Diabetes Mellitus Conference #3

Jackie Dorsey RN, MS, ANP

Exercise and the Diabetic patient

THERAPEUTIC BENEFITS OF
EXERCISE
Decrease
Lower
May decrease need to
reach target BG levels
Reduce

Reduce
Improve

BENEFITS SPECIFIC
FOR THE TYPE 2 DIABETIC
Decreases
Decreases percentage
May delay onset of Type 2 diabetes

General Guidelines for Exercise

Exercise does not have to be vigorous
Exercise is best done after meals
Exercise plans should be individualized
It is important to monitor blood glucose before,
during, and after exercise to determine the effect
of exercise on the blood glucose.

General Guidelines for Exercise

Be alert to the possibility of delayed exercise-induced
hypoglycemia
Effects of exercise on BG level may last up to 48 hours
Stretch for 5-10 minutes before and after exercise
Maintain good posture during exercise
Hydrate before beginning exercise
Wear proper shoes for comfort and injury prevention

When is exercise related hypoglycemia likely

to occur?
When insulin or antidiabetic medication is
peaking
If exercise is strenuous or prolonged and CHO
is not replaced

When would you suggest to a diabetic

patient, who takes an antidiabetic agent, the
most appropriate time to exercise?

One hour after eating a meal

After the ingestion of 15 gm of CHO

For every 45 minutes of activity the individual
should consume another 15 gm of CHO

What items would constitute 15 Gms of

CHO?
17 grapes

8-10 life savers

4-6 oz. of juice
Sport drinks which contain 80-100 calories
from CHO

Why does exercise induced hyperglycemia

occur?
Strenuous Activity or Exercise
Perceived by body as stress
Release of counterregulatory hormones
(glucagon, epinephrine, growth hormone,
cortisol)
Temporary elevation of blood glucose
Hyperglycemia

Type 1 diabetic should avoid

exercise if BG level is > 300
mg/dl without urine ketones
present or if BG level is > 250
mg/dl with urine ketones
present.

INSTRUCTIONS FOR DIABETICS DURING

ILLNESS/ SICK DAY GUIDELINES
Medications
Continue as before unless otherwise advised by
health care team

Supplemental insulin doses may be required in

Type 1 diabetes mellitus

INSTRUCTIONS FOR DIABETICS DURING

ILLNESS/ SICK DAY GUIDELINES
Blood sugar monitoring
Increase frequency to every 4 hour
Assess urine for presence of ketones especially
during fevers and when BG is > 240 mg/dl

INSTRUCTIONS FOR DIABETICS DURING

ILLNESS/ SICK DAY GUIDELINES
Intake
Continue CHO intake by substituting regular soda,
regular jello, popsicles, or Gatorade
Small, frequent meals
Drink adequate amount of fluids to prevent
dehydration

INSTRUCTIONS FOR DIABETICS DURING

ILLNESS/ SICK DAY GUIDELINES
Instruct pt. to keep good written records of BGs & urine
ketones as soon as they become sick so that they are
prepared to relay this information to the MD.
Contact MD
BG is > 240 mg/dl
Moderate to large amounts of ketones in the urine

unable to keep anything down

Prevention
Seasonal Flu vaccine
Good hand washing

Blood Glucose Monitoring

A BG test measures the
amount of sugar (glucose) in
a sample of blood
BG monitoring refers to the
ongoing measurement of
blood sugar (glucose)

Monitoring can be done at

any time using a portable
device called a glucometer

Blood Glucose Monitoring

The traditional glucose meter comes with test strips, small
needles called lancets, and a logbook for recording numbers if
the meter is used in the home
In the hospital setting, specific documentation flowsheets are
used per agency policy
There are many different kinds of meters, but they all work
essentially the same way

Blood Glucose Monitoring

Blood Glucose Monitoring

How the Test is Performed

Inform the patient
Include slight discomfort

Gather all equipment

timing is important

Wash your hands

Clean the area of the finger per agency policy
Avoid using the pads of the finger
Allow area to completely dry before pricking the finger
Provide the patient with a gauze pad for application of slight
pressure

How the Test is Performed

Prick finger with lancet
Wipe away the first drop of blood, and then allow a full
second drop of blood to fall onto the pad of test strip
The test strip uses a chemical substance to determine the
amount of glucose in the blood
Newer monitors can use blood from other areas of the body beside the
fingers, reducing discomfort.

