Transcript Lecture 12 Diabetes Mellitus

Medical Surgical Nursing
Diabetes Mellitus
Endocrine Pancreas
• Islets of Langerhans
• Beta cells
– Insulin
Insulin
• Produced and
secreted by…
– Beta cells
Insulin
• Primary function…
– Stimulates the active
transport of glucose
– from the blood into
muscle, liver and
adipose tissue 
– __?__ blood glucose
levels
• i
Glucose Content of Food
• Consume food  glucose  blood stream
• *Carbohydrates
– Starch
• Simple
• Complex
Secretion of Insulin
• Is stimulated by:
– What change in homeostasis causes the beta cells
to secrete insulin?
– Hyperglycemia
• Glucose levels in the bloodstream regulate the
rate of insulin secretion
The major action of insulin
• i blood glucose levels
• h the permeability of target cell membrane to
glucose
– Main target cells
• Muscle
• Liver
• Adipose tissue
Pathophysiology sumamry
• Increased blood glucose levels 
• Gland
– Pancreas 
• B cells 
• Insulin 
• Target cells (muscles) 
– (insulin pulls glucose from the blood into the muscles) 
• Decrease blood glucose levels
Insulin info
• In the absence of insulin, glucose is not able to
get into the cells and it is excreted in the urine
– Glycouria
• Brain cells are not dependent on insulin for
glucose intake
Function of Insulin
• Need insulin for
glucose to cross cell
membrane
• No insulin  no
glucose into the cell
• Glucose stays in the
blood 
• Hyperglycemia
Diagnostic tests
• Blood glucose /
Fasting blood glucose
• Glycosylated
Hemoglobin Assay
Blood Glucose
Fasting blood Glucose
• Measures blood glucose
levels after fasting
• Results
–
–
–
–
Normal – 70-115 mg/dL
Diabetic level > 126 mg/dL
Critical > 400 mg/dL
Critical < 50 mg/dL
Fasting Blood Glucose
Nursing Responsibility
•
•
•
•
Fast 6-8 hours
Water OK
No insulin or anti-diabetic meds
Exercise will effect results
Glycosylated Hemoglobin Assays (Hgb
A1C)
• % of glycosylated hemoglobin
– RBC lifecycle
• @ 120 days (4 months)
– Glucose slowly binds with Hgb  glycosylated
– h serum glucose level  h glycosylated Hgb
levels
Hgb A1C
• Provides an average blood glucose levels
– Past 2-3 months
• Can be taken any time
• Normal levels (non-diabetic)
– 4-6%
• Diabetic level (goal)
– <8%
Small group questions
1. What are the Islets of Langerhans?
2. What cells of the pancreas secrete insulin?
3. What stimulates insulin to be secreted?
What is diabetes mellitus?
• Group of disordered characterized by chronic
hyperglycemia
• Due to faulty insulin production
• (Not Diabetes Insipidus)
Type 1 – Diabetes Mellitus
• Destruction of the Beta cells
• Result in
– NO insulin production
– Insulin dependent
S&S of Type 1 DM
• Hyperglycemia
– ↑ blood glucose levels
– No insulin 
– Glucose stays in the blood stream
S&S of Type 1 DM
• Glycosuria
– Glucose in the urine
S&S of type 1 DM
• Polyuria
• Nocturia
S&S of Type 1 DM
• Polydipsia
– Excessive thirst
S&S of Type 1 DM
• Polyphagia
– Excessive hunger
S&S of Type 1 DM
• Dehydration
– Assessment?
•
•
•
•
Skin turger
Mucus membranes
Thirst
BUN level
Small Group Questions
1. Why would a person with high glucose levels have
polyphagia?
2. Explain why polyuria is a common symptom of
diabetes Mellitus Type 1.
3. What is hyperglycemia?
4. Why does hyperglycemia happen in Type 1 diabetes
mellitus?
Small Group Questions
5. What is a normal level for a FBS?
6. Define the following terms: Glucose,
Glycosuria.
7. What does an Hgb A1c measure? What are
normal values for a diabetic and nondiabetic?
