Angeles University Foundation

College of Nursing
A.Y. 2010-2011

Nursing Care Management 103

Management of Endocrine Disorders: DIABETES MELLITUS

A. DEFINITION: A metabolic disease characterized by elevated levels of glucose in the blood resulting from
imbalance between insulin supply and demand due to defective insulin secretion, insulin action or
both.

1. Review of Health Promotion and Primary Disease Prevention

2. Secondary Disease Prevention

Diagnosis of DM

Fasting Blood glucose

• Generally reflects glucose level from hepatic production.
• In clients with DM, food and insulin are withheld until after the specimen is obtained.
• Diagnosis of DM is made when the client’s FBS level is greater than 126 mg/dL.
• Values between 110 – 125 mg/dL indicate impaired fasting glucose.
• Provides the best indication of overall glucose homeostasis and is the preferred method of diagnosing DM.
• No caloric intake for at least 8 hours
• Normal result: 70-110 mg/dl

Casual Blood Glucose level or RBS

• Diagnosis of DM is made with clinical manifestations and RBS level greater than 200 mg/dL
• Blood sample can be drawn any time of day without regard to fasting
• Elevated blood glucose levels may occur after meals, after stressful events, in samples drawn from an IV site,
or in cases of DM
• Normal up to 140mg/dl

Postload Blood Glucose Level

- samples are drawn 2hrs after a standard meal and reflect efficiency of insulin-mediated glucose uptake by
peripheral tissues.
• -Normal result: blood glucose should return to fasting levels within 2hrs.
• -If > 200mg/dl during an oral glucose tolerance test (OGTT) confirms DM

 Oral Glucose Tolerance Test – not used as routine test

- client ingests 150g-300g of CHO per day for 3 days before the test
- sample is drawn to test FBS & the client is given 75g of glucose in water to drink, blood samples are obtained
at intervals afterwards (after 1 & 2 hrs)
- client cannot consume any food or fluid other than water between the glucose load ingestion & the end of
the test.

LABORATORY TESTS RELATED TO DM

Glycosylated Hemoglobin
- Glucose normally attaches itself to hemoglobin molecule on a RBC and it will never dissociate.
- The higher the blood glucose level, the higher the glycosylated hemoglobin.
- A1C – average blood glucose level measured over the previous 3 months
- Stated in percentage and is useful in evaluating long term glycemic control
- ADA recommends < 7% to prevent complications of DM
- Done semiannually in clients who have met the primary goal for glycemic control ( <7%)
- Quarterly in clients who have not met the primary goal for glycemic control
- Bleeding, asplenia, pregnancy lead to falsely low A1C concentrations.
- High aspirin doses, alcohol ingestion, uremia, elevated Hgb levels, and heparin therapy cause falsely elevated
A1C levels.

Glycosylated Albumin Level

- Glucose also attaches to CHON primarily albumin
- It represents the average blood glucose level over the previous 7-10 days
- Useful when short-term determinations of average blood glucose level are desired

Connecting Peptide (C-Peptide) Level

- When proinsulin produced by pancreatic beta cells is broken apart by an enzyme, two products are formed:
INSULIN and C-Peptide.
- Insulin and C-peptides are formed in EQUAL amounts
- Indicates amount of endogenous insulin production
- DM 1 – no or low C-peptide
- DM 2 – normal to elevated C- Peptide

Ketonuria
- Use of dipstrips or tablets
- Presence of ketones in urine indicates that the body is using fat as a major source of energy, which may result
in ketoacidosis.
- Results are indicated by color changes
- All clients with DM should test their urine for ketones during acute illness or stress, when blood glucose is
>240 mg/dL, when they are pregnant or have evidence of ketoacidosis (N/V, abdominal pain)
 - Although urine testing for ketones is important, urine glucose testing is not reliable method for monitoring.

