7. diabetes melitus

7/28/2019 7. Diabetes Melitus

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By : Hj. Muaeni, SKp, MKep


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DIABETES

Suatu sindroma gangguan metabolis

sebagai akibat suatu difisiensi sekr

biologis dari insulin atau keduanya.

Karakteristik difisiensi insulin yg utaprotein dan lemak

DM refers to disorders characterized

. Muaeni, SKp, MKep / Diabetes Mellitus. Muaeni, SKp, MKep / Diabetes Mellitus. Muaeni, SKp, MKep / Diabetes Mellitus. Muaeni, SKp, MKep / Diabetes Mellitus

.

Diabetes akan mengalami pengoba

dewasa membuat centers for disease

is the seventh leading cause of death

DM is major risk factor for morbiditycerebrovasculer disease and peripher

Penting mempertahankan konsentia

bahan makanan dapat digunakan ol

gonad.

MELLITUS

e dgn hiperglikemia yg tdk semestinya

si insulin at. berkurangnya efektifitas

a adl gg. dlm metabolisme carbohidrat,

y fasting hyperglycemia or bloodglucose

an sepanjang hidup dan pd populasi

control and prevention (CDC, 1997)

an mortality due to coronary disease,l vascular disease

i glucosa yg konstan satu-satunya

h otak, retina, epitelium germinal dari


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PATOFI

Berkurangnya sekresi insulin

(faktor heridi

Salah satu

Berkurangnya pemakaian glukosa ol

.... MuaeniMuaeniMuaeniMuaeni,,,, SKpSKpSKpSKp,,,, MKepMKepMKepMKep / Diabetes Mellitus/ Diabetes Mellitus/ Diabetes Mellitus/ Diabetes Mellitus

glukosa darah (300 mg 1200 mg/dl)Sgt meningkatkan mobilitas lemak

terjadinya metabolisme lemak yg ab

pembentukan darah aterosklerosis

Berkurangya protein dalam jaringan tu

IOLOGI

leh sel beta pulau langerhans.

er, obesitas)

efek utama

h sel-sel tubuh naiknya konsentrasi

dari daerah penyimpanan lemah

ormal & endapan kolesterol pd dinding

buh


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Selain itu terjadi yg tdk tampak dgn mud

Hilangnya glukosa dlm urine klien DM* Jumlah glukosa yg memasuki tubul

diatas kadar kritis

* Suatu kelebihan yg bermakna tdk ddlm urine (100 mg/dl at. lebih gl

Dehidrasi akibat kenaikan kadar gluko

*


(12 x dr normal)

efek yg bermakna

Dehidrasi sel-sel jaringan glukosa

pori2 membran sel & naiknya tekan

timbulnya perpindahan osmotik air kel

h

us ginjal (filtiasi glomerulus) meningkat

t direabsorpsi & sebaliknya dikeluarkankosa)

a darah

tdk dpt dgn mudah berdiffusi melewati

n osmotik dlm cairan ekstraseluler

ar dari sel (dehidrasi selluler)


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Dehidrasi seluler, keduanya glukosa kosmotik

Efek osmotik dari glukosa dlm tubabsorpsi cairan tubulus


e ese uru an : e angan ca rancairan ekstrasell yg selanjutnya de

e dalam urin, dpt menimbulkan diuresis

lus ginjal yg sangat mengurangi ke

yg sanga anya m ur n e rasidrasi kompensatorik intrasell


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Clasification of Diabetes Mellitus and

Current

Classification

Previous

Classifications

Type I :

Insulin

DependentDiabetes

Mellitus

Juvenile diabetes

Juvenile onset

diabetes

Ketosis prone

diabetes


- 10% of allDiabetes

Brittle diabetes

Related Glucose Intolerances

Clinical Characteristic and Clinical

Implications

Onset any age, but usually young (


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Type 2 : Non

insulin

dependent

diabetes

(NIDDM) (90%

-95% of all

Adult onset diabetes

Maturity onset

diabetesKetosis resistant

diabetes


diabetes :obese 80% of

type 2; non

obese 20% of

type 2)

Acute complication of hyperglicemia;

diabetic ketoacidosis

Onset any age, usually over 30 yrs

Usually obese at diagnosis

Causes include obesity, heredity, orenvirontmental factors

No islet cell antibodies

ecrease n en ogenous nsu n, orincreased with insulin resistance

Most patients can control blood

glucose through weight loss if obese

Oral antidiabetic agents mayimprove blood glucose lefels if

dietary modification and exercise are

unsuccessful


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Diabetes

mellitus

Secondary

diabetes


assoc ate w tother

conditions or

syndrome

ay need insulin on a short or long term

asis to prevent hyperglycemia

etosis rate, except in stress or infection

cute complication ; hyperglycemic

yperosmolar non ketotic syndrome

ccompanied by conditions known or

uspected to cause the disease

ancreat c ases , ormonabnormalities, drugs such as

orticosteroid and estrogen containing

reparations

epending on the ability of the pancreaso produce insulin,the patient may

equire treatment with oral antidiabetic

gens or insulin


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Gestational

diabetes

Gestational diabetes O

s

Dpl

c

(

T

st


le

O

Gr

*

nset during pregnancy, usually in the

cond or third trimester

ue to hormones secreted by theacenta, which inhibit the action of insulin

ove normal risk for perinatal

mplications, especially macrosomia

bnormalmaly large babies)

eated with diet and if needed, insulin to

rictly maintain normal blood glucose

vels

ccurs in about 2%-5% of all pregnancis

lucose intolerance transitory but maycurs

n subsequent pregnancies


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Impaired

glucosetolerence

Borderline diabetes

Latent diabetes

Chemical diabetes

Subclinical diabetesI

30%-40% will develop overt diabetes

(usually type 2) within 10 years

(especially if obese)isk factors includes obesity, age older

than 30 years, family history of

diabetes, previous large babies (over 9

lb)creaning test (glucose challenge test)

should be performed on all pregnant

women e ween an wee sgestation

ral glucose tolerence test value

between 140 mg/dL (7.7 mmol/L) and200 mg/dL (11 mmol/L)

mpaired fasting glucose is defined as a

fasting plasma glucose between


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Asympromatic

diabetes

110

m

29%

Abo

ac

Rensig

May


Previous

abnormality ofglucose

tolerence (Pre

AGT)

