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Diabetes- Chapter 43
Revised 11/10
Types of Diabetes
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Type 1—insulindependent diabetes
mellitus (IDDM)
Insulin produced in
insufficient amount
Requires insulin
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Type 2—non-insulindependent diabetes
mellitus (NIDDM)
Decreased production
of insulin or decreased
cell sensitivity to insulin
May be treated with
oral drug and/or insulin
Four Pillars of Management of
Diabetes
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Meal planning referred to as medical
nutrition therapy
Activity and exercise
Medication
Self monitoring of blood glucose
(SMBG)
Insulin
A hormone produced by the beta cells
in the pancreas that acts to maintain
blood glucose levels within normal
limits
Insulin
Essential for the use of glucose in
cellular metabolism and for proper
protein and fat metabolism
Insulin
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Controls the use of glucose, protein,
and fat in the body
Lowers blood sugar by inhibiting
glucose production by the liver
Insulin
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Available as purified extracts from beef
and pork pancreas (used infrequently)
Synthetic insulins, such a human insulin
and insulin analogs; derived from
strains of Escherichia coli (recombinant
DNA), fewer allergies with this than
extracts of beef and pork
Activates a process that helps glucose
molecules enter the cells
Stimulates the liver glycogen synthesis
Insulin (Con’t)
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Used to treat diabetes mellitus and
control more severe and complicated
forms of type 2 diabetes
Insulin Injections
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Must be injected into the subcutaneous
in the legs, arms, stomachs or buttocks.
Cannot be taken orally
ADMINISTERING INSULIN BY
INJECTION
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Administered with an insulin syringe
Insulin Preparations
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See handout from Introduction to
Pharmacology
Text, page 546
Onset, Peak, and Duration of
Action
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Define onset, peak and duration
Insulin Contraindications
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Contraindicated if patient has
hypersensitivity to any ingredient in the
product (older preparations made with
beef and pork) and if the patient is
hypoglycemic
Precautions
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Used cautiously with renal and hepatic
impairment and during pregnancy and
lactation
Interactions
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See table 49-1 Drugs that Decrease and
Increase the Hypoglycemic Effect of
Insulin, page 547
Include as nursing considerations
Drugs that Decrease the
Hypoglycemic Effect of Insulin
Drugs that Increase the
Hypoglycemic Effect of Insulin
MIXING INSULINS
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Insulins tend to bind and become
equilibrated
Inject within 5 minutes of mixing
Regular which is additive free, is
combined with intermediate-acting
insulin such as Humulin
Mixing Insulins
Promoting Optimal Response
to Insulin Therapy
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Will be individualized
Expect adjustments when under stress
and with any illness, particularly
illnesses resulting in nausea and
vomiting
Examples of Insulin
Administration using a Sliding
Scale
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Handout from Morton Hospital (use as
an example)
Double sided (reverse has how to treat
hypoglycemia)
Follow agency protocol
Preparing Insulin for
Administration
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Current insulin bottle at room
temperature, except Lantus which is
refrigerated
Rotating Injection Sites
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Rotating sites prevents lipodystrophy
(atrophy of subcutaneous fat)
Lipodystrophy interferes with absorption
of insulin
Body Diagram of Appropriate
Sites
Methods of Administering
Insulin
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Parenteral-subcutaneous or intravenous
Insulin Pump
Inhalation
Insulin Pumps
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Newer technology. Attempts to mimic the
body’s normal pancreatic function.
Only regular insulin is used.
Needle inserted subcutaneously and left in
place for 1-3 days
Battery operated.
Amount of insulin injected can be adjusted
according to blood glucose levels (monitored
4-8 times a day)
Inhaled Insulin
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Food and Drug Administration approved the
first noninjectable insulin in a dry inhalation
powder in early 2006 (Exubera).
Monitoring and Managing
Adverse Reactions
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Must know signs and symptoms of
hypoglycemia and hyperglycemia
Signs of Hyperglycemia
Signs of Hypoglycemia
Educating the Patient and
Family
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Review principles of teaching the adult patient
Noncompliance may be a problem with some patients
(may be related to lack of understanding of disease
process or medications or management)
Establish a thorough teaching plan for patients newly
diagnosed, for patients with changes in treatment
plan
Include teaching on diet, glucose monitoring,
medications, adverse reactions, hygiene, exercise,
sick day protocols, medic alert bracelets
Nursing Diagnoses
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Anxiety and Fear
Impaired Adjustment, Coping, and
Altered Health Maintenance
Acute confusion related to
hypoglycemic reaction
Oral Drugs
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Sulfonylureas
Biguanides
Alpha-glucosidase inhibitors
Meglitinides
Thiazolidinediones
Hormone Mimetic Agents –many diffferent
actions to help lower blood sugar levels, see
page 424; Januvia, Byetta, Symlin
See Summary of Drugs- pages 420-421
Sometimes oral antidiabetic drugs are used in
combinations
Sulfonylureas
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Examples—tolbutamide (Orinase), glipizide (Glucotrol),
glyburide (Diabeta, Micronase), glimepiride (Amaryl)
Act to lower blood glucose by stimulating the beta cell to
release insulin
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Adverse Reactions—
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Nursing considerations:
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Secondary failure may occur (may lose effectiveness, may
prescribe another sulfonylureas or add another oral
antidiabetic drug such as metformin
Biguanides
Example—metformin (Glucophage)
 Action—reduces hepatic glucose production and
increases insulin sensitivity to muscle and fat cells
 Adverse Reactions—
Rare SE: lactic acidosis with kidney failure
 Nursing implications; give with meals. Glucophage XR
given once daily with evening meal. Glucophage
must be stopped 48 hours before and after radiology
studies that use iodine
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Alpha-Glucosidase Inhibitors
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Examples—acarbose, miglitol
Action—lower blood sugar by delaying
carbohydrate digestion and absorption
Adverse Reactions—
Nursing considerations:
Meglitinides
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Examples—nateglinide (Starlix), repaglinide
(Prandin)
Action—stimulate insulin release from the
pancreas in response to a glucose load
Adverse Reactions –
Nursing considerations:
Thiazolidinediones
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Examples—rosiglitazone (Avandia- now
off market), pioglitazone (Actos)
Action—decrease insulin resistance and
increase insulin sensitivity by modifying
several processes
Adverse Reactions—
Nursing considerations:
Combination Agents
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Metaglip- glipizide and metformin
Glucovance-glyburide and metformin
Actoplus Met- pioglitazone and
metformin
Avandamet- rosiglitazone and
metformin
Duetact- Pioglitazone and glimepiride
Avandaryl- rosiglitzone and glimepride
Pharmacologic Algorithm for
Treating Type 2 Diabetes
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See text, page 422
Emergency Medications to
Elevate Glucose
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Glucagon IM (glucagon is a hormone
produced by the alpha cells of the
pancreas-stimulates the conversion of
glycogen to glucose in the liver. . return
to consciousness within 5-20 minutes)
IV D50
Key Concepts
Case Study
Timothy Jones is admitted to your unit
with a diagnosis of new onset type 1
diabetes mellitus. His blood sugars have
stabilized and he is beginning to ask
questions. How would you answer the
following questions?
What is diabetes?
Why can’t I be on pills instead of insulin?
Why do I have to test my blood sugars?
What should I do if it is too high or too low?
Does insulin have any side effects? What
should I watch for?