Nursing Care of Patients with Diabetes

 

DIABETES MELLITUS

Definition:

Diabetes is a group of metabolic diseases characterized by increased levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both.

Types and Causes

1.      Type 1 Diabetes Mellitus

Type 1 diabetes (formerly called juvenile diabetes mellitus, insulin-dependent diabetes mellitus, or IDDM) is caused by destruction of the beta cells in the islets of Langerhans of the pancreas. When the beta cells are destroyed, they are unable to produce insulin.

2.      Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (formerly called adult-onset diabetes mellitus, non–insulin-dependent diabetes mellitus, or NIDDM). In type 2 diabetes mellitus, tissues are resistant to insulin.

3.      Gestational Diabetes

Gestational diabetes mellitus (GDM) occurs in pregnancies, especially in women with risk factors for type 2 diabetes. The extra metabolic demands of pregnancy trigger the onset of diabetes.

4.      Prediabetes

Prediabetes usually occurs before the onset of type 2 diabetes. Those with prediabetes may be able to prevent the onset of diabetes with weight loss and exercise.

5.      Other Types of Diabetes

·       Secondary diabetes can develop as a result of another chronic illness that damages the islet cells, such as pancreatitis or cystic fibrosis.

·       Prolonged use of some drugs, such as steroid hormones, phenytoin, thiazide diuretics, and thyroid hormone, can also impair insulin action and raise blood glucose.

·       Less common causes include pancreatic trauma and other endocrine disorders.

Risk factors:

·       Physical inactive

·   First degree relative with diabetes

·       Hypertension ≥ 140/90 mm Hg.

·       HDL cholesterol < 35 mg/dL and/or triglyceride level >250 mg/dL.

·       Diagnosis of prediabetes

·       Prior history of GDM

·       History of cardiovascular disease

·       History of insulin resistance

Signs and Symptoms:

·       Polydipsia (excessive thirst),

·       Polyuria (excessive urination), and

·       Polyphagia (excessive hunger).

·       Fatigue and weakness,

·       Sudden vision changes,

·       Tingling or numbness in hands or feet,

·       Dry skin, skin lesions

·       Delayed wound healing and

·       Recurrent infections.

Pathophysiology:

                      Diet high in Carbohydrates
                          + Sedantary life Style
                                      + Genetic

                                             ⬇️

              Insulin levels increase in blood stream

                                             ⬇️ 

                      Cell becomes resistant to insulin

                                             ⬇️

                      Blood glucose levels becomes high

                                             ⬇️

                                   Type 2 Diabetes

Diagnostic Criteria:

1.      Fasting Plasma Glucose Level

When the fasting plasma glucose is 126 mg/dL or greater, diabetes is diagnosed.

If the fasting plasma glucose is between 100 and 125 mg/dL, the patient has prediabetes.

2.      Random Plasma Glucose

Diabetes is diagnosed if the Random Plasma Glucose is 200 mg/dL or greater, with symptoms of diabetes.

3.      Oral Glucose Tolerance Test

An OGTT measures blood glucose at intervals after the patient drinks a concentrated carbohydrate drink. Diabetes is diagnosed when the blood glucose level is 200 mg/dL or greater after 2 hours. A result between 140 and 199 mg/dL at 2 hours leads to a diagnosis of impaired glucose tolerance and prediabetes.

4.      Glycohemoglobin

The glycohemoglobin test (also called glycosylated haemoglobin, or HbA1c [haemoglobin A1C]). It reflects the average blood glucose level for the previous 2 to 3 months.

A normal HbA1c is 4% to 6%.

An HbA1c of 6.5% or higher is diagnostic for diabetes.

An HbA1c between 6% and 6.5% indicates prediabetes.

Complications of Diabetes Mellitus.

Complications associated with diabetes are classified as acute and chronic.