Latent

diabetes

Prediabetes

reSho

Curr

Prev

pr

Peri

mg/dL (6 mmol/L) and 126 mg/dL (7

ol/L)

eventually develop diabetes

e normal susceptibility to

erosclerosis disease

l and retinal complications usually notnificant

be obese or non obese; obese should

uce weightld be screened for diabetes periodically

ent normal glucose metabolism

ios history of hyperglycemia ( eg during

gnancy or illness)

dic blood glucose screening after


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Potential

abnormality

of glucose

Prediabetes


to erence(pot AGT)

age 40 if there is a family history of

diabetes or if sympromatic

Encourage ideal body weight,because loss of 10-15 lbs may

improve glycemic control

No history of glucose intolerence

Increased risk of diabetes if :

Obesity

Mother of babies over 9 lbs at birth

Member of certain Native American

Indian tribes with high prevalence ofdiabetes (eg. Pima)

Screening and weight advice as in Pre

AGT


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CLINICAL MAN

Clinical manifestations of diabetes inclu

and polyphagia. Polyuria (increased uri

occur as a result of the excess loss of flpatient also experiences polyphagia (

catabolic state incude by insulin defien

fats. Other symptoms include fatigue


tingling or numbness in hands or feet, drecurrent infections. The onset of type

nausea, vomiting, or abdominal pains.

IFESTATIONS :

de the three Ps : polyuria, polydipsia,

ation) and polydipsia (increased thirst)

id associated with osmotic diuresis. Thencreased appetite) resulting from the

y and the break down of proteins and

nd weakness, sudden vision changes,

ry skin, sores that are slow to heal, anddiabetes may also be associated with


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Mayor Risk Factors

Family histori of diabetes (parents or sibli

Obesity (more than 20% above a persons

Origin (African-Ameracan, Hispanic-Ameri

Age older than 45 years plus any of the p

Previously indetified impaire glucose toler

Hypertention (> 140/90 mmHg)


High density lipoprotein cholesterol level(0.90 mmol/L) and tryglyceride levels > 2

(2.82 mmol/L)

History of gestational diabetes or deliveryFrom American Diabetes Association (1

diabets. Diabets Care, 21 (suppl, 1) S20-

for type 2 Diabetes

gs)

ideal body weight)

can, Native American or Asian-American)

eceing factors

nce or use of certain prescription drugs

35 mg/dL0 mg/dL

of babies weighing more than 9 pounds98q). Position statement : screening for

2


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Problems of Regulation and Metaboli

ACUTE COMPLICATIONS OF DIABET

Diabetic ketoacidosis (DKA) is associ

H er l cemia h erosmolar non ket

Three emergencies related to major devi

occur in clients who have diabetes


insulin defiency, profound dehydration,Hypoglicemia occurs in conditions of i

All three conditions need emergencyinappropriatelly treated or not treated

m

S

ted with insulin defiency and ketosis

tic s ndrome HHNS is associated with

ations from normal blood glucose level

and the absence of ketosissulin excess

treatment and can result in death ift all


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CRONIC

Cardiovaskular Didease : AMI,

cardiogenic shock

Peipheral vascular disease Cebrovascular disease

Macrovascular


Microvascular Ocular complication : retinopathy, n

Diabetic neurophaty

Diabete nephropathy Male erectile dysf

Congesti heart failure, dysrhythmias

on prolifhative retinopathy


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NURSING PROSES :

Assesment and Diagnostic Findings

Gula darah test

Oral glucosa tolerance test Glycosylated Hemoglobin Assays

HB glukosa tetap melekat pd he

Darah


Urine

Urine testing for ketone bodies

( DM tipe I(+) )

Test fungsi ginjal

Test urine glukosa

mengukur % glukosa yg melekat pd

oglobin selama hidup sel darah merah,

Laboratory Profile : Blood Glucose Values


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Laboratory Profile : Blood Glucose Value

Tes

Normal Range f

Adult

Fasting blood

glucose

< 110 mg/dL (6.1

mmol/L)

Elderly : levels ri10 mg/dL per

decade of age


Glucose Tolerance

Test (2 hour post

glucose load)

< 140 mg/dL (7.

mmol/L)

s

r

Significance of Abnormal Finding

e

Elevayions > 126 mg/dL (7.0

mmol/L) (obtained on 2 occasions)

are diagnostic of diabetes, even inolder adults

Levels > 140 mg/dL (7.8 mmol/L)

and < 200 mg/dL (11.1 mmol/L) =

IGT (Impaired Glucose Tolerance) Levels > 200 mg/dL diagnostic of

diabets in non pregnants adults


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Glycosylated

(glycated)

hemoglobin Alc

(HbAlc)

4% - 6%


Levels over 8% indicate poor

diabetic control with need for

adherence to regimen or chages

therapy


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Education Guide : Plasma Gluce Testi

