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NUR 1021
STUDY GUIDE TOPIC:
DIABETES & COMPLICATIONS
A.
Objectives:
1.
2.
3.
Describe normal actions and functions of the pancreas.
Explain the pathophysiology , risk factors and manifestations of Type I & Type II diabetes
Contrast Type 1, Type 2, and gestational diabetes, including initial symptoms, medical and
nursing treatment regimens, complications, and appropriate patient outcomes for each.
3. Describe etiologic factors associated with diabetes.
4. Relate the clinical manifestations of diabetes to the alterations in glucose metabolism.
5. Provide the rationale for diagnostic tests used for screening, diagnosis and monitoring of
DM.
6. Identify the major guidelines of care when teaching a patient administration of insulin
7. Compare the acute complications of hypoglycemia, hyperglycemia/diabetic ketoacidosis and
hyperglycemic hyperosmolar syndrome and appropriate nursing interventions for each.
8. Discuss best practices of self-care management of DM related to diet planning, sick day
management, exercise and foot care.
9. Describe the major long term complications associated with diabetes and the associated
nursing and medical management.
10. Relate special situations that a diabetic can encounter with a hospitalization and the care
management implications.
B.
Required Readings:
Hinkle and Cheever. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing.
Chapter 51, pp. 1416-1421, 1425-1427, 1435-1461.
NUR 1021 Spr Pck Diabetes/
-2C.
Study Outline:
1.
Define diabetes mellitus.
2.
Describe laboratory tests used to diagnose diabetes and nursing care implications.
3.
Describe the normal function of insulin in a person who does not have diabetes.
4.
What is the incidence of diabetes?
5.
Differentiate between Type I and Type II diabetes. Describe two other types of diabetes.
6.
Describe Type II diabetes: name, definition, prevalence, whom it affects, onset, severity,
emergency situation, when Type II is usually detected, warning signs and symptoms, cause
(etiology), pathophysiology, management (interventions).
7.
Discuss assessment and nursing interventions for a patient with HHS.
Think about diabetic complications. They are always dreaded and can often be avoided by
an astute patient and/or nursing observations and excellent care. Learn how to assess for
these complications when they are still in an early treatable stage.
What laboratory values are associated with these conditions? Teach patients how to watch
for them and to prevent them.
8.
Describe Type I diabetes: name, definition, prevalence, whom it affects, onset, severity,
emergency situation, cause (etiology), pathophysiology, management (interventions).
9.
Describe assessment of Type I diabetes—what symptoms and problems are usually present
and why.
10. Discuss DKA.
11. Discuss hypoglycemia.
12. Discuss long term complications of diabetes. Discuss assessment and interventions for
these.
13. Describe hemoglobin lab test A1C and its purpose.
14. Discuss foot care and diabetic teaching.
15. Discuss sick days and management of same.
16. Discuss use of oral hypoglycemic agents.
NUR 1021 Spr Pck Diabetes/
TEACHING PLAN FOR DIABETES MELLITUS
The Behavioral Objectives for the Teaching Plan:
1.
The patient will describe the diabetic medications that he is on and how to properly take the
medications.
2.
The patient will demonstrate proper skin and foot care.
3.
The patient will perform self-monitoring of blood glucose using a blood glucose meter as
evidenced by demonstration of the technique to the nurse or nurse practitioner.
4.
The patient will describe the benefits of regular exercise and how regular exercise can improve
blood glucose control.
5.
The patient will discuss sick-day management of diabetes mellitus.
