Aims and Objectives

As an evolving and dynamic resource, the ICN Rural and Remote Nursing Network:

Provides a global forum for identification and discussion of issues related to rural and remote nursing Promotes awareness of rural and remote nursing so that the roles, contributions and expertise of rural and remote nurses are understood, respected and optimized within the health care system Assists with the development and sharing of knowledge, tools and guidelines which rural and remote nurses can use to embed specialized skills and competencies into their practice Promotes sound rural and remote nursing practice across the globe Establishes links between the ICN Rural and Remote Nursing Network and other international organizations, resources and networks to promote the sharing and exchange of knowledge, expertise and experience

On July 2nd 2009 at the ICN congress in Durban, South Africa, members of the Rural and Remote Nursing Network's core steering group met with and listened to hundreds of nurses that expressed concerns related to rural and remote nursing. This meeting provided a wonderful opportunity for nurses across the globe to voice their concerns to the core steering group. The group took notes and spoke briefly about how they hope to make the network more active, increase communication venues, and increase list serve membership. The core steering group inform the ICN of problems that need to be addressed in rural and remote areas, ultimately providing the framework for some of ICNs initiatives.

Nursing care plans for Diabetes Mellitus

Nursing care plans for Diabetes Mellitus, Diabetes mellitus is a disorder in which the level of blood glucose is persistently raised above the normal range. Diabetes mellitus is a syndrome with disordered metabolism and inappropriate hyperglycemia due to either a deficiency of insulin secretion or to a combination of insulin resistance and inadequate insulin secretion to compensate. Diabetes mellitus occurs in two primary forms: type 1, characterized by absolute insufficiency, and the more prevalent type 2, characterized by insulin resistance with varying degrees of insulin secretory defects. Diabetes mellitus is a group of metabolic diseases characterized by elevated levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both (ADA], Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, 2003. Causes for Diabetes Mellitus The cause of both type 1 and type 2 diabetes remains unknown, although genetic factors may play a role. Diabetes mellitus results from insulin deficiency or resistance. Insulin transports

glucose into the cell for use as energy and storage as glycogen. It also stimulates protein synthesis and free fatty acid storage. Insulin deficiency or resistance compromises the body tissues access to essential nutrients for fuel and storage. The resulting hyperglycemia can damage many of the bodys organs and tissues. Type 1 diabetes is due to pancreatic islet B cell destruction predominantly by an autoimmune process, and these patients are prone to ketoacidosis. Type 2 diabetes is the more prevalent form and results from insulin resistance with a defect in compensatory insulin secretion Insulin, a hormone produced by the pancreas, controls the level of glucose in the blood by regulating the production and storage of glucose. Risk Factors For Diabetes Mellitus Include:

Obesity. Physiologic or emotional stress, which can cause prolonged elevation of stress hormone levels. pregnancy, which causes weight gain and increases levels of estrogen and placental hormones, which antagonize insulin metabolic syndrome, which is considered a precursor to the development of type 2 diabetes mellitus some medications that can antagonize the effects of insulin, including thiazide diuretics, adrenal corticosteroids, and hormonal contraceptives

Classification of Diabetes Mellitus There are several different types of diabetes mellitus; they may differ in cause, clinical course, and treatment. The major classifications of diabetes are:

Type 1 diabetes (insulin dependent diabetes mellitus) is caused by B-cell destruction, usually leading to absolute insulin deficiency

a)

Immune mediated

b) Idiopathic

Type 2 diabetes (previously referred to as non insulin dependent diabetes mellitus) ranges from those with predominant insulin resistance associated with relative insulin deficiency, to those with a predominantly insulin secretory defect with insulin resistance

