02.03 Diabetes Management

In this lesson we’re going to talk about the priorities for management and nursing care for a patient with Diabetes Mellitus. If you haven’t watched the first video in this module about the pathophysiology of Diabetes, make sure you do that - it will help all of this to make so much more sense.

I cannot stress enough how important it is for us to know how to manage a patient with Diabetes. These days our population is sicker than ever and MANY of our patients come with a set of comorbidities that I lovingly refer to as “The Usual”. I’m getting report and I almost always hear this. “The patient has a past medical history of CAD, Hypertension, Diabetes, Hyperlipidemia, CKD, COPD. Oh, and they’re a smoker, and morbidly obese.” All of these conditions exacerbate each other and severely shorten the patients’ lifespan. It’s up to us to educate and encourage them to make the necessary changes.

So let’s quickly review patho. Remember that Type 1 Diabetes Mellitus is when the immune system attacks and destroys all the beta cells in the pancreas, so the patient has absolutely NO insulin production and is dependent on supplemental insulin. In Type 2 Diabetes Mellitus, they either don’t make enough insulin to meet their body’s needs OR they have become resistant to the insulin they do have...or both. Most of these patients can be managed with medication and lifestyle changes, but they may require insulin in severe cases.

So what does our assessment look like? Well, we’re going to see hyperglycemia - that’s usually considered a BGL (or blood glucose) of 126 mg/dL or greater times 2 episodes for an official diagnosis. We’ll also see hyperosmolarity because of the excessive glucose - remember that’s when you have way more particles than water in a solution. Both of these things are going to cause what’s known as the Three P’s, which are the classic signs of diabetes. That’s Polyuria or excessive urination, Polydipsia, or excessive thirst, and Polyphagia, or excessive hunger. Basically as this osmolarity builds up, fluids will start to shift into the bloodstream to try to balance out this concentrated solution - that causes dehydration in the cells - hence the thirst, but it also causes a lot of water to be filtered out through the kidneys, hence the urination. All the while, this blood glucose isn’t actually making it into the cells, so the cells are hungry - which sends a signal to the brean saying EAT! We’ll also see an elevated Hemoglobin A1c, or you might hear “glycosylated hemoglobin” - this is a blood test that tells us the average blood sugar over the last 3 months. In diabetics, it’s usually above 6.5. Our goal is less than 6. Check out the Labs course to learn more about blood sugar levels, hemoglobin A1c, and osmolarity.

Now we may also see signs related to those vascular complications we talked about - blurry vision because of the retinopathy, numbness and tingling because of the neuropathy, and non-healing wounds because of the inflammation and poor circulation. They are especially prone to ulcers on their feet or toes because they tend to not be able to feel when a wound starts. Then they keep walking around on it and it gets worse and worse. This ulcer you see here is actually quite minor compared to some that I’ve seen. But this probably started the size of a pinhead and has grown significantly. So we teach patients to inspect their feet EVERY day and to do really good foot care, which we’ll talk about in a second.

When it comes to medications, Type 1 Diabetics are insulin-dependent, so we will give them SubQ insulin and teach them how to self-administer. Most of the time, by the time you encounter a diabetic patient in the hospital, they may already know how to self-administer. Usually, we use these insulin pens in the hospitals. Now, for Type 2 Diabetics, they don’t usually require insulin except in severe cases, so they will get oral antidiabetic agents. The two most common classes are sulfonylureas like Glipizide and biguanides like metformin. Check out the Pharmacology course to learn more about those two. The biggest thing that will help the patient keep their blood sugars managed is diet and exercise. They should avoid simple sugars like desserts and candy, and focus on high quality protein, non-starchy vegetables, and whole grains. In some cases, Type 2 Diabetes can actually be WHOLLY managed with diet and exercise if the patients are willing to commit.

