Whilst diabetes preventative care can help avoid the development of type 2 diabetes mellitus, adequate diabetes nursing management can help avoid or reduce the occurrence of serious diabetes complications, such as short-term complications which include hypoglycaemia, diabetic ketoacidosis, hyperosmolar non-ketotic coma, as well as long-term complications which include microvascular and macrovascular complications, and neuropathy.
Short-Term Diabetes Complications
Hypoglycaemia
Hypoglycaemia can be defined as a glucose concentration of 3.9mmol/l or below.
An individual with hypoglycaemia can be asymptomatic, usually due to adaptation of the brain to chronic hypoglycaemia, which presents with symptoms even at normal blood sugar levels. This can be avoided if the individual experiences a few weeks of good glycaemic control.
An individual with hypoglycaemia may also present with mild symptoms which can be self-managed, severe symptoms requiring medical assistance, and even coma.
Hypoglycaemia Causes
- insulin or sulphonylurea overdose (deliberate or accidental) – insulin can cause hypoglycaemia; metformin does not
- inaccurate injection administration
- renal and liver impairment cause pharmacokinetic change, possibly leading to a hypoglycaemic episode; individuals with renal and liver impairment should be monitored closely
- delayed or forgotten meal, or insufficient carbohydrate intake
- alcohol intake – food needs to be taken with alcohol, otherwise hypogycaemia can be triggered
- exercise – can trigger a hypoglycaemic episode following exercise or even several hours after
- hot weather or saunas – insulin is absorbed quicker in warmer temperatures, thus, saunas and hot weather should be avoided
- honeymoon period (following diagnosis is usually a period a.k.a. honeymoon period in which remaining beta cells may pump out enough insulin to control blood glucose, thus may require less insulin)
Nursing Management of Hypoglycaemia
If the patient presents with mild hypoglycaemia:
- give 15-20g of glucose such as a sugary drink – water with 2 teaspoons of sugar
- repeat after 10 minutes
- check if patient is still hypoglycaemic through HGT testing
- if stable give a snack eg. brown bread sandwich to prevent recurrence
NOTE: sugar helps stabilise the patient for that moment; a snack helps maintain glucose level higher for a longer period of time.
If the patient is uncooperative:
Administer GlucoGel (formerly known as Hypostop – raises sugar levels quickly and provides a fast-acting energy boost in the form of Dextrose Gel – 40% dextrose).
NOTE: following a hypoglycaemic episode, ALWAYS ESTABLISH CAUSE eg. problem with insulin administration.
If the patient is unconscious:
- adjust patient into the recovery position
- administer glucagon by intramuscular or subcutaneous injection OR 50cc of 50% dextrose intravenously.
Preventative Measures
The older person is at increased risk of suffering from fall injuries, heart attacks and strokes during hypoglycaemic episodes. Thus, teach older adults at risk of hypoglycaemia:
- to carry an ID bracelet at all times
- to check their blood glucose levels prior to risky activities
- to know and identify early signs of an impending hypoglycaemic episode
Diabetic Ketoacidosis
Diabetic Ketoacidosis is the most acute state of Type 1 Diabetes. Diabetic Ketoacidosis onset may be both gradual or sudden, and is characterised by the following findings:
- hyperglycaemia (15.0mmol/l and over)
- ketonuria (if cells are not supplied with enough glucose, the body burns fat for energy whilst producing ketones which can show up in the blood and urine, evident in a urine dipstick test)
- pH of 7.3 or less (normal blood pH level is 7.35 to 7.45)
Common causes for DKA include:
- infection – most common cause of DKA eg. gastroenteritis, flu, small infection etc.
- stressors – traumatic injuries and/or increased stress
- insulin cessation – common in adolescents; patients need to be reminded that diabetes is a condition for life, thus needs to be controlled with ongoing treatment
- anuria (not passing urine) – a minimum of 30ml/hr of urine should be passed
- not eating – increases risk of DKA
Kussmaul Breathing
Kussmaul Breathing is a sign of DKA. It is characterised by sweet-smelling breath which is rapid and deep. It manifests as a compensatory mechanism due to build-up of carbon dioxide and lack of oxygen.
Diabetes Nursing Management of DKA
An individual with DKA needs:
- treatment for hyperglycaemia – patient needs to be kept nil-by-mouth along with administration of a continuous low dosage of insulin by IV pump. NOTE: monitor blood glucose levels and ensure it isn’t lowered at a rate faster than 5mmol/hr to avoid cerebral oedema.
- treatment for dehydration, electrolyte imbalance, and acidosis – patient needs administration of IV fluids with electrolytes (eg. Hartmann’s – a clear solution of sodium chloride, potassium chloride, calcium chloride dihydrate and sodium lactate 60% in water) to help with dehydration and electrolyte imbalance, and insulin, which usually also corrects acidosis without the need for sodium bicarbonate administration. NOTE: monitor serum potassium levels and ECG tracings to ensure correct potassium level is achieved, and monitor for signs of fluid overdose. NOTE: if not NBM, patient should be encouraged to drink high-carb drinks eg. broth, soup, juices etc.
- treatment for precipitating factors – DKA is commonly induced by infection, thus, antibiotic therapy should begin following C&S specimen, wound drainage, or blood results are obtained.