PATHOPHYSIOLOGY OF DIABETES Insulin is secreted by beta cells, which are one of four types of cells in the islets of Langerhans in the pancreas. Insulin is an anabolic, or storage, hormone. When a person eats a meal, insulin

secretion increases and moves glucose from the blood into muscle, liver, and fat cells. In those cells, insulin: Transports and metabolizes glucose for energy Stimulates storage of glucose in the liver and muscle (in the form of glycogen) Signals the liver to stop the release of glucose Enhances storage of dietary fat in adipose tissue Accelerates transport of amino acids (derived from dietary protein) into cells Insulin also inhibits the breakdown of stored glucose, protein, and fat. During fasting periods (between meals and overnight), the pancreas continuously releases a small amount of insulin (basal insulin); another pancreatic hormone called glucagon (secreted by the alpha cells of the islets of Langerhans) is released when blood glucose levels decrease and stimulate the liver to release stored glucose. The insulin and the glucagon together maintain a constant level of glucose in the blood by stimulating the release of glucose from the liver. Initially, the liver produces glucose through the breakdown of glycogen (glycogenolysis). After 8 to 12 hours without food, the liver forms glucose from the breakdown of noncarbohydrate substances, including amino acids (gluconeogenesis). Type 1 Diabetes This form of diabetes is immune-mediated in over 90% of cases and idiopathic in less than 10%. The rate of pancreatic B cell destruction is quite variable, being rapid in some individuals and slow in others. Type 1 diabetes is usually associated with ketosis in its untreated state. It occurs at any age but most commonly arises in children and young adults with a peak incidence before school age and again at around puberty. It is a catabolic disorder in which circulating insulin is virtually absent, plasma glucagon is elevated, and the pancreatic B cells fail to respond to all insulinogenic stimuli. Exogenous insulin is therefore required to reverse the catabolic state, prevent ketosis, reduce the hyperglucagonemia, and reduce blood glucose. Immune-mediated type 1 diabetes mellitus (type 1A) Most patients with type 1 diabetes mellitus have circulating antibodies to islet cells (ICA), insulin (IAA), glutamic acid decarboxylase (GAD65), and tyrosine phosphatases (IA-2 and IA2-) at the time the diagnosis is made. These antibodies facilitate screening for an autoimmune cause of diabetes, particularly screening siblings of affected children, as well as adults with atypical features of type 2 Diabetes). Antibody levels decline with increasing duration of disease. Also, low levels of anti-insulin antibodies develop in almost all patients once they are treated with insulin.

This theory is referred to as the hygiene hypothesis. None of these factors has so far been confirmed as the culprit. Part of the difficulty is that autoimmune injury undoubtedly starts many years before clinical diabetes mellitus develops. Idiopathic type 1 diabetes mellitus (type 1B) Less than 10% of subjects have no evidence of pancreatic B cell autoimmunity to explain their insulinopenia and ketoacidosis. This subgroup has been classified as idiopathic type 1 diabetes and designated as type 1B. Although only a minority of patients with type 1 diabetes fall into this group, most of these are of Asian or African origin. Type 2 Diabetes Mellitus Circulating endogenous insulin is sufficient to prevent ketoacidosis but is inadequate to prevent hyperglycemia in the face of increased needs owing to tissue insensitivity (insulin resistance). The two main problems related to insulin in type 2 diabetes are insulin resistance and impaired insulin secretion. Insulin resistance refers to a decreased tissue sensitivity to insulin. Normally, insulin binds to special receptors on cell surfaces and initiates a series of reactions involved in glucose metabolism. In type 2 diabetes, these intracellular reactions are diminished, thus rendering insulin less effective at stimulating glucose uptake by the tissues and at regulating glucose release by the liver. The exact mechanisms that lead to insulin resistance and impaired insulin secretion in type 2 diabetes are unknown, although genetic factors are thought to play a role. Despite the impaired insulin secretion that is characteristic of type 2 diabetes, there is enough insulin present to prevent the breakdown of fat and the accompanying production of ketone bodies. Therefore, DKA does not typically occur in type 2 diabetes. Prediabetes Prediabetes is an abnormality in glucose values intermediate between normal and overt diabetes. Impaired Fasting Glucose

A new category adopted by the American Diabetes Association in 1997 and redefined in 2004. Occurs when fasting blood glucose is greater than or equal to 100 but less than 126 mg/dL.