Insert the test strip into glucometer

The meter will display the blood sugar results as a number on
a digital display

Sliding Scale Insulin

In order to normalize the blood sugar levels of the
patient the MD may prescribe all or part of the
patients insulin on a sliding scale basis
The dose or doses are determined on the basis of the
patients blood sugar results
Sliding scale is broadly defined as a set of
instructions meant to adjust the dose of insulin in
accordance with the results of the patients blood
sugar levels, activity level and meals

Sliding Scale Insulin

Sliding scale insulin provides for better control of
blood glucose since the insulin dosage is matched
to the patients current need which is indicated
by the blood sugar at that specific time
The RN has a critical responsibility to document
the test times, the patients blood sugar results
and the amounts and types of insulin
administered

Sliding Scale Insulin

Read example 1 & 2 and determine how much insulin to administer
to the patient using the sliding scale below.
2 units regular insulin if blood sugar is less than 180
4 units regular insulin if blood sugar is 181-240
6 units regular insulin if blood sugar is 241-320
8 units regular insulin if blood sugar is 321-400

ANSWER:
1. 4 units
2. 2 units

Pages 41 and 42 should have been

completed as part of your pre-conference
work.

Insulin (high alert medication)

Critical Thinking Activities

Case Scenario #1
Determine the sliding scale insulin based on the
BG results for listed coverage
0600
2 units
1200
0 units
1800
6 units
2400
0 units/Call MD

Insulin (high alert medication)

Critical Thinking Activities

Case Scenario #2
Determine and document the amount of Insulin to be
given at
0630
6 units
1130
6 units
1630
2 units

Insulin (high alert medication)

Critical Thinking Activities
Case Scenario #2

Determine how much insulin is needed for the HS dose

Regular Sliding Scale Insulin 4 units
NPH Insulin 12 units
Draw this amount up and administer to the injection pad
Discard fluid from syringe into Dixie cup
Draw up equivalent amount of air into syringe then administer
to injecta pad
(Most agencies require 2 nurses to witness drawing up the insulin and co-sign)

Case Study 1

What assessment data would you document

for this patient?
NPO after 6 p.m.

Took her glyburide (high alert medication) today

c/o feeling weak, unsteady and jittery

Case Study 1

Based on your assessment what does the

above data indicate?
low BG?
high BG?

Case Study 1

List 2 priority nursing diagnoses with two

matching priority outcomes
Risk for unstable blood glucose
Risk for falls

Case Study 1

Priority outcomes for Mrs. Zimmer

Maintain normal blood glucose levels
No falls during hospitalization

Case Study 1

Mrs. Zimmers actual BG was 37. What

therapeutic nursing intervention (TNIs) would
you implement? List TNIs in priority order.
Notify MD
Anticipate administration of IV Dextrose (D50)
Teach how to prevent incident

Case Study 2
What assessment data would you document
for this patient?
Type 1 Diabetic
Strenuous activity hiking
Weak, sweaty
Rapid pulse

Case Study 2

Based on your assessment what does the

above data indicate?
low BG?
high BG?

Case Study 2

List at least 1 priority nursing diagnosis and

one matching priority outcome.

Risk for unstable blood glucose

Case Study 2
Priority outcomes for Jimmy:
Maintains normal BG levels

Case Study 2
List TNIs in priority order
Simple CHO or oral glucose paste orally if awake
enough to swallow
Do not overtreat
Recheck BG 15 minutes after treatment
Repeat until BG > 60 mg./dl

Case Study 2
List TNIs in priority order
Jimmy should eat regularly scheduled meal/snack
to prevent rebound hypoglycemia
If no improvement after 2 or 3 doses of simple
CHO or Jimmy becomes unconscious
give Glucagon 1 mg 1M/SC
Have Jimmy eat a complex CHO after recovery
In acute care setting 20-50 ml. D50 IV push

Case Study 3
What assessment data would you document
for this patient?
Type 1 DM
Blurred vision
Polyuria, Polydipsia
Increased stress
Not following her dietary regimen and exercise
plan

Case Study 3
Based on your assessment what does the
above data indicate?
low BG?
high BG?

Case Study 3
List 2 priority nursing diagnoses with two
matching priority outcomes for Anne.
Diagnoses:
Risk for fluid volume deficient
Risk for unstable blood glucose
Outcomes:
- Maintain urine output 30 mL/hr
- Maintain normal blood glucose levels

Case Study 3
TNIs in priority order
Monitor intake and output
Provide Ann with information on diet and exercise

Case Study 3
What additional teaching would you include?

Reinforce BG monitoring

Pediatric Considerations
Chart on page 49
provides you with
important material
regarding diabetes and
pediatrics. Should have
been completed prior
to conference. Review
on your own.

View Video
Diabetic Emergencies: Hyperglycemia and
Ketoacidosis
VHS-193A (10 min.)