Do not eat flood or drink any liquid

Fasting plasma blood glucose

Oral glucose tolerance test

Eat a balanced diet with carbohydra


of 3 days while maintaining normal Carbohydrate restriction, bedrest,

with the test. Phenytoin (dilantin), a

and glucocorticoids adversely affect

The test is ferformed in the morning

ng

or at least hours

te intake of at least 150 g for a minimum

hysical activitycute illness, and certaindrugs interfare

ovularity drugs, diuretics, nicotinic acid,

results

after 1 10 to 12 hour fast


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A fasting blood sample is obtained

You will be asked to drink 300 ml

minutes of the fasting blood sample

Blood sample are drawn at 30 minut

During the test, you will remain at

liquids


Report any signs sugesting hypoglnervousness, and confusion

(75 g) of a flavores beverage within 5

intervals for 2 hours (60 90)

rest and not be able to smoke or drink

ycemia, such as weakness, dizziness,

Nursing Guidelines for assessing a patie

nt with Diabetes Mellitus


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Nursing Guidelines for assessing a patie

Assestment Item

PATIENT HISTORY

Duratation of diabetes

reason for admission or

appointment

Ask the pati

made

Ask the patiseeking care


Insulin therapy

eaten for thpatient unde

taught diet

If the patientobserve pati

hospital. Ask

of the insulin

nt with Diabetes Mellitus

Special Considerations

nt when the diabetes diagnosis was

nt to describe the reason in detail for

previous 2 day to determine whetherstands and complies with a previously

has been administering insulin at home,nt prepare and administer insulin in the

the patient to state the name and dose

nd time

taken and to

describe its action according to onset


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Antidiabetic oral agents

Self blood glucose

taken and to

peak, and du

If the patien

patient to st

whether he

insulin and or

If the patient


mon tor ng

Knowledge of acute

complications

observe whdescribe low

Ask the pati

treatment oketoacidosis

describe its action according to onset,

ation

takes oral antidiabtic agents, ask the

ate name of the agents. Ask patient

or she knows the difference between

al antidiabetics agents

has been doing this procedure at home,

ile its performed. Ask the patient tohe or she interprets the result.

nt to state the causes, symptoms, and

hypoglycemia, hyperglycemia, and


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Knowledge of sick day

management

Foot care routine

Ask the patie

sick days re

whether patiespecially in

diarhea.

Ask the patieof the feet.

implications o


Exercise

Basic physiology of

diabetes

Determine wactive lifestyl

effect of exerc

Ask the patie

effect the bod

nt to describe how he or she manages

arding diet and medication. Detemine

nt understands implications of illness,ections, nausea, and vomiting, and

t to describe how he or she takes careDetermine whether patient understand

foot care problems

ether the patient leads a sedentary orand whether he or she understands the

ise on blood glucose levels

t to explain what diabetes is and how it


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Long term degeneraivechanges

Personal history

Ask the patieoccur with di

Find out whlifestyle, inclu

activities; wh


Diabetic identification Ask to see th

or carries

nt to list the long term changes that canbetes and how to delay their onset

ther patient lives alone or with others;ding occupations hobbies, and weekend

ther patient receives social assistance

diabetic identification the patient wears

PHYSICAL EXAMINATION


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PHYSICAL EXAMINATION

Infections

Diabetic dermopathy

Asses for the

in the groin, tvaginal yeast

Asses for urin

Examine the

spots; kno


Xanthomas

lipodystrophy foot and

leg problems

,

reddened lesi

Examine the

are you yelloExamine ins

lipodystrophy

presence or history of Candida albicans

he axillae, and under the breast, and ofinfections in females

ary tract infections

tibial area for the presence of shin

n ask diabetic dermopathy, and for

ns with sharply defined borders

lbows and knees for xanthomas, which

fat defositlin injection sites for the presence of


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Examine the

reddened areExamine the

and hard to c

Palpate the d

Examine the

Palpate ankle


Physical condition Asses weight,

Asses for

dyspnea, irre

edema, orhosExamine han

feet and legs for sores, blisters,

s, or ulcerstoenalis to see whether they are thick

t

rsalis pedis and posterior tibial pulse

orsal part of the foot for hair loss

for edema

blood pressure and pulse

ymptoms of cardiovaskular disease

ular apical or brachial pulse, dependent

atic hypotensions for sores, burn or muscle atrophy


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Asses for gastroi

especially at nigAsses for impote

Asses for loss of


ntestinal disturbances, such as diarrhea,

tnce or other reproductive problems

sensations in extrimities


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Analysis

Common Nursing Diagnoses an

1. Risk for injury relate to hyperglice

2. Risk for injury related to stress of

Common nursing diagnoses for th


.

4. Pain related to peripheral nerve d

5. Risk for injury related to visual

neuropathy)

6. Altered renal tissue perfussionabnormalities (diabetic nephropat

Collaborative Problems

mia

surgery

diabetic client include :

ysfunction (diabetic neuropathy)

sensory percetual alterations (diabetic

elated to the renal effects of vascularhy)

Primary collaborative for the diabe ic client include :


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1. Potential Complications : Hypogli

2. Potential Complication : Diabetic3. Potential Complication : Hy

Syndrome

Primary collaborative for the diabe

In addition the common nursing diag

clients with diabetes have one or mor

Additional Nursing Diagnoses and


Altered Nutrition : more than body rfood intake and physical activity, lac

skills

Risk for fluuid volume deficit relat

mechanisms, hyperglycemic osmotic

decreased oral intake and dehydration

Pain related to insulin injections or ca

cemia

Ketoacidosiserglycemic Hyperosmolar Nonketotic

ic client include :

oses and collaborative problems, some

e of the following :