Type 2 DM
• Pathophysiology
– The pancreas cannot
produce enough
insulin for body’s
needs
– Impaired insulin
secretion
Type 2 DM
• Weakened Beta cells Due to over use
Insulin and Type 2 DM
• Not all clients require insulin
–1/3 will at some time
• Stress
• Illness
Risk Factors for Type 2 DM
• Family history
• Obesity
• Gestational diabetes or large baby
Type 1 vs. Type 2
• Age of onset
• Age of onset
– Usually < 30
– Usually > 40
Type 1 vs. Type 2
• Body wt at onset
– Normal to thin
• Insulin production
– None
• Insulin injections
– Always
• Body wt at onset
– 80% overweight
• Insulin production
– Not enough
• Insulin injections
– Sometimes
Type 1 vs. Type 2
• Management
– Insulin
– Diet
– Exercise
• Management
– Diet (wt. Loss)
– Exercise
– Possibly oral
hypoglycemic meds
– Possibly insulin
Other specific types of Diabetes
Mellitus
• Gestational
• Pancreatitis
• Drug or chemical induces diabetes (steroids)
S&S of Diabetes Mellitus
• Definition:
– A group of disorders characterized by chronic
Hyperglycemia
• 3 P’s
– Polydipsia
– Polyuria
– Polyphagia
S&S of Hyperglycemia
• Neurological
– C/O headache
– Dull senses
– Stupor
– Drowsy
– Blurred Vision
S&S of Hyperglycemia
• Cardiovascular
– Tachycardia
– Decreased BP
– (Dehydration)
• Respiratory
– Kussmaul's respirations
– Sweet and fruity breath
– Acetone breath
S&S of Hyperglycemia
• Gastro-intestinal
– Polyphagia
– N/V
– Polydipsia
S&S of Hyperglycemia
• Genital-urinary
– Polyuria
– Glycosuria
• Skeletal-muscular
– Weak
S&S of Hyperglycemia
• Integumentary
– Dry skin
– Flushed face
Small Group Questions
Mr. McMillan is a 50 year old client brough into
the ER with extreme fatigue and dehydration.
After the MD sees him the nurses asks Mr.
McMillan some additional questions. Based
on the clients answers the nurse requests that
the MD add a glucose level to the lab work.
The results are 800mg/dL.
Small group questions
1. What question did the nurse most likely ask?
2. Why was Mr. McMillan fatigued?
3. Why was he dehydrated?
Medical Management of DM
• No cure
• Goal is Control! And prevent complications
• Individualized treatment plans
– Diet
– Exercise
– Meds
Dietary management of DM
Foundation of Diabetic control
• Goals
– Maintain near-normal blood glucose levels
– Achieve optimal serum lipid levels
– Provide adequate calories for reasonable weight
– Prevent & treat acute complications of insulintreated diabetes
– Improve overall health through optimal nutrition
The exchange system
• Six categories
–
–
–
–
–
–
Starch
Meat
Milk
Vegetable
Fruit
Fat
General guidelines of Dietary
Management
• Protein
– 20%
• Fat
– 20%
• Carbohydrates
– 60%
• ADA: American
Diabetic Association
Diabetic Meal
• Small frequent meals
– CONSISTENCY!
•
•
•
•
Amount of calories
Amount of carbohydrates
Time
Snacks
Plan
Diabetic Meal Plan
• If the client is obese, the key to treatment is…
– Weight loss!
Meal Plan considerations
•
•
•
•
Food preferences
Lifestyle
Schedule
Ethnic / Cultural
background
Alcohol and Diabetes
• Increase risk of…
– Hypoglycemia
– Moderation
Exercise and Diabetes
• i blood glucose levels
More Benefits of exercise
• Increases circulation
• Improve serum lipid
levels
• Improves cardiovascular
status
• Assist with wt control
• Decreases stress
Rules for the exercising diabetic
• Talk to MD first
• Regular vs. sporadic
• Correlate exercise and
glucose levels
• Don’t exercise when
hypoglycemic
• Don’t exercise when
hyperglycemic >250
Rules for the exercising diabetic
• Do not exercise when
insulin is peaking
• Carry a quick source
of sugar
• Best time = 60-90
minutes after a meal
Rules for the exercising diabetic
• Proper footwear
• May need a preexercise snack
• Consistency!
Monitoring Glucose
• Glucometers
• FSBS
• 2-4 times a day
Small Group Questions
1. Give signs & symptoms of hyperglycemia by body
system (Why do they manifest these symptoms?)
2. A diabetic meal plan’s main goal is to maintain near
normal glucose levels. How is this done?
3. The exchange diabetic meal plan is divided into six
categories, what are they?
Small Group Questions
4. What affect does alcohol have on a diabetic?
5. What affect does exercise have on a diabetic?
6. What council would you give a diabetic
regarding exercise?