Now, we want to point out some of the most important AND most commonly tested things when it comes to insulin administration. First - you MUST know onset and peak times. We’ve attached a cheatsheet to this lesson that has those timings on it. I know, I remember this from nursing school, it’s a pain in the butt - but it’s SO important. You may get a question in nursing school or on the NCLEX like “You administer Regular Insulin at 8am, during which time frame should you monitor for hypoglycemia” - so you need to know that the patient is at risk for hypoglycemia during the PEAK times, and that Regular insulin peaks between 2-4 hours. Also remember to rotate sites like we talked about before. Know that the ONLY type of insulin that you can give a patient IV is going to be Regular insulin - everything else is SubQ. If you see “Insulin Reaction” that typically means hypoglycemia. What are the signs of hypoglycemia? Cool, clammy, tired. Remember “Cool and clammy, give ‘em candy”. And for hyperglycemia it’s “dry and hot, insulin shot” - so they’ll be hot, have dry mouth, and probably be thirsty.

In terms of using insulin from a vial - remember that these syringes are in Units, NOT mL. We don’t want to use expired or cloudy insulin unless it’s meant to be cloudy like NPH. The vials expire 90 days after opening. If you’re mixing insulins, remember to always draw up clear before cloudy. This is a common drag and drop ordering question on the NCLEX. Check out the Insulin lesson in the Pharmacology course, it has a great explanation of how to do this mixing process and you NEED to know it.

So what are our top nursing priorities for a patient with Diabetes - well the first is skin assessment and wound care. Like I’ve said before, we need to do a thorough skin assessment, especially on their feet. I mean, look between the toes, under the toes, the heels, etc. Guys, you MUST take off the patient’s socks and LOOK at their feet - it is SO important. We also want to do meticulous wound care and keep those wounds clean and dry. You can consult your Wound Care specialist nurse if you need guidance on wound care and check for wound care orders in the chart. We also want to be prepared for hypoglycemia management - sometimes patients respond much quicker to insulin than expected and they can drop their sugars. Remember - cool and clammy, give ‘em candy. So we’re gonna use the 15-15 rule. We want to give them 15g of sugar, then re-check in 15 minutes. If they can take things PO, this is 5 or 6 pieces of candy, or 4 ounces of juice or soda. We even have glucose tablets or gel in some facilities. But, remember that hypoglycemia can cause decreased LOC, so if they aren’t alert enough to take PO, we give them a ½ amp of D50 IV. Either way, we do that, then re-check in 15 minutes and intervene again if necessary. Make sure your patient who is receiving insulin has some sort of hypoglycemia protocol ordered. Again, we want to prioritize really good foot care - that means keeping their feet warm and dry, wearing foot protection at all times, especially if they’re up and walking around, and not wearing socks that are too tight. And finally, patient education is a huge priority. Check out the outline attached to this lesson to see a detailed list of important patient education topics.

So, as you probably could have already guessed, our top nursing concepts for a patient with diabetes mellitus are glucose metabolism, tissue/skin integrity, and patient education. Check out the care plan attached to this lesson to see more detailed nursing interventions and rationales.

So, let’s recap - diabetes causes hyperglycemia which can cause damage to vessels and nerves. The classic symptoms are the three P’s - polyuria, polydipsia, and polyphagia. Type 1 Diabetics require insulin, while Type 2 Diabetics can take oral antidiabetic agents or use diet and lifestyle changes to manage their sugars. You have to know the insulin precautions we talked about. This is the TOP medication error I see in students and new grads, I even made an insulin error myself when I was on orientation. Stick to the basics of med administration and follow the safety things we talked about, and you’ll be fine. And then remember that meticulous skin and wound care is imperative - we want to prevent those wounds from spreading or becoming so infected that the only option is amputation. And, of course, educate, educate, educate.

Check out the DKA and HHNS lessons to know how to manage acute exacerbations of diabetes. And don’t miss all the resources attached to these lessons to help you see the big picture for these patients. Now, go out and be your best selves today. And, as always, happy nursing!