Download Diabetic Nephropathy

Nursing Care and Interventions in
Managing Type II Diabetes Mellitus
Keith Rischer, RN, MA, CEN
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Objectives for Today…
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Describe the onset, clinical manifestations, laboratory findings
and pathologic mechanisms of type 2 diabetes.
Identify clients at risk for type 2 diabetes
Differentiate between macro & microvascular complications of
chronic diabetes.
Compare the mechanisms of action, side effects and nursing
considerations of the oral antidiabetic medications for type 2
diabetes.
Compare the time action profile, and nursing considerations of
insulin to control type 2 diabetes.
Identify nursing care priorities to treat and prevent complications
of chronic diabetes.
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Background
90-95% of all diabetes
 Family history 2-4x risk developing
 Obesity
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 Increased
resistance to insulin
 Impaired suppression of glucose production
by liver
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Patho of Type II Diabetes
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Pancreas secretes less insulin
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Beta cells of pancreas
Insulin resistance
Initial increase in insulin
 Leads to beta cell exhaustion & failure
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Increased glucose production by liver
Metabolic syndrome
Insulin resistance
 Abd. Obesity
 HTN-high cholesterol
 High triglycerides, CRP, low LDL, atherosclerotic
changes
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Those at Highest Risk…
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Overweight
 Abd
obesity
>age 40
 Inactivity
 Hypertension
 High cholesterol
 Parents with type II DM
 Gender & Ethnic influences
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Clinical Manifestations
Asymptomatic
 Same as Type 1
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 Fatigue
 Polyuria
 Polydipsia
Vaginal yeast infections
 Wounds that do not heal
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Laboratory Diagnosis for Type 2
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Symptoms of DM plus casual ^ 200 mg/dL
 Fasting
^ 126
 2-hr ^ 200
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Urine
 Albumin
 Ketones
 Protein
 Glucose
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Macrovascular Complications
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Cardiovascular disease (most common)
 2-3
X greater than non-DM, Women more
 MI leading cause of death
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Cerebrovascular disease
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glucose levels lead to greater brain injury
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Microvascular Complications
Eye and vision complications
 Retinopathy which is leading cause of new
 linked to fasting BG >129
 Cataracts, glaucoma, macular degeneration
Diabetic Nephropathy
 Leading cause of ESRD
 Early sign… microalbuminuria
 Neurontin or Amitriptyline to manage pain
blindness
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Diabetic Neuropathy
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Clinical Manifestations
 Loss of sensation, pain, weakness
 Late complication
 foot ulcers/deformaties (Charcot’s joints),
amputations
 CV
 GI
 GU
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Male Erectile Dysfunction
Occurs at higher rate and earlier age as
compared to general population
 Affects 50% of males
 Treatments
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 penile
implants
 medications
 counseling
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Medications: Sulfonylurea Agents p.1512-1515
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Mechanism
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Require some beta-cell function
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Stimulates pancreas to secrete more insulin
Increases insulin sensitivity
Hypoglycemia most common SE
Glipizide (Glucatrol)-30” before meals
Glyburide (Diabeta)-with first meal
 Adverse effects
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Hypoglycemia
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Impaired renal-liver function elevates levels
Onset 15-30”…peak 1-2h…duration 24 hours
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Oral Therapy
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Biguanides (Metformin or Glucophage)
 Decreases
liver glucose release and
decreases cellular insulin resistance
 Should not cause hypoglycemia
 Avoid those with renal disease (causes lactic
acidosis in those with renal, liver, CHF or
ETOH)
 Withhold 48 hours before using contrast
media and surgery requiring anesthesia
 Avoid ETOH…causes lactic acidosis
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Oral Therapy
Thiazolidine-diones (Avandia, Actos)
 Enhance insulin action
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 Decreasing
insulin resistance
Can be used with insulin or sulfonylurea
 Need periodic liver tests to assess for
damage
 Cause weight gain
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 Due
to fluid retention
 Elevates HDL as well as LDL & triglycerides
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Oral Therapy
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Combination meds
 Combine
with insulin
 Orals combined with other orals
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Drug Selection
 Based
on cost, age, client’s ability to
manage, response to meds
 Body’s response to oral DM meds
decreases, so clients may have to go on
insulin
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Insulin
Needed for type 1 and often for type 2
 Assess elderly’s ability to give insulin
 Types of insulin
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 Rapid
 Short
 Intermediate
 Long
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acting
Know the onset, peak, and duration
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Foot Assessment & Care
Do not smoke
 Inspect feet daily
 No bare feet
 Trim toenails
 Use lotion
 Report non-healing breaks
 Complete foot assessment with provider
at least 4 times a year.