Onset – Peak - Duration
• Onset
– The time period from
injection to when it
begins to take effect
• Peak
– When insulin is
working its hardest
and therefore blood
glucose levels are at
their lowest
Onset – Peak - Duration
• Duration
– Length of time the
insulin works or lasts
Types of Insulin –
Very short acting/ rapid acting
• Lispro (Humalog)
• Aspart (Novolog)
Appearance
Onset
Peak
¼ hour
Clear
1 hour
• Insulin pumps
• Rapid reduction of glucose level
Duration
3 hours
Types of Insulin –
Short-acting / regular
• Humalog R; Novolin R; Iletin II Regular
Appearance
Onset
Peak
Duration
Types of Insulin –
Short-acting / regular
• Humalog R; Novolin R; Iletin II Regular
Appearance
Clear
Onset
Peak
Duration
Types of Insulin –
Short-acting / regular
• Humalog R; Novolin R; Iletin II Regular
Appearance
Onset
Clear
½ - 1 hr
(1 hour)
Peak
Duration
Types of Insulin –
Short-acting / regular
• Humalog R; Novolin R; Iletin II Regular
Appearance
Onset
Peak
Clear
½ - 1 hr
(1 hour)
2-3 hrs
(3 hour)
Duration
Types of Insulin –
Short-acting / regular
• Humalog R; Novolin R; Iletin II Regular
Appearance
Onset
Peak
Duration
Clear
½ - 1 hr
(1 hour)
2-3 hrs
(3 hour)
4-6 hrs
(5 hours)
• Administered 20-30 minutes before meals
• IV
• Usually given 4 x a day
Types of Insulin –
Intermediate-acting
• NPH; Humulin N; Lente: Novolin L; Novolin N
Appearance
Onset
Peak
Duration
Types of Insulin –
Intermediate-acting
• NPH; Humulin N; Lente: Novolin L; Novolin N
Appearance
Cloudy
Onset
Peak
Duration
Types of Insulin –
Intermediate-acting
• NPH; Humulin N; Lente: Novolin L; Novolin N
Appearance
Onset
Cloudy
2-4 hrs
(2 hrs)
Peak
Duration
Types of Insulin –
Intermediate-acting
• NPH; Humulin N; Lente: Novolin L; Novolin N
Appearance
Onset
Peak
Cloudy
2-4 hrs
(2 hrs)
6-12 hrs
(12 hrs)
Duration
Types of Insulin –
Intermediate-acting
• NPH; Humulin N; Lente: Novolin L; Novolin N
Appearance
Onset
Peak
Duration
Cloudy
2-4 hrs
(2 hrs)
6-12 hrs
(12 hrs)
16-20 hrs
(24 hrs)
• Administer after meals
• Usually given 2x a day
• Eat at onset!
Learning Tip: Even and Odd
• Short-acting think odd
– (1-3-5)
• Intermediate-acting
think even
– (2-12-24)
Regular vs. Intermediate (NPH)
When should insulin be
administered
• Short-acting / regular
– 30 min before meals (ac)
– Do not allow more than 30 min to pass by without eating
•  hypoglycemia
• Intermediate acting
– After meals (pc)
• If mixed (regular & intermediate)
– 30 min before meals
What route is insulin
administered
• IV
– Regular
• Sub-cutaneous
Syringe Types
• Insulin syringe
• 27-29 gauge
Route (Self Administration)
• Subcutaneous tissue
– If you can “pinch an inch”
• 90 degree angle
– If you can’t “pinch an inch”
• 45 degree angle
Area’s of injection
•
•
•
•
Abdomen
Arm
Thigh
Hips
Factors affecting absorption rates
• Quickest
– Abdomen
What would you do?
Which of the following is frequently best to teach / do
first when doing initial diabetic training?
A. How & where to purchase insulin
B. Preparation & storage of insulin
C. Mixing insulin with return demonstration
D. Self-injection of insulin
E. Learning O-P-D of insulin types
Insulin Pumps
•
•
•
•
•
Portable infusion pump
Subcutaneous needle
Continuous/basal rate
Additional bolus if needed
Change site q24-48 hours
Insulin Pumps
• S/E - risks
– Hypoglycemia
– Infection
– Hyperglycemia
Small Group Question
Mrs. Evans is 60 year old women with type 2 DM. She
is on Intermediate Acting Insulin [Novolin L (Lente)]
every morning. She normally eats her meals at
8:00 AM, 12:00 PM, and 6:00 PM.
