NURSING CLIENT DISTURBANCE endocrine system: DIABETES MELLITUS

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NURSING CLIENT DISTURBANCE endocrine system: DIABETES MELLITUS

NURSING CLIENT DISTURBANCE endocrine system: DIABETES MELLITUS

Diabetes mellitus is a chronic disease that often occurs in adults. Even so heavily dependent on the type of diabetes and age of clients, both require a variety of nursing care. The disease is characterized by hyperglycemia caused by inadequate relative insulin deficiency or settled. This disease is a type of disease that often occurs, although no clear cause. Clients with diabetes mellitus will experience throughout their lives change in lifestyle and health status. Nursing care provided in order service to the diagnosis of disease and treatment complications. The primary role is as an educator, a good nurse at the hospital and the community.
Diabetes mellitus is characterized by glucose intolerance. The disease is caused by an imbalance between insulin supply and insulin demand.
DM can be caused by insulin unmet needs or the insulin produced is not effective resulting in high levels of blood glucosa. DM also causes disruption of protein and fat metabolism. DM related to microvascular, macrovascular, and neuropathy.
There are two main types of diabetes:

Insulin-dependent diabetes mellitus (IDDM / type I).
Non-insulin-dependent diabetes mellitus (NIDDM / type II).

Incident:
U.S.: 85-90% suffering from NIDDM.
DM can cause permanent disability:

blindness in adults.
renal failure (U.S.: 25% of dialysis patients suffering from DM).
50-70% non-traumatic amputations.
increased risk of coronary heart disease and stroke.

Clients with diabetes are two times would be at risk of coronary heart disease and three times the risk of stroke.
Etiology:
IDDM:
Often occurs before 30 years of age. Also called Juvenile diabetes, a disorder characterized by hyperglycemia (meningkatkatnya blood sugar levels).
Genetic and environmental factors is the trigger IDDM. Therefore, a higher incidence of viral infection or the presence (of environment), so that environmental influences believed to have a role in the occurrence of DM. Clients who have predisposing factors, viral infections and micro-organisms, such as coxsackievirus B and streptococcus = etiologic factor.
Virus / micro-organisms will attack pulau2 Langerhans pancreas, which makes the loss of insulin production. It can also be due to auto immune responm, where the antibody itself would attack the pancreatic beta cells.
Hereditary factors, also believed to play a role emergence of this disease.
NIDDM
Viruses and human leucocyte antigen does not appear to play a role of NIDDM.
Hereditary factors play a huge role.
Obesity Research reports that one determinant factor of approximately 80% of clients NIDDM NIDDM are overweight (20% above ideal body weight).
Overweight need a lot of insulin for metabolism. The occurrence of hyperglycemia when the pancreas does not produce enough insulin or when the body needs insulin receptor number decreased or impaired (often occurs in overweight people).
Increasing age is a factor that causes the pancreas ririko become more reduced.
Risk factors:
Clients with a family history of suffering from diabetes mellitus is a major risk, particularly IDDM.
Primary prevention of NIDDM is to maintain an ideal body weight. Secondary prevention of weight loss programs, exercise, and diet.
Therefore, DM can not always be prevented, then you should already be detected at an early stage. Tanda-tanda/gejala found are:

obesity.
feeling of excessive thirst, hunger, diuresis, and loss of body weight.
baby was born more than normal.
have a family history of DM.
Age over 40 years.
If found increased blood sugar.

Pathofisologis:
IDDM
Associated with inflammation of the pancreas and Langerhans pulau2 also an autoimmune response.
Coxsackievirus B infection known sabagai perasang autoimmune response, although various etiologic factors may occur. After viral infection, then the beta cells will form the antigen. Beta cell antigens in about 85% were IDDM.
Solving fat and protein will lead to ketosis, which will happen accumulation produced ketone bodies during fatty acid oxidation.
Insulin deficit
+
associated with risk factors

