Alert Any patient with a wound that has lasted more than 8 weeks and who has tried standard wound care and revascularization without improvement should consider hyperbaric oxygen therapy. This treatment may speed healing by allowing more oxygen to get to the wound and may therefore result in fewer amputations.
Keeping glucose at near-normal levels for 5 years or more reduces both the onset and progression of retinopathy, nephropathy, and neuropathy. In type 2 diabetes, blood pressure control as well as smoking cessation reduces the onset and progression of complications, including cardiovascular disease.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Diabetic complications during pregnancy:
Treatment
(Professional Guide to Diseases (Eighth Edition))
Treatment of both the newly diagnosed and the established diabetic is designed to maintain blood glucose levels within acceptable limits through dietary management and insulin administration. Many females with overt diabetes mellitus require hospitalization at the beginning of pregnancy to assess physical status, check for cardiac and renal disease, and regulate diabetes.
For pregnant patients with diabetes, therapy includes:
❑ bimonthly visits to the obstetrician and the internist during the first 6 months of pregnancy; weekly visits may be necessary during the third trimester
❑ maintenance of fasting blood glucose levels at or below 100 mg/dl and 2-hour postprandial blood glucose levels at or below 120 mg/dl during the pregnancy
❑ frequent monitoring for glycosuria and ketonuria (ketosis presents a grave threat to the fetal central nervous system)
❑ weight control (gain not to exceed 3 to 3½ lb [1.4 to 1.6 kg] per month during the last 6 months of pregnancy)
❑ high-protein diet of 2 g/day/kg of body weight, or a minimum of 80 g/day during the second half of pregnancy; daily calorie intake of 30 to 40 calories/kg of body weight; daily carbohydrate intake of 200 g; and enough fat to provide 36% of total calories (however, vigorous calorie restriction can cause starvation ketosis)
❑ exogenous insulin if diet doesn’t control blood glucose levels. Be alert for changes in insulin requirements from one trimester to the next and immediately postpartum. Oral antidiabetic drugs are contraindicated during pregnancy because they may cause fetal hypoglycemia and congenital anomalies.
Generally, the optimal time for delivery is between 37 and 39 weeks’ gestation, although with reassuring antenatal testing and no evidence of macrosomia, 40 weeks or later is also feasible. The insulin-dependent diabetic may require hospitalization before delivery for frequent monitoring of blood glucose levels and prompt intervention if complications develop.
Depending on fetal status and maternal history, the obstetrician may induce labor or perform a cesarean delivery. During labor and delivery, the patient with diabetes should receive continuous I.V. infusion of dextrose with regular insulin in water. Maternal and fetal status must be monitored closely throughout labor. The patient may benefit from half her prepregnancy dosage of insulin before a cesarean delivery. Her insulin requirement will fall markedly after delivery.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Diabetic ketoacidosis:
Treatment (Tx)
(Professional Guide to Diseases (Eighth Edition))
Insulin, I.V. fluids, sodium bicarbonate
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Hereditary fructose intolerance:
Treatment
(Professional Guide to Diseases (Eighth Edition))
Treatment of hereditary fructose intolerance consists of exclusion of fructose and sucrose (cane sugar or table sugar) from the diet. Otherwise, treatment is supportive as the patient’s progress is monitored.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Adolescent pregnancy:
Treatment
(Professional Guide to Diseases (Eighth Edition))
The pregnant adolescent requires the standard prenatal care that’s appropriate for an adult. However, she also needs psychological support and close observation for signs of complications.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Cardiovascular disease in pregnancy:
Treatment
(Professional Guide to Diseases (Eighth Edition))
The goal of antepartum management is to prevent complications and minimize the strain on the mother’s heart, primarily through rest. This may require periodic hospitalization for patients with moderate cardiac dysfunction or with symptoms of decompensation, toxemia, or infection. Older women or those with previous decompensation may require hospitalization and bed rest throughout the pregnancy.
Drug therapy is often necessary and should always include the safest possible drug in the lowest possible dosage to minimize harmful effects to the fetus. Diuretics and drugs that increase blood pressure, blood volume, or cardiac output should be used with extreme caution. If an anticoagulant is needed, heparin is the drug of choice. Cardiac glycosides and common antiarrhythmics, such as quinidine and procainamide, are often required. The prophylactic use of antibiotics is reserved for patients who are susceptible to endocarditis.