Collaborative Problems

quirentment related to an imbalance ofk of knowledge, and ineffective coping

d to fluid shifts, failure of regulatory

diuresis, polyuria, vomiting, diarrhea,

ilarry blood glucose testing


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Altered oral mucous membranes rela

and uncontrolled blood glucose levels

Knowledge deficit related to a lack of

about disease process, nutrition man

control and mouth care

Altered urinary eliminationwith oveneuropathy

Chronic constipation related to diabeti


Diarrhea related to diabetic neuropath

Risk for impaired skin integrity relat

bloods glucose levels, decreased mob

Risk for infection related to encrease

perfussion, inadequity primary defeneffect of chronic disease

Risk for infection related to wounds,

site, or the gums

ted tomicrovascular circulatory changes

familiarity with information resources

agement, exercise, medications, weight

flow incontinence related to diabetic

neuropathy

ed to decreased circulation, increased

ility and decreased sensation

blood glucose levels, decreased tissue

es (e.g break in skin integrity) and the

rinari tract infection, intravenous acces

f ( )


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Risk for altered sexuality patterns (

decreased cisculation or phsichologic

Risk for altered sexuality patternspsychological stressors of diabetes l

changes in neurologic control of ge

limitations imposed by the disease or

Anticipatory grieving related to pe

consequence of diabetes


consequence of diabetes

Self esteem disturbance related to in

of diabetic regimen

Anxiety related to the diagnosis odiabetes and self care regimens

Fear related to the diagnosis of diab

and self care regimens

ale) related to autonomic neuropathy,

l considerations

(female) related to the physical andubrication, painful inter course with the

italia, the effect of actual or perceived

heraphy and altered self concept

ceived loss of body functions as a

bility to deal with the self care demands

f diabetes, potential complications of

tes, potential complications of diabetes

Risk for ineffective individual copin

lf i d d d

relatedto a chronic disease, a compleks

i l t


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self care regimen and decreased so

Risk for ineffective family copin

disease, a comples self care regim

Powerlesness related to the

amputations, renal failure, renal fail

Social isolation related to visual i

role and a complex self care regim


Risk for noncomplience with schronicity of the prescribed regime

Risk for altered health maintena

nutition therapy, weight control,

exercise, self mo nitoring of blood

care hypoglycemia and available r

ial support

, compromised, related to a chronic

n and decreased social support

omplications of diabetes (blindness,

ure and neuropathy)

pairment or blindness, adoption of sick

n)

lf care related to the complexityand

ce related to insuficient knowledge of

eight maintenance, benefit and risk of

lucose, medications, sick day care, foot

sources

NURSING CARE PLAN : PATIE T WITH DIABETES MELLITUS


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Expected Patient Outcomes

Ambulatory a

NURSING DIAGNOSIS : ineffective mana

knowledge of adequate exercise program,

potensil side effect of glucose lowering ag

during acute minor illness as manisted

management, inaccurate responses to quest


ar c pa on n exerc se program

Appropriate dietary preperation and

intake

Safe, effecive administration of GLA

Demonstration of proper blood glucosetesting and recording of meaurements

Plan of action for self in event of illness

and symptoms lasting > 24 hr

Nursing Interventions and Rationales

d Home Care

ement of therapeutic related to inadequate

diet dan weight control, administration and

ents (GLAs), glucose monitoring, and care

y frequent questioning regarding diabetic

ions about diabetic management.

an n v ua ze exerc se program w

patient because exercise is an integralpart of diabetic management

Review step to prevent hyperglycemia

and hypoglycemia because activity

changes and cause changes in insulin

needs

Review diet and problem areas with

patient to provide appropriate teaching

Counsel on weight loss if appropriate


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Counsel on weight loss if appropriate

because excess weight complicates

diabetic management Refer to dietician because dietary

management of diabetes can be

complex and requires ongoing

monitoring Review GLA administration; have

patient give return demonstration of

insulin injection to ensure profer

technique

Assess injection sites to determine

need for changing sites or initiating

treatment to problematic areas Review symptoms and treatment of

hypoglycemia so early treatment can

be initiated

Demonstrate glucose testing; have

ti t i t d t ti t


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patient give return demonstration to

ensure proper technique

Review glucose records with patient

and explain how to identify trends to

improve glucose control

Remind patient to call physician if bloodglucose is > 250 mg/dl (13.9 mmol/L)

and ketonuria is present so appropriate

developtment of diabetic ketoacidosis(DKA)

Review effect of stress on glycemic

control so patient is aware that stresscan increase glucose level

Review sick day care so patient can

make appropriate adjustment in

diabetic management


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Assist patient in devising a sick dayplan, including foods to have on hand

and family member or friend who can

be with patient during illness episode,

to be ready to properly managediabetes when illness occurs

Review symptoms needing attention of

physician, including blood glucose

level > 250 mg/dl (13.9 mmol/L),

ketonuria, fever, nausea, and vomiting

so patient can contact physician when

necessary to prevent occurrence ofDKA and hyperglycemia hypersmolar

nonketosis (HHNK)

NURSING DIAGNOSIS : Risk for infecti n related to depressed immune system,


40/81

NURSING DIAGNOSIS : Risk for infecti

inadequate circulation and environtmental p

Verbelazation of steps to prevent

infection (skin care, foot care,

regular dental care)

