1. Care of Clients with Diabetes Mellitus 1 Part2 - Complications

2. Somogyi effect Periods of hypoglycemia followed by rebound hyperglycemia Hypoglycemia causes some diabetics to release epinephrine Decrease evening dose or move to bedtime or increase bedtime snack Diagnose with a 2 or 3 am blood sugar 2

3. Dawn phenomenon Nocturnal release of growth hormone- leads to an increase in glucose around 4-8 am; normal for everyone Treat with increase of evening insulin or move supper insulin to bedtime More severe in adolescence 3

4. Acute complications Hypoglycemia Diabetic ketoacidosis: DKA Hyperosmolar hyperglycemic syndrome: HHS 4

5. Hypoglycemia-causes Too little food- or delayed Too much diabetic medicine Too much exercise without compensation Alcohol intake without food 5

6. Hypoglycemia- symptoms Tremors, Nervousness Irritability, personality changes, abnormal behavior Cool, clammy skin with diaphoresis Increased heart rate Hunger, Headache Unsteady gait, slurred or incoherent speech Vision changes: double or blurred vision Seizures, coma 6

7. Hypoglycemia- management Immediate ingestion of 15 g. of simple CHO 4 oz of juice 4 oz of regular soda 1 tablespoon of honey or syrup 2 tablespoons of raisins 3-4 hard candy Commercial dextrose product: 3-4 tablets 7

8. Hypoglycemia- management Repeat tx if no improvement in 15 min. If not eating a regular meal within the next 1-2 hours follow with additional food that contains protein & CHO 4 oz milk, slice of bread, peanut butter & crackers 8

9. Hypoglycemia- severe reaction 50% Dextrose: IV 20-50 ml Followed by infusion of D5W Glucagon: subcutaneous or IM .5- 1 mg Raises the blood glucose level by 20-30 within a few minutes Person should eat as soon as regain consciousness Causes N/V 9

10. Glucagon Glucagon can cause vomiting, so be sure to place the person on his or her side prior to injecting so they do not choke. After injecting glucagon, follow with food once the person regains consciousness and is able to swallow. 10

11. Hypoglycemia: severe Glucose gel or cake icing gel can be put on the cheek inside the mouth Honey rubbed into gums also has worked Inform patients to always wear medical alert identification 11

12. Hypoglycemia: severe 15 grams of fast acting CHO will raise blood glucose by approximately 45 points in 10-15 minutes Do not treat with high-fat foods: chocolate, ice cream Over treatment is common 12

13. Diabetic ketoacidosis (DKA)- etiology Too little insulin with increased caloric intake Physical or emotional stress Undiagnosed DM 13

14. DKA: Too little insulin Glucose cannot enter cells & be used for cellular energy Body releases & breaks down stored fats & proteins to provide needed energy Free fatty acids from stored triglycerides are released & metabolized in the liver in such large amounts that ketones are formed. Excess ketones- Acidosis 14

15. DKA-Pathophysiology Hyperosmolarity: hyperglycemia (glucose > 250) dehydration (serum osmolarity normal or just above normal) Fluid & electrolyte imbalance: osmotic diuresis Metabolic Acidosis PH < 7.30 Norm: 7.35- 7.45 HCO3 < 15 Norm: 22-26 Urinary ketones >3+ Norm: 0 15

16. DKA- symptoms Develops rapidly over 24 hours Increased blood glucose- > 250 mg/dl Abdominal pain, N/V Kussmaul’s respiration Acetone noted on breath- fruity Hypotension 16

17. DKA- treatment Insulin: IV infusion of regular insulin Replacement of fluids to correct hypovolemia NS 10-20 ml/kg of body weight over first 1-2 hours 17

18. DKA- treatment Correct electrolyte imbalance Changes in serum potassium, calcium, magnesium, & phosphate can occur Hyperkalemic: potassium can’t get into the cells without insulin. When administer insulin the potassium reenters the cell & patient runs a risk for hypokalemia 18

19. DKA: Nursing Interventions Take hourly glucose levels Obtain ABG’s Monitor electrolytes every 1-4 hours Cardiac monitor to watch for dysrhythmias Assess every 1-4 hours VS Urine output Neurologic status 19

20. DKA: complication Cerebral edema Can occur 6-10 hours within start of treatment Occurs when blood glucose falls too rapidly: causing fluid to shift into the brain cells Can also occur with sodium levels dropping too rapidly. Fluid replacement must be monitored carefully 20

21. DKA Once the patient’s blood glucose is stable and the patient can have food by mouth or through a feeding tube, subcutaneous insulin can begin Give first subcutaneous insulin 1-2 hours before you discontinue the insulin infusion 21

22. Sick Day Management When sick: Always take diabetes medicine Test glucose at least every 4 hours Call the doctor if: Blood glucose consistently > 250 mg/dl Ketone test is moderate to high Feel sick & vomit Think you might have an infection Keep well hydrated Replace foods with liquids that contain CHO 22

23. Hyperosmolar hyperglycemic syndrome- HHS Severe hyperglycemia > 600 mg/dl Takes days or weeks to fully develop Type 2 diabetes with diminished renal function &/or cardiac disease 23

24. HHS Causes: infection: UTI, pneumonia, sepsis inadequate adherence with insulin regimen new diagnosis of diabetes Triggers: MI & CVA Surgery Pancreatitis Medications Pregnancy 24

25. HHS- symptoms Reflect dehydration & altered CHO, fat, & protein metabolism Thirst Tachycardia Polyuria Fatigue Weight loss Blurred vision Altered mental status Coma 25