1.      Acute complications are:

·       Hypoglycemia

·       Hyperglycemia and Diabetes Keto Acidosis (DKA)

·       Hyperglycemic Hyperosmolar Non-ketotic Syndrome (HHNS)

2.      Chronic complications are:

v  Macrovascular (large vessel) disease:

·       Coronary vascular disease

·       Cerebrovascular disease

·       Hypertension

·       Peripheral vascular disease

v  Microvascular (small vessel) disease:

·       Diabetic Retinopathy

·       Diabetic Nephropathy

·       Neuropathy

·       Diabetic foot ulcer

Management:

Medical management for clients diabetes includes restoring and maintain blood glucose levels as near as possible by

1.      Balanced diet,

2.      Exercise,

3.      Use of oral hypoglycemic agents or insulin,

4.      Health education and

5.      Monitoring by follow-up and check ups.

1.      Balanced diet:

§  A balanced diet low in carbohydrate, low in fat and cholesterol is ideal for diabetes.

§  Advice the patient to avoid junk foods.

§  Instruct to increasing intake of low glycemic food.

§  Advice to eat lot of fibre rich diet and drink adequate amount of water

§  Advice to eat small frequent meals than three large meals.

§  Weight reduction is a primary treatment of type 2 diabetes.

2.      Exercise :

§  Exercise is important factors in controlling blood glucose and lipid level.

§  Regular scheduled, moderate exercise performed for at least 30 minutes per day.

§  An aerobic exercise, strengthening exercise, and stretching exercise can help the diabetic patients

3.      Oral hypoglycemic agents:

§  Alpha-glucosidase inhibitors (AGIs) Blocks the action of enzymes in digestive tract that break down the carbohydrates. Example: Acarbose

§  DPP-4 inhibitor Inhibits DPP-4, an enzyme that breaks incretins. Example: Sitagliptin

§   Biguanides Decreases glucose production by liver; increases glucose uptake by muscle. Example: Metformin

§ Thiazolidinediones Reduce insulin resistance in muscles. Example: Pioglitazone, Rosiglitazone

§  Sulfonylureas Stimulate insulin secretion by pancreas, increase insulin receptor sensitivity. Example : glipizide, glimepiride, glyburide

4.      Insulin:

§  Insulins are available in rapid-acting, short-acting, intermediate-acting, and long-acting preparations.

§  Insulin is administered by sterile, single-use needles and either disposable insulin syringes or a multiple dose insulin pen.

§   Insulin injections should be given in a different subcutaneous site with each dose to avoid tissue injury.

§  Aspirating for blood before injection and rubbing the site after injection are not recommended with insulin injections.

Nursing Diagnoses:

·       Imbalanced Nutrition: less than body requirements  

         related to insulin deficiency

·       Fear related to medication injection.

·       Risk for unstable blood glucose level related to effect of insulin                     

·       Activity Intolerance related to poor glucose control.

·       Deficient Knowledge related to use of oral hypoglycemic agents and injectable agents.

·       Risk for Impaired Skin Integrity related to decreased sensation and circulation to lower extremities.

·       Ineffective Coping related to chronic disease and complex selfcare regimen.

ASSESSMENT OF INTEGUMENTARY SYSTEM

ASSESSMENT OF INTEGUMENTARY SYSTEM

PATIENT PROFILE

Name                                       :       

Age                                          :       

Sex                                          :       

IP No                                       :       

Unit                                          :       

Ward                                        :

Date of Admission                   :

Religion                                   :       

Marital Status                          :       

Educational                             :

Reason for hospitalization       :

PRESENT HISTORY

C.O.L.D.S.P.A

C       -        Character           

O       -        Onset                  

L        -        Location             

D       -        Duration             

S        -        Severity              

P       -        Pattern               

A       -        Associated factors

SKIN

Current skin problem

          Rashes / LesIon / Dryness / Oilness / Drainage / Bruising / Swelling / Pigmentation increased.

Aggravating factor     :

Relieving factor           :

Change in tattoo or birthmark – color / size / shape.

