Nursing process in diabetes mellitus: why is it needed. diagnostic and treatment and other departments. Help from a nurse in a hospital

Urgent Care with hypoglycemic coma.

Depends on the severity of the condition: if the patient is conscious, it is necessary to give food rich in carbohydrates (sweet tea, white bread, compote). If the patient is unconscious - intravenous drip injection of 20-50 ml of 20-40% glucose solution. If there is no consciousness for 10-15 minutes - intravenous drip injection of 5-10% glucose solution until the fighter will not regain consciousness.

Emergency care for hyperglycemic coma

Immediate hospitalization. Warm the patient. Gastric lavage 5%

sodium bicarbonate solution or isotonic sodium chloride solution (part of the solution is left in the stomach). Cleansing enema with a warm 4% sodium bicarbonate solution. Oxygen therapy. Intravenous drip isotonic solution sodium chloride at the rate of 20 ml/kg body weight (cocarboxylase is added to the dropper, ascorbic acid, heparin).Insulin administration at a dose of 0.1 U/kg/h in 150-300 ml of isotonic sodium chloride solution (in the first 6 hours, 50% of the total amount of liquid is administered)

> The role of m/s in the organization of schools “School of Diabetes Mellitus”

The goal and objectives of the school are to teach patients with diabetes mellitus methods of self-control, adaptation of treatment to specific living conditions, prevention of acute and chronic complications diseases.

As for children, training at the “School of Diabetes Mellitus” must be adapted to the age and degree of puberty of the patient. The formation of age groups of students is based on this principle.

1) The first group includes parents of newborns and children of the first years of life with diabetes. Young patients are completely dependent on parents and medical staff (eating, injections, monitoring), and therefore need to form a close relationship with the worker providing medical care. It is important to create psychological contact with the mother of a sick child, since against the background of increasing stress, her connection with the child decreases and depression is noted. Problems that need to be solved by the training “team” medical workers V in this case, are: mood swings in a newborn child with diabetes; the connection between injections and monitoring blood glucose levels with painful sensations, which arise as a result of medical procedures and are associated in a child with a doctor’s white coat. These barriers make it necessary to establish trust with the family of the affected child and to learn how to monitor diabetes, since hypoglycemia in newborns is common and can lead to serious complications.

2) In many countries around the world, the feasibility of educating preschoolers with diabetes mellitus and whether the final outcomes of diabetes mellitus depend on education in this area have been widely discussed. age group. However, parents report the need and importance of training and support.

3) The third group of education includes children school age. Classes for these patients include topics:

l assistance and regulation of the transition to a student’s lifestyle, development of self-esteem (self-esteem) and relationships with peers;

b training in injection skills and glycemic monitoring;

b recognizing and understanding the symptoms of hypoglycemia;

b improved understanding of self-management of the disease;

b adaptation of diabetes mellitus to schooling, eating at school, physical activity and sports;

b inclusion of blood glucose monitoring and injections into the school regime;

ь advice to parents on gradual development independence of the child with the transfer of corresponding responsibility.

There is dissatisfaction among school-aged children that doctors talk to parents rather than to them. Educational programs that focus on the patient's age are effective for children and their families.

Sick children can also be included in the third, school group. adolescence. Adolescence is a transitional phase of development between childhood and adult life and has a number of biological and psychological characteristics, which cause some problems in the management of diabetes mellitus in such patients. Deterioration of diabetes control in this age group is often associated with irregular eating, insufficient physical activity, unclear implementation of doctor’s orders, endocrine changes associated with puberty and other factors. Features of the areas of work at the “School of Diabetes Mellitus” for adolescents include:

b development of trusting relationships between a teenager, a group of students and a “team” of specialists;

l help the teenager determine priorities and set small achievable goals, especially if there are contradictions between the social needs of the teenager and the restrictions associated with the presence of diabetes;

b ensuring understanding physiological changes puberty, their influence on insulin doses, solving emerging problems with body weight control, diet regulation;

ь explanation of the importance of screening early symptoms complications of diabetes mellitus and improved metabolic control;

b confidential conversations with a teenager about the process of puberty, strengthening his sense of self-confidence, but at the same time maintaining trust and support from his parents;

l help the adolescent and parents form relationships with a new level of parental involvement in the management of diabetes.

Nursing care diabetes mellitus:

> Organization of therapeutic nutrition for diabetes mellitus

Treatment should be comprehensive and include diet therapy, insulin therapy, and dosed physical activity.

Diet therapy. Mandatory for everyone clinical forms diabetes mellitus Its main principles: individual selection of daily caloric content: a balanced and physiological diet in terms of the content of proteins, carbohydrates, minerals, fats, vitamins (table No. 9); fractional six meals a day with an even distribution of calories and carbohydrates (breakfast - 25%, second breakfast - 10% , lunch - 25%, afternoon snack - 10%, dinner - 25%, second dinner - 15% of daily calories). Easily digestible carbohydrates are excluded from the diet. It is recommended to replace them with carbohydrates containing a large number of fiber (it slows down the absorption of glucose). Sugar is replaced with sorbitol or xylitol. Moderate restriction of animal fats.

