Diabetes Mellitus Complications

hi and welcome to the Newark station I'm Maria Mobley and today we are going to learn about complications associated with diabetes mellitus as always these videos are for educational purposes I really hope they're helping you all and if you didn't check out my video about introduction to diabetes and the pathophysiology along with patient education please do so before we get into the complications of diabetes so you all are gonna take care of many diabetic clients and it's essential to understand first off how we treat diabetes which we talked about in the first video but also how to catch complications early and intervene quickly to try to assist them and promote optimal outcomes so I've listed complications and on the back of the board we'll get to DKA and HHS which are the hyper glycemic complications but first we're going to start with hypoglycemia I need you future nurses to understand if the blood glucose goes less than 70 you need to act and you need to act right now you don't need to gather any more data you don't need to assess you need to get a simple carbohydrate in them and so when you think about carbohydrates you think about sugars and starches right this is simple carbohydrate breaks down very quickly into energy so pretty much just give them sure so if you walk in there and let's say you have a diabetic client let's say they went to a CT scan our MRI and you come back and they could have missed their breakfast chain train and you all of a sudden notice that they're sweating and maybe they have a headache or maybe they're really irritable those are all potential signs of hypoglycemia I listed a couple signs for you diaphoresis change in behavior tachycardia palpitations headache slurred speech hypoglycemia is a very serious condition it can lead seizures they can lead to a comatose state however remember you walk in that room we can't act unless we absolutely know the problem so you walk in the room and they have a headache and they're sweaty and they're angry they could just be mad that they missed their breakfast tray so remember we always have to do ad pi we have to start with assessment well that assessment data isn't enough information for us to go ahead and give them sugar so we need that objective sure sure information that's telling us it's hypoglycemia so if you see any of those concerns you need to get a finger stick very quickly and if that finger stick result shows you that the glucose level is less than 70 milligrams per deciliter you need to act if it's 69 you need to act so critically thinking because this is true in the real world but remember I also gear you to test according to the NCLEX perfect world critically thinking what type of sugar or simple carb a carbohydrate you're gonna give them is related to their responsiveness okay so think about it you walk in the room and they're difficult to rouse should we put anything into their mouth absolutely not what risk does that create what safety implication does that create if they have a change in behavior if they're difficult to arouse that they are confused or have slurred speech we put something in their mouth that could be an aspiration risk so I really want you to think if there's any change of behavior if there's any change in level of consciousness you do not need to be putting oral medications into their mouth because we're we could be doing harm if if they vomit and they can't control it and it gets down into their airway okay so just think the medication we administer priority wise is related to responsiveness yes you can and do need to know your facility protocols you could have a client with a glucose level in the 30s and they look absolutely fine yes you most likely if they look absolutely they're responding you can give them oral medication but that glucose is so low you might need to be given them d5w okay I'm sorry d50 W which we'll talk about in terms of treatment in one second so let's think walking room we saw concerns of hypoglycemia and remember know all the symptoms that your instructor gives you for testing purposes that's just a few of the many signs of hypoglycemia we get that blood glucose stick finger stick and it's less than 70 you need to act if it's in the 60s they're responsive let's get them a oral simple carbohydrate or we can just say sugar quickly a lot of times you'll see us run and go get orange juice or we'll run and get a coke but remember if it's a coke it needs to not be diet we need sugar okay diet cokes and the diet sodas have all the artificial sweeteners in that no we mean real sugar so again critically thinking your intervention or what we give for hypoglycemia dependent on responsiveness if they are responsive we can give oral entities that will give them sugar quickly a lot of times you see us grab a coke orange juice we have glucose tabs available we have glucose gel available so we can give an oral simple carbohydrate or just give them sugar orally okay if they're unresponsive or a change in behavior a decreased level of consciousness don't put anything in their mouth that topic anytime there's a change of behavior decrease level of consciousness you Hallie's have an aspiration risk we can't say it's airway because they're not choking right here right now but you better think safety remember back to my maslow's video any risk of physical can actually turn into a safety problem so you need to keep them safe okay so what we typically do is give 50% extras it usually comes in this 50 ml syringe and you can hook it straight up to their IV access or their line access and push it in it's very sticky it's very hard to push you really want to watch that IV site and make sure that it's not infiltrating but we can give that directly into their circulatory system we can get glucagon as well maybe they are difficult to get access on we can give them I am injection of glucagon and this