Saturday, March 16, 2019

MANAGE NURSING CARE AT HOME, Ch. 15, "Endocrine...Diabetes"


    Working in conjunction with the nervous system, the endocrine system is responsible for secreting substances, hormones, which are then transported via the circulatory system to target organs. It is the hormones which regulate the proper functioning of the target organs.   

    The secreted hormones regulate numerous bodily processes and functions such as metabolism, growth and development, tissue function such as insulin release, urinary elimination, reproductive activity, steroid production, and water metabolism for example.  The glands which are associated with this system include the pituitary, thyroid, parathyroid, pineal, adrenal, as well as the pancreas, ovaries, and testes which perform other functions as well as endocrine. 

    You can liken this system to a home’s thermostat which regulates temperature.  If the temperature is too cold, the thermostat turns the heat turn on; upon reaching the desired temperature, or if too hot, the thermostat turns the heat off.  The endocrine system works in a similar manner.  It ensures that the body maintains an ideal functioning level based upon hormone levels in the blood that are sent to the brain (the thermostat) for evaluation.  If the hormonal levels are not optimal, the brain sends signals, via the pituitary, to other endocrine glands which direct target organs to carry out a task.  All of this is done via hormones, chemical messages, which turn a target organ on or off.

    A portion of the brain, the hypothalamus, by constantly assessing hormone levels in the blood, dictates a gland’s release of hormones to maintain optimal body functioning.  It is continuous, and changes are made constantly depending on what the body’s needs and requirement may be at any given moment.  This is a feedback mechanism, but it is not immediate in its response.  The target organ’s response time is usually not immediate and prolonged because the hormonal message is delivered via the circulatory system (blood).   

    As stated previously, hormone levels in the blood are first evaluated in the brain by the hypothalamus.  The hypothalamus then sends signals to the pituitary gland.  The pituitary gland, often called the “master gland of the body” causes hormonal release or suppression by any of the endocrine glands.  The target organs then respond so the body maintains an optimal level of function (homeostasis).  

    Because there are many players in this system, breakdowns can occur anywhere during this feedback cycle.  This includes:  1) a malfunction occurs between the hypothalamus and pituitary gland; 2) the pituitary gland is unsuccessful in communicating commands to a target gland; 3) the target gland receives instructions from the pituitary but is unable to act on them because it is unable to secrete, or restrain from secreting its hormone; and 4) the target organ of the hormone is unresponsive to the hormone. 

    To identify a disease process, it is necessary to determine whether it is a problem of communication between the pituitary and target organ, or simply an inability for the target organ to comply with pituitary’s direction to secrete a hormone (hypo-responsiveness). 

    Disorders and illnesses from this system result when a gland secretes too little of a hormone (hypo-secretion), resulting in a hormonal deficiency so homeostasis cannot be maintained.  The opposite is also true.  If there is an overproduction (hyper-secretion), too much of the hormone is released into the body.  Hormone levels, whether too high or low, create numerous diseases that may require life-long treatment to maintain normal levels. 

    Once the cause of the disorder is determined based upon specific testing of the pituitary and target gland, the diagnosis typically is handled by medication or surgical removal (excision) of part or all a gland, but usually one that does not require long-term nursing services.  However, diabetes may not be treated this way.  Therefore, the focus of this section will be devoted to Diabetes Mellitus. 

    Diabetes Mellitus is a chronic disease of the endocrine section of the pancreas which secretes insulin.  Lack of insulin causes high and damaging levels of sugar in the blood (hyperglycemia).  As a disorder of carbohydrate metabolism, is it evidenced by the body’s inability to use nutrients for fuel and storage.   This hyperglycemia is the disease’s hallmark and is caused by an inadequate or complete lack of insulin production or resistance to insulin’s action.  Other typical signs of the disease include increase urination (polyuria), increased thirst (polydipsia), and increased hunger (polyphagia). 

    Diabetes is the most common of all endocrine disorders.  While the actual cause is not known, there is an auto-immune factor, a life-style and age component, as well as a genetic predisposition.  Two types of diabetes are diagnosed and depend on the circumstances and age upon which the disease presents.  Regardless, this is a life-long chronic and incurable disease.  Patients are usually tasked with life style changes and medication administration to counteract the disease process.  However, with compliance and adherence to proper therapy, in accordance to the patient’s underlying health, there can be decreased complications and prolonged life.  