glucosa products and penggungaan glucosa

Hyperglycemia
Osmotic diuresis

Extracellular dehydration

Insufisensi renal hypovolemia
Hyperosmolarity severe shock

Fluid shifts tissue hypoxia

Dehydration aisdosis intracellular lactate

Coma
Manifestation IDDM
IDDM-à lack of insulin to transport glucose through the cell membrane into the cell. Glucose molecules together in the bloodstream, causing hyperglycemia. Hyperglycemia causes serum hyperosmolality, resulting from intracellular fluid into the circulation. Increased blood volume will also increase renal blood flow, and hyperglycemia will influence the occurrence of osmotic diuresis, so that will increase urine output (polyuria). When blood glucose levels exceed renal threshold of glucosa (usually 80 mg / dL-à glucosa will dieksresikedalam urine (glucosuria). Decrease in intracellular volume and increased urine output causes dehydration. The mouth becomes dry and thirsty sensor activated, causing a person drinks a lot (polydipsia .)
Because glucose can not enter into the cells without insulin, energy production will decline. Decreased energy will stimulate the race hungry, and someone to eat more (polyphagia). Despite an increase in food intake, a person will lose weight due to loss of body fluids and solving ptotein and fat as an effort to provide sumber2 energy, resulting in malaise and fatigue associated with decreased energy.
Vision problems will occur as a result of osmotic effect that causes swelling of the eye lens.
Thus the classic manifestation of IDDM is polyuria, polydipsia, and polyphagia, followed by weight loss, malaise, and fatigue. Manifestations can berentang from mild to very severe depending on the level of insulin deficiency.
Diabetic ketoacidosis (DKA).
Untreated IDDM will happen deficit of insulin causes fat deposits solved, resulting in hyperglycemia and fatty acid mobilization with the result of ketosis (keto produced by the liver). Àakan cause metabolic acidosis which is called diabetic ketoacidosis (DKA).
Laboratory tests indicating the occurrence of DKA:

blood glucosa levels> 300 mg / dL.
Plasma pH
Plasma bicarbonate
The presence in serum ketone.
presence of urine ketones in the urine and glucosa.
levels of serum sodium, potassium, chloride hand and not normal.

Pressure on the central nervous system effect which causes the accumulation of ketone acidosis can cause death .. Treatment aims to reduce hyperglycemia, regulate fluid and electrolyte balance, restore normal blood pH. Usually given intravenous fluids and insulin treatment.
NIDDM
It usually occurs at various ages, but often at the age above 35 years. Hereditary plays a role of NIDDM. Other risk factors of NIDDM in people who are overweight, age, members of high-risk ethnic
Although the real cause of NIDDM is unknown, but generally indicated that due to limited beta cell response to the occurrence of hyperglycemia, peripheral insulin resistance, abnormal insulin receptor. If sufficient insulin product will prevent any breaking of fat so it does not happen ketosis.
NIDDM is characterized by a nonketosis diabetes. The amount available is insufficient insulin to lower blood sugar levels by making glucose from muscle and fat cells.
There are two groups of NIDDM that are classified as overweight and obesity did not happen.
In general, overweight people with NIDDM.
Obesity increases the need for glucose, which occurs inability to respond to elevated levels of glucose insulin.
The manifestation of NIDDM:
NIDDM patients have clinical manifestations slowly and often do not realize that the disease has occurred. Hyperglycemia is usually not as heavy as IDDM, but the same symptoms, especially polyuria and polydipsia. Polyphagia often not visible, and weight loss are not always there. As a result of hyperglycemia: haziness of vision, fatigue, paresthesia, and skin infections.
If insulin is reduced, especially stes emotional and physical stress, individuals can experience KDA NIDDM.
Complications of Diabetes Mellitus:
Diabetes mellitus, if not handled properly will lead to complications in various organs such as eyes, kidneys, heart, blood vessels feet, nerves, etc..
Complications of vascular disorders (angiopatik diabetic).
Microvascular: The kidneys and eyes.
Macrovascular: heart disease, leg blood vessels, blood vessels of the brain.
Neuropathy: Micro-and macrovascular.
Easily arise infection.
Diagnostic test;

Blood glucose.
fasting blood sugar: Fasting is not eating for 4 hours, but still liquid. Do not be examined on glucose infusion clients. Rata2 for adults: 110 mg/100 mL.
Postprandial blood sugar: In test after meals. Kadang2 consideration be given some food tewrtentu.
Self-monitoring devices for blood sugar.
Toilerance Glucose test; Client requires a normal diet daslam a few days before the test done.

Medical Management
How the client can control the sugar pengeaturan datah.
To control, there are 3 factors that must interact:

Diet.
Insulin or oral mendication to lower blood sugar.
Exercise.