Content:
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General overview of diabetes
Blood glucose monitoring and goals of blood glucose monitoring
Medications and insulin
Complications from diabetes
Skin and foot care
Exercise and diabetes
Diet and diabetes
Coping with diabetes
Sick-day management
Questions and answers
Review of any concepts requested by patients
- Adapted from nursesaregreat.com – Teaching Plan for Diabetes Mellitus
Internet Resources for Nurses on Diabetes:
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American Association of Clinical Endocrinologists (AACE). http://www.aace.com
American Association of Diabetes Educators. http://www.aadenet.com
American Diabetes Association (ADA). http://www.diabetes.org
American Dietetic Association. http://www.eatright.org
BD Diabetes. http://www.bd.com/diabetes
Diabetes Care Journal. http://carediabetesjournal.com
NUR 1021 Spr Pck Diabetes/
COMPARISON OF TYPE I (IDDM) & TYPE II (NIDDM) DIABETES MELLITUS
CHARACTERISTIC
(Variable)
TYPE I (IDDM)
TYPE II (NIDDM)
Factor
Insulin dependent
Ketosis prone
Non-insulin dependent
Not ketosis prone
Former Term
Juvenile Onset Diabetes Mellitus
(JODM)
Adult Onset Diabetes Mellitus (AODM)
Onset
Usually before age 30
Usually after age 40
Prevalence (%)
Diabetes Population
5-10%
80-90%
Weight Pattern
Usually thin
Usually obese
Family History
Uncommon
Common
Genetic Predisposition
HLA DR-3, DR-4, B-8, B-15, DW3 and
DW4
Suspected—currently being investigated
Insulin Production
0 to small amounts
Low, normal, or high amounts
C-peptide
0 to small amounts
Usually normal
Islet Cell Antibodies
Common at onset
Uncommon
Insulin Sensitivity
High
Low
Ketosis
Common
Uncommon
Hypoglycemia
Diabetic ketoacidosis (DKA)
Infections
Non-ketotic hyperosmolar hyperglycemic
coma (NHHC)
Infections
Chronic
Microvascular
Eyes (retinopathy)
Kidneys (Nephropathy)
Nerves (Neuropathy)
Macrovascular
Feet (Ulcers/Amputations)
Heart/Blood Pressure (MI, Hypertension,
CHD)
Brain (CVA)
Nerves (Neuropathy)
Methods of Control
(in order of importance)
Insulin (dependent)
Diet
Exercise
Diet, oral agents, and/or insulin
(requiring)
Exercise
Major Educational Focus
Insulin therapy/adjustments
Glucose monitoring
Sick day management
Hypo/Hyperglycemia
Diet
Exercise
Diet (weight reduction)
Oral agents (insulin)
Foot care
Glucose monitoring
Hypo/Hyperglycemia
Community resources
Exercise
Factors That Inhibit Independence with Self-Care
Vision impairment/blindness
Neuropathy
Denial
Adherence
Visual impairment
Neuropathy
Amputations
Adherence
Complications:
Acute
NUR 1021 Spr Pck Diabetes/
NUR 1021
STUDY GUIDE TOPIC:
PHARMACOLOGICAL MANAGEMENT OF DIABETES MELLITUS
A. Objectives:
1.
Discuss the therapeutic mechanism of action of insulin
2.
Define onset, peak, and duration for the various types of insulin.
3.
Demonstrate and/or describe the preparation and administration of a prescribed dose of insulin
to a patient
4.
Write a plan for teaching a patient (teenager, middle age adult, and older adult) how to
administer insulin to himself, stating your rationale for each step in your teaching plan, and
then role play or demonstrate teaching a patient according to your plan.
5.
Demonstrate correct mixing and administration of insulin.
6.
Describe the correct fingerstick glucose testing procedure.
7.
Discuss the use of antidiabetic agents across the life span
8.
Describe non-insulin medications used to treat diabetes mellitus. Include mechanisms of
action, side effects, administration, and patient teaching.
B.
Required Readings:
Hinkle and Cheever. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing.
Chapter 51, pp. 1427-1435.
Karch. Focus on Nursing Pharmacology.
Chapter 38, pp. 610-633.
Taylor. Fundamentals of Nursing.
pp. 811-827
C.
Study Outline:
1.
Discuss proper syringe and technique to use.
2.
How do you mix two insulins?
-2-
3.
What are the appropriate sites for insulin injection?
4.
At what angle do you give insulin?
5.
What three things do you check before giving insulin?
6.
Which insulin can be given IV?
Which insulins cannot be mixed?
7.
Which insulins are cloudy? Why?
8.
What is a sliding scale?
9.
At what temperature do you give insulin?
10. With whom do you double check insulin? What do you need to take with you for the check?
11. What is the action of insulin?
-312. Which insulins are:
short acting
__________________________________________________________________________
intermediate
__________________________________________________________________________
long acting
__________________________________________________________________________
combination
__________________________________________________________________________
What is the onset, peak and duration for?