Impaired Glucose Tolerance

Defined as blood glucose measurement on a glucose tolerance test greater than or equal to 140 mg/dl but less than 200 in the 2-hour sample. Asymptomatic; it can progress to type 2 diabetes or remain unchanged.

May be a risk factor for the development of hypertension, coronary heart disease, and hyperlipidemias.

Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) is defined as carbohydrate intolerance occurring during pregnancy. Occurs in approximately 4% of pregnancies and usually disappears after delivery. Women with GDM are at higher risk for diabetes at a later date. GDM is associated with increased risk of fetal morbidity. Screening for GDM for all pregnant women other than those at lowest risk (under age 25, of normal body weight, have no family history of diabetes, are not a member of an ethnic group with high prevalence of diabetes) should occur between the 24th and 28th weeks of gestation.

Diabetes Associated with Other Conditions

Certain drugs can decrease insulin activity resulting in hyperglycemia corticosteroids, thiazide diuretics, estrogen, phenytoin. Disease states affecting the pancreas or insulin receptors pancreatitis, cancer of the pancreas, Cushings disease or syndrome, acromegaly, pheochromocytoma, muscular dystrophy, Huntingtons chorea.

CLINICAL MANIFESTATIONS Clinical manifestations of all types of diabetes include the three Ps: polyuria, polydipsia, and polyphagia. Polyuria (increased urination) and polydipsia (increased thirst) occur as a result of the excess loss of fluid associated with osmotic diuresis. The patient also experiences polyphagia (increased appetite) resulting from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats. Other symptoms include fatigue and weakness, sudden vision changes, tingling or numbness in hands or feet, dry skin, skin lesions or wounds that are slow to heal, and recurrent infections. The onset of type 1 Diabetes may also be associated with sudden weight loss or nausea, vomiting, or abdominal pains, if DKA has developed. DIABETES MANAGEMENT The main goal of diabetes treatment is to normalize insulin activity and blood glucose levels to reduce the development of vascular and neuropathic complications. Drugs for Treating Hyperglycemia The drugs for treating type 2 diabetes fall into several categories:

1) Drugs that primarily stimulate insulin secretion by binding to the sulfonylurea receptor. Sulfonylureas remain the most widely prescribed drugs for treating hyperglycemia. The meglitinide analog repaglinide and the D-phenylalanine derivative nateglinide also bind the sulfonylurea receptor and stimulate insulin secretion. 2) Drugs that alter insulin action: Metformin works in the liver. The thiazolidinediones appear to have their main effect on skeletal muscle and adipose tissue. 3) Drugs that principally affect absorption of glucose: The glucosidase inhibitors acarbose and miglitol are such currently available drugs. 4) Drugs that mimic incretin effect or prolong incretin action: Exenatide and DPP 1V inhibitors fall into this category. 5) Other: Pramlintide lowers glucose by suppressing glucagon and slowing gastric emptying.

Insulin Insulin is indicated for type 1 diabetes as well as for type 2 diabetic patients with insulinopenia whose hyperglycemia does not respond to diet therapy either alone or combined with other hypoglycemic drugs. Therefore, the therapeutic goal for diabetes management is to achieve normal blood glucose levels (euglycemia) without hypoglycemia and without seriously disrupting the patients usual lifestyle and activity. There are five components of diabetes management Nutritional management Exercise Monitoring Pharmacologic therapy Education Nursing Process Nursing Care Plans For Diabetes Mellitus Nursing Assessment Nursing Care Plans For Diabetes Mellitus

Obtain a history of current problems, family history, and general health history. o Has the patient experienced polyuria, polydipsia, polyphagia, and any other symptoms? o Number of years since diagnosis of diabetes

