Pancreas Disorders

a. Chronic disorder of impaired carbohydrate, protein, and lipid metabolism caused by a deficiency of insulin

b. An absolute or relative deficiency of insulin results in hyperglycemia.

c. Type 1 diabetes mellitus is a nearly absolute deficiency of insulin; if insulin is not given, fats are metabolized for energy, resulting in ketonemia (acidosis).

d. Type 2 diabetes mellitus is a relative lack of insulin or resistance to the action of insulin; usually, insulin is sufficient to stabilize fat and protein metabolism but not carbohydrate metabolism.

e. Metabolic syndrome is also known as syndrome X and the individual has coexisting risk factors for developing type 2 diabetes mellitus; these risk factors include abdominal obesity, hyperglycemia, hypertension, high
triglyceride level, and a lowered HDL (high-density lipoprotein) cholesterol level.

f. Diabetes mellitus can lead to chronic health problems and early death as a result of complications that occur in the large and small blood vessels in tissues and organs.

g. Macrovascular complications include coronary artery disease, cardiomyopathy, hypertension, cerebrovascular disease, and peripheral vascular disease. (Refer to Chapter 60 for information on cardiovascular disorders.)

h. Microvascular complications include retinopathy, nephropathy, and neuropathy.

i. Infection is also a concern because of reduced healing ability.

j. Male erectile dysfunction can also occur as a result of the disease. Obesity is a major risk factor for diabetes mellitus.

a. Polyuria, polydipsia, polyphagia (more common in type 1 diabetes mellitus)

b. Hyperglycemia

c. Weight loss (common in type 1 diabetes mellitus, rare in type 2 diabetes mellitus)

d. Blurred vision

e. Slow wound healing

f. Vaginal infections

g. Weakness and paresthesias

h. Signs of inadequate circulation to the feet

i. Signs of accelerated atherosclerosis (renal, cerebral, cardiac, peripheral)

a. The total number of calories is individualized based on the client’s current or desired weight and the presence of other existing health problems.

b. Day-to-day consistency in timing and amount of food intake helps control the blood glucose level.

c. As prescribed by the physician, the client may be advised to follow the food exchange recommendations of the American Diabetic Association diet or U.S. dietary guidelines (MyPyramid) issued by the U.S. Departments of Agriculture andHealth and Human Services.

d. Carbohydrate counting may be a simpler approach for some clients; it focuses on the total grams of carbohydrates eaten per meal. The client may be more compliant with carbohydrate counting, resulting in better
glycemic control; it is usually necessary for clients undergoing intense insulin therapy.

e. Incorporate the diet into individual client needs, lifestyle, and cultural and socioeconomic patterns.

a. Exercise lowers the blood glucose level, encourages weight loss, reduces cardiovascular risks, improves circulation and muscle tone, decreases total cholesterol and triglyceride levels, and decreases insulin resistance and glucose intolerance.

b. Instruct the client in dietary adjustments when exercising; dietary adjustments are individualized.

c. If the client requires extra food during exercise to prevent hypoglycemia, it need not be deducted from the regular meal plan.

d. If the blood glucose level is higher than 250 mg/dL and urinary ketones (type 1 diabetes mellitus) are present, the client is instructed not to exercise until the blood glucose level is closer to normal
and urinary ketones are absent. Instruct the client with diabetes mellitus to
monitor the blood glucose level before, during, and after exercising.

a. Oral medications are prescribed for clients with diabetes
mellitus type 2 when diet and weight control therapy have failed to maintain
satisfactory blood glucose levels.

b. Assess the client’s knowledge of diabetes mellitus and
the use of oral hypoglycemic agents.

c. Assess vital signs and blood glucose levels.

d. Assess the medications that the client is currently
taking.

e. Aspirin, alcohol, sulfonamides, oral contraceptives, and
monoamine oxidase inhibitors increase the hypoglycemic effect, causing a
decrease in blood glucose levels.

f. Glucocorticoids, thiazide diuretics, and estrogen
increase blood glucose levels.

g. Teach the client to recognize the signs and symptoms of
hypoglycemia and hyperglycemia.

h. Teach the client to avoid over-the-counter medications
unless prescribed by the physician.

i. Inform the client with type 2 diabetes mellitus that
insulin may be needed during stress, surgery, or infection.

j. Teach the client about the importance of compliance with
the prescribed medication.

k. Advise the client to wear a Medic-Alert bracelet. To
prevent a serious reaction, inform the client taking a sulfonylurea to avoid
consuming alcohol.

a. Insulin is used to treat types 1 and 2 diabetes mellitus
when diet, weight control therapy, and oral hypoglycemic agents have failed to maintain
satisfactory blood glucose levels.

b. Aspirin, alcohol, oral anticoagulants, oral hypoglycemic
medications, b-blockers, tricyclic antidepressants, tetracycline, and monoamine
oxidase inhibitors increase the hypoglycemic effect of insulin, causing a
further decrease in the blood glucose level.

