NUR 133

Dyslipidemia

Assessment and Management of

Patients With Diabetes
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Dyslipidemia Treatment

 Prevention is key:
o Maintain healthy weight – BMI<26
o Regular physical activity – 30 min 5+ days/week
o Maintain diet low in saturated fats <7% of calories/d
 Limit red meat, low fat dairy;
o Maintain diet low in cholesterol <200 mg/d
o Smoking cessation
o Increase dietary fiber 20 – 30 gm/d

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Pharmacologic Therapy: Dyslipidemia
 Several classes of medications:
o ↓ Total cholesterol
 ↓ LDL cholesterol
 ↑ HDL cholesterol
o ↓ Triglycerides
 Statins- HMG CoA Reductase Inhibitors: Atorvostatin
o Side effects: Myopathy, rhabdomyolysis, liver
toxicity
 Monitor for: muscle pain, abdominal pain,
jaundice
 Lab surveillance: CPK, LFTs
 Interactions: grapefruit juice; Fibrates

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Antilipemics: Rhabdomyolysis

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Diabetes

 A group of diseases characterized by hyperglycemia

caused by defects in insulin secretion, insulin action, or
both
 Affects nearly 25.8 million people in the United States;
one third of the cases are undiagnosed
 Prevalence is increasing
 Minority populations and older adults are
disproportionately affected

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Classifications of Diabetes

 Type 1 diabetes
 Type 2 diabetes
 Latent autoimmune diabetes of adults (LADA)
 Gestational diabetes
 Diabetes associated with other conditions or syndromes
 Refer to Table 46-1

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Functions of Insulin

 Transports and metabolizes glucose for energy

 Stimulates storage of glucose in the liver and muscle as
glycogen
 Signals the liver to stop the release of glucose
 Enhances storage of dietary fat in adipose tissue
 Accelerates transport of amino acids into cells
 Inhibits the breakdown of stored glucose, protein, and fat

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Insulin: Necessary for Cellular Glucose
Uptake

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Type 1 Diabetes
 Insulin-producing beta cells
in the pancreas are
destroyed by a combination
of genetic, immunologic,
and environmental factors
 Results in decreased insulin
production, unchecked
glucose production by the
liver and fasting
hyperglycemia
 Affects 5% of adults with
diabetes

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Type 2 Diabetes

 Insulin resistance and

impaired insulin
secretion
 Affects 95% of adults
with diabetes, onset
over age 30 years,
increasing in children
r/t obesity
 Slow, progressive
glucose intolerance
and may go
undetected for years

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Pathogenesis of Type 2 Diabetes

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Latent Autoimmune Diabetes of Adults
(LADA)

 Subtype of diabetes in which progression of autoimmune

beta cell destruction in the pancreas is slower than in
types 1 and 2 diabetes
 Not insulin dependent in the initial 6 months of disease
onset.
 Clinical manifestation of LADA shares the features of
types 1 and 2 diabetes
 Emerging subtype has led some to propose the diabetes
classification scheme should be revised to reflect changes
in the beta cells in the pancreas

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 Risk Factors

 Type 1: early-onset,  Type 2: obesity, age, previous

familial, genetic identified impaired fasting
predisposition, possible glucose or impaired glucose
immunologic or tolerance, hypertension
environmental (viral or ≥140/90 mm Hg, HDL ≤35
toxins) factors mg/dL or triglycerides ≥250
 Refer to Chart 46-1 mg/dL, history of gestational
diabetes or babies over 9
pounds

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Clinical Manifestations

 Depends on the level of hyperglycemia

 “Three Ps”
o Polyuria
o Polydipsia
o Polyphagia
 Fatigue, weakness, vision changes, tingling or numbness
in hands or feet, dry skin, skin lesions or wounds that are
slow to heal, recurrent infections
 Type 1 may have sudden weight loss