Recognition of signs of infection and

need for intervention

r

p

r

l

a


r

p

sp

i

i

n related to depressed immune system,

thogens

sses for sign of infection such as fever,

dness, swelling or pus at trauma of

ressure site; fever to ensure early

cognition and treatment

sses oral civity, skin, pulses, particulary

wer extremities and pedal pulses to detect

reas of infection or poor circulation

eview skin and foot care, have patient giveturn demonstration of foot care to ensure

atient understanding

eview signs of infection, including redness,

elling, pus and when to contact health carerovider to ensure patient recognizes

fection and notifies health care provider if

dicated so treatment can be initiated

NURSING DIAGNOSIS : Self esteem disturbance related to lifestyle changes imposed


41/81

by diabetes and its treatment and frustation

negative feelings about self, resistence to in

Verbelazation of positive attitude about

self and ability to manage disease

Plan for continued contact with health

care provider for health monitoring


at progerssion of disease as manifested by

orporating treatment regimen into lifestyle

Encourage patient to discuss diagnosis

and its implications so appropriate

counseling and interventions can be

palnned Suggest individualized diabetes education

and support group toincrease patients

now e ge ase an mee o er peop e

with diabetes

Suggest creative approaches to problems

with patient because patient may be

overwhelmed initially by compexity of

disease management

Assure patient of continued value and self

worth to minimize impact of diabetes

onpatients self esteem

COLLABORA IVE PROBLEMS


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Nursing GoalsAcute Ma

POTENTIAL COMPLICATION


Monitor for signs of DKA and HHNK Report deviations from acceptable

parameters

Carry out appropriate medical andnursing intervention

Nursing Interventions and Rationalesagement

DKA and HHNK related to in adequate

insulin and excess blood glucose

secondary to increased caloric intake,

physical or emotional stress, or

undia nosed

Asses for signs of DKA such asincrease in urination; vomiting;

somnolence; dehydration; dry; loose

skin; hypotention with weak, rapid

pulse, coma; hyperglicemia > 250mg/dl (13.9 mmol/L); presence of

urine ketones; PH < 7.3 to ensure

early recognitzion and intervention

Asses for signs of HHNK such as


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hyperglycemia > 00 mg/dl (27.8

mmol/L), serum osmolality > 300

mOsm/kg (300 mmol/kg, absence of

ketonuria to detect signs of HHNK

Administer insulin per physician order

to stabilize blood glucose level Administer fluid and alectrolyte

replacement as ordered to correct

dehydration

monitor input and out put and vital

signs to detect signs and symptoms

of iadequate tissue perfusion

Asses for precipitating factors toprevent resurrence and identify

teaching needs

Hypoglycemia related to low blood glucose


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POTENTIAL COMPLICATION

Monitor for signs of hypoglycemia

Report deviations from acceptable

parameters

Carry out appropriate medical andnursing intervention


Hypoglycemia related to low blood glucose

secondary to too much insulin

Assess for signs of hypoglicemia such as

cold sweats; weakness; trembling;

nervousness; irritability; pallor; increase

in heart rate; confusion; fatigue;abnormal bahavior to ensure prompt

identification and treatment

.

when symptoms are mild) to provide anindicator for treatment

Provide quick acting carbohydrate

sources such as 6-8 oz orange juice, 1

cup milk, or 6-8 oz soft drink to quicklyreverse hypoglycemia; give orally only if

patient is alert enough to swallow to

prevent aspiration.

Rimprovement or patient is


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Rimprovement or patient is

comatose, administer 1 mg glucagon

subcutaneously or 30-50 ml of 50%IV dextrose per physician order to

stimulate hepatic response to convert

glycogen to glucose

When patient improves and is alert,

provide long acting carbohydrate or

next scheduled meal to kee blood

glucose levelwithin acceptable range Asses for precipitating factors such

as history of too much insulin, to little

food, unusual amounts of exercise,

or delayed eating to preventrecurrence and identify precipataring

epeat oral dose in 10-15 min if no

factors

Li k d i t t k DM


46/81

Lima komponen dari

(United Kingdom Prospective D

NutritionManagem


Education

Pharmacologic

anagement untuk DM

abetes Study Group / UKPD98)

alnt

Exercise

Monitoring

Oral Antidiabetics Agents Used in the

United States


47/81

Generic (Trade) Name

Table Size

(mg)

First Generation

Sulfonylureas

accrohexamile (dymelor)chlorpropamide (diabinese)

tolazamide (tolinase)

250 500

100, 250

100, 20, 50


tolbutamide (orinase)

Second Generation

Sulfonylureas

glipizide (glucatrol)glipizide (glucatrol XL)

gliburide (micronase)

250, 500

5, 10

5, 10

1.25, 2.5, 5

Usual Daily

Dose (mg)

Maximum

Dose (mg)

Duration of

Action (h)

250-1500 (D)

100-500 (S)

100-750 D

1500

750

1000

12 24

60

12 24

500-2000 (D)

5-25 (D)

5 (S)

2.5 10 (D)

3000

40

10

20

6 12

10 24

24

12 24


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glimeperida (amaryl)

biguanides merformin

(gluphages)

Alpha Glucosidase Inbitorsacarbose (precose)

Thiazolidinediones

1, 2, 4

500

50, 10

200 400


trog tazone rezu n

Meglitinides repaglinide

(parandin)

1.5, 1, 2

= Divided Dose

= Single Dose

1 2 (S)

1500 (D)

1500 (D)

200400 S

8

2500

2500

600

24

8

8

-

0.5 - 4 16 2

Long Theraphy for Diabetes Mellitus : Oral Agents


49/81

DrugUsual Dosage &

Duration First

Generation

Sulfonylurea

Acetohexamide(Dymelor,

Dimelor)

250-750 mg q 12-24 h

Maximum : 1500 mg/da

Duration : 24 60 h


chlorpropamide

(Diabenese,

Novopropamide)

100-500 mg q 24h

Maximum : 500 mg/day

Duration : 24 60 h

Nursing

Interventions

Rationale

Emphasize eating

habits and pattern

Monitor renal

function

There Is high

incidence of hypoglycemia in

diabetics with renal

Emphasize eating

habits and pattern

s

impairment

The long half life of

the drug is

associated with ahigh incidence of

hypoglycemia

Tolazimide 100-500 mg q 12 24 h Administers with Taking with meal


50/81

(Tolinase)