Drug treatment. The main treatment for diabetes mellitus is the use of insulin. The dose depends on the severity of the disease and the loss of glucose in the urine during the day. For every 5 grams of glucose excreted in the urine, 1 unit of nsulin is prescribed. The drug is administered subcutaneously, intramuscularly and intravenously. There are different insulins short acting(peak action 2-4 hours after administration, duration pharmacological action 6-8 hours) - acrapid, insulinrap, humulin R, homorapid; average duration actions (peak after 5-10 hours, action 12-18 hours) - B-insulin, lente, long, insulong, monotardNM, homophan; long-acting (peak after 10-18 hours, action 20-30 hours) - ultralong, ultralente, ultratard NM.

In case of a stable course of the disease, combinations of short- and long-acting insulin preparations are used.

In addition, sulfonamide drugs (I and II generations) are prescribed - diabinez, bucarban (oranil), diabeton, and also use biguanides - phenformin, dibiton, adebit, sibin, glucophage, diformin, metaphormin.

Nursing process with diabetes mellitus. Diabetes - chronic illness, characterized by a violation of the production or action of insulin and leading to disruption of all types of metabolism and, first of all, carbohydrate metabolism.

1. Insulin-dependent type - type 1.

2. Insulin-independent type - type 2.
Type 1 diabetes mellitus is more common in people young, type 2 diabetes mellitus - in middle-aged and elderly people. One of the main risk factors is hereditary predisposition (type 2 diabetes mellitus is hereditarily more unfavorable), also important role obesity, unbalanced nutrition, stress, pancreatic diseases, toxic substances play a role. in particular alcohol, diseases of others endocrine organs.
Stages of diabetes:
Stage 1 - prediabetes - a state of predisposition to diabetes mellitus.
Risk group:
- Persons with a family history.
- Women who gave birth to a live or stillborn child weighing more than 4.5 kg.
- Persons suffering from obesity and atherosclerosis.
Stage 2 - latent diabetes - is asymptomatic, the fasting glucose level is normal - 3.3-5.5 mmol/l (according to some authors - up to 6.6 mmol/l). Latent diabetes can be detected by a glucose tolerance test, when the patient, after taking 50 g of glucose dissolved in 200 ml of water, experiences an increase in blood sugar levels: after 1 hour it is above 9.99 mmol/l. and after 2 hours - more than 7.15 mmol/l.
Stage 3 - overt diabetes - characteristic following symptoms: thirst, polyuria, increased appetite, weight loss, itchy skin(especially in the perineal area), weakness, fatigue. In blood test increased content glucose, it is also possible to excrete glucose in the urine.
Nursing process in diabetes mellitus:
Patient problems:
A. Existing (present):
- thirst; - polyuria: - itchy skin. dry skin: - increased appetite;
- weight loss; - weakness, fatigue; decreased visual acuity;
- pain in the heart; - pain in the lower extremities; - the need to constantly follow a diet;
- the need for constant administration of insulin or taking antidiabetic drugs (Maninil, Diabeton, Amaryl, etc.);
Lack of knowledge about:
- the essence of the disease and its causes; - diet therapy;
- self-help for hypoglycemia; - foot care;
- calculation grain units and creating a menu; - using a glucometer;
- complications of diabetes mellitus (coma and diabetic angiopathy) and self-help for comas.
B. Potential:
Risk of development:
- precomatose and comatose states: - gangrene lower limbs;
- acute heart attack myocardium; - chronic renal failure;
- cataracts and diabetic retinopathy with blurred vision;
- secondary infections, pustular skin diseases;
- complications due to insulin therapy;
- slow healing of wounds, including postoperative wounds.
Collection of information during the initial examination:
Asking the patient about:
- following a diet (physiological or diet No. 9), about the diet;
- physical activity during the day;
- ongoing treatment:
- insulin therapy (name of insulin, dose, duration of action, treatment regimen);
- antidiabetic tablet drugs (name, dose, features of their administration, tolerability);
- recent studies of blood and urine tests for glucose levels and examinations by an endocrinologist;
- the patient has a glucometer and the ability to use it;
- the ability to use a table of bread units and create a menu based on bread units;
- ability to use an insulin syringe and pen;
- knowledge of places and techniques for insulin administration, prevention of complications (hypoglycemia and lipodystrophy at injection sites);
- keeping a diary of observations of a patient with diabetes mellitus:
- past and present visits to the “Diabetes School”;
- development in the past of hypoglycemic and hyperglycemic coma, their causes and symptoms;
- ability to provide self-help;
- the patient has a “Diabetes Passport” or “ Business card diabetic";
- hereditary predisposition to diabetes mellitus);
- concomitant diseases(obstruction of the pancreas, other endocrine organs, obesity);
- patient complaints at the time of examination.