Proteinuria
- Protein in the urine indicates kidney disease
- Indicates early nephropathy, long before it would be evident on routine UA
- ALL patients with DM should be tested for microalbuminuria ANNUALLY
- Patients taking nephrotoxic medications should be tested more frequently

SELF MONITORING OF BLOOD GLUCOSE (SMBG)

• The key to management of DM is to keep blood sugar as close to normal as possible
• It provides immediate feedback and data on blood sugar level
• Is recommended for all clients with DM
• It is a way to know how body responds to food, insulin, activity and stress
• Frequency and timing depend on the needs and goals of each patient
• DM 1 and Pregnant women taking insulin – 3 or more times daily
• Testing is done before each meal, before bedtime and possibly in the middle of the nigh (3 AM)
• DM 2 = frequency is agreed upon by patient and HCP
• DM 2 taking OHA – no need to monitor as often as a DM 2 patient taking insulin
• Extra times to SMBG levels should include the following:
o When starting a new drug (oral agent) or insulin
o When starting OTC drug that could affect blood glucose (eg. steroid)
o When sick or under stress
o When the patient thinks the glucose level is too low or too high
o When the patient loses/gains weight
o When there is a change in medication dose, eating plan or physical activity plan

3. Tertiary Disease Prevention

A. Medical Management
Includes restoring and maintaining blood glucose levels to as near as normal as possible by balanced diet, exercise
and use of OHA or insulin.

Oral antidiabetic agents

1. Sulfonylureas
- stimulate the beta cells to secrete insulin
- 2nd gen sulfonylureas increase tissue response to insulin (insulin sensitizer), decrease hepatic
production of glucose, decrease absorption of glucose in the small intestine and decrease triglyceride and LDL levels.

2. Meglitinides
- stimulate the beta cells to secrete insulin
3. Biguanides
4. Thiazolidinediones
- – increase insulin action at receptors and post-receptors in hepatic and peripheral tissue to
decrease insulin resistance and often decrease triglyceride level
5. Alpha glucosidase inhibitors –
- delay the digestion of complex CHO and certain sugars to blunt the peak of blood glucose and
insulin levels after meal.

6. Incretin Mimetics
• New class of medication based on incretin hormones
• Incretin hormones are GI hormones that are released following food ingestion
• Glucagon-like peptide (GLP-1) and glucose dependent insulinotropic polypeptide (GIP)
• They play a role in stimulating insulin secretion and facilitating homeostasis following food ingestion.

Byetta (Exenatide) - GLP-1 receptor agonist.

• Indicated for people with DM 2 who are not adequately controlled with sulfonylurea, metformin or combination
of both.
• Enhances insulin secretion in response to elevated blood glucose
• RISK OF HYPOGLYCEMIA – if used with sulfonylurea, or combination of metformin and sulfonylurea.
• SE: n/v, diarrhea.

7. Amylinomimetics/Antihyperglycemic
Symlin (Pramlintidine)
• injectable drug for use in people with DM type 1 and 2
o regulates glucose concentration in post prandial state,
o enhances satiety leading to weightloss
o decreases mealtime insulin requirements
o improves glycosylated hemoglobin levels
o slows gastric emptying
o suppress glucagon secretion
• SE: Nausea – tx: ingest amylin with 30 g of CHO or 250 calories
• C/I: Not compliant with current insulin regimen or does not check glucose level 3-4 times a day
o history of hypoglycemia requiring assistance
o diagnosed with gastroparesis and use medication that stimulate gastric motility
o Pediatric and pregnant patients

Other related medications

 • ACE inhibitors – to decrease blood pressure and minimize and nephropathic changes
• Aspirin or Ticlopidine – decrease risk of thrombus formation
• calcium channel blockers and diuretics – to manage hypertension
• Antilipemic drugs – prevent or treat micro and macrovascular complications

Insulin Therapy
- “Inhaled insulin,” insulin patch, oral spray or capsule

Type of Insulin Appearance Onset Peak Duration

Rapid acting
Humalog (Insulin Lispro) clear 5-15 min 1 hr 2-4 hrs
NovoLog (Insulin Aspart)
Short acting
Humulin R (Regular) clear 0.5-2 hrs 2-4 hrs 4-6 hrs
Semi-lente clear 1-2 hrs 4-6 hrs 8-12 hrs

