Diabetes teaching


Original Discussion Topic: My question to you is what symptoms do you normally see with high blood sugars? What are potential problems for people who have high blood sugars?

What would you do with a patient who is obviously non-compliant with their blood sugar management, what steps would you have take and how would you resolve it?

Response from classmate 1:

There are many different signs and symptoms of hyperglycemia.  Some of them include headache, fatigue, sugar in the urine, polyuria, polydipsia and polyphagia.  When an elevated blood sugar is left untreated it can cause diabetic ketoacidosis.  In order to understand ketoacidosis, you have to understand how the body uses glucose.  We know that the pancreas produces insulin and that insulin is what helps transport glucose into the cells to be used for energy. Without glucose being transported into the cells, the body has to find another source of energy.  It starts to break down fat which causes a buildup of acids (ketones) in the bloodstream.  The signs and symptoms of diabetic ketoacidosis usually develop quickly and can include polydipsia, polyuria, nausea and vomiting, shortness of breath, fatigue, confusion, abdominal pain and a fruity-scented breath.  If left untreated, diabetic ketoacidosis can be fatal (Mayo Clinic, 2016).
I came across another complication that I wasn’t familiar with which is Hyperglycemic Hyperosmolar Syndrome.  HHS is more commonly seen in patients with type 2 diabetes who have an underlying infection or illness that leads to a decrease in fluid intake. “HHS is characterized by hyperglycemia, hyperosmolarity, and dehydration without significant ketoacidosis.” (Avichal, 2017).  According to the American Diabetes Association, diagnostic features include
-Plasma glucose level of 600mg/dl or greater
-Effective serum osmolality of 320 mOsm/kg or greater
-Profound dehydration, up to an average of 9L
-Serum pH greater than 7.30
-Bicarbonate concentration greater than 15 mEq/L
-Small ketonuria and low to absent ketonemia
-Some alteration in consciousness
The major difference between HHS and DKA is that most patients with HHS don’t develop significant ketoacidosis.  “Insulin remains available in amounts sufficient to inhibit lipolysis and ketogenesis but insufficient to prevent hyperglycemia. Hyperosmolarity itself may also decrease lipolysis, limiting the amount of free fatty acids available for ketogenesis.” (Avichal, 2017).
Other complications of untreated hyperglycemia include neuropathy, diabetic nephropathy, blurry vision, cataracts, glaucoma, and retinopathy, and cardiovascular disease.
When caring for a diabetic patient who is non-compliant I think the first place to start is with education.  When a patient understands their diagnosis and the consequences of not practicing adequate self-care, they are more likely to adhere to a care plan.  One article I read on diabetesdaily.com addresses the issue of patients not taking or refilling their medication regularly.  They found that “only 50% of people with type 2 diabetes (PWT2D) are still taking their oral medications one year after it was prescribed and only 20% are still taking injectable therapies, such as insulin, after one year. There was one recent publication that reported 30% of PWT2D never even filled their prescriptions for a new diabetes medication in the first place!” (Edelman, 2016).
It is important that patients know and fully understand how dangerous it is to ignore this disease.  Non-compliance potentially leads to greater expenses for those particular patients because of higher rates of hospitalizations and complications.  Many patients also struggle with the cost of medications and glucose monitoring supplies.  If this is the case, it is important that the physician, nurse and patient work together to find both a medication that fits the patient’s needs as well as budget and insurance.  There are many ways for patients to get discounts or find generic products to help decrease the cost of care as well as outside resources that aid in financial assistance.

Response from classmate 2

Diabetes mellitus is an endocrine disorder that results when the pancreas is unable to produce enough insulin. Insulin is the hormone made by the pancreas and released into the bloodstream when needed. When the sugar level rises, the pancreas secretes more insulin so the larger amount of sugar can move out of the blood and into cells. When the sugar level falls too low, insulin secretion stops and the hormone glucagon is released. This allows the liver to release stored up energy into the blood.
There are two types of diabetes mellitus, type 1 and type 2. Some of the signs and symptoms of diabetes are, fatigue due to the lack of energy production, and hyperglycemia because the glucose cannot be energized. The diabetic patient is frequently thirsty and has dry mucous membranes. The lens of the eye becomes affected by the deposits of sugar and edema which results in visual difficulties. Glycosuria is present because the body tries to eliminate excess glucose from the blood. This wasting of sugar causes the weight loss and hunger of the diabetic patient.
People who have elevated blood sugars for long periods of time may lose limbs, develop retinopathy, and experience end-stage kidney disease.
If you are baffled by how many patients, particularly those with diabetes, don’t take their medications as prescribed, you’re not alone. Doctors feel frustrated by the same thing. When patients are non-compliant with maintaining their blood sugars, it affects the doctor’s ability to provide optimal care. Non-compliant patients also cost the system tons of bucks in terms of higher rates of complications, hospitalizations, lost days from work, not to mention the human suffering that affects the entire family when a person is not under control and develops a complication. If I was taking care of a non-compliant patient, I would help the patient understand why it is important for their good health to take their medications as they are prescribed. I would encourage the patient to maintain their optimal level of health by educating, motivating, and supporting the patient by addressing their individual physical and emotional fears, needs, and concerns.
Just recently I read a Peer-Reviewed article about primary care providers who find that diabetes is harder to treat compared with five other chronic conditions. The article went on to say that physicians are non-compliant with taking care of patients with diabetes because physicians are frustrated with the characteristics of the disease itself, the complexity of its management, and a perceived lack of support from society and the healthcare system for their efforts to control diabetes. (Listed below is the website for this article)
Here are 3 Nursing Diagnoses and Interventions for Diabetes Mellitus.
1. The risk for Impaired Skin Integrity: People with diabetes is at risk for reduced blood flow to the neurons causing decreased sensation in the arms and legs. This makes it harder for the person to detect injuries. Decreased blood flow in the feet and lower legs increase the risk of poor tissue healing in the event of injury.
Intervention: The nurse should conduct baseline and ongoing assessments of the client’s feet which includes Musculoskeletal assessment, Neurological assessment, Vascular examination, assessment of hydration status, Assessment for lesions, corns, and calluses, and Teach foot hygiene. (Callahan,2015, pg.762)