short acting
__________________________________________________________________________
intermediate
__________________________________________________________________________
long acting
__________________________________________________________________________
combination
__________________________________________________________________________
13. What is the antidote for insulin?
14. Describe an insulin reaction what steps should be taken.
15. Discuss self-blood glucose monitoring, using various machines.
16. Discuss how you would teach a patient to administer insulin to himself.
17. Discuss alternative methods of insulin delivery:
Insulin pens
Insulin pumps
18. Compare and contrast actions of various oral hypoglycemic agents.
19. Discuss the concept of insulin resistance and its relationship to the treatment of diabetes.
MARION TECHNICAL COLLEGE
NUR 1021
DIABETIC CLINICAL WORKSHEET
SPRING TERM
Name________________________________
Sliding Scale for Insulin:
1. Find a Sliding Scale for Insulin on a patient’s medsheet.
Write the sliding scale here:
Pt. Initials___________
Room______
2. Find the Doctor’s Order stating the sliding scale. Is it transferred to the medsheet correctly?
Date____________
Yes_____
or
No_____
3. What was the patient’s last AccuCheck?
Date____________
Time____________
AccuCheck____________
4. When did the patient last receive insulin from the sliding scale? ____________________________
What was the AccuCheck? __________
How much insulin? __________
5. a. Is the patient on a routine insulin other than a sliding scale?
b. State the insulin, dosage, and times.
c. What is the onset, peak and duration of this insulin?
6. What is the onset, peak, and duration of the regular insulin?
INSULIN REACTION INFORMATION
SLOW ONSET
RAPID ONSET
HIGH BLOOD SUGAR
DIABETIC ACIDOSIS
HYPERGLYCEMIA
LOW BLOOD SUGAR
INSULIN REACTION
HYPOGLYCEMIA
WATCH FOR:
WATCH FOR:
 Increased thirst and
urination.
 Large amounts of sugar
and ketones in urine.
 Weakness, abdominal
pains, generalized
aches.
 Loss of appetite,
nausea and vomiting.
 Heavy labored
breathing.
 Excessive sweating,
faintness.
 Headache.
 Pounding of heart,
trembling, impaired
vision.
 Hunger.
 Not able to awaken.
 Irritability.
 Personality change.
WHAT TO DO:
WHAT TO DO:
 Call the doctor.
 Give patient fluids
without sugar if able to
swallow.
 Continue usual urine
tests.
 Give sugar or food
containing sugar
(honey, candy, fruit).
 Do not give fluid if
patient is not conscious.
 Give glucagon if loss of
consciousness.
 Call the doctor.
CAUSES:
CAUSES:
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Too little insulin.
Failure to follow diet.
Infection, fever.
Emotional stress.
 Too much insulin.
 Not eating enough
food.
 Unusual amount of
exercise.
 Delayed meal.
NUR 1021
STUDY GUIDE TOPIC:
DIABETIC NUTRITION
A.
Objectives:
1. Describe the significance of weight control in management of diabetes mellitus (DM).
2. Discuss essential concepts related to meal planning with the patient who has insulindependent DM.
3. Demonstrate obtaining and analyzing a food intake history.
4. Describe the caloric distribution that is recommended by the American Dietetic Association
(ADA) for persons with DM.
5. Discuss the following food classification systems: exchange lists, nutrition labels/CHO
counting, healthy food choices, My Plate Food Guide, and glycemic index.
6. Describe the significance of other related dietary concerns for a person with diabetes.
B.
Required Readings:
Hinkle and Cheever. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing.
Chapter 51, pp.1422-1425
CURRENT TRENDS AND ISSUES IN
NUTRITIONAL MANAGEMENT OF DIABETES
I.
GOALS OF DIET THERAPY FOR INDIVIDUALS WITH DIABETES MELLITUS
A. Achieve optimal metabolic outcomes related to glycemia, lipid profiles, and blood pressure
levels.
B. Attain and/or maintain an ideal body weight.
C. Provide for normal physical growth in the child.
D. Maintain plasma glucose as near the normal physiologic range as possible.
E. Prevent and/or delay the development and/or progression of complications associated with
diabetes, insofar as these are related to metabolic control.
F. Modify the diet as necessary for complications of diabetes and for associated diseases.
G. Make the dietary prescription as attractive and realistic as possible.
MEAL PLANNING WITH DIABETES
I.
What is Diabetes (definition)
A. Type I
- Insulin not available
- Ketoacidosis
- Thin, thirsty
Key = Consistency
B. Type II
- Pancreas still makes insulin
Keys = adherence to diet
oral hypoglycemics
weight control
moderate activity
II.