Family members diagnosed with diabetes, their subsequent treatment, and complications Perform a review of systems and physical examination to assess for signs and symptoms of diabetes, general health of patient, and presence of complications. o General: recent weight loss or gain, increased fatigue, tiredness, anxiety o Skin: skin lesions, infections, dehydration, evidence of poor wound healing o Eyes: changes in visionfloaters, halos, blurred vision, dry or burning eyes, cataracts, glaucoma o Mouth: gingivitis, periodontal disease o Cardiovascular: orthostatic hypotension, cold extremities, weak pedal pulses, leg claudication o GI: diarrhea, constipation, early satiety, bloating, increased flatulence, hunger or thirst o Genitourinary (GU): increased urination, nocturia, impotence, vaginal discharge o Neurologic: numbness and tingling of the extremities, decreased pain and temperature perception, changes in gait and balance

Nursing Diagnosis Nursing care plans for Diabetes Mellitus Common nursing diagnosis found in Nursing care plans for Diabetes Mellitus

Imbalanced Nutrition: More than Body Requirements related to intake in excess of activity expenditures Fear related to insulin injection Risk for Injury (hypoglycemia) related to effects of insulin, inability to eat Activity Intolerance related to poor glucose control Deficient Knowledge related to use of oral hypoglycemic agents Risk for Impaired Skin Integrity related to decreased sensation and circulation to lower extremities Ineffective Coping related to chronic disease and complex self-care regimen

Nursing Intervention and Evaluation Nursing care plans for Diabetes Mellitus No 1 Nursing Diagnose Outcome Imbalanced Nutrition Nutrition: More balance than Body between Requirements needs and related to intake intake in excess of activity expenditures Intervention Assess current timing and content of meals. Advise patient on the importance of an individualized meal plan in meeting weightloss goals. Reducing intake of carbohydrates may benefit some patients; however, fad diets or diet plans that stress one food group and eliminate another are generally not recommended. Discuss the goals of dietary Evaluation Maintains ideal body weight with body mass index less than 25

therapy for the patient. Setting a goal of a 10% (of patients actual body weight) weight loss over several months is usually achievable and effective in reducing blood sugar and other metabolic parameters. Assist patient to identify problems that may have an impact on dietary adherence and possible solutions to these problems. Emphasize that lifestyle changes should be maintainable for life. Explain the importance of exercise in maintaining/reducing body weight. o Caloric expenditure for energy in exercise o Carryover of enhanced metabolic rate and efficient food utilization Assist patient to establish goals for weekly weight loss and incentives to assist in achieving them. Strategize with patient to address the potential social pitfalls of weight reduction. Assist patient to reduce fear of Demonstrates injection by encouraging self-injection of verbalization of fears regarding insulin with insulin injection, conveying a minimal fear sense of empathy, and identifying supportive coping techniques. Demonstrate and explain thoroughly the procedure for insulin self-injection Help patient to master technique by taking a step-by-step approach. o Allow patient time to handle insulin and syringe to become

Fear related to Fear less or insulin injection discrease

familiar with the equipment. o Teach self-injection first to alleviate fear of pain from injection. o Instruct patient in filling syringe when he or she expresses confidence in self-injection procedure. Review dosage and time of injections in relation to meals, activity, and bedtime based on patients individualized insulin regimen. Closely monitor blood glucose Hypoglycemia levels to detect hypoglycemia. identified and Instruct patient in the treated importance of accuracy in appropriately insulin preparation and meal timing to avoid hypoglycemia. Assess patient for the signs and symptoms of hypoglycemia. o Adrenergic (early symptoms) sweating, tremor, pallor, tachycardia, palpitations, nervousness from the release of adrenalin when blood glucose falls rapidly o Neurologic (later symptoms) lightheadedness, headache, confusion, irritability, slurred speech, lack of coordination, staggering gait from depression of central nervous system as glucose level progressively falls Treat hypoglycemia promptly with 15 to 20 g of fast-acting carbohydrates. Encourage patient to carry a

