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Endocrine 3A Part 3 Long Term Complications of Diabetes • Macro vascular complications – Arteriosclerosis • Characterized by thickening and loss of elasticity of the arterial walls “hardening of the arteries”. – Coronary Artery Disease – Cerebrovascular Disease – Peripheral vascular disease Coronary/cerebrovascular disease Changeable risk factors • Weight control • Low-fat diet • Treat hypertension • Treat hyperlipidema • Regular exercise • Control blood glucose levels • Smoking • Diabetes Unchangeable risk factors • Age • Gender • Family history • Race Microvascular complications • Characterized by basement membrane thickening • Effects smallest blood vessels • Due to hyperglycemia Diabetic Retinopathy • Damage to the tiny blood vessels that supply the eye • Small hemorrhages occur • Damage is due to hyperglycemia Prevention • Control – Glucose – BP Prevention • • • • No straining Use laxatives Avoid lowering head Avoid lifting above shoulders Retinopathy: Medical Management • Photocoagulation “laser” treatment • Control hypertension • Control blood glucose • No smoking Retinopathy: Nursing Considerations • • • • Expected Odds are good Frequent eye exams Bilateral but uneven Other Optic Complications • Cataracts • Lens Changes • Extraocular muscle palsy • Glaucoma Nephropathy • Damage to the tiny blood vessels within the kidney. • Due to – Hyperglycemia Nephropathy: Etiology • h glucose levels – Stress kidney’s filtration mechanism • Blood protein leaks into urine • Pressure in blood vessel of kidney h • Kidney failure Nephropathy: Pathophysiology Normally • Kidneys filter blood • Small molecules & waste squeeze through kidneys urine • Big stuff (I.e. protein, RBC), stay in blood where they belong Nephropathy: Pathophysiology • Diabetes damages the system • Filters start to leak • Protein and RBC lost in urine – Microalbuminuria – Macroalbuminuria – Proteinuria Nephropathy: Pathophysiology • Filters collapse • Lose of filtering ability – Kidney failure – ESRF / ENRD • Waste products build up in blood • Dialysis • Kidney transplant Nephropathy: S&S / Dx • Proteinuria / albuminuria • i urine output • Edema • BUN & Creatinine ↑ • h BP Nephropathy:Prevention • • • • Control BG Control HTN Tx UTI No nephrotoxic substances • i Na • i Protein Nephropathy:Management • Tight glucose control • Anti-hypertensives – Calcium-channel blockers – Alpha blockers – ACE inhibitor • Dialysis • Transplant Neuropathy • Damage to the Nerves due to hyperglycemia • Most common complication • Various Types of Neuropathies… Neuropathy • Sensory-Motor Polyneuropathy – AKA peripheral neuropathy – Paresthesias: primarily lower extremities – i deep tendon reflexes Neuropathy Sensory-motor Numb feet i proprioception i sensation Unsteady gait h risk foot injury Neuropathy: Management • Control serum glucose levels • Pain control – Analgesics (nonnarcotic) – Tri-cyclic antidepressants – Anticonvulsants Neuropathy: • Autonomic neuropathy – Autonomic NS – Can affect almost any system Autonomic Neuropathy • Cardiovascular – Tachycardia – Orthostatic hypotension – MI Autonomic Neuropathy • Gastro-intestinal – Delayed gastric emptying – Constipation – Diarrhea Autonomic Neuropathy • Urinary – Retention – Neurogenic bladder Autonomic Neuropathy • Reproductive – Male impotence Autonomic Neuropathy • Adrenal Gland – “Hypoglycemic Unawareness” – Adrenal Medulla – Adrenergic symptoms – No longer feel S&S – Strict BG control & frequent monitoring Autonomic Neuropathy • Sudomotor neuropathy – – – – No sweating Anhidrosis dry feet foot ulcers Infections • High risk of foot infections – Neuropathy • Pain sensation – i • Pressure sensation – i • Dryness – h • Fissures – h Infections • Peripheral vascular disease – Circulation • i – WBC • i – Oxygen • i – wound healing • Poor – Antibiotics • i – Gangrene Infections • Immuno-compromised – WBC + hyperglycemia = sluggish WBC’s Infections • Once they occur difficult to treat – Poor circulation – Antibiotic not get there – Sluggish WBC’s – Unknown wounds Infections • Particular concern – Foot infections/wounds Boils: AKA: "furuncles" round, pus-filled bumps on the skin D/T: Staphylococcus aureus bacteria Cellulites • noncontagious inflammation of the connective tissue of the skin, • D/T bacterial infection • Treatment – Antibiotics – Analgesics Infections of concern • UTI’s • Yeast Infections • Periodontal disease Infections of concern Gangrene • term to describe the decay or death of an organ or tissue • d/t i blood supply. Infections of concern (FYI) • Necrotizing fasciitis – Flesh eating disease High risk for foot infections • • • • • • Duration of diabetes h Age Smoking i Peripheral pulses i Sensation Deformities/pressure areas • Hx of foot ulcers Progression of events • • • • Soft tissue injury Injury not sensed Infection Drainage, swelling, redness • Gangrene Management of infections • Bed rest • Antibiotics – Topic vs. IV • Debridement • Control Glucose levels • ? Amputation Nursing Management • Teach foot care – prevention • Teach wound care Guideline to Healthy Feet • Wash daily – Dry between toes – Lubricate dry feet • Inspect – Mirror – Family – Between toes Guideline to Healthy Feet • Avoid activities that i circulation – Smoking – Crossing legs – Tight socks Guideline to Healthy Feet • Good shoes – – – – Comfortable Closed toe No bare feet New shoes • Break in slowly Guideline to Healthy Feet • Prevent injuries – Wear socks • Cotton • Light color • No wrinkles – Check inside of shoe Guideline to Healthy Feet • No temperature extremes – Check bath water – No water bottles – No heating pads Guideline to Healthy Feet • See doctor regularly – Podiatrist – Trim straight across – Do not cut calluses or corns Guideline to Healthy Feet • Range of Motion Diabetics & Surgery BS levels _____ during stress, surgery & illness – h If not controlled (BG) osmotic diuresis dehydration Diabetics & Surgery • Risk of _________ if give shot of NPH and then NO surgery or surgery delayed – Hypoglycemia Diabetics & Surgery • Management – Check BS before surgery – No sub-Q – IV Hospitalized diabetic • Independence • Sliding scale • Diets – NPO • Still need insulin – Clear liquids • Most simple carbs • Low sugar if possible NCLEX Question Peripheral vascular disease is most common in patients with A. an aneurysm. B. viral pneumonia. C. leukemia. D. diabetes mellitus. NCLEX Question The nurse is reinforcing the importance of proper foot care to the elderly diabetic. The woman states that they surely must have something more important to discuss. The nurse correctly replies: A. “Foot care as well as any other type of hygiene is always important.” B. “We can skip this if you prefer.” C. “All right, just remember that you will be more prone to foot odor.” D. “Diabetics can easily develop severe foot injury or infection without knowing it.”