Dietitian’s Role
A. Assessment of diet teaching needs and previous knowledge base of patient
B. Teaching and/or review of teaching needed with patient and any significant others
regarding diet’s role in diabetes management
C. Development of an appropriate “meal plan”
- Considerations: Normal routine
Food preferences
Eating habits
Medications
Activity level
Nutritional needs
D. Other specific teaching:
- Portion control
- Food preparation methods
- Food labeling
- Eating out
- Sick days
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Increased risk of heart disease
Fiber
Exercise
Meal timing
Realistic goal
III. Exercise in Meal Planning
A. Estimate caloric needs (as needed)—usually this is already determined by the
physician or dietitian
1. Desirable body weight x 10 = basal needs
2. Add calories for activity
a. Sedentary - desirable body weight x 13
b. Moderate - desirable body weight x 15
c. Active - desirable body weight x 18-20
3. Add calories for:
a. Pregnancy - 300 calories for normal weight gain
b. Lactation - 500 calories for milk production
c. Weight gain - 500 calories to gain 1 lb per week
-24. Subtract 500 calories per day to obtain a weight loss of 1 lb per week
(3,500 kcal per pound)
5. Often diabetic diets are not ordered as specific calorie levels anymore—
especially in the hospital--We have a traditional diabetic meal based on about
1800 calories.
B. Method for diabetic diet calculation
1. An ideal diabetic diet should be composed of:
55% carbohydrate (50-55%)
20% protein (10-20%)
25% fat (25-30%--less than 10% saturated)
2. Each gram of carbohydrate = 4 calories
Each gram of protein = 4 calories
Each gram of fat = 9 calories
3. Case study:
Suppose we had a patient who needed 1500 calories per day. Let’s make up a
meal plan for him or her—
1500 calories x 55% carbohydrate = 825 calories from CHO
825 calories
4 cal/gram
= 206 grams carbohydrate
1500 calories x 20% protein = 300 calories from protein
300 calories
4 cal/gram
= 75 grams protein
1500 calories x 25% fat = 375 calories from fat
375 calories
9 cal/gram
= 42 grams fat
4. Traditional method of meal planning:
Evenly distribute carbohydrate and calories between meals and snacks as
possible.
5. Carbohydrate counting method of meal planning:
Evenly distribute carbohydrate and calories between meals and snacks as
possible. 200 grams carbohydrate would be our goal for the day, however, we
would need to make up specific goals for each meal. Exchanges are more
flexible with the CHO counting:
Starch = fruit = milk = carbohydrate exchange
15 g = 15 g = 12 g = 15 g carbohydrate
C. Some patients may be unable to comprehend the exchange lists and a more
simplified method (or no added sugar) will be used.
-3D. Attempt to work out a diabetic meal plan for yourself determining your own caloric
needs and preferences
IV. Nursing’s Role
A. Assess patient’s nutritional status upon admission/initial contact, including BMI.
B. Note laboratory tests as available: serum albumin, prealbumin, serum protein,
serum ferritin, Hgb, Hct, electrolytes.
C. Weigh daily or weekly, as appropriate.
D. Monitor and record food intake.
E. Assess usual intake, and compare with Food Pyramid.
F. Observe patient’s ability to eat.
G. Teach patient how to maintain a food diary.
H. Teach use of food labels.
I. Treat the obese patient with respect and concern.
J. Collaborate with dietitian and reinforce dietitian’s instructions.
Source: Ackley and Ladwig. (2011). Nursing Diagnosis Handbook. pp. 576-587.
CARBOHYDRATE REPLACEMENT
Replacements are needed for diabetic patients who are not eating well.
In order to prevent hypoglycemia, please use the following food replacement schedule.
For each serving of the following foods not eaten, use one replacement food.
No replacement is needed for meat, fat, or vegetables that are not eaten at one meal. If
meat is not eaten for more than one meal, please notify the dietitian to ensure adequate
protein replacement.
Food will need replacement if one-half or more of the serving is not eaten.
Replace the following:
ONE SERVING (15 g CARBOHYDRATE)
MILK - 1 CUP
FRUIT
BREAD/STARCH
REPLACEMENT FOODS (15g carbohydrate)
(one serving portions)
1. 1 container fruit juice (apple, orange, or pineapple)
2. 4 ounces regular soda (Shasta)
3. 1 container regular jello
4. 1 slice of toast
5. 1 package cooked cereal (oatmeal or cream of wheat)
(*Do not use oatmeal with low sodium diets)
6. 1 box cold cereal (+ 1 cup milk = 2 servings)
7. 1 package graham crackers
8. 1 package saltines or 3 packages low sodium crackers
9. 1 container ice cream
10. 1 cup 2% milk
11. 1 can ready-to-serve soup (low sodium if needed)
12. 1 jar baby food fruit (applesauce, pears, peaches)
If two servings (30 g carbohydrates) are needed for replacement, you may use:
½ cup sherbet or ½ cup regular pudding or 2 replacement foods above
USING FOOD LABELS
Nutrition facts on food labels can help you with food choices. These labels are required by law for
most foods and are based on standard serving sizes.