1. What time should she take her morning insulin?
2. When will this dose onset?
3. When will this does peak?
4. What does this insulin look like?
Mrs. Sweet Peas takes 13 units of Short-Acting Insulin [Humalog
R] q ac. Her meals are B-8:00 AM, L-12:00 PM, D-7:00PM
1. What time should Mrs. Peas take her mid-day
(lunch)dose of insulin?
2. When this dose onset?
3. When will this dose peak?
4. What does this insulin look like?
Mrs. Gumdrop takes 6 units of Intermediate
Acting Insulin [NPH] at HS (10PM). She eats
her meals at: B-7AM,
L-11AM, D-5PM.
• When will this dose onset?
A. 9 AM
B. 7:30 AM
C. 7 PM
D. 10:30 PM
E. 12 AM
Mrs. Gumdrop takes 6 units of Intermediate
Acting Insulin [NPH] at HS (10PM). She eats
her meals at: B-7AM,
L-11AM, D-5PM.
• When will this dose peak?
A. 1 AM
B. 10 PM
C. 10 AM
D. 9 PM
E. None of the above
Mrs. Gumdrop takes 6 units of Intermediate
Acting Insulin [NPH] at HS (10PM). She eats
her meals at: B-7AM,
L-11AM, D-5PM.
• What does this insulin look like?
A. Clear
B. Cloudy
Mr. Chocolate Chip Cookie takes 10 units of
Regular Insulin [Novolin R] q AM. His meals are
at : B-7AM, L-11AM, D-5PM.
• When should he take his morning does of
insulin?
A. 6 AM
B. 6:30 AM
C. 7 AM
D. 7:30 AM
E. None of the above
Mr. Chocolate Chip Cookie takes 10 units of
Regular Insulin [Novolin R] q AM. His meals are
at : B-7AM, L-11AM, D-5PM.
• When will this does peak?
A. 7:30 AM
B. 8:30 AM
C. 9:30 AM
D. 10:30 AM
E. None of the above
Mr. Chocolate Chip Cookie takes 10 units of
Regular Insulin [Novolin R] q AM. His meals are
at : B-7AM, L-11AM, D-5PM.
• What does this insulin look like?
A. Clear
B. Cloudy
Ms. Eng Ewe takes 10 units of Short-Acting
Insulin [Iletin II Lente] and 5 units of
Intermediate Acting Insulin [NPH] q AM. Her
meals are B-8AM, L-12PM, D-7PM
• When should she take her insulin injection?
A. 7:00 AM
B. 8:00 AM
C. 9:00 AM
D. 10:00 AM
E. None of the above
Ms. Eng Ewe takes 10 units of Short-Acting
Insulin [Iletin II Lente] and 5 units of
Intermediate Acting Insulin [NPH] q AM. Her
meals are B-8AM, L-12PM, D-7PM
1. When will her insulin onset
2. When will her insulin peak
Mixing Insulin – How to
#1 Assemble equipment
• Insulin
• Syringe
• Alcohol swab
• MD order
Mixing insulin – How to
#2 Check MD order for
dose and types
Mixing insulin – How it
#3 Roll the bottle of
intermediate acting
insulin (DO NOT
SHAKE)
Mixing insulin – How it
#4 Wipe the top of both
vials with alcohol
swab
Mixing insulin – How it
#5 Draw up and inject
an amount of air
equal to the dose of
intermediate acting
insulin into the cloudy
vial. Then remove
syringe from the vial
Mixing insulin – How it
#6 Draw up and inject
an amount of air
equal to the amount
of short-acting insulin
into the clear vial.
*Leave syringe in the
vial
Mixing insulin – How it
#7 Draw up the correct
amount of
clear/regular insulin.
Mixing insulin – How it
#8 Double check with
another nurse if this is
the institutions policy.
Mixing insulin – How it
#9 Remove the syringe
and insert into the
cloudy vial. Carefully
draw up the correct
amount of insulin.
Mixing insulin – How it
#10 Double check with
another nurse before
removing the syringe
from the vial
What do you do if you draw up too much
intermediate acting insulin with mixing?
A. Push it back into the vial and re-draw up the
correct amount.
B. Waste the med and start over with the same
syringe.
C. Waste the med and start over with a clean
syringe.
D. Who cares, a little extra never hurt anyone!
Just give it to the patient.
What do you do if you draw up too much
Regular/clear insulin when mixing?
A. Push it back into the vial and re-draw up the
correct amount.
B. Waste the med and start over with the same
syringe.