c. Glucocorticoids, thiazide diuretics, thyroid agents, oral
contraceptives, and estrogen increase the blood glucose level.

d. Illness, infection, and stress increase the blood glucose
level and the need for insulin; insulin should not be withheld during illness, infection,
or stress because hyperglycemia and ketoacidosis can result.

e. Instruct the client to recognize the signs and symptoms
of hypoglycemia and hyperglycemia.

f. The peak action time of insulin is important to explain
to the client because of the possibility of hypoglycemic reactions occurring during
this time. Regular insulin is the only insulin that can be administered
intravenously. It is used in the emergency treatment of diabetic ketoacidosis.

a. Redness, swelling, tenderness, and induration or a wheal
at the site of injection may occur 1 to 2 hours after administration.

b. Reactions usually occur during the early stages of
insulin therapy.

c. Instruct the client to cleanse the skin with alcohol
before injection.

a. Lipoatrophy is loss of subcutaneous fat and appears as
slight dimpling or more serious pitting of subcutaneous fat; the use of human
insulin helps prevent this complication (Fig. 54-4).

b. Lipohypertrophy is the development of fibrous fatty
masses at the injection site and is caused by repeated use of an injection site
(Fig. 54-5).

c. Instruct the client to avoid injecting insulin into
affected sites.

d. Instruct the client about the importance of rotating
insulin injection at one anatomical site.

a. The client receiving insulin develops immune antibodies
that bind the insulin, thereby decreasing the insulin available for use in the
body.

b. Treatment consists of administering a purer insulin
preparation.

c. Insulin resistance is also the term used for lack of
tissue sensitivity to the insulin from the body, which results in
hyperglycemia.

a. Dawn phenomenon results from reduced tissue sensitivity
to insulin that usually develops between 5 and 8 AM (prebreakfast hyperglycemia
occurs); it may be caused by nocturnal release of growth hormone.

b. Treatment includes administering an evening dose (or
increasing the amount of a current dose) of intermediate-acting insulin at
about 10 PM.

a. Normal or elevated blood glucose levels are present at
bedtime; hypoglycemia occurs at about 2 to 3 AM, which causes an increase in
the production of counterregulatory hormones.

b. By about 7 AM, in response to the counterregulatory
hormones, the blood glucose rebounds significantly to the hyperglycemic range.

c. Treatment includes decreasing the evening (predinner or
bedtime) dose of intermediateacting insulin or increasing the bedtime snack.

1. Subcutaneous injections and mixing insulin: See Chapter
55.

a. Continuous subcutaneous insulin infusion is administered
by an externally worn device that contains a syringe attached to a long, thin,
narrow-lumen tube with a needle or Teflon catheter attached to the end.

b. The client inserts the needle or Teflon catheter into the
subcutaneous tissue (usually on the abdomen) and secures it with tape or a
transparent dressing; the pump is worn on a belt or in a pocket; the needle or
Teflon catheter is changed at least every 2 to 3 days.

c. A continuous basal rate of insulin infuses; in addition,
based on the blood glucose level, the anticipated food intake, and the activity
level, the client delivers a bolus of insulin before each meal.

d. Both rapid-acting and regular insulin (buffered to
prevent the precipitation of insulin crystals within the catheter) are
appropriate for use in these pumps.

a. A skin sensor device that monitors the client’s blood
glucose continuously; the information is transmitted to the pump, determines
the need for insulin, and then the insulin is injected.

b. The pump holds up to a 3-day supply of insulin and can be
easily disconnected for activities such as bathing.

a. A jet injector is a needleless device that delivers
insulin through the skin under pressure in an extremely fine stream.

b. Insulin administered by this device usually absorbs faster.

c. The injector can cause bruising at the site of insulin
delivery.

a. The goal of pancreatic transplantation is to halt or
reverse the complications of diabetes mellitus.

b. Transplantations are performed on a limited number of
clients (generally, these are clients who are undergoing kidney transplantation
simultaneously).

c. Immunosuppressive therapy is prescribed to prevent and
treat rejection.

1. Self-monitoring provides the client with the current
blood glucose level and information to maintain good glycemic control.

2. Monitoring requires a finger prick to obtain a drop of
blood for testing.

3. Alternative site testing (obtaining blood from the forearm,
upper arm, abdomen, thigh, or calf) is nowavailable using specific measurement
devices.

4. Tests must be used with caution in clients with diabetic
neuropathy.

5. Client instructions (Box 54-17)

1. Urine testing for glucose is not a reliable indicator of
the blood glucose level and is not used for monitoring purposes.

2. Instruct the client in the procedure for testing for urine
ketones.

3. The presence of ketones may indicate impending
ketoacidosis.

4. Urine ketone testing should be performed during illness
and whenever the client with type 1 diabetes mellitus has persistently elevated
blood glucose levels (higher than 240 mg/dL for two onsecutive testing
periods).