NOTE: If patient is sick with flu/cold etc., blood glucose needs to be monitored, insulin needs to be administered still. Within the body, carbs start to be broken down in an attempt to avoid going into DKA. Monitoring carb intake to avoid going into hyperglycaemia is recommended.
Additionally, monitor frequently the patient’s:
- vital signs: blood pressure, pulse, temperature, and respirations
- level of consciousness
- intake and output
- urine
- blood glucose
- ketone bodies
- GFR renal profile – to check kidney function and serum electrolytes
- HbA1c – to monitor glucose for the past 3 months
- CBC – to check volume of white blood cells (low white blood cell count may be a sign of infection which could have been the reason behind the patient going into DKA
- ABGs, serum K levels, urea, and RBGs – to check the partial pressure of CO2 and to see if the patient is going into respiratory acidosis; tests also give an indication of electrolyte status (eg. potassium is lost in DKA due to polyuria, and kidney function may become impaired, causing electrolyte imbalance)
- ECG (due to risk of cardiac arrest from hypokalaemia)
and ensure that the patient:
- receives mouth care due to NBM and dehydration
- for dehydration encourage patient to drink water unless NBM, in which case, IV fluids should be administered – monitor fluid intake and output!
- is cared for in case of pain (assess for need of analgesics), abdominal pain, nausea (administer antiemetics) and vomiting (provide vomiting bags just in case)
- is kept safe (attention: side rails, frequent turnings, call bell at arms’ length, and skin care)
- airway patency is maintained (if unconscious)
- always provide reassurance (helps reduce patient anxiety)
DKA Possible Treatment Complications:
- hypokalaemia
- hypotension
- dehydration
- impaired renal function
- cardiac arrest
- HAIs – ensure proper infection control principles are maintained so as to avoid patient getting an infection (may already be infected since infection is one of the problems leading to DKA)
When DKA is resolved:
- insulin is administered subcutaneously (insulin IV should be continued for 1hr following SC insulin injection)
- food is provided 30 minutes following insulin administration
- monitor for DKA recurrence
- teach patient ways to prevent recurrence
Hyperosmolar Non-Ketotic Coma
Hyperosmolar non-ketotic coma usually happens in individuals who have not been diagnosed with diabetes, usually type 2 diabetes, and is more common in individuals over 60 years of age. Characteristics are usually less severe, and most commonly develop over a long period of time.
Characteristics of hyperosmolar non-ketotic coma include:
- hyperglycaemia
- dehydration
- no ketoacidosis
Nursing Management of Hyperosmolar Non-Ketotic Coma
Patients with Hyperosmolar Non-Ketotic Coma need to be treated in the same way as in Diabetic Ketoacidosis EXCEPT:
- if serum Na (Sodium) is MORE THAN 155mmol/l use 0.45% NaCl instead of 0.9% NaCl
- patient may require insulin infusion at a lower rate
- patient should be administered an anticoagulant due to an increased risk for thromboembolism
- patient should have central venous pressure catheter
NOTE: following resolution, patient may require insulin subcutaneously for a few weeks before transitioning to new treatment regimen consisting of diet, exercise, and hypoglycaemic agents.
Long-Term Diabetes Complications
Microvascular Complications
Microvascular complications of diabetes are long-term complications which affect small blood vessels. Complications typically include:
- retinopathy – retina disease (most common cause of blindness in young people)
- nephropathy – kidney function deterioration (affects 45% of diabetic patients, 25% of which develop end-stage renal disease)
- peripheral neuropathy – impaired sensation in the peripheries (feet and hands)
- autonomic neuropathy – bowel and bladder disorders
MACROVASCULAR COMPLICATIONS
Macrovascular complications of Type 2 Diabetes are primarily diseases of the coronary arteries, peripheral arteries, and cerebrovasculature. Cardiovascular disease is the primary cause of death in diabetic patients. Early macrovascular disease is associated with atherosclerosis.
Preventative Measures for Microvascular and Macrovascular Complications
- in patients with stable glycaemic control assess glycaemic status through A1C or other glycaemic measurements at least every 6 months
- in patients with unstable glycaemic control and/or who have had recent treatment change assess glycaemic status through A1C at least every 3 months
- promote lipid management through the Mediterranean Diet or DASH, reduction of saturated fat and trans fat intake, increase in healthy fats intake, viscous fiber, plant sterols intake (found in vegetable oils, nuts and seeds), and increased physical activity to prevent atherosclerosis development
- promote optimum glycaemic control in patients with triglyceride levels of >150mg/dL (1.7mmol/L) and low HDL Cholesterol amounting to <40mg/dL (1.0mmol/L) in men and <50mg/dL (1.3mmol/L) in women
- screen for renal disease at least yearly through urinary-albumin-to-creatinine ratio and estimated glomerular filtration rate (EGFR) in individuals with 5 years or more of type 1 diabetes, and in all individuals with type 2 diabetes (monitor every 6 months patients with >300mg/g creatinine and EGFR 30-60mL/min/1.73m2)
- refer to ophthalmologist for eye complication screening patients with type 1 diabetes within 5 years of diabetes diagnosis, and patients with type 2 diabetes upon diabetes diagnosis
- provide general preventative diabetic foot self-care education to all patients with diabetes, and refer to registered podiatrist for annual foot evaluation to identify risk factors for ulcer formation and amputations
Statin Therapy
CVD Risk Assessment Tool for Healthcare Professionals
ESC CVD Risk Calculation App (Apple or Android)
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