C. Waste the med and start over with a clean
syringe.
D. Who cares, a little extra never hurt anyone!
Just give it to the patient.
How would you do it?
Give 8u Humulin R and 12u NPH sub-q, qAM.
Sliding Scale
• Used during
– Surgery
– Illness
– Stress
• Determines insulin dose based on FSBG
• FSBS check usually every 4-6 hrs
• Usually regular insulin is used
Sample Sliding Scale
•
•
•
•
•
•
Check FSBS before meals and at HS (2200)
4u Humulin R insulin for glucose 151-200 mg/dL
6u Humulin R insulin for glucose 201-250 mg/dL
8u Humulin R insulin for glucose 251-300 mg/dL
10u Humulin R insulin for glucose 301-350 mg/dL
Call MD for glucose >350 mg/dL
Questions for sliding scale
•
• Check FSBS before meals and
•
•
•
•
•
at HS (2200)
4u Humulin R insulin for
glucose 151-200 mg/dL
6u Humulin R insulin for
glucose 201-250 mg/dL
8u Humulin R insulin for
glucose 251-300 mg/dL
10u Humulin R insulin for
glucose 301-350 mg/dL
Call MD for glucose >350
mg/dL
A.
B.
C.
D.
E.
If FSBS 189 how much
insulin would you give?
None
4 units
6 units
8 units
10 units
Questions for sliding scale
•
• Check FSBS before meals and
•
•
•
•
•
at HS (2200)
4u Humulin R insulin for
glucose 151-200 mg/dL
6u Humulin R insulin for
glucose 201-250 mg/dL
8u Humulin R insulin for
glucose 251-300 mg/dL
10u Humulin R insulin for
glucose 301-350 mg/dL
Call MD for glucose >350
mg/dL
A.
B.
C.
D.
E.
If FSBS 309 how much
insulin would you give?
None
4 units
6 units
8 units
10 units
Questions for sliding scale
•
• Check FSBS before meals and
•
•
•
•
•
at HS (2200)
4u Humulin R insulin for
glucose 151-200 mg/dL
6u Humulin R insulin for
glucose 201-250 mg/dL
8u Humulin R insulin for
glucose 251-300 mg/dL
10u Humulin R insulin for
glucose 301-350 mg/dL
Call MD for glucose >350
mg/dL
A.
B.
C.
D.
E.
If FSBS 120 how much
insulin would you give?
None
4 units
6 units
8 units
10 units
Questions for sliding scale
•
• Check FSBS before meals and
•
•
•
•
•
at HS (2200)
4u Humulin R insulin for
glucose 151-200 mg/dL
6u Humulin R insulin for
glucose 201-250 mg/dL
8u Humulin R insulin for
glucose 251-300 mg/dL
10u Humulin R insulin for
glucose 301-350 mg/dL
Call MD for glucose >350
mg/dL
A.
B.
C.
D.
E.
If FSBS 60 how much
insulin would you give?
None
4 units
6 units
8 units
10 units
Pre-mixed insulin
• NPH + Regular
• Novolin 70/30
– 70% NPH
– 30% regular
Insulin Storage
• Vial NOT being used
refrigerate
• Vial in use  room
temperature
• Storage life un-refrigerated = 1
month
Insulin Therapy Complications
• Hypoglycemia
• Causes
– Too much insulin
– Too little food
– Extreme exercise
S&S of Hypoglycemia
• Neuro
–
–
–
–
Dizzy / faint
Nervous / Irritability
Blurred vision
Numb tongue or lips
S&S of Hypoglycemia
• Cardiovascular
– Full bounding pulse
• Respiratory
– Shallow breathing
• Gastro-intestinal
– Polyphagia
S&S of Hypoglycemia
• Genital-urinary
– No polydipsia
– No polyuria
• Skeletal/muscular
– Weak
– Trembling / tremor
• Integumentary
– Perspiring/ Moist
– Pale
Small group Questions
1. When is a sliding scale commonly used?
2. A tuberculin syringe is also calibrated in units. Is
it OK to use a TB syringe to draw up insulin?
3. What route is insulin administered?
4. Compare the signs and symptoms of hyper and
hypoglycemia
– How come they are not all opposite signs and
symptoms?
– Why are some so similar?
– Which symptoms can you look for to tell the
difference between hyper and hypoglycemia? (*)
– What is the biggest risk factor in using an insulin
pump?