    Under normal functioning, the pancreas secretes insulin into the blood.  The purpose of insulin is to decrease blood glucose (sugar) levels by “transporting” it into cells where it is used as an energy source for normal cellular body functioning as well as to store remaining sugar in the liver in the form of glycogen.  This prevents accumulation of sugar in the blood, as it is either stored until it is needed or used for cellular function. 

    Without glucose as an energy source, because insulin is not available, the body breaks down fatty acids.  Although short term energy is provided by fats, their incomplete metabolism creates ketones.  When these ketones accumulate they can cause lasting detrimental effects and death because they lower the pH of the blood (ketoacidosis), which has small range for the body to function. 

    In addition, as fats break down and high levels of sugar remain in the body, blood vessel damage occurs.  Results include atherosclerosis and other cardio-vascular insufficiencies, stroke, nerve damage, peripheral vascular disease and poor circulation, resulting in neuropathy with pain and numbness in extremities, especially feet, along with renal insufficiency and loss requiring dialysis, as well as vision damage or blindness, and skin ulcerations, slow wound healing with associated decreased infection resistance due to decreased blood flow, gangrene, perhaps even amputation.

    Without diabetes, insulin secretion is increased by the pancreas when blood glucose levels rise approximately thirty to sixty minutes after meals to transport glucose for energy.  Insulin levels then decrease and return to normal two to three hours after glucose levels in the blood decrease.  

    With diabetes, without insulin, glucose is not removed from the blood and used for energy, and the body is required to perform metabolism of other nutrients to obtain energy.  To control diabetes, medication (insulin or oral drugs) is given to try to mimic the normal functioning of the pancreas.

    There are two types of diabetes mellitus which are differentiated by age of onset, etiology (cause) of the disease, and other presenting factors: 

Type 1 – IDDM (insulin-dependent diabetes mellitus) usually presents at 25 years old or less.  Its onset is abrupt, and the patient’s weight is less than or within the normal range.  In fact, the patient may be losing weight even though presenting with polyphagia (increased appetite).  Outstanding is the lack of insulin present.  The reason for this lack may be immune-related, due to genetic predisposition, or of a completely unknown cause (idiopathic).  The speed that the pancreas function is destroyed is variable, but the rate happens more rapidly in the young.  

    To control this type of diabetes insulin is administered by injection and diet is regulated.  Insulin administration and dosage is very individualized and patient-specific.  The goal of insulin injections is to provide the body with a proper level of glucose in the blood for the body to function normally while keeping the levels from becoming dangerously low (hypoglycemia).  Often, different types of insulin must be injected to mimic the natural effect of those released by the body, such as rapid, intermediate, and long-acting insulin.  In addition, the timing of the injections will vary based upon issues such as the amount of blood glucose that was tested from a blood sample, timing of meals, length and type of exercise performed, the injection site, and the type of insulin that will be injected.

    Levels of glucose in the blood must be tested daily to manage this disease.  By using a drop or two of blood from a finger stick put on a special testing paper, the amount of sugar in the blood is read by machine.  This process may occur many times a day.  The amount of insulin dictated by a physician (endocrinologist) is then injected into the body.  Specific body sites are used to inject insulin because it must be introduced into the skin, not muscle.  In addition, different sites use (metabolize) the insulin faster than others, providing more rapid absorption rates, therefore altering peak action times.  The sites used for injection include the abdomen, upper arms, thighs, and hips.

    Usually, vascular and neurologic changes eventually develop.  Because the body itself secretes no insulin, and as it is injected into tissues rather than being released as needed, blood glucose levels often fluctuate and are difficult to control within a desired range.  But if detected early, with patient compliance, the manifestations of the disease, although eventually presenting, can be offset with proper diet, patient compliance, and medical attention

Type 2 – NIDDM (non-insulin-dependent diabetes mellitus) occurs more frequently, usually presents after age 40, and is a gradual process.  The patient is often obese.  Some insulin may be present in the body, but the amount being secreted may be insufficient to meet the body’s needs.  However, at times there is also a complete deficiency of insulin production.  There is a strong inherited and predisposition to this type of diabetes, but it often lacks auto-immune destruction of the pancreas that typifies Type 1.  These patients do not usually have increased appetites or exhibit weight loss but do suffer from side effects such as itchy skin (pruritus) and numbness (peripheral neuropathy) related to long-lasting glucose and fat metabolism. 

