Individuals Experiencing Diabetes Mellitus

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Individuals Experiencing Diabetes Mellitus

• NURS2016

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Diabetes Mellitus

• A multisystem disease related to
• Abnormal insulin production
• Impaired insulin utilization
• Both

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Diabetes Mellitus

• Leading cause of heart disease, stroke, adult
  blindness, and non-traumatic limb amputation
• In Canada, 7th leading cause of death
• Hospitalization rates are 2.4 and 5.3 X greater
  for adult and child than general population
• Diabetes higher in Algoma and Cochrane
• The number of Ontarians with diabetes has
  increased by 69 per cent over the last 10 years
  and is projected to grow from 900,000 to 1.2
  million by 2010

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Local Reality (2007)

• NELHIN 7.5
• Nipissing Parry Sound 6.7
• Timiskaming 10
• Ontario as a whole 6.1

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Type 1

• Formerly known as juvenile diabetes
• Most often occurs under 30 years of age
• Peak onset 11-13 years

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Type 1Onset of Disease

• Manifestations develop when the pancreas can no
  longer produce insulin
• Rapid onset of symptoms
• Present in ER with ketoacidosis

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Type 1

• Weight loss
• Polydipsia
• Polyuria
• Polyphagia

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Type 1

• Diabetic Ketoacidosis
• Occurs in the absence of exogenous insulin
• Life threatening
• Results in metabolic acidosis

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Type 2

• Formerly called adult onset diabetes
• Accounts of 90 of patients with diabetes
• Usually gt40 years of age
• Recently seen in children as young as 10
• 80-90 are overweight

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Type 2

• Onset of disease is gradual
• May be undetected for years

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Recommended blood glucose targets for people with
diabetes

• HB AIC
• Fasting blood glucose/ blood glucose before
  meals (mmol/L) Blood glucose two hours after
  eating (mmol/L)
• Target for most patients with diabetes 7.0 4.0
  to 7.0 5.0 to 10 Normal range 6.0 4.0 to 6.0
  5.0 to 8.0
• This information is based on the Canadian
  Diabetes Association 2008 Clinical Practice
  Guidelines for the Prevention and Management of
  Diabetes in Canada and is a guide. Talk to your
  doctor about YOUR blood glucose target ranges.
  A1C is a blood test that indicates an average of
  your overall blood glucose levels over the past
  120 days. A1C targets for pregnant women and
  children 12 years of age and under are different.

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Diabetes MellitusCollaborative Care

• Goals of diabetes management
• Reduce symptoms
• Promote well-being and quality of life
• Prevent acute complications
• Delay onset and progression of long-term
  complications

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Clinical Manifestations
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Diabetic Ketoacidosis

• A medical emergency
• Sometimes brought on by stress, surgery,
  pregnancy, puberty, infection
• 1 cause person with diabetes not taking his/her
  insulin (fed up or non-compliance)
• S S
• ketosis
• dehydration
• electrolyte and acid-base imbalance

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DKA

• Abd pain
• Nausea
• Vomiting
• Hyperventilation
• Fruity odor to breath
• If untreated,
• Altered LOC
• Coma
• death

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Diabetic Coma

• Bicarbonate buffering system fails to compensate
  for ketosis
• Respirations increase in rate and depth
  (Kussmauls respirations) breath has fruity or
  acetone odour
• Renal system attempts to excrete ketones which
  leads to hemoconcentration
• Hemoconcentration impedes blood circulation
  leads to tissue anoxia lactic acid production
• The rise in lactic acid production further
  acidifies blood pH
• Rising ketones eventually overwhelms the bodys
  defenses against the acid the body succumbs to
  coma

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Hypoglycemia

• To treat low blood sugar the 15/15 rule is
  usually applied. Eat 15 grams of carbohydrate and
  wait 15 minutes. The following foods will provide
  about 15 grams of carbohydrate
• 3 glucose tablets
• Half cup (4 ounces) of fruit juice or regular
  soda
• 6 or 7 hard candies
• 1 tablespoon of sugar
• After the carbohydrate is eaten, the person
  should wait about 15 minutes for the sugar to get
  into their blood. If the person does not feel
  better within 15 minutes more carbohydrate can be
  consumed. Their blood sugar should be checked to
  make sure it has come within a safe range.