Oral Hypoglycemic Agents
Sulfonylurea
Cholpropamide (Diabanese)
Glipizide (Glucotrol)
Glimepride (Amaryl)
Glyburide (Diabeta, Micronase)
Oral Hypoglycemic Agents
Biguanides
Metformin (Glucophage)
Glucovance
Sulfonyurea+Biguanide
Oral Hypoglycemic Agents
• Oral hypoglycemic meds are not Insulin
• Oral hypoglycemic meds require some production of
insulin
• Oral hypoglycemic agents are used in the treatment
of type ___DM
– Type 2
• Oral hypoglycemic meds are meant to supplement
diet and exercise, not replace them
Oral Hypoglycemic Agents
• Oral hypoglycemic meds cannot be used
during pregnancy
• Oral hypoglycemic meds may need to be held
temporarily and insulin prescribed if BS levels
rise due to stress or illness etc.
• Action varies so effect may be enhanced by
use of multiple meds
Sulfonylureas
• Sulfonylurea’s work primarily by h the
secretion of insulin by directly stimulating the
pancreas
Sulfonylurea
• Side-effects of Sulfonylurea
– Hypoglycemia
– GI upset
Biguanides
• Biguanides work primarily by aiding insulin’s
action on peripheral receptor sites (target
cells)
• Biguanides are NOT associated with episodes
of hypoglycemia
• Biguanides + sulfonylurea may h the glucose
lowering effect
Biguanides
• Major side effects of Metformin are:
– Anorexia/ wt. Loss
• Metformin is contraindicated in patients with
Renal impairment
Can diabetes pills help me?
•
•
•
•
•
Only Type 2 DM
Results vary
Effectiveness wears off
Insulin may still need to be taken occasionally
Pregnant…
Small Group Questions
It’s your turn!
Small Group Questions
1. A type 1 DM asks you “Why do I have to have insulin
injections, why can’t I just take the Insulin pills?” How would
you answer him?
2. Mrs. Murdock is a Type 2 DM. She was taking Glucatrol 20
mg BID. The MD changed her meds today to Micronase 5 mg
PO BID and Glucophage 500 mg PO BID. Mrs. Murdock asks
you why she is taking two medications now, instead of just
increasing the dose of Glucatrol?
Hypoglycemia
• Definition: When blood glucose levels fall
below 70mg/dL
• < 50mg/dL = severe
Hypoglycemia: Etiology
• Any time
– Usually: Before meals or a night
• Too much insulin or oral hypoglycemic meds
• Too little food
• Excessive exercise
Hypoglycemia:
Dx & Assessment
• Signs & Symptoms
• Can occur suddenly!
• If pt is a long time
diabetic 
• No early S&S
Hypoglycemia:
Dx & Assessment
• #1 Dx tool
– Lab Values
• FSBS
Hypoglycemia can result:
• When a patients
baseline blood glucose
level is 100mg/dL 
• When a patients
baseline blood glucose
level is 200mg/dL 
– Drops to 60 mg/dL
– Drops to 120 mg/dL
Hypoglycemia:
Medical Management
• Assess for S&S
• P blood sugar level
• Admin. fast sugar
Hypoglycemic Protocol: Sample
• For BG <60 mg/dL
– If patient can take PO, give 15g of fast acting
carbohydrate.
– Check FSBG q 15 minutes and repeat above if
BG<80.
Glucose Fast!
• 15 g fast acting
carbohydrate
– 4-6 oz. Juice/soda
Rules to remember
•
•
•
•
•
•
Do not add sugar to OJ
Recheck FSBS q 15 min until WNL
Avoid high fat  slows absorption of glucose
Instruct: carry fast sugar
NPO if “unconscious” or confused
If meal is >1 hr away, follow with a protein and
complex carbohydrate
Hypoglycemia treatment
Unconscious
• Position: side lying
Hypoglycemia
Gerontological Consideration
• Cognitive deficits 
– not recognize S&S
• Decreased renal function 
– oral hypoglycemic meds stay in body longer
• More likely to _________a meal
– Skip
• Vision problems 
– inaccurate insulin draws
Hypoglycemia
Nursing measures
• Follow protocol
• Teach
– Carry simple sugar at all times
– S&S or hypoglycemia
– How to prevent Hypoglycemia
– Check FSBS if you suspect  NOW!
Treating Hyperglycemia
• Assess for
– S&S
• Check
– FSBS
• Administer
– insulin per MD order
Medical Management/treatment
• Monitor Fluid and electrolytes
– Especially K+
– Push fluids