Page 53 Complete Your CE Test Online - Click Here Acute complications of hyperglycemic crisis Acute complications of hyperglycemic crisis may occur with diabetes. Failure to treat these complications appropriately can lead to coma or even death. These two complications are diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic nonketotic syndrome (HHNS)[11] . DKA is seen most often in patients who have type 1 diabetes. It may actually be the first sign of the disease. HHNS is seen most often in patients who have type 2 diabetes, but it can occur in any patient whose insulin tolerance is stressed or who has undergone procedures such as peritoneal dialysis, Hemodialysis, tube feedings, or total parenteral nutrition[11] . These complications occur when inadequate levels of insulin cause interferes with the body cells’ ability to take in glucose and convert it to energy. Thus, glucose accumulates in the blood, and the cells lack the energy needed to function. This triggers the liver to convert glycogen to glucose and still more glucose is released into the blood. But no matter how much glucose is manufactured and released into the bloodstream, the cells are not able to utilize it because of insulin deficiency[5,11,6] . Blood glucose levels become grossly elevated, serum osmolarity increases, and high amounts of glucose are present in the urine (glycosuria). This triggers osmotic diuresis and massive fluid loss, which, in turn, causes electrolyte loss. Water loss is greater than glucose and electrolyte loss and dehydration continues along with a decreased glomerlular filtration rate and an eventual reduction of the amount of glucose excreted in the urine. As glucose excretion decreases, blood glucose levels continue to increase. This cycle continues, and if not stopped, leads to shock, coma, and death[11] . DM alert! DKA also leads to the conversion of fats into glycerol and fatty acids, which cannot be quickly metabolized and accumulate in the liver. There they are converted into ketones. Ketones accumulate in the blood and urine, causing acidosis[11] . DKA and HHNS are medical emergencies and require immediate treatment to correct fluid loss, electrolyte imbalances, and acid-base imbalances. Insulin is administered to correct hyperglycemia[5,6,11] . Signs and symptoms DM may develop gradually or abruptly[5,11] . The most common symptom is generalized fatigue. Hyperglycemia “pulls” fluid from the tissues of the body, which causes characteristic symptoms (in both type 1 or type 2 diabetes) of polyuria (excessive urination), excessive thirst (polydipsia), and excessive eating (polyphagia)[5,6,11] . Other signs and symptoms include[5,6,11] : ● ● Dehydration. ● ● Dry, itchy skin. ● ● Frequent infections of the skin. ● ● Poor skin turgor. ● ● Unexplained weight loss. ● ● Vision changes. ● ● Weakness. Type 1 diabetes usually causes a rapid development of symptoms including effects of muscle wasting and loss of subcutaneous fat[11] . Persons affected by type 2 diabetes generally have a symptom onset that is vague and gradual[5,11] . Diagnosis According to American Diabetes Association (ADA) guidelines, DM can be diagnosed if patients manifest any of the following[5] : ● ● Symptoms of DM plus a random, nonfasting blood glucose level equal to or greater than 200 mg/dl. ● ● Fasting blood glucose equal to or greater than 126 mg/dl. ● ● Oral glucose tolerance test (2-hour sample) results equal to or greater than 200 mg/dl. Diagnostic alert! Questionable results require that diagnosis be confirmed by repeat testing on a different day[5] . The ADA recommends the following testing guidelines[5] : ● ● Test people aged 45 and older who have no symptoms every 3 years. ● ● People with characteristic signs and symptoms should be tested immediately. ● ● High risk groups should be tested frequently. An ophthalmologic exam may reveal diabetic retinopathy. Acetone is present in urine, and blood tests for glycosylated hemoglobin show recent glucose cortisol[5] . Blood glucose levels are classified by the ADA as[5] : ● ● Normal: 126 mg/dl. Treatment and nursing considerations Treatment goals are to optimize blood glucose levels and decrease complications[11] . Medications Many types of drugs are used to treat DM. Treatment of type 1 DM includes insulin replacement. Current forms of insulin replacement therapy include single-dose, mixed-dose, split-mixed dose, and multiple-dose regimens, which may be administered via an insulin pump. Insulin may be rapid, intermediate, or long-acting or a combination of rapid- and intermediate-acting[5,11] . Persons with type 2 DM may require oral antidiabetic medications that stimulate insulin production, increase cellular sensitivity to insulin, and suppress hepatic gluconeogenesis[5] . A variety of drugs have proven helpful in treating DM such as[5,14] : ● ● Sulfonylureas, which stimulate pancreatic insulin release. ● ● Meglitinides, which cause immediate, brief release of insulin and are given before meals. ● ● Biguanides, which decrease hepatic glucose production. ● ● Alpha-glucosidase inhibitors, which slow glucose breakdown and decrease postprandial glucose peaks. ● ● Thiazolidinediones, which enhance the action of insulin. ● ● Synthetic analogue of human amylin, which helps control glucose and is used with insulin. Diet Patients require in-depth dietary instruction. Each patient’s diet is planned specifically for him/her and should take into consideration dietary preferences to facilitate compliance. Patients with type 2 diabetes often need to lose weight. If this is the case, weight loss strategies should be incorporated into the diet plan [5,6] . Exercise Exercise is encouraged as part of a healthy lifestyle and is especially helpful in the management of type 2 diabetes. Exercise facilitates weight loss, improves glucose tolerance, and increases insulin sensitivity [11] .