    While diet is essential to manage this type of diabetes, medications are often varied.  If the patient is not obese, sometimes dietary changes alone can control it.  Oral medications (hypoglycemic medications) may treat the mild/moderate forms of the disease that is usually associated with obesity but not severe enough to require insulin.  There are numerous oral medications, and they work differently on the body.  For example, some may stimulate the pancreas to produce more insulin.  Other drugs may work to delay absorption of glucose by acting on digestion by the small intestine.  However, if the patient’s glucose levels are not lowered sufficiently using the oral medications, and the disease is severe, insulin may need to be injected.  A variety of medications are tried first to provide a controlled level of sugar in the blood, as determined by finger sticks, prior to initiating injectable medications.

    Compared with Type 1, the same vascular and neurologic changes usually develop.  However, one major difference is that this type of diabetes is usually easy to control, and stable once proper medication is determined, and the patient is compliant with treatment.  But it is important to note that because this diabetes type is long in progressing, it is often diagnosed late, once other complications have manifested. 

Care Considerations for Diabetes Mellitus
1) Although family members can support the patient, ultimately the patient must have conviction and be self-motivated to comply with the management of diabetes due to life-style changes and blood monitoring, diet restrictions and potentially painful interventions.   Medication administration, especially insulin injections, requires a strict control to maintain blood glucose levels at an optimum range.  This may require self-testing of blood before meals, at various times during the day, and before bed.  Based upon the blood results, self-administration of insulin, which is injected into the skin, may be required.  In addition, dietary changes are usually essential.   This may include reduction or elimination of favorite foods and/or addition of items that are not preferred. Life-style modifications, compliance, and motivation to make these changes are essential for treatment.  The patient is responsible for reducing the disease process, or the rapidity of its harmful effects.   The patient must restrict his diet.  The patient must test his blood sugar.  The patient may possibly inject himself with insulin.  While family members can assist, especially with household dietary changes, ultimately the patient must comply with a diabetes-friendly diet.  Emotional support proves vital, along with support groups and counseling.
2) Teaching is essential for the patient to understand the ramifications of diabetes.  Compliance is increased when the patient understands the broadly encompassing effects of the disease and damage to vessels which provide oxygen to various structures:  eyes, kidneys, skin, for example. Diabetes can cause secondary problems such as blindness, renal failure which may require dialysis, and osteomyelitis and amputation due to infection, respectively.  A patient’s more diligent and active treatment observance to control diabetes, once consequences are detailed, often occurs when complications and progression of the disease are understood. 
3) Finger-sticks are necessary to obtain scientific and measurable levels of glucose in the blood.  Required for insulin injections, these self-tests are also often necessary to determine efficacy of oral hypoglycemic agents.  The number of times to test will be dictated by a physician.  Initially, and if compliance if a factor, this may need to be performed numerous times a day.  A meaningful record should be maintained not only to capture data but to ensure completion.  Technique in performing finger sticks should be taught by a diabetes-specialist nurse or other professional and the instruction should include at least one family member.  A professional in the field will teach the optimum technique.  In addition, in times of hypo- or hyperglycemic crisis, someone else can perform testing if the patient is unable to do so.
4) Management of insulin is required.  Most injectable insulins require refrigeration but should be at room temperature prior to administration.  The patient should verify these requirements with a health-care professional and/or pharmacist.  Improper storage can degrade efficacy of insulin and greatly reduce its effectiveness.
5) If injecting insulin, sites of injection matter greatly.  Learn and identify the proper sites on the body for administration, which usually include the abdomen, upper arms, thighs, and hips.  Each site differs in rate of absorption, and of those listed previously, the abdomen has the most rapid action and the least rapid action is from injections at the hips.  Physical constraints may dictate not using a site. Sites will likely need to be rotated. Consult a medical professional. 