2. The risk for Injury: The client with diabetes is at risk for injury for multiple factors. Changes in blood glucose alter levels of consciousness and may cause seizures. The impaired mobility, sensory deficits and neurological effects of complications of diabetes increase the risk of accidents, burns falls, and trauma. (Callahan, 2015, pg,763)

Intervention: To help the client decrease the risk of injury the nurse should assess for causative factors such as blurred vision, hypoglycemia, hyperglycemia, cataracts, unstable gait, and teach the patient about safety in the home.

3. The risk for Infection: Patients with diabetes are at increased risk for infection. The risk of infection

Intervention:  The nurse should teach meticulous handwashing, monitor for manifestations of infections, discuss the importance of skin care, teach dental measures, and teach women with diabetes the symptoms and preventive measures of vaginitis caused by Candida Albicans. (Callahan,2015, pg762)

Response to classmate 3

Signs and symptoms of elevated blood sugars
• increased thirst
• headaches
• trouble concentrating
• blurred vision
• frequent urination
• fatigue (weak, tired feeling)
• weight loss
• Dry mouth.
Hyperglycemia (high blood sugar levels) occurs when your blood sugar (also called glucose) is higher than your body needs to function normally.
Immediate problems with high blood sugar level are life-threatening. People with type 1 diabetes and some people with type 2 diabetes have an increased risk for DKA (Diabetic Ketoacidosis) when the cells do not get the sugar they need for energy the body breaks down fat instead of glucose, releasing Ketones into the bloodstream.
Long-term complications with elevated blood sugar cause damage to large blood vessels called Macrovascular disease. Macrovascular disease is a buildup of plaque, increasing patient at risk for coronary artery disease, heart attack, and stroke.  Elevated blood sugars also cause damage to the small blood vessels called Microvascular disease. The Microvascular disease can lead to the loss of vision, kidney disease, and nerve damage throughout the body.
Diabetic neuropathy is common with patients who have high blood sugars. Nerve damage can decrease or block the movement of nerve impulses or messages to organs, legs, arms, and other parts of the body. Nerve damage can also affect internal organs and lead patients to injury they may not feel.
A patient being noncompliant with their high blood sugar levels put them at risk for all of the above listed. As a nurse, I would assess the following to determine the patients coping.
I would assess the client’s psychosocial resources, emotional, support, financial, lifestyle, and communication skills. I then would explore with the client and family the effects of the diagnosis and treatment of diabetes on finances, occupation, energy levels, and relationships.  Effective coping involves maintaining emotional balance, a healthy self-concept, and satisfying relationships, as well as handling emotional stress. As a nurse, I would also teach them about setting goals and reaching out to others for support. Provide information about support groups and resources such as suppliers, journals, books, and cookbooks for individuals with diabetes. Clients who are living on limited incomes or are without health insurance may need assistance in accessing special programs offered by pharmaceutical companies or local clinics to help them pay for their prescriptions. Sharing with others who have similar problems provides opportunities for mutual support and problem-solving. Using available resources improves the ability to cope.

Patient diagnosed with diabetes are at risk for impaired skin integrity and infection. Teaching the patient the importance of hygiene and to assess lower extremities may prevent wounds and infection in the future.

Nurse’s diagnosis- Risk for infection r/t high glucose levels e/b non-compliant
Goal: Being compliant to the daily dose of insulin being given when glucose levels are high.
1. Assess for signs of infection and inflammation
2. Patient will ensure good hygiene is maintained
3. Patient will provide skin care and keep skin dry
4. Administer antibiotics or fungal cream as needed
5. Example who to administer insulin safely

Nurse’s diagnosis- Impaired skin integrity r/t lack of circulation to extremities e/b nerve damage

Goal: Drink 240ML q4hrs to maintain hydration and skin integrity.
1. Examine wound characteristics
2. Evaluate adequacy of nutrition and sleep hygiene
3. Check for secretions or drainage of any type
4. Maintain fluid intake
5. Ensure to move or rotate q2hrs to prevent pressure sores