is just few of the many interventions that we have for hypoglycemia so of course geared towards your instructor but critically thinking their responsiveness will determine if you can give something by mouth or if you need to stick to a parenteral route okay if we need to stick to our IV route or I am round all right and then again also third glucose is extremely low even if they are responsive we might need to give them intravenous intervention just to get those levels up quickly okay so once we intervene with our medications or with our Coker juice you need to be checking that blood sugar most facility protocols take you 15 minutes until we get it back to an appropriate level and I also didn't write up here but these are simple carbohydrates they break down very quickly for the body to utilize energy to utilize the glucose however once we get that glucose back above 70 a lot of times you see us given a complex carbohydrate a lot of times we're going to give them maybe a starch or sugar and a starch so it doesn't break down as quickly and kind of keeps their glucose evened out inside their body okay so you can see us give them graham crackers with peanut butter or a peanut butter sandwich or something like that to just maintain those glucose levels so they don't go back into rebound hypoglycemia when that fast sugar breaks down really quickly okay so hypoglycemia future nurses you act and you act immediately if that level is 69 you need to be doing something and I need you to know your facilities and protocols when you get to the site that you'll work at it will tell you what dependent on responsiveness what what you can administer it will tell you how often to check their glucose levels after that hypoglycemic episode but in the NCLEX perfect world a blood glucose level of less than 70 you don't gather any more data you act and you're going to intervene by giving them glucose of some form and remember it's dependent on their responsiveness because if they are unresponsive or have a change of level consciousness change of behavior do not put anything in their mouth okay so let's move on to decreased perfusion I want you to think again think about glucose remember with a lack of insulin or insulin resistance we have glucose sitting in our blood and it's not being transported into our cells where we want it to be stored okay are being transported into our liver which is the primary organ of storage for glucose so if all that glucose is sitting in our blood think about your blood vessels your veins your arteries all right glucose is sticky right can't a lot of glucose start to adhere to the lumen of the vessels so if we have a lot of glucose adhering to the lumen of your vessels it's very similar to plaque or cholesterol and is this making it narrowed is it leading to decreased oxygen perfusing through your vessels right because think your arteries is what supplies all your oxygenated blood to your cells to your tissues to your organs so we have decreased oxidative blood to everywhere you know or to certain sites that could lead to your perfusion complications so we split it up into macro vascular macro meaning larger but blood vessels and micro meaning smaller blood vessels okay let's just look at of our macrovascular complications coronary artery disease so that means this vessel is supplying the oxygen to my heart now I start to have all this gluco build up glucose build up and of course you can have plaque in cholesterol build-up as well depending on their diet depending on if they are overweight depending on if they have a lack of physical activity in their lifestyles so decrease oxygen to my heart muscle but could that lead to I listed coronary artery disease but diabetic clients have an increased risk of heart attack okay hypertension your vessels right the more narrowed they are isn't it more pressure trying to force our blood through can actually lead to high blood pressure stroke what if this vessel was your cerebral artery what is it's having a lack of perfusion to our brain that can lead to a stroke what if this vessel is now going to our lower extremities that could lead to your peripheral vascular diseases your proofer arterial disease or your peripheral venous disease I have a really good video on that if y'all want to check it out as well but just think macro that's the macro vascular our bigger blood vessels our arteries supplying our lower extremities our heart our brain they're starting to get built up with glucose among other things leading to decreased perfusion so with diabetic clients if they start complaining about chest pain you better start working them up for a heart attack if they start complaining let's say that you walk in and they have slurred speech they have left-sided weakness we need to intervene quickly to treat them for stroke and to start ruling out and doing our NIH Stroke Scale and all those things getting them to a diagnostic study to detect into her and are they having a stroke or not so you need to look for these complications if they're complaining or feel assess any signs a decreased perfusion depending on where the perfusion problem is you need to intervene quickly and again diabetes could be placed in multiple sites in your curriculum it might not have gotten the heart attack or stroke but just know if their baseline changes and they have a difference in their cognition or they have chest pain or let's say there they have a decreased sensation to their legs and their pulses are weak that is not normal we need to start assessing and gathering more data in Guinea and figuring out what the problem is so we can help them as quickly as possible and then we got our micro vascular complications you need to think your small blood vessels so I put an affront at the first nefra you should always think kidneys so a lot of times students think that the kidneys are supplied by big arteries like our heart