When is the usual onset of gestational diabetes? What nursing considerations are there for a patient with diabetes undergoing surgery? …
Endocrine Handout Day 2
I Medical Surgical management of Diabetes Mellitus
A Medical
B Surgical
C Dietary/Nutritional
1 Goals
Maintain a near-normal _____________________________________
Achieve optimal ___________________________________________
Provide adequate _________ to maintain or attain a reasonable
weight
Prevent and treat acute _____________ of insulin-treated
diabetes
Improve _______________ through optimal nutrition
2 The Exchange System
4-Categories
1
2
3
4
3 ADA
4 Alcohol
D Exercise
1 Exercise decreases the blood glucose by increasing the uptake of
glucose by body muscles and improving insulin usage
2 Benefits to exercise for everyone:
3 Benefits of exercise specifically for those with Diabetes
Mellitus
4 Precautions to exercise:
Small Group Questions:
1 Why are pancreas transplants uncommon?
2 Give signs and symptoms of hyperglycemia by body systems
3 A diabetic meal plans
main goal is to maintain near normal glucose
levels How is this done?
4 The exchange diabetic meal plan is divided into four categories; what
are they?
5 What affect does alcohol have on a diabetic?
6 What affect does exercise have on a diabetic?
7 What council would you give a diabetic regarding exercise?
E Monitoring Glucose and ketones
1 Self-monitoring of blood glucose
2 Urine testing for glucose
3 Urine Ketone Testing
II Insulin
A Onset - Peak - Duration
|Types of insulin |Appearance |Onset |Peak |Duration|Nursing |
| | | | | |Management |
|Rapid Acting/Very | | | | | |
|short-acting: | | | | | |
|Lispro Humalog | | | | | |
|Aspart | | | | | |
|Short-acting / | | | | | |
|Regular | | | | | |
|Humulin R | | | | | |
|Humalog R | |
| | | |
|Semilente | | | | | |
|Intermediate-acting:| | | | | |
| | | | | | |
|Humulin N | | | | | |
|Humulin L | | | | | |
|NPH | | | | | |
|Lente | | | | | |
|Long-acting: | | | | | |
|Humulin U | | | | | |
|Ultralente | | | | | |
Learning Tip: Even and Odd
To remember the onset, peak and duration of intermediate-acting think even
2-12-24
To remember the onset, peak and duration of short-acting insulin think odd
1,3,5
1 When should insulin be administered?
2 What route is insulin administered by?
Small Group Questions:
Mrs Evans is a 60year old woman with type II diabetes She is on Lent
Insulin every morning She eats her meals at 8:00 AM, 12:00
PM, and 6:00
PM
1 If Mrs Evans eats her breakfast at 8:00 am every morning, what time
should she take her insulin?
2 At what time of day should she be alert for symptoms of low blood sugar?
3 What should the nurse instruct Mrs Evans to do, not do, or to be aware
of at this time?
Mrs Gumdrop takes 6 units NPH at HS 10:00 PM She eats her meals every
day at:
Breakfast - 7:00 AM
Lunch - 11:00 AM
Dinner - 5:00 PM
1 When is she most at risk for hypoglycemia?
2 What can she do to prevent this?
Mr Chocolate Chip Cookie takes 10 units Humulin R q am His meals are:
Breakfast - 7:00 AM
Lunch - 11:00 AM
Dinner - 5:00 PM
1 When should be take his morning dose of insulin?
2 When will Mr Chip blood sugar levels be at their lowest?
3 What should he do, or not do at this time?
More Insulin Peak Sample Questions
Assume the following people eat at 8:00 AM, 12:00 PM and 6:00 PM
For each of the following consider the type of insulin administered
and the time at which it was administered When would the insulin
peak? When would this person be most at risk for hypoglycemia
considered the meal schedule? When
would be a good time to exercise
for this person?
1 Humulin R @ 7:30 AM
a Peak
b Risk for hypoglycemia
c Good exercise time
2 Humulin N @ 8:00 AM
a Peak
b Risk for hypoglycemia
c Good exercise time
3 Humalog R @ 11:30 AM
a Peak
b Risk for hypoglycemia
c Good exercise time
4 Humulin L @12:00 PM
a Peak
b Risk for hypoglycemia
c Good exercise time
5 Semilente @ 5:30PM
a Peak
b Risk for hypoglycemia
c Good exercise time
6 NPH @ 10:00 PM
a Peak
b Risk for hypoglycemia
c Good exercise time
7 Lente @6:00 PM
a Peak
b Risk for hypoglycemia
c Good exercise time
8 Humulin R @ 8:00 AM
a Peak
b Risk for hypoglycemia
c Good exercise time
9 Humulin N @ 10:00 AM
a Peak
b Risk for hypoglycemia
c Good exercise time
10 Lente @ 6:00 AM
a Peak
b Risk for hypoglycemia
c Good exercise time
11 Humalog R @ 1:00 PM
a Peak
b Risk for hypoglycemia
c Good exercise time
12 Semilente @ 10:00 PM
a Peak
b Risk for hypoglycemia
c Good exercise time
B Mixing insulin/ Drawing up insulin
Learning Tip: Clear to Cloudy
When mixing insulin, remember CLEAR TO CLOUDY Always draw up
the clear insulin first This involved injecting air in the cloudy
vial first This is because if the clear is drawn up last, the
cloudy insulin may contaminate the vial If the cloudy insulin is
unknowingly contaminated by the clear insulin, the clear will be
absorbed and the effect minimal
1 How to Mix Insulin
a Assemble equipment:
b Check __________________________
c Roll ________________________________
d Wipe _____________________________________
e Draw up and inject an amount of ______________equal to the
dose of intermediate- acting insulin into the cloudy vial
Remove syringe from vial
f Draw up and inject an amount of __________equal to the amount
of short-acting insulin into the clear vial Leave the
syringe in the vial
g Draw up
______________________________________Double check
amount with another nurse
h Remove the syringe and insert ___________________________
Carefully draw up the correct amount of insulin Double check
again with another nurse before removing the syringe from the
vial
2 What do you do if you draw up too much long-acting insulin?
3 If you have the following order: Give 5u Humulin R and 10 u NPH
sub-q, q am How would you draw up the dosage?
