Acute Complications
Hypoglycemia
Hypoglycemia is a complication of diabetes. It is also called an insulin reaction or low blood glucose. Hypoglycemia occurs when the blood glucose levels drop below 60 mg/dL. The cause is when more insulin is available than is necessary and may be a result
from an insulin overdose, insufficient food consumption, or increased activity (Potts & Mandleco, 2007).
Symptoms of mild to moderate hypoglycemia may include
*Drowsiness
*Lightheadedness/dizzy
*Irritability
*Tremors
*Sweating/diaphoretic
*Pallor
*Confusion/poor concentration
*Feeling strange
*Hungry
*Rapid heart beat
*Numbness or tingling around mouth or tongue
*****Severe hypoglycemia symptoms (rare) may lead to unconsciousness and convulsions and can be life-threatening if not treated promptly (Potts & Mandleco, 2007).
***Note that diaphoresis is a clinical feature that distinguishes hypoglycemic reaction from a ketoacidosis reaction.
Treatment
For mild hypoglycemia may include: Eating a food that contains 15 grams of a fast-acting carbohydrate (sugar)
1/2 cup of juice or regular soda
5 sugar cubes
1 small box of raisins
6-7 hard candies (not sugar free)
3 glucose tablets (5 grams of glucose each)
8 oz. skim milk
Patients should be instructed to always carry a quick-acting carbohydrate in their purse or pocket, even in their vehicle. After
administration or consumption of any food listed above, wait 15 minutes and recheck the blood glucose levels. May repeat if necessary. If the next meal is more than an hour away, may eat one of the following: 1 peanut butter sandwich, cheese and crackers, or drink 1 cup of skim milk (Texas Diabetes Council, 2007).
Moderate hypoglycemia treatment may include 10-15 grams of a carbohydrate but will also require some medical assistance.
Severe episodes of hypoglycemia require IV glucose or IM glucagon. Treatment options, glucagon preparation and administration of IM glucagon should be taught to the caregivers. Medical assistance is required for administration of IV glucose and other measures to prevent further complications.
from an insulin overdose, insufficient food consumption, or increased activity (Potts & Mandleco, 2007).
Symptoms of mild to moderate hypoglycemia may include
*Drowsiness
*Lightheadedness/dizzy
*Irritability
*Tremors
*Sweating/diaphoretic
*Pallor
*Confusion/poor concentration
*Feeling strange
*Hungry
*Rapid heart beat
*Numbness or tingling around mouth or tongue
*****Severe hypoglycemia symptoms (rare) may lead to unconsciousness and convulsions and can be life-threatening if not treated promptly (Potts & Mandleco, 2007).
***Note that diaphoresis is a clinical feature that distinguishes hypoglycemic reaction from a ketoacidosis reaction.
Treatment
For mild hypoglycemia may include: Eating a food that contains 15 grams of a fast-acting carbohydrate (sugar)
1/2 cup of juice or regular soda
5 sugar cubes
1 small box of raisins
6-7 hard candies (not sugar free)
3 glucose tablets (5 grams of glucose each)
8 oz. skim milk
Patients should be instructed to always carry a quick-acting carbohydrate in their purse or pocket, even in their vehicle. After
administration or consumption of any food listed above, wait 15 minutes and recheck the blood glucose levels. May repeat if necessary. If the next meal is more than an hour away, may eat one of the following: 1 peanut butter sandwich, cheese and crackers, or drink 1 cup of skim milk (Texas Diabetes Council, 2007).
Moderate hypoglycemia treatment may include 10-15 grams of a carbohydrate but will also require some medical assistance.
Severe episodes of hypoglycemia require IV glucose or IM glucagon. Treatment options, glucagon preparation and administration of IM glucagon should be taught to the caregivers. Medical assistance is required for administration of IV glucose and other measures to prevent further complications.
Diabetic Ketoacidosis (DKA)
DKA is a form of metabolic acidosis that develops when there is an acute insulin deficiency or inability to use whatever insulin the pancreas secretes. It is more commonly seen in Type I DM, although some patients with Type II DM may experience as well.
***Note that diaphoresis is a clinical feature that distinguishes hypoglycemic reaction from a ketoacidosis reaction.
More information on DKA is discussed in the pathophysiology and clinical manifestations sections.