Intermediate acting
NPH/Humulin N White, milky 2-4 hrs 4-10 hrs 10-16 hrs
Lente/Humulin L cloudy
Humulin 70/30 (Premixed) 0.5-1 hr Dual 10-16 hrs

Long acting
Humulin U (ultralente) clear 6-10 hrs None 18-30 hrs

Very Long acting

Lantus (Insulin glargine) clear 1 hr None 24 hrs

Insulin Sources: pork pancreas, beef pancreas

-Human insulin (chemically recombinant DNA) – peaks more precisely & predictably
- has shorter duration of action
- has reduced antigenicity
- does not cause lipoartrophy/lipodystrophy
b. Insulin dosage: starting dose = 0.5 ‘u’/kg/day (2/3 in am & 1/3 in pm)
c. Insulin pump therapy (continuous subcutaneous insulin infusion): small pump worn externally, which
injects insulin SQ into the abdomen through an indwelling needle site changed every 1-3 days.
d. Inhaled insulin

MANAGEMENT OF ACUTE COMPLICATIONS OF DIABETES MELLITUS

A. DIABETIC KETOACIDOSIS (DKA)

 Rehydrate/ Reversal of Shock

HOUR 1
15-20 ml/kg PNSS or PLRS

HOUR 2
Same fluid at 15 ml/kg
0.45% NSS if with increased NA, heart failure or a child

Hour 3
Reduce fluid intake to 7.5 ml/kg in adults. 0.45% NSS

Hour 4
Adjust fluid intake to meet clinical need. Consider UO in calculation
a. PNSS 1 L during the first hour, followed by additional 6 to 10 liters of solution over
the next 24hours
b. Or 45% NaCl, D5W
c. Monitor I&O, v/s, respiratory status, signs of fluid overload
-administer blood, albumin or other plasma volume expanders alternately with PNSS

 Restore Potassium Balance

IV replacement of potassium is based on plasma K concentration:

<3 mEq/L, infuse ≥0.6 mEq/kg/hour
3-4 mEq/L, infuse 0..6 mEq/kg/hr
4-5mEq/L, infuse 0.2-0.4 mEq/kg/hr
6 mEq/L. withhold until K concentration is <6.0 mEq/L

Recheck plasma K every 2 hours if previous value was <4 or >6 mEq/L
a. Frequently assess and measure urine output
b. Assess for hyperkalemia/hypokalemia
c. Replace potassium carefully
d. Resume intake of potassium-rich foods if the client has recovered
e. Monitor Na, Cl and phosphate levels

 Reversal of Metabolic Acidosis (Correct pH and administer insulin)

 a. administer sodium bicarbonate to clients with a blood pH of 7.1 or less
b. administer low-dosage insulin therapy (5-10 units/hr)

B. HYPERGLYCEMIC, HYPEROSMOLAR, NONKETOTIC SYNDROME (HHNS)

 Rehydrate/ Reversal of Shock and Restore Electrolyte Balance

a. infusion of PNSS over a 2-hour period, followed by administrations of hypotonic (0.45%) saline solution
b. administration of K, Na, Cl, PO4, insulin
c. Frequently assess and measure urine output, central venous pressure

C. HYPOGLYCEMIA

 Return blood glucose to normal levels

Mild Hypoglycemia
• 10-15 g of CHO contained in the following:
o 4 oz orange juice
o 6 oz regular soda
o 6-8 oz 2% milk
o 6-8 lifesaver candies
o 1 small (2 0z) tube of cake icing
o 4 tsp granulated sugar

Moderate Hypoglucemia
• 20-30 g of CHO
• 1 mg Glucagon IM/ SQ

Severe Hypoglycemia
• 25 g 50% Dextrose IV
• 1 mg Glucagon IM or IV

 Prevent hypoglycemia

Other Hypoglycemic Disorders

Somogyi Effect
• Decrease evening dose of intermediate acting insulin or increase bedtime snack
Dawn Phenonmenon
• Administer NPN at 10:00 PM

CHRONIC COMPLICATIONS OF DIABETES MELLITUS

B. Surgical Management

Pancreas transplant
Indications: DM Type 1
Contraindications: Kidney failure
DM type 2
Problems that unable the client to withstand surgery