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Foot Assessment & Care
Without sensation, risk for injury
 Peripheral sensation management monofilament
 Footwear - protective shoes
 Wound Care 
 elimination
of pressure: contact cast
 Wound Care clinics
 Growth hormones
 Debridement
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Treatment: Chronic Pain
Maintain normal BG levels
 Anticonvulsants - Neurontin
 Antidepressants - Amitriptyline
 Capsaicin cream
 Pain Clinics and specialty services
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Treatment: Visual Disturbances
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Many times loss of central vision
Assistive devices
 special insulin devices: magnifier on bottle
 talking glucometers
 coding objects: wrap rubber band around bottle
 Fluorescent lighting above object
 Society for the blind - large print
 Treatment:
 Laser (photocoagulation)
 Vitrectomy (aspiration of blood, membranes,
fibers)
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Diabetic Glomerulosclerosis (CKD)
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Glomeruli changes
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Capillary basement thickening
Patho
Glucose incorporated into noncellular components
 Influenced by high glucose levels
 HTN and smoking accelerate progression
 Albumin-protein in urine reflect progression of disease
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Treatment: Renal
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Tight blood glucose control
Random urine test for albumin/creatinine
Control of BP - low sodium diet
Aggressively treat UTI
If nephropathy - restrict protein
Avoid dehydration - careful use of diuretics
Dialysis
Avoid drugs that injure kidney, if IV dye - give
fluids prior
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Exercise Therapy
Essential part of treatment
 Also increases well-being
 Can produce hypoglycemia or
hyperglycemia
 Low intensity aerobic best - walk, swim
 20 to 40 minutes performed 4 to 7
days/week
 Keep logs to note progress
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Exercise Therapy
Complete physical check up before
exercise program initiated
 Exercise with a friend
 Always carry a simple sugar
 Always carry ID
 Athletes who are diabetic - extra planning
Monitor BG levels to determine effects on
their body
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Diet
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15 - 20% protein, 80% COH, <10% saturated fat
Moderate to high dietary fiber - gradual. If a food has 5 or >
GM/ fiber can deduct from COH
Alcohol - 2/day for men, 1 for women
Food labels vital
Individual meal plans
Consistent meals and snacks
Type 2 - may be on calorie restriction for wt loss
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Physical & Emotional Needs
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Entire family affected - stress of diagnosis
Prepare same meals for family - “not special”
Group education classes - cooking classes
Most is one to one education to tailor to client
Assess individual educational needs considering
lifestyle, attitude, goals, ethnic, home,
background
Wealth of teaching materials - printed, electronic
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Non-Compliance
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Sometimes lack of knowledge, lack of power:
Role of nurse to empower
Peer pressure
Lack of motivation - unaware of consequences
Poor family history of previous members
Inadequate finances
Unfamiliar with health care system
Lack of advocate
History of obesity
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Community Resources
Home care for post hospital teaching
 Out patient diabetic education
 Contact for emergency
 Assistance with shopping or cooking
 Referrals to local resources - Traveling
clinics, senior citizens
 American Diabetes Association
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Hyperglycemic-Hyperosmolar
Nonketotic Syndrome and Coma
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Caused by hyperglycemia
 Increased insulin resistance & CHO intake
Absence of ketones & higher glucose levels (BG >800)
than keto-acidosis
High blood osmolarity (>350 mOsm/L)
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Pulls water out of body cells including brain
Mortality 50%
Gradual onset
Coma, confusion, decreased Glasgow, Seizures
Treatment:
 IV fluids 6 to 20 liters in 24 hours
 IV insulin
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