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Diabetes MellitusCollaborative Care

• Patient teaching
• Nutritional therapy
• Drug therapy
• Exercise
• Self-monitoring of blood glucose

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Complications Acute

• Acute
• Hypoglycemia sweating, tremor, tachycardia,
  palpitations, nervousness, hunger, -- confusion,
  numbness lips/tongue, slurred speech, --
  irrational/combative behaviour disoriented,
  seizures, loss of consciousness
• Immediate Treatment 15gm of fast-acting carb

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Complications Acute

• Diabetic Ketoacidosis
• Hyperglycemia dehydration and electrolyte loss,
  acidosis
• Polyuria, polydipsia, blurred vision,
  dehydration, weakness, headache
• Tx rehydration, electrolyte balance, reversing
  acidosis
• Monitoring fld/electrolyte status, glucose
  levels, administering insulin drip blood
  glucose is usually corrected before acidosis

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Complications Long-Term

• Angiopathy
• Retinopathy
• Nephropathy
• Neuropathy
• Skin problems
• Infection

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Nutritional Therapy

• Overall goal assist people in making changes in
  nutrition and exercise habits that will lead to
  improved metabolic control
• Canadas Food Guide Exchange System

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Nutritional therapy

• Type 1
• Meal plan based on the individuals usual food
  intake and is balanced with insulin and exercise
  patterns
• Type 2
• Emphasis placed on achieving glucose, lipid, and
  blood pressure goals
• Caloric reduction

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Nutritional therapy

• Food composition
• Individual meal plan developed with a dietician
• Nutritionally balanced
• Does not prohibit the consumption of any one type
  of food
• Dietician provides initial support

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Exercise

• Essential part of diabetes management
• Increases insulin sensitivity
• Lowers blood glucose levels
• Decreases insulin resistance
• Several small complex carbohydrate snacks can be
  taken q30m during exercise

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Exercise

• Best done after meals
• Monitor blood glucose levels before, during and
  after exercise

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Blood Glucose Monitoring

• Enables patient to make self-management decisions
• Important for detecting episodic hypo or
  hyperglycemic events

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Nursing Management

• Assessment
• Weight loss/gain
• Thirst
• Hunger
• Healing pattern

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Nursing Management

• Nursing diagnosis
• Ineffective therapeutic regime management
• Fatigue
• Risk for infection
• Powerlessness

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Nursing Management

• Goals
• Active patient participation
• No episodes of acute hypo or hyperglycemia
• Maintaining normal blood glucose levels
• Prevent complications
• Lifestyle adjustment with minimal stress

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Ontario Launches Diabetes Strategy

• 741 Million Plan Will Make Patients Partners In
  Care July 22, 2008
• Ontario is investing 741 million in new funding
  on a comprehensive diabetes strategy over four
  years to prevent, manage and treat diabetes. 

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Diabetes Strategy

• The strategy includes an online registry that
  will enable better self-care by giving patients
  access to information and educational tools that
  empower them to manage their disease. The
  registry will also give health care providers the
  ability to easily check patient records, access
  diagnostic information and send patient alerts.  

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Key elements of the strategy include

• Increasing access to team-based care closer to
  home by mapping the prevalence of diabetes across
  the province and the location of current diabetes
  programs in order to align services and address
  service gaps.
• Ontarios diabetes strategy will help tackle a
  growing and expensive health care challenge..
  Treatment for diabetes and related conditions
  such as heart disease, stroke, and kidney disease
  currently cost Ontario over 5 billion each year.

• Improving access to insulin pumps and supplies
  for more than 1300 adults with type 1 diabetes by
  funding these services for people over the age of
  18.
• Expanding chronic kidney disease services,
  including greater access to dialysis services.
• Implementing a strategy to expand access to
  bariatric surgery. 
• Educational campaigns to prevent diabetes by
  raising awareness of diabetes risk factors in
  high risk populations, such as the Aboriginal and
  South Asian communities.