Complications:
• Vessel Thrombosis – characterized by sharp and sudden decrease in urine amylase levels and rapid increases
in blood glucose levels, gross hematuria, tenderness in graft area and severe pain in ilia fossa.
• Rejection - fever, increased serum creatinine and BUN, weight gain and graft tenderness
o PRoteinuria – chronic rejection
o Decreased urine amylase, hyperglycemia and graft tenderness
o Preventive measure: Immunosppressive therapy with monoclonal antibodies (OKT3) or polyclonal antibody
preparations (cyclosporine [Sandimmune] and azathioprine [Immuran] and prednisone).
• Infection.

Outcomes: Discharged from the hospital within 7-10 days without the need for insulin.

 Pancreas and Pancreas-Kidney Transplantation

- Client’s own pancreas is left intact and the new pancreas is anastomosed to the iliac artery and vein, through
which insulin can enter the systemic pathway.

- whole or segment/ ISLET CELL TRANSPLANT

Management of a client with DM undergoing other types of surgery
Preoperative Nursing Care
• Preop lab tests including FBS, post prandial blood glucose, HgA1C, serum electrolytes, BUN, CreatinineCBC,
ECG, cardiac enzymes and CXR
• Early morning scheduling of surgery so that client’s diet and insulin regimen undergo as little disruption as
possible
• NPO including OHAs on the morning of surgery
• IV infusion of insulin for insulin dependent or insulin requiring clients, usually with 5% glucose to prevent
hypoglycemia
• Blood glucose determination 1 hour before the surgery
Intraoperative Nursing Care
• Management depends on the severity of DM and extent of surgery.
• Regular insulin dose based on client’s glucose level can be given IV
• Insulin is not administered subcutaneously during intraoperative period because its absorption is affected by
body temperature, circulatory blood volumes and certain anesthetics.

Postoperative Nursing Care

• Goal: Stabilize client’s vital signs, correct fluid and electrolyte imbalance, reestablish control of DM, prevent
wound infection and promote wound healing.
• Administer prescribed IV infusions and regular insulin until the client can take oral nourishment
• Once the client can tolerate fluids, offer those that contain calories to prevent hypoglycemia
• Obtain blood glucose levels 4-6 times daily
• Resume the client’s prescribed preoperative insulin type and dosage once blood glucose control is
reestablished
• Observe for signs of hypoglycemia such as decrease in blood pressure or increase in HR in a client who
remains unresponsive from anesthesia
• Avoid catheterization, if possible, to prevent bladder infection
• Change wound dressings with meticulous sterile technique to prevent wound infection
• Assess the client’s wound and incision frequently to monitor for signs of infection.
• Observe for and treat manifestations of skin breakdown, especially if the client has peripheral vascular disease
or neuropathy

C. Nursing Management

Fluid Volume deficit may be related to Osmotic diuresis (from hyperglycemia), Excessive gastric losses: diarrhea,
vomiting, Restricted intake: nausea, confusion Possibly evidenced by Increased urinary output, dilute urine, Weakness;
thirst; sudden weight loss, Dry skin/mucous membranes, poor skin turgor, Hypotension, tachycardia, delayed capillary
refill

Interventions
• Monitor vital signs:
o Note orthostatic BP changes;
o Respiratory pattern, e.g., Kussmaul’s respirations, acetone breath;
o Respiratory rate and quality; use of accessory muscles, periods of apnea, and appearance of cyanosis;
o Temperature, skin color/moisture.
• Assess peripheral pulses, capillary refill, skin turgor, and mucous membranes.
• Monitor I&O; note urine specific gravity.
• Weigh daily.
• Maintain fluid intake of at least 2500 mL/day within cardiac tolerance when oral intake is resumed.
• Promote comfortable environment. Cover patient with light sheets.
• Investigate changes in mentation/sensorium.
• Administer fluids as indicated:
o Isotonic (0.9%) or lactated Ringer’s solution without additives;
o Albumin, plasma, dextran.
• Insert/maintain indwelling urinary catheter.
• Monitor laboratory studies, e.g.:
o Hct;
o BUN/creatinine (Cr);
o Serum osmolality;
o Sodium;
o Potassium.
• Administer potassium and other electrolytes via IV and/or by oral route as indicated.
• Administer bicarbonate if pH is less than 7.1.
• Insert NG tube and attach to suction as indicated.