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Diagnostic Findings

Fasting blood
glucose 126
mg/dL or more

Casual glucose
exceeding 200
mg/dL

Refer to Chart 51-

2 for ADA
diagnostic criteria

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Medical Management of Diabetes

Main goal is to normalize insulin activity and blood

glucose levels to reduce the development of
complications.
The ADA now recommends HgbA1c less than 7%

Diabetes management has five components:

o Nutritional therapy
o Exercise
o Monitoring
o Pharmacologic therapy
o Education

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Dietary Management Goals

 Control of total caloric intake to attain or maintain a

reasonable body weight

 Control of blood glucose levels

 Normalization of lipids and blood pressure to prevent

heart disease

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Role of the Nurse

Be
Knowledgeabl Be knowledgeable about dietary management
e

Communicate important information to the dietician or other management

Communicate specialists

Reinforce Reinforce patient understanding

Support Support dietary and lifestyle changes

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Meal Planning

 Consider food preferences, lifestyle, usual eating times,

and cultural and ethnic background
 Review diet history and need for weight loss, gain, or
maintenance
 Caloric requirements and calorie distribution throughout
the day; exchange lists
o Carbohydrates: 50% to 60% carbohydrates;
emphasize whole grains
o Fat: 30%, limiting saturated fats to 10% and <300 mg
cholesterol
o Nonanimal sources of protein (e.g., legumes, whole
grains) and increase fiber
 Refer to Table 46-2 for exchange list

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Glycemic Index

 Combining starchy foods with protein and fat slows

absorption and glycemic response
 Raw or whole foods tend to have lower responses than
cooked, chopped, or pureed foods
 Eat whole fruits rather than juices; this decreases
glycemic response because of fiber (slowing absorption)
 Adding food with sugars may produce lower response if
eaten with foods that are more slowly absorbed

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Other Dietary Concerns

ALCOHOL NUTRITIVE AND MISLEADING FOOD

NONNUTRITIVE LABELS
SWEETENERS

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 Exercise

Lowers blood sugar

Aids in weight loss,
easing stress, and
maintaining a
feeling of well-being
Lowers
cardiovascular risk
Refer to Chart 46-4

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Exercise Precautions

 Exercise elevates blood sugar levels; insulin must be

adjusted
 Insulin normally decreases with exercise; patients on
exogenous insulin should eat a 15-g carbohydrate snack
before moderate exercise to prevent hypoglycemia
 Potential postexercise hypoglycemia: refer to Chart 46-5
 Need to monitor blood glucose levels
 Gerontologic considerations

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Insulin Therapy

 Blood glucose monitoring:

o Cornerstone of diabetes management
o Self-monitoring of blood glucose (SMBG) levels has
dramatically altered diabetes care
 Categories of insulin: refer to Table 46-3
o Rapid acting
o Short acting: regular insulin
o Intermediate acting: NPH insulin
o Very long acting: “Peakless”

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Insulin Regimen

 Varies from 1 to 4 injections per day

 Combination of a short-acting insulin and a longer-acting
insulin
 Table 46-4 describes several insulin regimens and the
advantages and disadvantages of each
 Two general approaches to insulin therapy:
o Conventional
o Intensive

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Complications of Insulin Therapy

 Local allergic reactions

 Systemic allergic
reactions
 Insulin lipodystrophy
 Resistance to injected
insulin
 Morning hyperglycemia

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Methods of Insulin Delivery

 Traditional subcutaneous
injections
 Insulin pens
 Jet injectors
 Insulin pumps
 Future: Implantable
insulin pumps

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Educating Patients in Insulin Self-
Management

 Use and action of

insulin
 Symptoms of
hypoglycemia and
hyperglycemia
o Required actions
 Blood glucose
monitoring
 Self-injection of
insulin
 Insulin pump use

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Oral Antidiabetic Agents

 Used for patients with type 2 diabetes who require more

than diet and exercise alone
 Combinations of oral drugs may be used
 Major side effect: hypoglycemia
 Nursing interventions: monitor blood glucose for
hypoglycemia and other potential side effects
 Patient education
 Table 46-5
o Sulfonylureas, Biguanides, TZDs