Notetaking Guide Provided on page 50

Acute Complications: Hyperglycemia & DKA

Definition
Precipitating Factors
Assessment Data
Treatment

Acute Complications: Hyperglycemia & DKA

Prevention
Teach patient:
to take antidiabetic medications as prescribed
proper technique to draw up and administer insulin
with return demonstration
maintain target blood glucose range

to monitor blood glucose as ordered

Acute Complications: Hyperglycemia & DKA

Prevention
Teach patient:
lifestyle changes that may be required to control
disease (exercise plan, adherence to diet)
S/S and how to treat
wear or carrying medical alert identification
ways to prevent hypo/hyperglycemia since activity
chances can effect insulin needs

DKA

Diabetic Ketoacidosis Case Study

Diabetic Ketoacidosis Case Study Group Activity
pp. 54-57
Faculty may choose to do some or all of this
pre-conference activity if time allows.

Diabetic Ketoacidosis Case Study p 55

1. Briefly explain the pathophysiology of the
development of diabetic ketoacidosis (DKA) in this
patient.

Answer
Diabetic ketoacidosis (DKA), also referred to as
diabetic acidosis and diabetic coma, can develop
quickly or over several days or weeks
For Mr. John, DKA developed as a result of too
little insulin accompanied by increased physical
stress (the flu), which increases the demand of the
body for insulin

Diabetic Ketoacidosis Case Study

2. What clinical manifestation(s) of

DKA does

this patient exhibit?

Answer:
Breathing deep and rapid, acetone smell on
breath, skin flushed and dry

Diabetic Ketoacidosis Case Study

3. What factors precipitated this patients DKA?

Answer:
Flu x 1 week
Vomiting and anorexia resulted in decreased caloric
intake
Stopped taking his insulin
When insulin supply is inadequate, glucose cannot be
properly used for cellular energy
In response to cellular starvation, the boy releases and
breaks down stored fats and protein to provide the
needed energy

Diabetic Ketoacidosis Case Study

What factors precipitated this patients DKA?
Answer:
Free fatty acids from stored triglycerides are
released & metabolized in the liver in such large
quantities that ketones are formed (ketonemia)
Excess ketones alter pH balance & acidosis
develops
More H2O is lost as ketones are excreted
(ketonuria) in an attempt to balance the pH

Diabetic Ketoacidosis Case Study

What factors precipitated this patients DKA?

Answer:
Gluconeogenesis from protein is the last resource
used by the body as a compensatory response to
provide a cellular energy source
Result is increase in BG and nitrogen levels
Due to prevailing insulin deficiency, this glucose
resource cannot be used and the BG level rises
further, adding to the osmotic diuresis

Diabetic Ketoacidosis Case Study

What factors precipitated this patients DKA?
Answer:
Dehydration and loss of electrolytes, particularly
potassium
Patients skin becomes dry and loose, and
Eyeballs become soft and sunken
Hypotension with a weak, rapid pulse may also
develop

Diabetic Ketoacidosis Case Study

4. What teaching should be done with this

patient and his family?
Answer:
Food intake is important during illness because the
body requires extra energy to deal with the stress
When he has a minor illness, such as a cold or the
flu, continue drug therapy and food intake
A carbohydrate liquid substitution, such as regular soft
drinks, gelatin dessert, or beverages such as Gatorade,
may be necessary

Diabetic Ketoacidosis Case Study

What teaching should be done with this patient
and his family?
Answer:
Extra insulin may be necessary to meet the extra energy
demand and prevent DKA
BG monitoring should be done every 1 to 2 hours by either John
or a person who can assume responsibility for care during the
illness
Urine output ,presence & degree of ketonuria should be
monitored, particularly when fever is present

Diabetic Ketoacidosis Case Study

What teaching should be done with this patient
and his family?
Answer:
Fluid intake should be increased to prevent
dehydration, with a minimum of 4 oz per hour for
an adult
Mr. John should be instructed to contact the health
care provider when BG is > 250 mg/dl (13.9
mmol/L), fever, ketonuria, & N/V occurs

Diabetic Ketoacidosis Case Study

5. What role should Mr. Johns wife have in
the management of his diabetes?
Answer:
If Mr. John is not able to effectively manage his DM
his wife can assist by
Frequent monitoring of BG levels
Encouraging fluids and food intake
Reporting abnormal BGs to MD as prescribed

Diabetic Ketoacidosis Case Study

6. Appropriate nursing diagnoses

Answer:
Deficient fluid volume
Risk for unstable blood glucose

Diabetic Ketoacidosis Case Study

Collaborative problems/Potential
complications
Answer:
Diabetic ketoacidosis
Hyperglycemia

Diabetes Mellitus Conference #3

Please review post conference
activities and the Diabetes
Mellitus Comprehensive review