Tolbutamide(Orinase,

Mobenol)

g q

Maximum : 2000

mg/day

Duration : 12 24 h

750-1500 mg q 1224Maximum : 3000

mg/day


Second

Generation

SulfonylureaAgents

2.4 5 mg q 12-24 h

Maximum : 40 mg/day

Duration : 12-24 h

h

meal

Administers 30minutes before

meals

g

helps to avoid

gastrointestinalupset

Taking 30 minutesbefore meals give

the best reduction

in ost randial

Administer 30

minute before

meals

hyperglicemia

Taking 30 minutes

before meals give

the best reductionin postprandial

hyperglicemia

Emphasize eating

h bit d tt

The long hal life of

th d i


51/81

Glyburide

(Micronase,

DiaBeta

2.5 20 mg q 24 h

Maximum : 20 mg/day


Euglocon)-

habits and patterns

Administers with

meals

the drug is

associated with a

high incidence of

hypoglicemia

Taking with meals

helps to avoid

gastrointestinal

Emphasize eating

habits and patterns

upset

The long hal life of

the drug is

associated with ahigh incidence of

hypoglicemia


52/81

Glimepiride

(Amaryl)

1-4 mg q 12-24 h

Maximum : 8 mg

Duration : 24 h


Biguanides

Metformin

(Glucophage)

500 mg q 12-24 h

Maximum : 2500

mg/day

Duration : 12 h

Take with first main

meal

Emphasize eating

habits andpatterns, and blood

glucose monitoring

result

Client with impaired

renal function are

more sensitive to

glucose lowering

effects of

glimepiride

Administer with

monitoring and

evening meals

Taking with meals

help to avoid

gastrointestinal

upset


53/81

Alpha

Glucosidase

Inhibitors

acarbose(Precose)

25 mg three times/day

Maximum : 100 mg

three times/day

Duration : 4-8 h


Thiazolidinedione

antidiabetic

Agents (Rezulin)

200-600 mg q 24 hMaximum : 600 mg/day

Duration : 24 h

Administer with first

bite of food

Delays carbohidrat

absorption

Administers withmeals

Taking with meal

help to avoi

gastrointestinal

upset

nsulin Preperations


54/81

Type Sou

Rapid Acting Insulin

insulin analog (Insulin lispro)

humalog (Lilly)

Short Acting Insulins

DNA tech


insulin injection (regular

crystaline insulin)

illetin II R (Lilly)

regular (novo nordisk)

humalin R (lilly)novolin R (novo nordisk)

velosulin BR (Novo nordisk)

illetin II U-500 (lilly)

Pork (puri

Pork

DNA techDNA tech

Semisynt

Pork (puri

ce

Onset

(hr)

Peak

(hr) Duration

nology

0.3 0.5 0.5 2.5 3.0 4.3

fied)

nologynology

etic

fied)

0.5 1

0.5

0.5 10.5

0.5

0.5

2 4

2.5 5

2 42.5 5

1 3

-

6 8

8

6 85 8

8

24

Intermediate Acting Insulins


55/81

isophane insulin suspension

(NPH insulin)

illetin II (lilly)

NPH (novo nordisk)

NPH pork (novo nordisk)humulin N (lilly)

novolin N (novo nordisk)

Pork (purifi

Beef

Pork (purifiDNA techn

DNA techn


Insulin zinc suspection

(lente insulin)

illetin II (lilly)

lente (novo nordisk)humulin L (lilly)

novolin L (novo nordisk)

Pork (purifi

Beef

Pork (purifi

DNA techn

DNA techn

ed)

ed)ology

ology

2

1.5

1.51 2

1.5

6 12

4 12

4 126 12

4 12

18 26

24

2418 24

18 24

ed)

ed)

ology

ology

2 4

2.5

2.5

1 3

2.5

6 12

7 15

7 15

6 12

7 15

18 24

24

22

18 24

18 24

fi d bi ti i li


56/81

fixed combination insulins

humulin 70/30 (lilly)humulin 50/50 (lilly)

novolin 70/30 (novo nordisk)

Long Acting Insulins

(Ultralente)

DNA techDNA tech

DNA tech


Buffered Insulins for use ineksternal pumps

humulin BR (lilly)

velosulin R (novo nordisk)

DNA tech

Pork (puri

ologyology

ology

0.50.5

0.5

2 123 5

2 12

2424

24

ology

ied)

0.5 1

0.5

Education Guide : Subcutaneous Insu

lin Administration


57/81

Wash your hands

Inspect the bottle for the type of insulin an

Gently roll the bottle of intermediate actin

Clean the rubber stopper with an alcohol

Remove the needle cover and pull back tamount of air should be equal to the insul

stoper and inject the air into the insulin bo


Turn the bottle upside down and draw the

Remove air bubbles in the syringe by tap

the bottle; Redraw the correct amount

Make certain the tip of the plunger is on t

available to ssist in measuring accurate d Remove the needle from the bottle. Rec

immediatelly

d the expiration date

insulin in the palms of your hands to mix it

wab

he plunger to draw air into the syringe. Thein dose. Push the needle through the rubber

tle

insulin dose into syringe

ing on the syringe or injection air back into

e line for your dose of insulin. Magnifers are

ses of insulinp the needle if the insulin is not to be given


58/81

Select a site within your injection ar

month

Clean your skin with an alcohol swab.the needle at 90 degree angle

Push the plunger all the way down.


e ease e p nc e s n

Pull the needle straight out quickly. Dshot

Dispose of the syringe and needle

container

a that has not been used in the past

Lightly grasp an area of skin and insert

his will push the insulin into your body.

o not rub the place where you gave the

without recapping in a puncture proof

Education Guide : How to mix a pres

and 20 U of NPH Insulin

ribed dose of 10 U of reguler insulin


59/81

Wash your hands

Inspect the bottle for the type of insuli

Gently roll the bottle of intermediate

to mix it Clean the rubber stopper with an alco


equal to the dose of insulin needed.acting insulin first. Withdraw the syring

Inject 10 U of air into the reguler insul

bubbles. Always withdraw the shorter

Withdraw 20 U of NPH insulin with the

any short acting insulin into the bottle.

and the expiration date

cting insulin in the palms of your hands

ol swab

.