Giving diet:
55-60% KH.
30% fat.
12-20% protein.
Treatment:
Oral hypoglycemic agents. : Lowering blood sugar by stimulating the pancreatic beta cells to release primarily insulin.
Oral Medicine:
- Above the age of 40 years.
- No riweayat ketosis.
- Not pregnant.
- Hyperglycemia mild / moderate.
Insulin therapy:
All clients with IDDM should be in too late insulin every day, but not necessarily with NIDDM insulin but enough with diet, exercise and oral hypoglycemic agents.
Insulin lowers glucose levels in the blood, because:

Improving the transport of glucose into the cells.
Inhibiting the conversion of glycogen and amino acids into glucose.

Some types of insulin with the speed of work:

Rapid-acting.
Intermediate-acting.
Long-acting.

However, in general have the same working properties of lowering blood sugar levels. But differ in terms of onset, peak, duration of glucose reduction.
More rapid absorption of insulin in the injection in the abdominal area, and quick reaction. Inoculation of the arms, legs and buttocks àrendah absorption and reaction-time ..
Complications of insulin:
1. Hypoglycemia: disturbance of consciousness, tachycardia, diaporesis. Blood sugar below 60 mg/100mL.
2. Tissue hypertrophy or atrophy: Jaringa who have hypertrophy (lipohypertrophy) where the injection of thickened tissue. Network of experienced atrophy (lipoatrophy), where tissue loss of fat under the skin in the area of ​​injection.
3. Erratic insulin action: Client responds to insulin, which marked the occurrence of hypoglycemia followed by hyperglycemia.
4. Insulin allergy: In insulin-sensitive clients
3. Surgical management
Pancreas transplants are usually performed. IDDM is usually done at the client. The new pancreas associated with arterial / venous iliac. But the exocrine secretion is channeled into the bladder and can not be absorbed.
NURSING
1. Decrease in fluid volume R / T osmotic diuresis due to hyperglycemia / excessive gastric losses: diarrhea, vomiting / restriction intake: nausea, confusion.
Supporting data:
- Increased urine output
- Weakness, thirst, weight loss badanb acutely.
- Kulis dry mucous membranes, skin tugor ugly.
- Hypotension, tachycardia, capillary refill lengthwise.
Objectives:
Clients will mendemosntrasikan adequate hydration, characterized by:
- Vs in the normal / stable.
- Clearly palpable peripheral pulse.
- Skin turgor and capillary refill good.
- Urine output is balanced.
- Electrolytes within normal limits.
Action:
- Assess the intensity of vomiting, and excessive urine output.
Rational: to estimate the total volume depletion. In the event of infection will be found the presence of fever and hipermetabolik which can result in increased IWL.
- Monitor Vs.
Rational: Hipovolumea manifested existence dipotensi and tachycardia.
- Assess the pattern of breathing: Respiratory kussmaul and breath odor of acetone.
Rational: Paru2 will issue a carbonic acid as a result of alkalosis respiratik (ketoacidosis). Bad breath acetone as a result of acetoacetic acid solution and handling of ketosis.
- Assess the RR and quality. Observe the use of accessory muscles, apnea, and the presence of cyanosis.
Rational: Handling of hyperglycemia and acidosis will cause the RR and the breath pattern closer to normal. But the increase in respiratory workload will demonstrate breathing shallow and quick, the cyanosis.
- Assess the temperature, and skin color.
Rational: As a result of fever and diaphoresis because the infection would show an increase in body temperature, skin redness appears. When dry skin as a result of dehydration.
- Assess the peripheral pulse, capillary refill, skin turgor, and mucous membranes.
Rational: as an indication of the level hydrasi / aduasi volume of circulation.
- Monitor I & O. Record the BD urine.
Rational: to estimate the needs of body fluids, the kidneys work and effectiveness of treatment.
- Weigh weight.
Rational: Weight loss as a result of excessive spending caran.
- Maintain fluid intake 2500/hari/dalam cardiac tolerance limits.
Rationale: Maintaining hydration / volume of circulation.
- Create a comfortable environment
Rationale: Avoid clients from heat to prevent excessive discharge (IWL).
- Assess the possibility of nausea, abdominal pain, vomiting.
Rational: Decrease in fluid and electrolyte will cause gastrointestinal motility disorders that cause vomiting.
- Observation of the possibility of a change in level of consciousness.
Rational: Amended mental status of clients as a result of an increase or decrease in glucose levels, electrolyte disturbances, acidosis, decreased cerebral perfusion, or hypoxia.
- Observation of the possibility of fatigue, crackles, edema, weight gain.
Rational: Overload of fluids and the presence of CHF.
- Provision of normal saline fluid to or without dextrose.
Rational: the type and amount of fluid needed depends on the level of fluid loss and client response.