A therapeutic abortion should be considered for patients with severe cardiac dysfunction, especially if decompensation occurs during the first trimester. Patients hospitalized with heart failure usually follow a regimen of cardiac glycosides, oxygen, rest, sedation, diuretics, and restricted intake of sodium and fluids. Patients in whom symptoms of heart failure don’t improve after treatment with bed rest and cardiac glycosides may require cardiac surgery, such as valvotomy and commissurotomy. During labor, the patient may require oxygen and an analgesic, such as meperidine or morphine, for relief of pain and apprehension without undue depression of the fetus or herself. Depending on which procedure promises to be less stressful for the patient’s heart, delivery may be vaginal or by cesarean birth. Forceps may augment vaginal delivery to minimize the need to push, which strains the heart.
Bed rest and medications already instituted should continue for at least 1 week after delivery because of a high incidence of decompensation, cardiovascular collapse, and maternal death during the early puerperal period. These complications may result from the sudden release of intra-abdominal pressure at delivery and the mobilization of extracellular fluid for excretion, which increase the strain on the heart, especially if excessive interstitial fluid has accumulated. Breast-feeding is undesirable for patients with severely compromised cardiac dysfunction because it increases fluid and metabolic demands on the heart.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Diabetes insipidus:
Treatment
(Handbook of Diseases)
Until the cause of diabetes insipidus can be identified and eliminated, administration of various forms of vasopressin can control fluid balance and prevent dehydration.
Vasopressin injection
This aqueous preparation is administered S.C. or I.M. several times a day because it’s effective for only 2 to 6 hours. This form of the drug is used as a diagnostic agent and, rarely, in acute disease.
Desmopressin acetate
This drug can be given orally, by nasal spray that’s absorbed through the mucous membranes or by S.C. or I.V. injection. Desmopressin acetate is effective for 8 to 20 hours, depending on the dosage.
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Source: Handbook of Diseases, 2003
Diabetes mellitus:
Treatment
(Handbook of Diseases)
Effective treatment for both types of diabetes normalizes blood glucose and decreases complications.
Type 1 diabetes
Treatment includes insulin replacement, diet, and exercise. Current forms of insulin replacement include single-dose, mixed-dose, split-mixed dose, and multiple-dose regimens. The multiple-dose regimens may use an insulin pump.
Human insulin may be rapid-acting (Regular), intermediate-acting (NPH or Lente), long-acting (Ultralente, Lantus), or a combination of rapid-acting and intermediate-acting (70/30, 75/25, or 50/50 of NPH and Regular).
Clinical tip Insulin Lispro or Novalogue may be used in place of Regular insulin. It’s rapid in onset (15 minutes) and makes waiting to eat after injection unnecessary. It has a short duration of action (4 hours), which decreases between-meal and nocturnal hypoglycemia.
Islet cell or pancreas transplantation is available and requires chronic immunosuppression.
Type 2 diabetes
Patients may require oral antidiabetic drugs to stimulate endogenous insulin production, increase insulin sensitivity at the cellular level, suppress hepatic gluconeogenesis, and delay GI absorption of carbohydrates.
UNDER STUDY: Studies have shown that treatment with a lipase inhibitor (such as orlistat) combined with a low-calorie diet significantly decreases the weight of overweight patients with type 2 diabetes. Patients following this therapy also displayed improvements in glycemic control and cardiovascular risk profile; levels of glycosylated hemoglobin, fasting glucose, and postprandial glucose improved significantly.
Both types
Treatment of both types of diabetes requires a diet planned to meet nutritional needs, to control blood glucose levels, and to reach and maintain appropriate body weight.
For the obese patient with type 2 diabetes, weight reduction is a goal. In type 1, the calorie allotment may be high, depending on growth stage and activity level. For success, the diet must be followed consistently and meals eaten at regular times.
UNDER STUDY: Vitamin E is under investigation for its cellular effects that can possibly reduce the risk of macrovascular disease in patients with type 2 diabetes mellitus. The antioxidant effects of vitamin E were supported, and it was found that, in high doses, vitamin E acts as an anti-inflammatory. It’s postulated that heart disease and stroke risk can be decreased because vitamin E reduces plaque formation at the endothelial level. Vitamin E may also have an effect on the metabolic syndrome that causes diabetes mellitus and may prevent the disease from occurring.
Complications
Treatment of long-term diabetic complications may include transplantation or dialysis for renal failure, photocoagulation for retinopathy, and vascular surgery for large-vessel disease. Meticulous blood glucose control is essential.
The Diabetes Control and Complications Trial has proved that intensive insulin therapy that focuses on keeping glucose at near-normal levels for 5 years or more reduces both the onset and progression of retinopathy (up to 63%), nephropathy (up to 54%), and neuropathy (up to 60%).