Always inject air into the intermediatee.

in. Be sure that the syringe is free of air

cting insulin first.

same syringe, being careful not to inject

(A total of 30 U should be in the syringe)


60/81


Gambar : Common Insulin I jection Sites

Gambar : Self Injection of Insulin


61/81


Outcome Criteria for Determining Ef

Education

ctiveness of Self Injection of Insulin


62/81

Insulin :

1. Identifies information on label of insuli

* Type (eg, NPH, regular, 70/30)

* Species (human, biosynthetic, pork)

* Manufacture (lilly, novo nordisk)

* Concentration (eg, U-100)


xpera on a e

2. Checks appearance of insulin

* Clear or milky white

* Checks for flocculaton (clumping, fro

3. Identifies where to purchase and scor

* Indicates approximately how long b

100 insulin)

* Indicates how long pened bottles ca

bottle :

sted appereance)

insulin :

ottle will last (1000 units per bottle U

be used

Syringes :

1. Identifies concentration (U-100) marki

g on syringe


63/81

1. Identifies concentration (U 100) marki

2. Identifies size of syringe (eg, 100-unit,3. Describe appropriate disposal of used

Preparation :1. Draws up correct amount and type of i

2. Pro erl mixes two insulin if necessar


3. Insert needle and injects insulin4. Describes site rotation

* Demonstrates injection with all anat

* Describes pattern for rotation, suchareas at the same time of day

* Describes system for remembering

across the abdomen as if drawing a d

g on syringe

30-unit)syringe

nsulin

mic areas to be used

as using abdomen only or using certain

ite locations, such as horizontal pattern

tted line

Knowledge of insulin action :


64/81

Knowledge of insulin action :

1. List presciption* Type and dosage of insulin

* Timing of insulin injections

2. Describes approximate time course of* Identifies long and short acting insuli

*


* Identifies need to delay food unti(indicated when injecting regular insuli

* Knows that longer time delay are s

time delays may need to be shortene

* Describes system for remembering

across the abdomen as if drawing a d

insulin action :ns by name

l 15 to 30 minutes after the injectionn)

fe when blod glucose level is high, and

when blood glucose level is low

ite locations, such as horizontal pattern

tted line

Incorporation of insulin injections int daily schedule :


65/81

1. Recites proper order of premeal diabe* May usemnemonic device such as

remember the order of activities (t =

e = eat)

* Describes information regarding h

before breakfast and dinner, test and


.

* Symptoms : shakiness, sweating, ne* Causes : too much insulin, too much

* Treatment : 10 to 15 g simple carb

tablets, 1 tube glucose gel, 0.5 to 1 cu* After initial treatment, follow with sn

cheese and crackers, milk and cracjer

tes activities :the word tie. which helps that patient

test blood glucose. I = insulin injection,

ypoglycemia such as test, insulin, eat

at, before lunch and bedtime

ervousness, hunger, weaknessexercise, not enough food

ohydrate, such as two or three glucose

p juiceck including strach and protein, such as

s, half sandwich

3 Desribes information regarding preve tion of hypoglicemia :


66/81

3. Desribes information regarding preve

* Avoid delays in meal timing

* Eat a meal or snack approximately e

* Do not skip meals

* Increase food intake before exercise

* Chech blood glucose regularly

*


* Carry a form of fast acting sugar at* Wear a medical identification bracel

* Teach family, friends, coworkers abo

* Have family, roommates, travellinglucagon for severe hypoglicemic rea

tion of hypoglicemia :

very 4 to 5 hours (while awake)

ll timest

ut sign and treatment of hypoglycemia

g companions learn to use injectabletions.


67/81

4. Regular follow up for evaluation of dia

* keeps written record of blood gluco

variations in diet.

* Keeps all appointments with health


ees p ys c an regu ar y usua y w

* States how to contact physician in c

* States when to call physician to repr

etes controll :

e, insulin doses, hy[oglicemia reactions,

rofessionals

our mes per year

se of emergency

variations in blood glucose levels

Focused Assestment of the Insuli

Home or

Dependent Diabetic Client During a

Clinic Visit


68/81

Asess overall mental status, wakefulness

Take vital signs and weight

- Fever could indicate infection

- Is blood pressure and weight within targ

Question client regarding any change in


client is utilizing areas and sites appropri

Inspect skin for inactness; wounds that

or burns. Assess any previously known

Question client regarding foot care

Assess lower extremities and feet forsensation, abnormal sensations, breaks i

, ability to converse

et range? Why or why not

isual acuity; check current visual acuity

telly

ave not healed, new sores, ulcers, bruises,

ounds for infection, progression of healing

peripheral pulses, lack of or decreasedn skin integrity, condiion of toes and nails


69/81

Questions client regarding color andbowel movements; assess abdomen

Review clients home health diary :

* Is blood glucose within targeted ran

* Is glucose mnitoring being recorded

* Is the clients food intake adequate


* Is exercise occuring regularly? Why

Assess clients ability to perform self

Assess clients procedures for obta

cleaning of equipment, disposing of s

Assess clients insulin preparation an

consistensy of stools and frequensy ofor bowel sounds.