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Fluid Balance (NOC)
Demonstrate adequate hydration as evidenced by stable vital signs, palpable peripheral pulses, good skin turgor and
capillary refill, individually appropriate urinary output, and electrolyte levels within normal range.

NURSING DIAGNOSIS: Nutrition: imbalanced, less than body requirements

May be related to
Insulin deficiency (decreased uptake and utilization of glucose by the tissues, resulting in increased protein/fat
metabolism)
Decreased oral intake: anorexia, nausea, gastric fullness, abdominal pain; altered consciousness
Hypermetabolic state: release of stress hormones (e.g., epinephrine, cortisol, and growth hormone), infectious
process
Possibly evidenced by
Increased urinary output, dilute urine
Reported inadequate food intake, lack of interest in food
Recent weight loss; weakness, fatigue, poor muscle tone
Diarrhea
Increased ketones (end product of fat metabolism)

Nursing Interventions
• Weigh daily or as indicated.
• Ascertain patient’s dietary program and usual pattern; compare with recent intake.
 • Auscultate bowel sounds. Note reports of abdominal pain/bloating, nausea, vomiting of undigested food.
Maintain nothing by mouth (NPO) status as indicated.
• Provide liquids containing nutrients and electrolytes as soon as patient can tolerate oral fluids; progress to
more solid food as tolerated.
• Identify food preferences, including ethnic/cultural needs.
• Include SO in meal planning as indicated.
• Observe for signs of hypoglycemia, e.g., changes in level of consciousness, cool/clammy skin, rapid pulse,
hunger, irritability, anxiety, headache, lightheadedness, shakiness.
• Perform fingerstick glucose testing.
• Monitor laboratory studies, e.g., serum glucose, acetone, pH, HCO3.
• Administer regular insulin by intermittent or continuous IV method, e.g., IV bolus followed by a continuous drip
via pump of approximately 5–10 U/hr so that glucose is reduced by 50 mg/dL/hr.
• Administer glucose solutions, e.g., dextrose and half-normal saline.
• Consult with dietitian for initiation of resumption of oral intake.
• Provide diet of approximately 60% carbohydrates, 20% proteins, 20% fats in designated number of
meals/snacks.
• Administer other medications as indicated, e.g., metoclopramide (Reglan); tetracycline.

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Ingest appropriate amounts of calories/nutrients.
Display usual energy level.
Demonstrate stabilized weight or gain toward usual/desired range with normal laboratory values.

NURSING DIAGNOSIS: Infection, risk for [sepsis]

Risk factors may include:
High glucose levels, decreased leukocyte function, alterations in circulation
Preexisting respiratory infection, or UTI

Nursing Interventions
• Observe for signs of infection and inflammation, e.g., fever, flushed appearance, wound drainage, purulent
sputum, cloudy urine.
• Promote good handwashing by staff and patient.
• Maintain aseptic technique for IV insertion procedure, administration of medications, and providing
maintenance/site care. Rotate IV sites as indicated.
• Provide catheter/perineal care. Teach the female patient to clean from front to back after elimination
• Provide conscientious skin care; gently massage bony areas. Keep the skin dry, linens dry and wrinkle-free.
• Auscultate breath sounds.
• Place in semi-Fowler’s position.
• Reposition and encourage coughing/deep breathing if patient is alert and cooperative. Otherwise, suction
airway, using sterile technique, as needed.
• Provide tissues and trash bag in a convenient location for sputum and other secretions. Instruct patient in
proper handling of secretions.
• Encourage/assist with oral hygiene.
• Encourage adequate dietary and fluid intake (approximately3000 mL/day if not contraindicated by cardiac or
renal dysfunction), including 8 oz of cranberry juice per day as appropriate.
• Obtain specimens for culture and sensitivities as indicated.
• Administer antibiotics as appropriate.