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Sites of Action of Oral Antidiabetic Agents

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Acute Complications of Diabetes

 Hypoglycemia
 DKA
 Hyperglycemic hyperosmolar syndrome (HHS)
 Comparison of DKA and HHS: refer to Table 46-6 & ATI
p.537

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Hypoglycemia

 Abnormally low blood glucose level (below 50 to 60

mg/dL); too much insulin or oral hypoglycemic agents,
excessive physical activity, and not enough food
 Adrenergic symptoms: sweating, tremors, tachycardia,
palpitations, nervousness, hunger
 Central nervous system symptoms: inability to
concentrate, headache, confusion, memory lapses,
slurred speech, drowsiness
 Severe hypoglycemia: disorientation, seizures, loss of
consciousness, death

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Management of Hypoglycemia

Give Retest Provide

Give 15 g of Retest blood Provide a snack

fast-acting, glucose in 15 with protein and
concentrated minutes; retreat carbohydrate
carbohydrate if ‹70 mg/dL or if unless the
• Three or four symptoms patient plans to
glucose tablets persist more eat a meal
• 4 to 6 oz of juice or than 10 to 15 within 30 to 60
regular soda (not minutes and minutes
diet soda)
testing is not
possible

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 Emergency Measures

If the patient cannot

swallow or is
unconscious:
o Subcutaneous or
intramuscular
glucagon (1 mg)
o 25 to 50 mL of
50% dextrose
solution IV

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Diabetic Ketoacidosis (DKA)
 Absence or inadequate
amount of insulin
resulting in abnormal
metabolism of
carbohydrate, protein,
and fat
 Clinical features
o Hyperglycemia
o Dehydration
o Acidosis
 Refer to Figure 46-7
 “Sick day rules”: refer to
Chart 46-9

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Assessment of DKA

 Blood glucose levels >300 to 1000

 Severity of DKA not only due to blood glucose level
 Ketoacidosis is reflected in low serum bicarbonate, low
pH; low PCO2 reflects respiratory compensation (Kussmaul
respirations)
 Ketone bodies in blood and urine
 Electrolytes vary according to degree of dehydration;
increase in creatinine, Hct, BUN

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Treatment of DKA

 Rehydration with IV fluid

 IV continuous infusion of regular insulin
 Reverse acidosis and restore electrolyte balance
 Note: rehydration leads to increased plasma volume and
decreased K; insulin enhances the movement of K+ from
extracellular fluid into the cells
 Monitor blood glucose, renal function and urinary output,
ECG, electrolyte levels, VS, lung assessments for signs of
fluid overload

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 Hyperglycemic Hyperosmolar Syndrome
 Hyperosmolar hyperglycemia is
caused by a lack of sufficient
insulin; ketosis is minimal or absent
 Hyperglycemia causes osmotic
diuresis, loss of water and
electrolytes, hypernatremia, and
increased osmolality
 Manifestations include
hypotension, profound dehydration,
tachycardia, and variable
neurologic signs caused by cerebral
dehydration
 High mortality rate

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 Treatment of HHS

 Rehydration
 Insulin administration
 Monitor fluid volume and
electrolyte status
 Prevention
o BGSM
o Diagnosis and
management of
diabetes
o Assess and promote
self-care
management skills

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 Long-Term Complications of Diabetes
 Macrovascular: accelerated
atherosclerotic changes,
coronary artery disease,
cerebrovascular disease, and
peripheral vascular disease
 Microvascular: diabetic
retinopathy (refer to Figure 46-8),
and nephropathy
 Neuropathic: peripheral
neuropathy, autonomic
neuropathies, hypoglycemic
unawareness, neuropathy, sexual
dysfunction

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Neuropathic Ulcers – Diabetes
Complications

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