or our brain they're actually supplied by capillaries which are very small blood vessels because you got your veins your arteries and your capillaries so nephropathy or kidney problems actually falls under micro vascular complications because the capillaries are what are perfusing the kidneys then you have your retinopathy your visual changes that can occur with diabetic clients and then our neuropathy when we think neuropathy we should think nerves right we can have decreased perfusion to nerves we could have nerve damage so a lot of clients with diabetic clients would neuropathy they have that numbness and tingling they have that decreased sensation so is it safe to put a heating pad on a diabetic clients feet or legs not no not in this NCLEX perfect world it's not even really in the real world because there's a risk of there's a risk that they cannot feel when that heat impact gets too hot diabetic clients we say always wear shoes always wear sturdy shoes wear white socks even when they're in the house because if they have neuropathy if they cut their foot they might not even realize it they might not even feel it so we really got to protect their feet we're educating them to get annual exams and to report any changes in vision really very quickly with your kidneys well let's think critically thinking how many ml of urine output do you need per hour to say that you have healthy kidney function they need to make sure they're peeing they need just we need 30 ml of urine outlet per hour they need to report changes in urination they need to report a decrease in urination they need to report weight gain or swelling if they're not excreting their urine appropriately so these are all complications that we need to look for and we need to catch them early and another complication we need to think about related to decreased perfusion is skin again if you have decreased oxygen circulating to the skin related to all that glucose or plaque or cholesterol buildup it could lead to poor wound healing so if a diabetic client does get a cut let's say in their leg it could heal much more slowly and it can dramatically increase the risk of infection so really educating the clients to protect themselves always again wearing sturdy shoes and socks making sure to do thorough feet inspections and skin inspections to see if any cut ulceration has developed and to really report signs and symptoms of infection quickly yes from the wound itself if they have a pre-existing wound but also systemic side that they're getting fevers chills if their white blood cell count is elevated we really want to protect their skin keep it well lotioned keep them well hydrated do thorough skin assessments and if they have any pre-existing wounds really monitoring them for infection again going all the way back to decreased perfusion so the last complications we're going to talk about are your complications related to hyper glycaemia elevated blood glucose levels so hyperosmolar hyperglycemic syndrome that's HHS I didn't have enough room to write the abbreviation but HHS vs diabetic ketoacidosis DKA so these are life-threatening conditions and I'm really gonna gear you towards the NCLEX perfect world because s as future nurses I feel for y'all that NCLEX is is crazy it's given you four right answers and I'm sure you get frustrated with your teachers like my students get with me they're like Miss Mobley that's right we know it's right it just might not be the best remember forbidding answers we have to gear y'all to get getting to picking the one answer choice that you know you walked in you did this and then you left the room and you kept them the safest and breathing or alive the best you could so I'm really gonna gear you towards answering those type of questions when you see HHS and DK so you're gonna see this red squiggly line HHS and DK a present very similarly and then there's this one big difference between the deuce two disorders that I'm going to talk about below the line okay so let's start both related to hyperglycemia elevated glucose levels so their glucose levels could be in the 400 500 600 asking the glucometer the finger sticks not able to read glucose levels for these clients they're so high so remember we always have serum levels we can draw on since a lab to get accurate glucose levels if the bigger stick isn't reading so extremely elevated glucose levels and if you remember from my first video in the path of diabetes your kidneys are gonna kick in and when I say you're let's just pretend we're diabetic like your kidneys are gonna kick in it's gonna help you cope and it's gonna start peeing off glucose right because our glucose levels in our blood are getting too high our kidneys again are gonna help pay off those excess glucose the excess glucose in our blood however what follows it water so your poly area and then you get thirsty polydipsia because you're losing a lot of fluid and then your body is still triggering you to eat because the energy is not being stored where we want it to be stored your glucose is not in your cells so your body's going to keep wanting to eat and eat to try to get that energy that your body is starving for but the P we're gonna focus on is polyuria because when we have such excess glucose levels and that dramatic amount of your nation it's going to lead to dehydration so your priority for HHS and DK is circulation and remember you will have data to support this you need to look at their physical assessment yes they have a high glucose level hyperglycemia is important but if you see signs of dehydration you see a low blood pressure so low blood volume and now their heart rate is getting high because the heart's just trying to pump whatever fluid is left in the body you see dry mucous membranes you see signs of decreased perfusion think about it when we're dehydrated the oxygen that is circulating and are in our blood and remember