6) When injecting insulin, specialized equipment is essential.  Used often are disposable single-use syringes with attached small 25- or 26- gauge needles that are half-inch in length.  These small needles ensure the insulin is delivered into the skin and not the muscle.  The small diameter of the needle reduces discomfort.  (The larger the gauge of the needle indicates a smaller diameter size.)  To reduce mistakes in doses, the syringes used must be calibrated in insulin units/mL – not milliliters (mL) solely, as insulin is prescribed in units.  Use of non-insulin, non-unit-measured syringes cannot be used – they are not interchangeable and can cause under- and/or over-medication administration.   If syringes are multi-use, ensure they are cleaned, dried, and cared for according to the manufacturer’s requirements.  And for efficacy and comfort reasons, never use a dull needle for administration of insulin.  Use of the proper equipment ensures safety, assures that the appropriate amount of insulin is instilled into tissue, and decreases risk of adverse reactions from inappropriately injected insulin. 
7) For preparation of insulin for administration, allow insulin to reach room temperature, or follow pharmacy recommendations.   Wash hands.  After testing blood glucose to determine amount of insulin to inject, fill syringe with that amount of air and inject the air into the vial, after cleansing vial top with alcohol.  Then withdraw units to be injected.  Ensure no air bubbles are present.  To prevent infection, washing hands frequently helps to eliminate contamination.  With excess glucose in the body, infection occurs more frequently.  Instilling air into the vial eases withdrawal of contents into the syringe.  Eliminate air bubbles to help ensure proper amount of insulin will be injected and that the syringe space is not reduced by air and that air will not be injected along with the medication. 
8) Preparation and insulin administration.  Wash hands.  Cleanse site with alcohol swab and allow to dry.  Pinch fold of skin, relax muscles, and insert needle at 90o angle into subcutaneous (non-muscle) tissue, penetrating the skin fold quickly. (If patient is very thin, insert needle at 45o angle.)   Do not change direction of needle during insertion or removal:  go in and out without turning.  Withdraw needle.  Messaging of area is detrimental and should not be done, but pressure applied to site is acceptable.  Rotate injection sites often to prevent hardening of the skin and other problems, such a dimpling or sunken areas.  Use abdomen, upper arms, thighs, and hips as directed by physician.  If using the same area of body, ensure at least a one-inch area is maintained between injection sites.  Cleansing site and washing hands minimizes risk for infection.  Rotating needle once inserted into skin causes discomfort and provides no benefit.  Massaging skin changes the route of insulin and causes decreased efficacy.  Rotating sites and allowing for injection margins of at least one inch minimizes atrophy of the skin to allow for lifelong injection sites.   
9) Know the signs and symptoms of hypoglycemia which can occur in Type 1 or Type 2 diabetes.  This condition results when there is too little glucose in the blood, typically resulting in an over-administration of insulin or medication, or taking insulin and then not eating, or exercise that was too intense or too long in duration.  Symptoms include headache, vagueness, nervousness, dizziness, uncoordinated movements, paleness (pallor), sweating, palpitations, and fast heart rate (tachycardia).  Eventual seizures, loss of consciousness and coma can occur.  If symptoms arise, first test the patient’s blood if able.  If blood glucose level is low or hypoglycemia is suspected, have patient consume a fast-acting carbohydrate such as orange juice, milk, hard candies, honey, bread/crackers, or other foods containing sugar.   Administer to patient’s safety and comfort.  Call 911 as necessary.  In addition, the patient should always have a readily available supply of candy or another sugar source that can be self-administered if the patient suspects possible hypoglycemia.  
10) Meticulous skin care is necessaryFeet should be inspected daily for small injuries that can be complicated due to decreased blood flow and lack of sensation (neuropathy).  Inspect feet while sitting down and hold them up to a mirror to reflect image.  This aids in obtaining full view of the soles of the feet, often difficult to visualize.  Never soak feet for any length of time.  Soaking leads to excessive softening of skin (maceration) and promotes infection because the skin is more prone to injury.  Wash and dry skin thoroughly.   Blot skin: do not rub.  Drying gently decreases harm to skin yet ensures moisture is removed.  Avoid constricting socks and foot wear.  These decrease blood flow which is already compromised.
11)  Provide full and complete gentle oral care.  Dental hygiene is essential to prevent dryness, gingivitis, and periodontal disease.  Obtain professional dental care often, every four to six months, to minimize diabetic complications.  Use soft toothbrushes when brushing.  Monitor for bad breath, unpleasant tastes, sore, red and/or bleeding gums, and tooth pain, and if these occur, consult your dentist as soon as possible.  These could be signs of oral infection and require professional treatment.