Risk for Injury Injury is not (hypoglycemia) appears related to effects of insulin, inability to eat

portable treatment for hypoglycemia at all times. Assess patient for cognitive or physical impairments that may interfere with ability to accurately administer insulin. Between-meal snacks as well as extra food taken before exercise should be encouraged to prevent hypoglycemia. Encourage patients to wear an identification bracelet or card that may assist in prompt treatment in a hypoglycemic emergency. Encourage patient to carry a portable treatment for hypoglycemia at all times. Assess patient for cognitive or physical impairments that may interfere with ability to accurately administer insulin. Between-meal snacks as well as extra food taken before exercise should be encouraged to prevent hypoglycemia. Encourage patients to wear an identification bracelet or card that may assist in prompt treatment in a hypoglycemic emergency. Advise patient to assess blood Exercises daily glucose level before and after strenuous exercise. Instruct patient to plan exercises on a regular basis each day. Encourage patient to eat a carbohydrate snack before exercising to avoid hypoglycemia. Advise patient that prolonged strenuous exercise may require increased food at bedtime to avoid nocturnal hypoglycemia.

Activity Intolerance related to poor glucose control

Normal Activity is appears

Instruct patient to avoid exercise whenever blood glucose levels exceed 250 mg/day and urine ketones are present. Patient should contact health care provider if levels remain elevated. Counsel patient to inject insulin into the abdominal site on days when arms or legs are exercised. Assess level of knowledge of disease and ability to care for self Assess adherence to diet therapy, monitoring procedures, medication treatment, and exercise regimen Assess for signs of hyperglycemia: polyuria, polydipsia, polyphagia, weight loss, fatigue, blurred vision Assess for signs of hypoglycemia: sweating, tremor, nervousness, tachycardia, light-headedness, confusion Perform thorough skin and extremity assessment for peripheral neuropathy or peripheral vascular disease and any injury to the feet or lower extremities Assess for trends in blood glucose and other laboratory results Make sure that appropriate insulin dosage is given at the right time and in relation to meals and exercise Make sure patient has adequate knowledge of diet, exercise, and medication treatment Immediately report to health care provider any signs of skin or soft tissue infection (redness, Verbalizes appropriate use and action of oral hypoglycemic agents

Deficient Knowledge related to use of oral hypoglycemic agents

Knowledge is sufficient

swelling, warmth, tenderness, drainage) Get help immediately for signs of hypoglycemia that do not respond to usual glucose replacement Get help immediately for patient presenting with signs of either ketoacidosis (nausea and vomiting, Kussmaul respirations, fruity breath odor, hypotension, and altered level of consciousness) or hyperosmolar hyperglycemic nonketotic syndrome (nausea and vomiting, hypothermia, muscle weakness, seizures, stupor, coma). Assess feet and legs for skin No skin temperature, sensation, soft breakdown tissue injuries, corns, calluses, dryness, hammer toe or bunion deformation, hair distribution, pulses, deep tendon reflexes. Maintain skin integrity by protecting feet from breakdown. o Use heel protectors, special mattresses, foot cradles for patients on bed rest. o Avoid applying drying agents to skin (eg, alcohol). o Apply skin moisturizers to maintain suppleness and prevent cracking and fissures. Instruct patient in foot care guidelines Advise the patient who smokes to stop smoking or reduce if possible, to reduce vasoconstriction and enhance peripheral blood flow. Help

Risk for Impaired Impaired Skin Skin Integrity Integrity is related to not appears decreased sensation and circulation to lower extremities

patient to establish behavior modification techniques to eliminate smoking in the hospital and to continue them at home for smoking-cessation program. 7 Ineffective Effective Coping related to coping chronic disease and complex selfcare regimen

Discuss with the patient the perceived effect of diabetes on lifestyle, finances, family life, occupation. Explore previous coping strategies and skills that have had positive effects. Encourage patient and family participation in diabetes selfcare regimen to foster confidence. Identify available support groups to assist in lifestyle adaptation. Assist family in providing emotional support.

Verbalizes initial strategies for coping with diabetes

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