it's lower blood volume where will our body try to cope where will it try to shoot it - it will shunt it to our vital organs our heart our lung in our brain right and our kidneys is is not going to be perfused as effectively so you're gonna start to see the v1 and creatinine levels elevate so your need to be looking clients with elevated glucose levels you need to be looking for signs and symptoms of dehydration and remember in the in click style questions it gives you your question if you see data that shows dehydration your priority now is circulation hyperglycemia does not Trump circulation and maslow's so yes will we give these clients insulin absolutely I talk about how we give IV regular insulin however if you can do one thing and one thing only for HHS and DKA their glucose is elevated and now they're showing signs of dehydration because of that excess poly area you need to give fluids fluids is your priority intervention because again circulation Trump's hyperglycemia in maslow's so administer fluids because you could have four answers give fluids give IV insulin assess vital signs assess your not that you can have all those answers and we do all of those answers in the real world that's why it's so frustrating the NCLEX style questions everything if I can do one thing and one thing only HHS the DKA clients are gonna die from circulatory collapse there their fluid volume is gonna get so low that they are going to go into shock and die from that so we are going to replace that lost volume that is your priority so administer fluids on both sides the type of fluids we always start with or primarily start with our isotonic fluids so your 0.9% sodium chloride we don't let fluid shifts if we have a proof for i'm ii and we give an isotonic fluid it stays in our circulatory system and stays in our intravascular space and that's where are depleted volume is so that's where we want the fluid to stay so we give our isotonic solutions 0.92 percent sodium is very typical you may see up lactated ringers but isotonic solutions to start with to replace that volume you will administer insulin and this is not the time to administer subcutaneous insulin this is the time to give intravenous insulin to try to get those glucose levels down much quicker and the only IV insulin that we have available is regular that is your short-acting insulin when you go back to pharmacology and we will be putting on up putting it on a pump and infusing it via a pump to these clients okay now let's talk about the differences between HHS and DK so remember both show in times of dehydration both administering fluids both given IV regular insulin but let's talk about the difference in the body on this side HHS the client still had some insulin prior to treatment okay so they had some insulin in their body there with still some glucose being transported into cells for energy or being stored for energy and glucose being utilized for energy so because there was some insulin in their body prior to treatment they did not have ketone development ketones are an acid and ketones are a byproduct of metabolism of certain sources such as muscle and fat cells so when we break down these cells that we don't want to break down ketones which is the acid develops well there is no ketone development on this side so is your acid base and balance affected no their pH should be normal their bicarbonate levels should be normal their actual electrolytes should be minimally affected if they're dehydrated they could show signs of hypernatremia but again their electrolytes should be minimally affected because acid-base imbalances are not occurring if you go back to my introduction to ask the basement chances remember 'but axiom is a really big electrolyte that's affected when we have acid-base imbalances and because the pH should be normal the bicarbonate level should be normal we might we're not gonna see it electrolyte disturbances that you would see when we talk about decay okay so on this side they do not go into an acid-base imbalance ABG should be normal they should not be showing signs of coping for acid-base imbalances such as coos moles or shifting a potassium so again acid-base is normal no ketone development let's talk about DKA DKA clients type 1 diabetic clients are primary example remember for my first video I talked about instances where glucose can get elevated infection a diabetic client that is sick is a prime example of when glucose levels can skyrocket let's say this type 1 diabetic got sick let's say they reduce their amount of insulin for that day or maybe didn't take it cuz they're not eating but their body has no insulin their beta cells are destroyed they're not secreting insulin so these clients had no insulin in their body or minimal to no insulin on their body prior to treatment are their cells starving for energy absolutely will certain products such as fat and muscle cells start to break down because the body starving for an energy absolutely and once these cells start to break down that's when you get ketone formation so in DKA and think it's called diabetic ketoacidosis which ketones are acid so it is increased acid in the body so because the client is starving for energy in the body had a cup and it started breaking down fast on fat muscle cells leading to ketones which are acids now we have increased acids in our body what is going to happen to our pH normal pH is 7.35 to 7.45 if it gets less than 7.35 isn't it more acidic so because of the increased acid because of positive urine and serum ketones our pH is going to start to decrease in DKA their pH can be less than 7.3 because they're in acidic state from this ketone formation their bicarbonate could be low less than or equal to 18 because bicarbonate is your base and they're in an acidic state okay and let's think about the acidic state that will occur for it to be a respiratory disorder they have to have