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Diabetic complications during pregnancy:
Treatment
(Handbook of Diseases)
Both the newly diagnosed and the established diabetic need dietary management and insulin administration to maintain blood glucose levels within acceptable limits. Most women with overt diabetes mellitus require hospitalization at the beginning of pregnancy to assess physical status, check for cardiac and renal disease, and regulate diabetes.
For pregnant patients with diabetes, therapy includes:
❑ frequent visits to the obstetrician and the internist during the first 6 months of pregnancy; weekly visits may be necessary during the third trimester, an internist may be consulted as necessary.
❑ maintenance of blood glucose levels at or below 95 mg/dl during the third trimester
❑ frequent monitoring for glycosuria and ketonuria (Ketosis presents a grave threat to the fetal central nervous system.)
❑ a high-protein diet of 2 g/day/kg of body weight (a minimum of 80 g/day during the second half of pregnancy), a daily calorie intake of 30 to 40 calories/kg of body weight, a daily carbohydrate intake of 200 g, and enough fat to provide 36% of total calories (However, vigorous calorie restriction can cause starvation ketosis.)
❑ exogenous insulin if diet doesn’t control blood glucose levels. Oral antidiabetic agents are generally contraindicated during pregnancy because they may cause fetal hypoglycemia and congenital anomalies.
Delivery
Generally, the optimal time for delivery is no different from a normal pregnancy, as long as blood sugars are controlled and no fetal compromise is present.
Depending on fetal status and maternal history, labor may be spontaneous induced or a cesarean section performed. During labor and delivery, the patient with diabetes should receive a continuous I.V. infusion of dextrose with regular insulin in water. Maternal and fetal status must be monitored closely throughout labor.
The patient may benefit from half her prepregnancy dosage of insulin before a cesarean delivery. Her insulin requirement will fall markedly after delivery.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Cardiovascular disease in pregnancy:
Treatment
(Handbook of Diseases)
Specific treatments vary before, during, and after delivery.
Before delivery
The goal of antepartum management is to prevent complications and minimize the strain on the mother’s heart, primarily through rest. This may require periodic hospitalization for patients with moderate cardiac dysfunction or with symptoms of decompensation, toxemia, or infection. Older women or those with previous decompensation may require hospitalization and bed rest throughout the pregnancy.
Drug therapy is usually necessary and should include the safest drug in the lowest possible dose to minimize harmful effects to the fetus. Diuretics and drugs that increase blood pressure, blood volume, or cardiac output should be used with extreme caution.
If an anticoagulant is needed, heparin is the drug of choice. A cardiac glycoside and an antiarrhythmic are typically required. The prophylactic use of antibiotics is reserved for patients who are susceptible to endocarditis.
A therapeutic abortion may be considered for patients with severe cardiac dysfunction, especially if decompensation occurs during the first trimester. Patients hospitalized with heart failure are usually treated with a cardiac glycoside, oxygen, rest, sedation, and a diuretic; intake of sodium and fluids is also restricted. Patients whose symptoms of heart failure don’t improve after treatment with bed rest and a cardiac glycoside may require cardiac surgery, such as valvotomy and commissurotomy.
During delivery
The patient in labor may require oxygen and an analgesic, such as meperidine or morphine, for pain relief and apprehension without undue depression of the fetus or herself. Depending on which procedure promises to be less stressful for the patient’s heart, delivery may be vaginal or by cesarean section. Operative vaginal delivery (for example, with forceps) is usually preferable to avoid the blood pressure changes that occur with pushing.
After delivery
Bed rest and medications already instituted should continue for at least 1 week after delivery because of a high incidence of decompensation, cardiovascular collapse, and maternal death during the early puerperal period. These complications may result from the sudden release of intra-abdominal pressure at delivery and the mobilization of extracellular fluid for excretion, which increase the strain on the heart, especially if excessive interstitial fluid has accumulated.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Polydipsia:
Patient counseling
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Teach the patient about his underlying disorder and its treatment. Discuss such self-care measures as diet, exercise, and home blood glucose monitoring. Explain the importance of reporting any significant weight gain or loss to his health care provider.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Polydipsia:
Nursing considerations
(Nursing: Interpreting Signs and Symptoms)
▪ Monitor the patient's intake and output.
▪ Weigh the patient daily.
▪ Check the patient's blood pressure and pulse in the supine and standing positions to detect orthostatic hypotension, which may indicate hypovolemia.
▪ Encourage adequate fluid intake, if appropriate.
Patient teaching
▪ Explain the underlying disorder and its treatments.
▪ Teach the patient about diet, exercise, and home blood glucose monitoring, if indicated.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
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