- Blood glucose levels can be elevated to 300 to 1000 mg/dL or more
- pH goes down, making it acidic; pH=6.8-7.3
- Bicarbonate buffers are exhausted thus causing the pH level to decrease. The body tries to compensate acidity by breathing it out which is exhibited through Kussmaul respirations.
- It can occur in people undiagnosed with diabetes
- Poor control of glucose levels due to non-compliance
- Severe, Hard to control diabetes
- Infection (which causes stress which creates high glucose levels)
***Note that diaphoresis is a clinical feature that distinguishes hypoglycemic reaction from a ketoacidosis reaction.
More information on DKA is discussed in the pathophysiology and clinical manifestations sections.
- Treatment includes IV administration of Regular insulin to rapidly reduce glucose levels (rate varies on glucose levels but may be in the rage of of approximately 5 units/hr)
IV fluids (isotonic) for rehydration, may be infused at 250-500 mL per hour; then changed to dextrose once patient stabilized to avoid hypoglycemia. - Potassium replacement given to replenish cellular stores
- Monitoring of serum electrolytes and glucose levels
- Test urine for glucose and ketones
- Be careful with patients with cardiopulmonary or renal disorders as this rapid fluid resuscitation can cause fluid overload and complicate their cardiac or renal function.
- Monitor for hyperkalemia since potassium levels may become elevated with dehydration and through potassium replacements. Hyperkalemia can cause cardiac dysrhythmias.
Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNKS)
HHNKS is similar to DKA except the patient does not produce ketones. This condition is seen more commonly in Type II DM, although some Type I DM may experience HHNKS when they have a low level insulin reserve remaining.
Blood glucose levels can rise well over 500 mg/dL, however the pH remains within normal levels 7.35-7.45. Fluid electrolyte imbalances do occur with HHNKS.
HHNKS can occur during a serious illness when the metabolic needs increase to exceed the capacity of available insulin. There is a fluid shift from within the cells out into the extracellular space, causing diuresis. With diuresis comes a loss of Na+ and K+. Since there is still some insulin being excreted with Type II DM, there is no breakdown of fats, therefore no ketones. HHNKS is more common in older adults and those who have not yet been diagnosed. It can also occur in non-diabetics receiving medications that elevate glucose levels and in those requiring kidney dialysis or total parenteral nutrition (TPN) (Timby & Smith, 2013, p. 799).
Blood glucose levels can rise well over 500 mg/dL, however the pH remains within normal levels 7.35-7.45. Fluid electrolyte imbalances do occur with HHNKS.
HHNKS can occur during a serious illness when the metabolic needs increase to exceed the capacity of available insulin. There is a fluid shift from within the cells out into the extracellular space, causing diuresis. With diuresis comes a loss of Na+ and K+. Since there is still some insulin being excreted with Type II DM, there is no breakdown of fats, therefore no ketones. HHNKS is more common in older adults and those who have not yet been diagnosed. It can also occur in non-diabetics receiving medications that elevate glucose levels and in those requiring kidney dialysis or total parenteral nutrition (TPN) (Timby & Smith, 2013, p. 799).
Signs and Symptoms can include:
Can also develop neurological symptoms due to lack of glucose to the brain. These symptoms include: paralysis, lethargy, coma, and seizures.
S & S of hypokalemia & hyponatremia are present (from loss due to diuresis)
Physical Exam reveals dry mucous membranes, poor skin turgor, blood glucose levels extremely elevated, and serum K+ and Na+ levels low.
Serum osmolarity is increased.
- hypotension
- mental changes
- polydipsia
- dehydration (from fluid losses)
- tachcardia
- fever
Can also develop neurological symptoms due to lack of glucose to the brain. These symptoms include: paralysis, lethargy, coma, and seizures.
S & S of hypokalemia & hyponatremia are present (from loss due to diuresis)
Physical Exam reveals dry mucous membranes, poor skin turgor, blood glucose levels extremely elevated, and serum K+ and Na+ levels low.
Serum osmolarity is increased.
HHNKS is treated with IV fluids and electrolytes to replace the low levels. Insulin is administered to decrease glucose levels. A central catheter may be placed to monitor the hemodynamic response to fluid replacement.