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Check the serving size on the label. Is it nearly the same size as the food exchange? You may
need to adjust the size of the serving to fit your meal plan.
Look at the grams of carbohydrate in the serving size. (One starch, fruit, milk, or other
carbohydrate has about 15 grams of carbohydrate.) So, if 1 cup of cereal has 30 grams of
carbohydrate, it will count as 2 starch choices in your meal plan. You may need to adjust the
size of the serving so it contains the number of carbohydrate choices you have for a meal or a
snack.
Look at the grams of protein in the serving size. (One meat choice has 7 grams of protein.) If
the food has more than 7 grams of protein in a serving, you can figure out the number of meat
choices by dividing the grams of protein by 7. Meats generally contain fat, too.
Look at the grams of fat in the serving size. (One fat choice has 5 grams of fat.) If one waffle
has 15 grams of carbohydrate and 5 grams of fat, it counts as 1 starch choice and 1 fat choice.
Look at the number of calories in the serving size. If there are less than 20 calories per serving,
it is a free food. However, if it has more than 20 calories, follow the steps listed above to count
the food choices.
Ask your dietitian for help using information on food labels.
exchanges.
Some food labels may also give
INSULINS
Rapid-Acting Insulin
Onset
Peak
Duration
 Insulin aspart (Novolog)
10-20 minutes
1-3 hrs
3-5 hrs
 Insulin glulisine (Apidra)
2-5 minutes
30-90 minutes
2 hrs
 Human lispro injection (Humalog)
< 15 minutes
30-90 minutes
2-5 hrs
Onset
Peak(hr)
Duration (hr)
30 minutes
2-4
5-7
Onset
Peak (hr)
Duration (hr)
1-1.5 hrs
4-12
24
Onset
Peak (hr)
Duration (hr)
Insulin glargine injection (Lantus)
60-70 minutes
None
24
Insulin detemir injection (Levemir)
1-2 hrs
3-6
5.7-24
Onset
Peak (hr)
Duration (hr)
30-60 minutes,
then 1-2 hrs
2-4 hrs,
then 6-12 hrs
6-8 hrs,
then 18-24 hrs
Short-Acting Insulin
Regular human insulin injection (Humulin R)
Intermediate-Acting Insulin
Isophane Insulin NPH injection (Humulin N,
Novolin N, ReliOn N)
Long-Acting Insulin
Combination Insulin
NPH and Regular
Humulin 70/30, Novolin 70/30, Novolog 70/30,
Humulin 50/50, Humalog 50/50, Humalog 75/25
Source: Karch. Focus on Nursing Pharmacology, page 619
Brunner & Suddarth Textbook of Medical-Surgical Nursing, page 1428
- OVER -
NON-INSULINS
Sulfonylureas
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acetohexamide (Dymelor)
chlorpropamide (Diabinese)
tolazamide (Tolinase)
tolbutamide (Orinase, Mobenol)
Second Generation Sulfonylureas
 glipizide (Glucotrol)
 glyburide (DiaBeta/Micronase)
 glimepiride (Amaryl)
Meglitinide Analogues
 repaglinide (Prandin)
 nateglinide (Starlix)
Biguanides
 metformin (Glucophage, Glucophage XL)
Alpha-Glucosidase Inhibitors
 acarbose (Precose)
 miglitol (Glyset)
Thiazolidinediones
 pioglitasone (Actose)
 rosiglitazone (Avandia)
Action
Increase insulin secretion in Type 2 diabetes
Action
Increase insulin secretion in Type 2 diabetes
Action
Increase insulin secretion in Type 2 diabetes; shortacting agents to prevent postmeal blood glucose
elevation
Action
Lowers basal and postmeal glucose by reducing
hepatic glucose production and increases tissue
sensitivity to insulin
Action
Prevents postmeal blood glucose elevation for
Type 2 diabetes
Action
Improves tissue sensitivity to insulin in Type 2
diabetes
Sources: Brunner and Suddarth’s Textbook of Medical-Surgical Nursing. pp. 1428 &1434-1435.
Karch, Focus on Nursing Pharmacology, pp. 624-625.
NUR 1021 Spr Pck Diabetes/