C Sliding Scale Insulin
1 Sample Sliding Scale
4u Humulin R insulin for glucose 151 - 200 mg/dl
6u Humulin R insulin for glucose 201 - 250 mg/dl
8u Humulin R insulin for glucose 251 - 300 mg/dl
10u Humulin R insulin for glucose 301 - 350 mg/dl
Call MD for glucose 350 mg/dl
2 If FSBS FSBS 189, how much insulin would you give?
3 If FSBS 309, how much would you give?
4 If FSBS 120, how much would you give?
5 If FSBS 60, how much would you give? Would you do anything?
D Insulin Injections
1 The four main areas for injection are:
2 LIPODYSTROPHY
3 Absorption issues
4 Flocculation:
Small group Questions
1 When is a sliding scale commonly used?
2 A tuberculin syringe is also calibrated in units Is it OK to use
a TB syringe to draw up insulin?
3 What route is insulin administered?
Insulin Pumps
E Complication of Insulin therapy
1 Hypoglycemia Insulin Shock
|Neuro | |
|Cardiovascular | |
|Respiratory | |
|Gastro-intestina| |
|l | |
|Genital-urinary | |
|Skeletal/muscula| |
|r | |
|Intugementary | |
a Compare the signs and symptoms of hyper and hypoglycemia
b How come they are not all opposite signs and symptoms?
c Why are
some so similar?
d Which symptoms can you look for to tell the difference between
hyper and hypoglycemia?
e Identify the components of a complete endocrine physical assessment
f What type of insulin is used in an insulin pump?
g What is the biggest risk factor in using an insulin pump?
h What qualifications would you look for in recommending a client for
using an insulin pump?
2 Local allergic Reactions
3 Insulin Resistance
4 Lipodystrophy
Causes of Morning Hyperglycemia:
| | |
|Characteristic |Treatment |
| | |
|INSULIN WANING | |
|Progressive rise in blood glucose | |
|from bedtime to morning | |
| | |
| | |
|22 23 0 1 2 3 |
|
|4 5 6 | |
| | |
|DAWN PHENOMENON | |
|Relatively normal glucose levels | |
|until about 3:00 AM, when the level | |
|begins to rise | |
| | |
| | |
| | |
|22 23 0 1 2 3 | |
|4 5 6 7 | |
| | |
|SOMOGYI EFFECT/PHENOMENON | |
|Normal or elevated blood glucose at | |
|bedtime, a decrease at 2-3 am | |
|hypoglycemic levels and a
| |
|subsequent increase in blood glucose| |
|levels, caused by the production of | |
|counter-regulatory hormones | |
|glucagons: which stimulates the | |
|liver to convert glycogen to glucose| |
|and release glucose into the blood | |
|stream | |
| | |
| | |
|22 23 0 1 2 3 | |
|4 5 6 7 | |
Questions from the reading
Brunners Suddarths Medical-Surgical Nursing
Chapter 41: Assessment and Management of Patients with Diabetes Mellitus
1 What is wrong with the following charting?
Mrs White is a 45-year-old type II IDDM
2 When is the usual onset of gestational diabetes?
3 What is the most
common complication of gestational diabetes?
4 When are women usually screened for gestational diabetes?
5 Why do type 2 diabetics not get DKA?
6 What happens after delivery for a woman with gestational diabetes?
7 What is the medical management for a patient with gestational
diabetes?
8 If you want to loose 1-2 pound a week weight, what changes should
you make in your diet?
9 What affect/risk factors does drinking alcohol pose to a diabetic?
10 What are precautions involved with diabetics and exercise?
11 What steps/procedures are recommended when a diabetic exercises?
12 What diagnostic test allows the medical team to know if glucose levels
have been near- normal over an extended period of time?
13 How do we test for an increase in ketone in the body?
14 When should a diabetic test for elevated ketone?
15 Review table 41-4 Which schematic most closely represents normal
pancreas activity? Why?
16 if you were a diabetic, which regiment would you want to follow? Why?
17 If a patient takes intermediate acting insulin, how many doses a day
are usually needed to provide 24 hours coverage?
18 What risk is there in
intensive treatment of diabetics in regards
to insulin administration?
19 How often are the needles/catheters changes on a patient with an
insulin pump?
20 Review Table 41-7 How would you respond to a patent that expressed
the different misconceptions?
21 Does insulin have to be refrigerated?
22 How do you prepare the skin for injection?
23 Do you aspirate when administering insulin injections?
24 What can cause hypoglycemia?
25 Why is hypoglycemia a particular problem for geriatric patients?
26 Why is glucagon used in the treatment of hypoglycemia? What side
effects does it have? What limitation does it have?
27 Review figure 41-8
28 How does a patient prevent DKA?
29 What are the sick day rules for a patient?
30 What teaching must be done to help a patient care for their feet?
31 What nursing considerations are there for a patient with diabetes
undergoing surgery?
32 Identify the special considerations involved with the following
dietary changes: NPO; Clear liquid; NGT or GO feedings
Source:jdrfgeorgia.org