12)  Risk for injury increases for the patient with diabetes due to multiple causes, depending on the progression and stage of the disease.  Neuropathies can affect gait and sensation.  Visual damage can cause blurred vision, cataracts, and other problems leading to blindness.  With variances in glucose in blood, especially hypoglycemia, seizures or altered levels of consciousness can be exhibited.  To prevent injury, ensure rooms are clear of debris.  Provide night lights to assist with visualization, especially if vision has been adversely affected.  Patients should always wear protective covering on feet, such as slippers or shoes – socks do not prevent injury.  Know the signs and symptoms of hypoglycemia to provide quick treatment and prevent severity.  Monitor water temperature to ensure it is not too hot and can cause injury.  Neuropathies cause loss of sensation and burns could easily occur without the patent noticing them in time.
13) Risk for infection increases in the diabetic patient.  Injuries are slower to heal due to decreased blood circulation.  In addition, glucose in the blood promotes bacterial growth.  Keep nails clean and intact.  Monitor for urinary tract infections and yeast infections, especially vaginally and in skin folds.  Be protective of feet, even regarding small cuts or abrasions.  Feet are a likely target for infection due to decreased blood supply, loss of sensation, and lack of visibility of the soles and outer aspects of feet.  Know the signs and symptoms of infection, which include temperature, pain, malaise, swelling, redness, and discharge.  Consult medical professionals should this occur.  Due to underlying diabetes and the effects of the disease, it is not recommended to self-treat infections.   
14) A diabetic diet should be followed by the patient.  This is as individualized to the patient as in his insulin regime.  Consultation with medical professionals, a nutritionist, and a dietician is recommended to determine the amount of carbohydrates, proteins, and fats that should be consumed to ensure a balance among caloric intake, energy utilization, and dosing and timing of insulin.  A diet that limits sugar, alcohol, salt, and fats is usually recommended.  In addition, eating complex carbohydrates decreases sugar levels and, therefore, the amount of insulin that needs to be injected.  Caloric intake is often reduced, especially in the obese patient.  Foods that promote satiation (feeling of fullness), especially those high in fiber, are suggested.  A food-exchange program is often taught which allows the patient to select set amounts of food, based upon specific patient parameters, from basic food groups to allow for independence, as well as teaching skills in reading food labels.  Dietary changes can greatly increase the efficacy of medications as well as leading to better quality of life in general.  Professionals can pinpoint specifics and knowledge in label reading can bring hidden bad ingredients to the forefront.  Consultation with professionals can provide eating strategies and options that may be overlooked by a layman.  This then increases compliance and makes eating a pleasure rather than a diet. 
15) Maintain records of tested blood glucose levels, insulin injected (including time administered, type, and amount given), and diet/foods eaten.  Records provide means for medical professionals to evaluate treatment regime.  They also enhance the participation and compliance of the patience by having “to do” and “record” actions.
16) Patient concerns include a lack of independence, an altered self- image, fear of economic loss due to illness or loss of work, coping with a chronic illness, and/or fear of complications.  With diabetes, more frequent visits to medical professionals will be required.  One is no longer free to do what and when he desires and may feel trapped by medication administration and dietary constraints.  With additional medications and doctor visits, funds may be depleted.  Fear of complications and living with a chronic illness can seem daunting for a newly diagnosed diabetic patient, especially when outward signs and symptoms of the disease may not have presented yet.  All of these are genuine concerns and realistic losses to the patient.  However, with patience and teaching, the patient becomes more aware and self-motivated. Control over the disease increases.  Over time, he will probably feel better, which also leads to continued compliance.  Stress the benefits, his accomplishments.  Allow for frustration and disappointment.  Backward steps may occur, but with encouragement, they will hopefully be few and progress will continue. 


Contact information:
Diane R. Beggin, RN
40 Sycamore Drive
Montgomery, NY 12549

Web site:

Book: HOW TO MANAGE NURSING CARE AT HOME, by Cooper and Beggin

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