a breathing problem this is not a breathing problem this is the body breaking down products that it shouldn't be because it means energy not a breathing problem so the disorder that DKA clients go into is metabolic acidosis and let's think about how our body copes and remember to review the acid-base imbalances videos if you can't remember the body is gonna coat the buffer system is gonna kick in right and potassium is gonna start to be pulled to the outside into the blood so hydrogen ion which is an acid can go into the cell so metabolic acidosis these clients could have hyperkalemia let's think the lungs can kick in next and the lungs controls co2 which is the acid so we're in this acidic state or your lungs gonna try to blow off the acid or is your breathing going to become shallow and try to retain the acid your lungs are gonna try to get rid of acid as a coping mechanism so these clients will have coos models respirations a coping mechanism to try to get rid of co2 which is an acid because it's trying to help this acidic state right now so you're gonna see very deep rapid labored breathing who's mas respirations okay and again your body's just trying to help you take it off acid and then let's think about what additional interventions we might need any time you have hyperkalemia or changes in attack in levels you're at risk for cardiac dysrhythmias so they would need to have EKG monitoring we would need to give medication to try to reduce those potassium levels you can see the great thing about insulin is it actually pushes potassium back into the cell which is what we want majority of our potassium decrease in your blood potassium levels so that can help with your potassium levels we might have to give other medications that would help reduce potassium levels we need to look at those ABG's and and see are our interventions improving this metabolic acidosis state so with our interventions is our pH raising and getting back to the normal 7.35 to 7.45 level is our bicarbonate levels increasing to try to get back to the normal levels so with DKA the primary difference versus HHS is they are now in an acid-base imbalance and you have to think about all those symptoms that come with a acid-base imbalance coos mom's changes in pH changes impact bicarbonate levels they have this fruity ketone breath okay that can occur and we additionally add on EKG monitoring maybe medications to reduce potassium levels and very severe cases so we can administer sodium bicarbonate to increase our base to try to help the acidic State so other interventions that are necessary because now they're in an acid-base imbalance and at the end of the day whatever interventions you do HHS first DKA you need to evaluate did they work and also did your treatment cause additional problems remember what is your priority for both if you can do one thing and one thing only they died from circulation so your priority intervention is to replace long give them isotonic fluids okay they have hyperglycemia so we're administering IV regular insulin when we start getting those insulin levels to appropriate levels we can then convert them or transfer them over to a subcutaneous administration of insulin but on both sides massive bolus inna fluids when you're evaluating if your intervention worked we should see decreased signs of dehydration that blood pressure should start to come up there mucus membranes just start to pump Iike moist if they had a change in level of consciousness or change in behavior that can occur with dehydration you need to see better responsiveness an improved level of awareness or level of orientation um but we could have given so many fluids that we threw them into fluid volume overload so look for that complication as well when you're evaluating do you start to see jvd when you're auscultate their lungs are there any signs of crackles or fluid volume overload so look for those complications also well we're giving IV regular insulin we can decrease and select insulin levels very quickly you also need to ensure that we're not decreasing them too quickly that we don't throw them into hypoglycemia so risk of hypoglycemia and over here you see risk of fluid volume overload and risk of decreased blood glucose or hypoglycemia I just didn't have enough room to write it out and then more so on this side both with treatment you can have risk of fluid volume overload risk of hypoglycemia because anytime we treat we can throw them into the opposite disorder and now more specifically to this side we need to be evaluating not just circulation don't just look at vital signs you're an output mean this membranes your physical assessment you still need to be looking at ABG disorders or imbalances so this side you need to be make sure that you're monitoring their ABG's you need to make sure you're looking at the EKG make sure that they don't have dysrhythmias related to imbalances and potassium okay and anytime we're giving medication to treat hyperkalemia you can also increase the risk of hypokalemia related a treatment so look for all those problems that can occur even with treatment because that's a good nurse you don't just intervene at the problem that's occurring you're evaluating to make sure that your interventions are working and also that those interventions aren't causing additional problems okay so I really hope this helps you I hope I kept it pretty simple basic to the point and as always y'all are the future y'all are the future nurses make it better together so this helped you please grab a friend grab another student in your class and help them so they can be successful on their tests as well as always take care

Channel: Maria Mobley, MSN, BSN, RN

Views: 8,147

Rating: 4.9603958 out of 5

Keywords: DIABETES MELLITUS, DM, DKA, HHS, HYPOGLYCEMIA, NCLEX PREP, NURSING TUTORIALS

Id: IoJFgMgBuGA

Length: 32min 53sec (1973 seconds)

Published: Mon Apr 08 2019