( Hyperglycemia – Ketonuria , Ketonemia , abd . Pain , Kussmous Resp , acetone breath , confusion , mental status coma death , pt BS > 250 )

• Observe for precipitating factors such as infection , stress , omission of insulin injection ( and treat it )

• Monitor B.S more frequently during acute physical / emotional stress , i.e., infection , surgery .

• Monitor urine ketones when BS > 250 -300 (q 1-2 hours)

• Detect Alteration in Mental status , neurocheck ( q 1-4 hours )

• Vital signs ( q 1-4 hours)

• Observe for signs of complications such as cerebral edema , hypo or hyperkalemia .

• A diabetic flow sheet for ongoing records

Cont,d

• Monitor hydration status& fluid intake and out put

• Dailey weight , SG urine

• Appropriate care for unconscious patient ( O2 , Gastric suction , Foley catheter, position ).

• Assist with diagnostic test ( BG, electrolyte , BUN , PH , PO2 , Pco2 , Hb , Hct , WBC , Ca , P )

2-Risk for injury related to hypoglycemia

• Recognize signs of hypoglycemia

• ( mobility of mood , irritability , shaky feeling , headache , hunger , Impaired vision , seizures,…)

• Alert at times when BG are Lowest ( e.g. at 11: 00 Am and Physical activity without additional food , after delayed, omitted , or incompletely consumed meal or snack .

Cont,d • Test for B. glucose• Bs < 70 mg / dl .• Elevate blood glucose • 10-15 gr of readily absorbed carbohydrates

( 3-6 ounces orange juice ,hard candy or milk ) • Repeat in 10-15 minutes if symptoms persist .• Fallow with complex carbohydrate and protein

( 10% of daily calories) • Un conscious child ( administer glucagons ,

positioning )• Space meals , snacks , making adjustments for

exercise , altered schedules , etc.

3-Imbalanced Nutrition

• Appropriate meal snack planning • Dietary balance of carbohydrate , fats and proteins • Provide extra foods during exercise • Time meal consistently to prevent hyperglycemia • Appropriate insulin & physical activity • Administer insulin before eating • Increase insulin dose or activity level when extra food is

eaten • Decrease insulin ( activity ).• concept of exchanges list • cultural beliefs and food preferences • Labels of food products

4- Risk for infection

Observe:• Local : erythema , pain , edema , warmth , drainage• General : Fever , Malaise , Weakness , anorexia , myalgia ,

arthralgia• Personal Hygiene• Regular dental care• Foot care• Proper care of cuts & scratches• Prevent , treat hyperglycemia • Protect lower extremities from injury• Inspect pressure point • Lotion to dry areas• Wound care• Discouraging smoking• Assess skin breakdown

5- Knowledge deficit for accept teaching :

Determine the educational needs • Adjust to diagnosis• Time , place , length , content of teaching • Variety of teaching & material teach• Nature of disease • Meal planning• Insulin• B. G testing • Urine testing • Hygiene • Exercise • Management of Hyperglycemia and Hypoglycemia • Chronic complication• Record keeping insulin , BG, food intake , exercise , illness . • Traveling & shopping

Education the major role in Nursing ongoing activity Education & self management

6-interupted family processes

• Positive self esteem • Express feeling about denial , irritation , guilt , anger ,

treat , anxiety , disappointment , inadequacy• Opportunity to adjust• Repeat information• Adolescent• Diabetes camps Group therapy • Differences as a part of life • Psychiatric counseling• Poor control need for support • Parent cope style & over protective ,neglectful ,

threatened.

Outline

Insulin– Preparations– storage – Other devices for insulin injection– Complications– Injection procedures– Simple chart

Insulin-Characteristics

Classification Preparation Onset Peak Duration

Rapid-acting Lispro 10-15 minutes 0.75-1 hour 2-4 hours

Aspart 10-15 minutes 0.75-1 hours 2-4 hours

Short-acting Regular IV: Immediate

IM: 5-30 min

SQ: 30-60 min

15-30 min

30-60 min

3-6 hr

2 hours

2-4 hours

6-10 hours

Intermediate NPH SQ: 3 hours 8-12 hours 18-24 hours

Lente SQ: 3 hours 8-12 hours 18-28 hours

Long-acting Ultralente SQ: 4 hours 16-18 hours 24-36 hours

Glargine SQ: 1.1 hours None 24 hours

Future Insulin Formulations

• Inhaled insulin: Delivers fine aerosol powder to deep lung; acts as a rapid-acting insulin.Release date: ?2006

• Sublingual: Phase II and III

• Intranasal: Bioavailability challenges

• Oral insulin: BioSante pharmaceuticals (preclinical trials)

• Insulin Mouth Sprays • Insulin Pills

Insulin Devices and Equipment

Syringes : SC (subcutaneous) injectionPen injectors

Examples: Humalog pen; Novopen; Lantus pen

Jet injectors (needle-less)Insulin Pumps: combination bolus and

continuous (basal) SC insulin infusion (CSII); use rapid-acting insulin

Insulin Pens

MiniMed Insulin Pump

Insulin Storage

• Refrigerate unopened insulin; patient should ALWAYS have a spare bottle available.

