Medical Surgical Nursing - Diabetes

Clinical Topic #7 Diabetes Management Student Guide Objectives: Student will:  Discuss pathophysiology, assessments, and nursing interventions for the prevention and treatment of diabetic ulcers.  Describe the purpose and process of blood glucose and urine ketones monitoring.  Differentiate between various insulin preparations.  Explain how to mix insulins accurately.  Describe administration of insulin with various devices.  Discuss pathophysiology, symptoms and interventions for hypoglycemia. FYI Normal Blood Glucose Levels: Kee states 60-110 mg/dL, Fundamentals 70-105 mg/dL, and Lewis 70-120 mg/dL. Students will only be tested on values within normal or abnormal limits for all of these ranges. However students may want to learn the Lewis level for ease in transition to subsequent semesters. Nursing Diagnosis: Impaired Tissue Integrity Blood Glucose, Risk for Unstable Infection, Risk for PC: Hypoglycemia/Hyperglycemia Discussion Questions: 1. What puts the diabetic patient at risk for foot ulcers?  Diabetic patients are at risk of developing diabetic neuropathy, more specifically, sensory neuropathy. Sensory neuropathy can cause loss of sensations like numbness of hands and feet and the sensations of temperature. When loss of sensations occur, it makes it harder for the patient to identify when injury or infection occurs, making it more difficult for the patient to identify when skin breakdown is occurring.

2. How would you assess the feet of a patient with diabetes? In a hospital setting I would check capillary refill of the toes. I would look for any redness, swelling, blisters, or cuts on the foot. I would recommend they receive a screening using a monofilament to asses LOPS. 3. What might you teach a patient to prevent diabetic foot ulcer development?  Wash Feet daily with mild soap and warm water

 Pat dry gently, especially between toes  Examine feet daily for cuts, blisters, swelling, and tender areas  Use mild foot powder for sweaty feet  Repeat skin infections and non-healing sores  Wear clean, absorbent socks or stockings that have not been mended 4. Describe appropriate interventions to promote healing of foot ulcers. Casting may be appropriate in order to redistribute weight on the plantar surface of the foot. Other forms of wound control for foot ulcers would include: debridgement, dressings, advanced wound healing products such as Regranex, vacuum-assisted closure, ultrasound, hyperbaric oxygen, and skin grafting. 5. Describe purpose and procedure for blood glucose monitoring. The monitoring of a person’s blood glucose level allows them to make self-management decisions regarding diet, exercise, and medication. One method of monitoring a persons blood glucose level is by the use of portable blood glucose meter, which takes a small drop of capillary blood and assesses the amount of glucose within it. Another way of measuring a person’s blood glucose is by the use of a Continuous Glucose Monitoring system. This system uses needles inserted subcutaneously that assess the blood glucose level every 1-5 minutes. 6. Describe the purpose and procedure for urine ketones monitoring. Monitoring urine ketones helps to prevent the development of conditions such as ketonuria or even worse, diabetic ketoacidosis. To monitor urine ketones, you will need testing dipstick, and a sterile urine cup. Collect the urine in the sterile cup, and using the testing dipstick, dip it into the urine. A positive result can indicate lack of insulin and diabetic acidosis. 7. Explain how insulin preparations are different? Identify onset, peak and duration for each. Insulin is prepared base on the patients specific pattern of blood glucose levels, lifestyle, eating, and activity patterns. The patient may receive mixed insulin, or they may receive multiple different doses.  Rapid Acting o Onset: 15mins o Peak: 60-90min o Duration: 3-4hrs  Short Acting

o Onset: 30-60mins o Peak: 2-3 Hours o Duration: 3-6 Hours  Intermediate Acting o Onset:2-4hr o Peak: 4-10 hr o Duration: 10-16 hr

 Long Acting o Onset: 1-2 hr o Peak: no Pronounced Peak o Duration: 24+hr

8. What are the devices currently used to administer insulin? Insulin can currently be administered with an insulin pen, insulin syringes, an insulin pump, as well as through an IV.

9. What is the appropriate method for mixing two different insulin preparations?  Wash Hands  Gently rotate insulin bottle if cloudy  Wipe off tops of vials with alcohol sponge  Inject the appropriate amount of air into both vials  Invert vial B and draw back the medication  Remove the needle, insert it in vial A and withdraw the medication

10. Explain the medical order for “correction dose” or “sliding scale.”

The term “sliding scale” or “correction dose” refers to the progressive increase in the premeal or nighttime insulin dose, based on pre-defined blood glucose ranges. Sliding scale insulin regimens approximate daily insulin requirements. 11. What is hypoglycemia? What are the causes and symptoms? Hypoglycemia is having a low level of glucose within the blood. This can occur when the glucose within the blood is used too quickly, not enough glucose is being produced or absorbed, or the amount of insulin in the blood is too high. Symptoms include, confusion, sweating, dizziness, nausea, and sleepiness. 12. How is hypoglycemia treated? Ingesting sugars into the body helps to treat hypoglycemia. Also taking Meglitinides daily help to lower the chance of hypoglycemia from happening in the first place.