Diabetes- Chapter 43

Revised 11/10

Types of Diabetes Type 1—insulin-

dependent diabetes mellitus (IDDM)

Insulin produced in insufficient amount

Requires insulin

Type 2—non-insulin-dependent diabetes mellitus (NIDDM)

Decreased production of insulin or decreased cell sensitivity to insulin

May be treated with oral drug and/or insulin

Four Pillars of Management of Diabetes

Meal planning referred to as medical nutrition therapy

Activity and exercise Medication Self monitoring of blood glucose

(SMBG)

Insulin

A hormone produced by the beta cells in the pancreas that acts to maintain blood glucose levels within normal limits

Insulin

Essential for the use of glucose in cellular metabolism and for proper

protein and fat metabolism

Insulin

Controls the use of glucose, protein, and fat in the body

Lowers blood sugar by inhibiting glucose production by the liver

Insulin Available as purified extracts from

beef and pork pancreas (used infrequently)

Synthetic insulins, such a human insulin and insulin analogs; derived from strains of Escherichia coli (recombinant DNA), fewer allergies with this than extracts of beef and pork

Activates a process that helps glucose molecules enter the cells

Stimulates the liver glycogen synthesis

Insulin (Con’t)

Used to treat diabetes mellitus and control more severe and complicated forms of type 2 diabetes

Insulin Injections

Must be injected into the subcutaneous in the legs, arms, stomachs or buttocks. Cannot be taken orally

ADMINISTERING INSULIN BY INJECTION

Administered with an insulin syringe

Insulin Preparations

See handout from Introduction to Pharmacology

Text, page 546

Onset, Peak, and Duration of Action

Define onset, peak and duration

Insulin Contraindications

Contraindicated if patient has hypersensitivity to any ingredient in the product (older preparations made with beef and pork) and if the patient is hypoglycemic

Precautions

Used cautiously with renal and hepatic impairment and during pregnancy and lactation

Interactions

See table 49-1 Drugs that Decrease and Increase the Hypoglycemic Effect of Insulin, page 547

Include as nursing considerations

Drugs that Decrease the Hypoglycemic Effect of Insulin

Drugs that Increase the Hypoglycemic Effect of Insulin

MIXING INSULINS

Insulins tend to bind and become equilibrated

Inject within 5 minutes of mixing Regular which is additive free, is

combined with intermediate-acting insulin such as Humulin

Mixing Insulins

Promoting Optimal Response to Insulin Therapy

Will be individualized Expect adjustments when under

stress and with any illness, particularly illnesses resulting in nausea and vomiting

Examples of Insulin Administration using a Sliding Scale Handout from Morton Hospital (use

as an example) Double sided (reverse has how to

treat hypoglycemia) Follow agency protocol

Preparing Insulin for Administration

Current insulin bottle at room temperature, except Lantus which is refrigerated

Rotating Injection Sites

Rotating sites prevents lipodystrophy (atrophy of subcutaneous fat)

Lipodystrophy interferes with absorption of insulin

Body Diagram of Appropriate Sites

Methods of Administering Insulin

Parenteral-subcutaneous or intravenous

Insulin Pump Inhalation

Insulin Pumps Newer technology. Attempts to mimic

the body’s normal pancreatic function. Only regular insulin is used. Needle inserted subcutaneously and left

in place for 1-3 days Battery operated. Amount of insulin injected can be

adjusted according to blood glucose levels (monitored 4-8 times a day)

Inhaled Insulin

Food and Drug Administration approved the first noninjectable insulin in a dry inhalation powder in early 2006 (Exubera).

Monitoring and Managing Adverse Reactions

Must know signs and symptoms of hypoglycemia and hyperglycemia

Signs of Hyperglycemia

Signs of Hypoglycemia

Educating the Patient and Family Review principles of teaching the adult patient Noncompliance may be a problem with some

patients (may be related to lack of understanding of disease process or medications or management)

Establish a thorough teaching plan for patients newly diagnosed, for patients with changes in treatment plan

Include teaching on diet, glucose monitoring, medications, adverse reactions, hygiene, exercise, sick day protocols, medic alert bracelets

Nursing Diagnoses

Anxiety and Fear Impaired Adjustment, Coping, and

Altered Health Maintenance Acute confusion related to

hypoglycemic reaction

Oral Drugs Sulfonylureas Biguanides Alpha-glucosidase inhibitors Meglitinides Thiazolidinediones Hormone Mimetic Agents –many diffferent

actions to help lower blood sugar levels, see page 424; Januvia, Byetta, Symlin

See Summary of Drugs- pages 420-421 Sometimes oral antidiabetic drugs are used

in combinations

Sulfonylureas Examples—tolbutamide (Orinase), glipizide

(Glucotrol), glyburide (Diabeta, Micronase), glimepiride (Amaryl)

Act to lower blood glucose by stimulating the beta cell to release insulin

Adverse Reactions—

Nursing considerations:

Secondary failure may occur (may lose effectiveness, may prescribe another sulfonylureas or add another oral antidiabetic drug such as metformin

Biguanides Example—metformin (Glucophage) Action—reduces hepatic glucose production

and increases insulin sensitivity to muscle and fat cells

Adverse Reactions—Rare SE: lactic acidosis with kidney failure Nursing implications; give with meals.

Glucophage XR given once daily with evening meal. Glucophage must be stopped 48 hours before and after radiology studies that use iodine

Alpha-Glucosidase Inhibitors

Examples—acarbose, miglitol Action—lower blood sugar by

delaying carbohydrate digestion and absorption

Adverse Reactions— Nursing considerations:

Meglitinides Examples—nateglinide (Starlix),

repaglinide (Prandin) Action—stimulate insulin release from

the pancreas in response to a glucose load

Adverse Reactions – Nursing considerations:

Thiazolidinediones

Examples—rosiglitazone (Avandia- now off market), pioglitazone (Actos)

Action—decrease insulin resistance and increase insulin sensitivity by modifying several processes

Adverse Reactions— Nursing considerations:

Combination Agents Metaglip- glipizide and metformin Glucovance-glyburide and metformin Actoplus Met- pioglitazone and

metformin Avandamet- rosiglitazone and metformin Duetact- Pioglitazone and glimepiride Avandaryl- rosiglitzone and glimepride

Pharmacologic Algorithm for Treating Type 2 Diabetes

See text, page 422

Emergency Medications to Elevate Glucose

Glucagon IM (glucagon is a hormone produced by the alpha cells of the pancreas-stimulates the conversion of glycogen to glucose in the liver. . return to consciousness within 5-20 minutes)

IV D50

Key Concepts

Case Study Timothy Jones is admitted to your unit

with a diagnosis of new onset type 1 diabetes mellitus. His blood sugars have stabilized and he is beginning to ask questions. How would you answer the following questions?

What is diabetes?Why can’t I be on pills instead of insulin?Why do I have to test my blood sugars?What should I do if it is too high or too

low?Does insulin have any side effects?

What should I watch for?