Nursing Considerations include monitoring blood glucose levels and assessing for electrolyte imbalances as well as dehydration, which are the most common symptoms in HHNKS. It is also important to ensure administration of insulin per medical orders, fluid and electrolyte replacement.
Evaluation of
Observe for neurologic deficits; assess cognition, alertness, level of consciousness.
Evaluation of
- hydration status
- I&Os
- skin turgor
- vital signs
- electrolyte studies
Observe for neurologic deficits; assess cognition, alertness, level of consciousness.
Chronic Complications
STATS
DM population at increased risk for:
DM population at increased risk for:
- Heart disease & stroke account for about 60-65% of deaths in people with diabetes.
- HTN (73% of those with DM have HTN)
- Blindness (DM leading cause of new blindness age 20-74)
- Kidney failure (DM cause of 44% of all new cases)
- Nervous system damage (60-70% of people w/ DM)
- Lower-limb amputations (60% of non-traumatic LE amputations among DM)
- Periodontal (gum) disease (Twice the risk)
- Problems during pregnancy (Birth defects or spontaneous abortion)
- People with DM are more susceptible to other illness with worse prognosis
Peripheral Neuropathy
Neuropathy referes to nerve pain related to pathologic changes in the nerves. Poor glucose control and decreased blood circulation to the nerve tissue results in neuropathy. Developed years after onset of diabetes and incidence increases with duration.
This nerve damage leads to sensory loss in fingers and toes and causes paresthesias or abnormal sensations like prickling, tinging, burning, or needle-like pain in affected areas. This nerve damage affects sensation which can cause patients to step on sharp objects or touch dangerous things without feeling. If left untreated this injuries become infected and due to poor circulation to extremities, it can delay healing. Often times, the persons toe, foot, or even leg must be amputated in order to save the patient's life as they can become septic if infection is allowed to spread. It is important to inspect the feet in the patient with DM to assess for any wounds or injury. Toenails must be clipped by a podiatrist, not by patient to ensure it is done correctly and to prevent injury. Patient must be educated on proper foot care. Read pages 801-802 for additional information on this topic.
This nerve damage leads to sensory loss in fingers and toes and causes paresthesias or abnormal sensations like prickling, tinging, burning, or needle-like pain in affected areas. This nerve damage affects sensation which can cause patients to step on sharp objects or touch dangerous things without feeling. If left untreated this injuries become infected and due to poor circulation to extremities, it can delay healing. Often times, the persons toe, foot, or even leg must be amputated in order to save the patient's life as they can become septic if infection is allowed to spread. It is important to inspect the feet in the patient with DM to assess for any wounds or injury. Toenails must be clipped by a podiatrist, not by patient to ensure it is done correctly and to prevent injury. Patient must be educated on proper foot care. Read pages 801-802 for additional information on this topic.
Diabetic Nephropathy
Over time, diabetes can lead to decreased renal function due to poor circulation to the kidneys. Type I DM is more likely to cause renal disease, that Type II, however people with Type II DM are also affected, especially if they are non-compliant with treatment. Renal impairment from diabetes comes from glomerular destruction which results in impaired filtration of blood during urine formation. This deterioration causes glomeruli to excrete serum proteins (albumin) and inables kidneys to excrete nitrogen waste products, which is why there is usually proteinuria (protein in the urine). Read page 803 for more information on this topic.
Diabetic Retinopathy
Due to vascular changes caused by diabetes, the person with DM can experience ocular changes. The retina suffers pathological changes due to circulation. Remember DM reduces circulation especially in smaller blood vessels which are present in the eye. Due to this lack of blood flow, many visual changes including blindness can occur. Read page 804 for more information on this topic.
Vascular complications
In diabetes, the blood vessel,s including all arteries and arterioles, are susceptible to changes. There is thickening of the arterial walls due to HTN from narrowing of the blood vessels from accumulation of glucose and lipids. There is also a higher incidence of coronary artery disease. Due to vascular changes, the patient with DM will experience decreased circulation to the extremities causing them to feel cool and be pale. Leg cramps often occur. Gangrene may occur when blood supply to the extremities is greatly diminished. Read page 804 for more information on this topic.