- Replace the urine bag / catheter.
Rational: to facilitate an accurate measurement of urine output
(Installation is done mainly on clients who have neurogenic bladder (urinary retention / incontinence).
- Monitor laboratory tests, such as hematocrit.
Rational: peemriksaan results will indicate the level of hydration. If there was an increase indicates interference with the osmotic diuresis.
- Monitor BUN
Rationale: Increased BUN showed split cells from dehydration or an indication of kidney failure.
- Monitor potassium.
Rational: hyperkalemia occurred in response to acidosis. But if the loss of potassium through the urine, there will be a decrease of potassium in the body.
- Give bicarbonate when pH is less than 7.0.
Rational: correction of acidosis.
2. Nurtisi less than body requirements R / T deficiency of insulin / decrease in oral intake: anorexia, nausea, abdominal pain, dangguan awareness / Hipermetabolik due to the release of stress hormones: epnineprin, cortisol, and GH or due process of infection.
Supporting data:
- Inadequate food intake.
- Loss of appetite.
- Weight loss.
- Weakness / fatigue.
- Poor muscle tone.
- Diarrhea.
Objectives:
Clients will consume exactly the amount needs calories / nutrients can be saved., Marked:
- Weight gain was balanced.
- Examination of albumin and globulin in normal limits.
- Good skin turgor.
- Consume food based on the program.
Action:
- Weigh weight.
Rational: Weight loss indicate inadequate nutrition clients.
- Auscultation bowel sound.
Rational hyperglycemia, and fluid and electrolyte imbalance causes a decrease in intestinal motility. If the decrease in intestinal motility lasted longer as a result of autonomic neuropathy associated with the digestive system.
- Provide soft food / liquid.
Rationale: Providing food and soft oral aims to restore bowel function and provided the client with a good level of awareness.
- Involve the SO in the diet plan clients.
Rationale: Adequate information on the SO diet will increase the understanding of the client and may participate in a diet program clients.
- Observation of signs of hypoglycemia such as: decreased level of consciousness, palpable surface of the cold, rapid pulse, hunger, anxiety, headache.
Rational: metabolism; KH will lower glucose levels, and when time was given insulin will cause hypoglycemia.
- Teach client to perform self monitoring of glucose (fingerstick glucose testing).
Rationale: Analysis of serum glucose is more accurate than urine glucose monitoring. Understanding the client in self monitoring will encourage the client to manage his diet consciousness.
- Give insulin.
Rational: to accelerate the transport of glucose into the cells.
- Consultation with a dietitian.
Rational: Estimating the level of dietary needs of clients.
3. Risk of infection R / T decrease leukocyte function / circulatory disorders.
Objectives:
The client will maintain the integrity of the body remains intact and protected from infection, marked:
1. There are no signs of infection.
2. No injuries.
3. There were no changes in skin color.
Action:
- Observation tanda2 infection / inflammation (fever, redness of skin, wound fluid, purulent sputum, urine, blurred).
Rational: redness, edema, wound, drainage of fluid from the wound showed an infection.
- Teach client to wash their hands properly, as well as health staff to maintain hand hygiene during the procedure.
Rationale: Prevent Cross-Contamination.
- Maintain aseptic technique, especially when setting up IV.
Rationale: The increase in blood glucose is a good medium for bacterial growth.
- Teach client to wash her vulva from the upper canopy.
Rational: Cleaning the vulva without regular movement will facilitate ekdalam bacteria enter the urinary tract and cause UTI.
- Maintain cleanliness of the skin, massage the bulge area, keep dry skin, dry linens and tidy.
Rationale: Impaired peripheral circulation can occur when placing the patient at risk of the condition of skin irritation.
- Auscultation of breath sounds.
Rational: Ronchi as an indication of accumulation of airway secretions in respect of peneumonia / bronchitis (as a result of DKA). It can also occur if pulmonary edema due to excessive IV administration of fluids / CHF.
- Partahankan semo Fowler position.
Rationale: Lung expansion, reduce / reduce the risk of aspiration.
- Teach client to cough and breath deeply.
Rational: cough reflex will release secretions in the airway and facilitate dindinmg expenditure of airway secretion.
- Help clients to oral care.
Rationale: Reducing the risk of disorders / diseases of the mouth and gums.
- Encourage the client to consume an adequate diet and fluid intake of 3000 mL / day (if not contraindicated).
Rationale: Increased urine output will prevent stasis and maintain the pH of urine that can prevent the growth of bacteria.
- Antibiotics if indicated.

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