e? Why or why not?

often enough?

nd approoriate? Why or why not?

or why not?

onitoring of blood glucose

ining and storing insulin and syringes,

ringes and needles

injection technique

Education Guide : Treatment of Hypo

For mild hypoglicemia (hungry, irritable,

licemia at Home

shaky, weak, headache, fully conscious,


70/81

For mild hypoglicemia (hungry, irritable,

blood glucose usually less than 60 mg/d

Treat the symptoms of hypoglycemia wit

one of the following :

* 2-3 glucose tablets* cup of orange or grape juice

* cup of regular soft drink


* 8 oz of skin milk

* 6-10 hard candies

* 4 cubes of sugar

* 2 packets of sugar

* 6 saltines* 3 graham crackers

Retest blood glucose in 15 minutes

shaky, weak, headache, fully conscious,

[3.4 mmol/L] :

h 10 to 15 g of carbohydrate. You can use

Retest blood glucose in 15 minutes

Repeat this treatment if symptoms do

Take same food or the next scheduled

not resolve

meal within 15 to 30 minutes


71/81

Take same food or the next scheduled

For moderate hypoglicemia (pale, cold

shallow respirations, marked chang

usually lessnthan 40 mg/dL [2.2 mmol

Treat the symptoms of hypoglicemi


Take additional food, such as low fat

For severe hypoglicemia (unable to sw

blood glucose usually less than

administered by family members :

Administer 1 mg of glucagon as intra

Administer a second dose in 10 minut

meal within 15 to 30 minutes

nd clammy skin, rapid pulse, rapid and

in mood, drowsiness, blood glucose

L]

with 15 to 30 g of rapidly absorbed

ilk or cheese, after 10 to 15 minutes

allow, unconsciousness or convulsions,

20 mg/dL (1.0 mmol/L), treatment

uscular or subcutaneous injection

s if the person reains unconscious

Notify a primary care provider immediatell

If still unconscious, transport the person t

and follow instructions

the emergency department


72/81

Give a smell meal when the person wake

EVALUATION

The ultimate evaluation of success of surviv

ability of the client to maintain blood gluc

outcome criteria for client education are li


Maintain blood glucose levels within the n Avoid acute and chronic complications of

Have a satisfactory and complete postope

Identify factors that increase potential for i

Practice proper foot care to prevent injury

Maintain intact skin of pain

Experience relief of pain

up and is no longer nauseated

l level and in depth diabetic education is the

ose levels within the normal range. Specific

ted below.

rmal rangeiabetes

rative recovery without complications

njury


73/81

Identify measures that increase comf

Maintain optimal vision

Be free from injury related to decreas Maintain optimal urinary output

Have an o timal level of mental statu


Have decreased episodes of hypogli Have minimized episodes of hypergli

rt

ed visual acuity

s functionin

emiaemia

NUTRITIONAL THERAPY

Factor Type 1 Diabetes Mellit

us Type 2 Diabetes mellitus


74/81

Factor Type 1 Diabetes Mellit

Total

Calories

Effect of

Increase in caloric i

possibly necessary to a

desirable body weight

restore body tissues

Diet and insulin necessa


diet

Distributio

n of

calories

glucose control

Equal distribution

carbohydrates for i

activity

us Type 2 Diabetes mellitus

ntake

hieve

and

r for

Reduction in caloric intake

desirable for the obese patient

of

nsulin

glucose control

Equal distribution not essential;

low fat desirable; consistency

of carbohydrate intake atmeals desirable

Consistency

in daily

Necessary for glucose c ntrol Desirable for weight reduction


75/81

intake

Uniform

timing of

meals

Grucial for NPH / Lent

programs; flexibility

multidose rapid actin i


Intermeal

and bedtimesnacks

Nutritional

supplementfor exercise

programs

Frequently necessary

Carbohydrates 20 g

moderate physical acti

insulin

with

sulin

Desirable but not essential

/hr for

ities

Not recommended

Necessary if patient controlled

of sulfonylurea or insulin

DIABETES MELLITUS


76/81

USA 15,7 million people 162.000 ke60 65 % Hipertensi

Etiologi not single disease grou

disorders charaktestined hyperglycemia DM penyebab

. ,

^ Structural abnormalities in variety ofhearth, kidneys and eyes, develop (

neuropathy)

^ Chrome hyperglycemia gabunga

DM is a associated with coplicatio

DM type 2 (90%)

iabetes Mellitus / Hj. Muaeni, SKp, MKepiabetes Mellitus / Hj. Muaeni, SKp, MKepiabetes Mellitus / Hj. Muaeni, SKp, MKepiabetes Mellitus / Hj. Muaeni, SKp, MKep

matian Afrika & Amerika, Caucasian

p (Genetally and dinically neterogenesu

abnormal keseimbangan glucosae sekresi at aktivitas dr insulin

organs and organ systems (theikroangiophaty, macroangiopathy,

dari semua

s in pregnancy


77/81

Auto immune sel destruction,

banyak agenuimun dan kemungk

antigens (HL Ag), protein on thechromosome G five groups of th

, ,

DR3, DR4 loci.

iabetes Mellitus / Hj. Muaeni, SKp, MKepiabetes Mellitus / Hj. Muaeni, SKp, MKepiabetes Mellitus / Hj. Muaeni, SKp, MKepiabetes Mellitus / Hj. Muaeni, SKp, MKep

tributed genetic predisposisi satu

inan zat-zat kimia huma leukocyte

cell surface concrolled by gens onamtigens have been regornized (A,

,


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7. diabetes melitus

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