Patient examination:
- color, humidity skin, presence of scratching:
- determination of body weight: - measurement of blood pressure;
- determination of the pulse on the radial artery and on the artery of the dorsum of the foot.
Nursing interventions, including working with the patient's family:
1. Conduct a conversation with the patient and his relatives about dietary habits depending on the type of diabetes mellitus and diet. For a patient with type 2 diabetes, give several sample menus for the day.
2. Convince the patient of the need to strictly follow the diet prescribed by the doctor.
3. Convince the patient of the need for physical activity recommended by the doctor.
4. Conduct a conversation about the causes, essence of the disease and its complications.
5. Inform the patient about insulin therapy (types of insulin, the beginning and duration of its action, connection with food intake, storage features, side effects, types of insulin syringes and syringe pens).
6. Ensure timely administration of insulin and taking antidiabetic medications.
7. Control:
- condition of the skin; - body weight: - pulse and arterial pressure;
- pulse on the artery of the dorsum of the foot;
- adherence to diet and nutrition; transmission to the patient from his relatives;
- recommend constant monitoring of glucose levels in blood and urine.
8. Convince the patient of the need for constant monitoring by an endocrinologist, keeping an observation diary, which indicates the levels of glucose in the blood, urine, blood pressure levels, foods eaten per day, therapy received, changes in well-being.
9. Recommend periodic examinations by an ophthalmologist, surgeon, cardiologist, nephrologist.
10. Recommend classes at the Diabetes School.
11. Inform the patient about the causes and symptoms of hypoglycemia and coma.
12. Convince the patient of the need to immediately contact an endocrinologist if there is a slight deterioration in health and blood counts.
13. Teach the patient and his relatives:
- calculation of grain units;
- creating a menu based on the number of bread units per day; recruitment and subcutaneous injection insulin with an insulin syringe;
- rules of foot care; - provide self-help for hypoglycemia;
- measuring blood pressure.
Emergency conditions for diabetes mellitus:
A. Hypoglycemic state. Hypoglycemic coma.
Causes:
- Overdose of insulin or antidiabetic tablets.
- Lack of carbohydrates in the diet.
- Insufficient food intake or skipping meals after insulin administration.
- Significant exercise stress.
Hypoglycemic conditions are manifested by a feeling of severe hunger, sweating, trembling of the limbs, and severe weakness. If this condition is not stopped, then the symptoms of hypoglycemia will increase: trembling will intensify, confusion in thoughts will appear, headache, dizziness, double vision, general anxiety, fear, aggressive behavior and the patient falls into a coma with loss of consciousness and convulsions.
Symptoms of hypoglycemic coma: the patient is unconscious, pale, there is no smell of acetone from the mouth. The skin is moist, plentiful cold sweat, muscle tone is increased, breathing is free. blood pressure and pulse are not changed, the tone of the eyeballs is not changed. In the blood test, the sugar level is below 3.3 mmol/l. there is no sugar in urine.
Self-help for hypoglycemic conditions:
It is recommended that at the first symptoms of hypoglycemia, eat 4-5 pieces of sugar, or drink warm sweet tea, or take 10 glucose tablets of 0.1 g, or drink from 2-3 ampoules of 40% glucose, or eat a few candies (preferably caramel ).
First aid for hypoglycemic conditions:
- Call a doctor.
- Call a laboratory assistant.
- Place the patient in a stable lateral position.
- Place 2 pieces of sugar behind the cheek on which the patient is lying.
Prepare medications:
40 and 5% glucose solution. 0.9% sodium chloride solution, prednisolone (amp.), hydrocortisone (amp.), glucagon (amp.).
B. Hyperglycemic (diabetic, ketoacidotic) coma.
Causes: - Insufficient dose of insulin. - Diet violations (high carbohydrate content in food) - Infectious diseases. - Stress. - Pregnancy. - Injuries. - Surgical IM.
Precursors: increased thirst, polyuria. Possible vomiting, decreased appetite, blurred vision, unusual severe drowsiness, irritability.
Symptoms of coma: lack of consciousness, smell of acetone from the mouth, hyperemia and dry skin, noisy deep breathing, decreased muscle tone- "soft" eyeballs. The pulse is threadlike, blood pressure is reduced. In the blood test - hyperglycemia, in the urine test - glucosuria, ketone bodies and acetone.
If there are signs of hyperglycemic coma, urgently call the emergency room.
First aid:
- Call a doctor.
- Give the patient a stable lateral position (prevention of tongue retraction, aspiration, asphyxia).
- Take urine with a catheter for rapid diagnostics of sugar and acetone.
- Provide intravenous access.
Prepare medications:
- short-acting insulin - actropid (fl.);
- 0.9% sodium chloride solution (vial); 5% glucose solution (vial);
- cardiac glycosides, vascular agents.