Change in pain perception / touch / temperature / itching / tingling / numbness.

Body odour: increased / decreased.

Perspiration: increased / decreased.

Hair and Nail:

Hair loss / change in hair condition

Hair loss: Patchy / Generalized

Nail changes: Colour / condition / appearance

PAST HEALTH HISTORY

History of – treatment / surgery / Allergic skin reaction / Medication.

History of – fever / nausea / vomiting / gastro intestinal or respiratory problem.

History of – Pregnancy / Irregular menstrual cycle.

FAMILY HISTORY:

          History of illness in the family – rashes / allergy / other skin problem / skin cancer.

LIFE STYLE & HEALTH PRACTICES:

          History exposure to – chemicals / paints / bleach / cleansing products etc.

          Routine skin care / hair care.

          Dietary History – History of food allergy / Fluid intake.

COLLECTING OBJECTIVE DATA:

PHYSICAL EXAMINATION:

Preparing the client:

          Prepare the client for skin, hair and nail examination ask the client to remove all clothing remove jewellery and wear examination gloves. 

Equipments:

Ø Examination lights

Ø Penlight

Ø Mirror for the clients self examination.

Ø Magnifying glass

Ø Centimeter ruler

Ø Gloves

Ø Woods light

Ø Examination gown drape

Temperature – warm / cold / increased / body temperature

Mobility and Turgor – Pinches easily and return to normal

                                           Loss of turgor / decreased mobility /

Edema – Normal skin rebound / no deepening

                    Edema scale – Trace

                                      1+

                                      2+

                                      3+

                                      4+

SCALP AND HAIR:

          Inspection and Palpation

Hair color – Pale / Black / Patchy grey hair / Copper red hair /

Cleanliness – Dry / oily / dandruff / Excessive scaliness / Raised lesion /

SKIN:

Inspection:

 General skin condition / evenly colored / Discoloration / Pale Albinism / Erythema / Cyanosis – central / Peripheral

Skin integrity:

          Intact / skin breakdown / skin lesion / striae / birthmark / scars.

Colour variation:

          Vitiligo / albinism / rashes / Butterfly rashes /

PALPATION:

Skin texture:

          Smooth / even / rough / Flaky / Dry skin / Very thin /

Skin Moisture:

          Moist / dry /diaphoresis

Hair distribution:

          Equal / unequal / excessive bald / hair loss / Hirsutism

          Hair loss – Equal / Unequal

NAILS

Inspect for

          Grooming – clean / Dirty / broken / jagged finger nails /

          Colour and markings – Pink / longititudinal / ridging / pigmented / Cyanotic / pain / Fungal infection

COMMON LABORATORY AND DIAGNOSTIC STUDIES

Wood’s light Examination:

          Wood light or long ulcer violet light is used mainly in the examination of epidermal pigmentary disorders and cutaneus infection, applying long UV light to the skin in dark room causes epidermal pigment to appear accentuated while dermal pigmentary disorder with normal epidermal finding are obscured.

Micro porium audounis         -        Bright blue green

Micro porium cannis             -        Bright blue green

Micro porium distortum         -        Bright blue green

Tinea tonsurans                    -        Non fluresant

Tinea versicolor                    -        Dull golden yellow

Bacterial

          Erythrasma          -        Brilliant coral, red pink

          Pseudomonas     -        Yellowish green

Surface microscopy:

                  Illuminated and evaluated with magnifier.

         Asymmetry, Border irregularity, color variation, Diameter, Elevation or enlargement.

Scraping:

          Scraping and examination

Culture:

          To identify microbes

Patch Testing:

          To diagnose the allergens

Biopsy:

          To identify the pathology

NUTRITIONAL ASSESSMENT

·       Follow any particular diet

·       History of allergy to any foods like sea foods, eggs, green leafy.

·       History of any new diet before.

·       Dinner outside the home.

·       Take normal nutritional.