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Knowledge: Infection Control (NOC)
Identify interventions to prevent/reduce risk of infection.
Demonstrate techniques, lifestyle changes to prevent development of infection.

NURSING DIAGNOSIS: Fatigue

May be related to
Decreased metabolic energy production
Altered body chemistry: insufficient insulin
Increased energy demands: hypermetabolic state/infection
Possibly evidenced by
Overwhelming lack of energy, inability to maintain usual routines, decreased performance, accident-prone
Impaired ability to concentrate, listlessness, disinterest in surroundings

Nursing Interventions
• Discuss with patient the need for activity. Plan schedule with patient and identify activities that lead to fatigue.
• Alternate activity with periods of rest/uninterrupted sleep.
• Monitor pulse, respiratory rate, and BP before/after activity.
• Discuss ways of conserving energy while bathing, transferring, and so on.
• Increase patient participation in ADLs as tolerated

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL

Endurance (NOC)
Verbalize increase in energy level.
Display improved ability to participate in desired activities.

Readiness for Enhanced self-care related to desire to learn about diabetes mellitus and management options, physical
activity for diabetes mellitus management and dietary management of DM

Interventions
• Explain the pathophysiology of DM
 • Plan a physical activity program
• Prevent complications from physical activity
o Make sure that patient is adequately hydrated before starting an exercise
o Eat 15-30 grams of CHO if glucose level is < 100mg/dl and should carry a snack
o If blood glucose level is 100-150 mg/dl – may exercise and eat a snack LATER
o If blood glucose level is > 250 mg/dl and the client has not eaten, ketone levels should be checked
o Avoid alcohol and beta blockers since they may increase the risk for hypo/hyperglycemia
• Plan a nutrition therapy to achieve target blood glucose level
o Calories- sufficient to achieve and maintain reasonable weight
o CHON – adequate to ensure maintenance of body protein stores; clients with DM have some protein
requirements as

Risk for unstable blood glucose r/t lack of knowledge and lack of previous experience with testing blood and urine and
lack of knowledge and lack of experience with self-injection of insulin

Nursing Interventions
• Provide instruction on blood glucose monitoring
• Provide instruction on urine testing
• Provide instruction on insulin administration

NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding disease, prognosis, treatment,
self-care, and discharge needs
May be related to
Lack of exposure/recall, information misinterpretation
Unfamiliarity with information resources
Possibly evidenced by
Questions/request for information, verbalization of the problem
Inaccurate follow-through of instructions, development of preventable complications

Nursing Interventions
• Create an environment of trust by listening to concerns, being available.
• Work with patient in setting mutual goals for learning.
• Select a variety of teaching strategies, e.g., demonstrate needed skills and have patient do return
demonstration, incorporate new skills into the hospital routine.

HEALTH EDUCATION:

A. The disease (pathology) & treatment modalities

B. Recognition & prevention of complications
C. Appropriate preventive behaviors and management

- FOOT CARE - inspect feet on a daily basis

- wear well-fitting, closed-toe shoes
- avoid walking bare-footed, use heat pads & shaving of calluses
- trim toenails straight across without rounding the corners
- NUTRITION
- EXERCISE
- MONITORING - demonstrate techniques
- discuss normal blood glucose range
- discuss when to test & how to record results
- what to do for abnormal results

-INSULIN ADMINISTRATION - provide instruction on insulin administration

a. insulin concentrations and preparation
b. insulin syringes= 100 ‘u’ in 1ml
c. insulin storage=refrigerators
- avoid temperature extremes < 36F or >86F
- vials can be stored at room temp. for 1 month
- inspect for flocculation
- pre-filled syringes = chemically stable for up to 3 wks. in refrigerator
f. site selection, rotation and techniques for self injection

GENERAL GUIDELINES:
a. abdomen, posterior arms, anterior thighs, hips
b. give injection in one area about an inch apart until whole area has been used
c. avoid sites above muscles that will be exercised heavily
d. rotate injection sites to decrease variability of absorption