• Store current vial at room temperature; (general rule) use within 30 days of opening as loss of potency occurs after 30 days.

• DO NOT FREEZE or expose to extreme conditions.

Insulin Storage (Time at 59-86%F)

• Lilly products– 28 days :Humulin R, Humulin N, Humulin

70/30, Humalog, and Humalog 75/25 vials; Humalog pen; Humulin R and Humalog cartridges

– 14 days: Humulin N pen– 10 days: Humalog 75/25 and Humulin 70/30

pens– 7 days: Humulin N and 70/30 cartridges

Insulin Complications

• Hypoglycemia: Low blood sugar

• Allergic reactions: Local; systemic

• Lipohypertrophy: Thickening of SC fat at injection site

• Lipoatrophy: Thinning of SC fat at injection site

Lipohypertrophy

Lipoatrophy at injection site

1 mg of freeze-dried glucagon (Vial) 1 ml of water for reconstitution (Syringe)

Emergency Kit Contents:

Combine immediately before use

Insulin• Preparing and Injecting Demonstration

– Wash hands– Roll insulin– Alcohol– Draw up air– Inject air (NPH then R)– Draw up insulin (clear before cloudy)– Double-check dose!!!!– Clean skin– Pinch up skin– Push in plunger– Remove needle– Press on site with swab– Properly dispose of needle/syringe

Insulin Administration Info

• Site of injection– Absorption: Abdomen>arm>leg– Rotate sites

• When to administer– Depends on type of insulin, type of

DM– Before meals– At bedtime

Insulin Administration Info

• Syringes– Disposal– Size depends on dose (1 mL=100 U)

• Do not interchange with tuberculin syringes

– Reuse?

Insulin Administration Info

• Mixing insulin– NPH and regular may be mixed– Glargine CANNOT be mixed with other insulin– R and L or R and U-wait 24 hours or give

immediately but be consistent– NPH should not be mixed with L or U– Lispro can be mixed with NPH and Ultralente,

but use within 15 minutes

Steps for Insulin Injections

1. Gather and organize all suppliesA. Insulin,

B. syringes,

C. alcohol swabs,

D. medical waste container

2. Wash hands and

injection site (will

discuss injection site

options later)

Steps for Insulin Injections

3. Inspect insulin vialA. Make sure that it is the correct type of

insulin.

B. Expiration date

C. Floaters, clumps, frosting, etc.

Steps for Insulin Injections

4. Roll intermediate and long acting insulin in hands

A. DO NOT SHAKE

5. If new vial, remove flat colored plastic cap

6. Clean rubber stopper A. One swipe B. Alcohol drying produces the anti-microbial effect.

Steps for Insulin Injections

7. Prepare syringeA. Remove from wrapper, remove

flat covered stopper

8. Pull plunger back until tip of plunger is at line for required number of units. If mixing, may pull back total number of units or each individually.

Steps for Insulin Injections9. With vial on flat surface

(recommended as opposed to holding vial as in picture), push needle through rubber stopper and inject air into vial. When mixing, inject air into CLOUDY first and then into clear.

10. Turn vial and syringe upside down (straight up) and remove necessary amount of insulin . When mixing, draw up CLEAR first.

Steps for Insulin Injections

11.Check for air bubbles, if present, push insulin back into vial and redraw dose or gently tap syringe. If air bubbles are discovered after drawing up second insulin when mixing, discard dose and begin again.

12.Pull needle out of rubber stopper.

Steps for Insulin Injections

Most insulin enters the blood:* fastest from the abdomen (stomach)* a little slower from the arms* even more slowly from the legs* most slowly from the buttocks

13. Choose Injection Site

Steps for Insulin Injections

14. Pinch up skin and push needle in all the way. Use a 90 degree angle

If person is thin or a child - 45 degree angle.

Pinching the skin prior to injection

Pinching the skin to give an insulin injection. A small pinch Pinching the skin to give an insulin injection. A small pinch with the finger and thumb is enough. with the finger and thumb is enough.

Steps for Insulin Injections

15.Push plunger all the way down and release pinched skin before pulling needle out of skin.

16.Pull needle straight out. Do not rub area.

17.Safely and properly dispose of used needle and syringe.

18.Ask the patient to return demonstrate to you.

Steps for Insulin Injections

Simple chart

Sick Day Management• Stress may ↑ blood glucose• Do NOT skip insulin!

– May need supplemental doses

• Maintain oral carbohydrate intake• Consume extra clear fluids• Measure blood glucose several

times (up to hourly)• Test urine for ketones

– If blood sugar >240 mg/dL

• Contact provider– Esp if ketones or BS >300 mg/dL

Blood Glucose Meters

• Patient Care Pharmacy Instructions

• Video-One Touch Glucometer

• Blood glucose log sample

خسته نباشیدخسته نباشید