Assessment And Management Of Diabetic Ketoacidosis

Diabetic Ketoacidosis: Diabetic ketoacidosis (DKA) results from absolute or relative deficiency of circulating insulin (Kitabchi AE, Umpierrez GE, Murphy MB, Kreisberg RA, 2006). DKA is characterized by severe depletion of water and electrolytes from both the intra and extracellular fluid compartments. Despite their dehydration, patients continue to maintain normal blood pressure and have considerable urine output until extreme volume depletion and shock occurs leading to a critical decrease in renal blood flow and glomerular filtration.

Assessment:

Perform a clinical evaluation to confirm the diagnosis and determine its cause. Carefully look for evidence of infection. Also weigh the patient. Assess clinical severity of dehydration. Assess level of consciousness using Glasgow coma scale [GCS].

Management:

Laboratory blood glucose should be measured at diagnosis. An ECG monitor should be applied until the patient is stable. Consulate the Diabetes Team as soon as possible for a decision on continuing management. Transfer to subcutaneous (SC) insulin one the patient is able to eat and drink properly. Do not stop the IV insulin until SC insulin has been given. Patient with known diabetes should go back to their previous insulin regimen. If possible identify the precipitating cause of DKA. Always inform the Diabetes Team so that education can be given to reduce the risk of future episodes of DKA.

Hyperosmolar non – ketotic coma (HONK): Type 2 diabetes, usually in patients over 60 years. This condition is characterized by hyperglycemia and high plasma osmolality without significant keton-uria or acidosis (Pinies JA, Cairo G, Gaztambide S, et al.1994).

Assessment:

Same as Diabetic ketoacidosis (DKA) but look for precipitating medical condition, e.g. sepsis, myocardial infarction etc

Management:

Management of Hyperosmolar non – ketotic coma is same as DKA . Also the insulin infusion rate should be halved as paradoxically these patients can be quite insulin sensitive. Elderly patients are more likely to need a CVP line to optimize fluid replacement. Risk of thromboembolic disease is high – anticoagulant fully if no contraindications. Most patient can be managed with oral hypoglycemic agents or diet, but recovery of insulin may take time and insulin may be required for few weeks.

Hypoglycemia: Hypoglycemia is the result of a mismatch between insulin dose, food consumed, and recent exercise and is rarely, if ever, a spontaneous event (Kovatchev BP, Cox DJ, Farhy LS, Straume M, Gonder-Frederick L, Clarke WL,2003).Because it can be accompanied by unpleasant, embarrassing, and potentially dangerous symptoms and because it causes significant anxiety and fear in the patient and their caregivers, it’s occurrence is a major limiting factor in attempts to achieve near normal BG levels (Clarke WL, Gonder-Frederick A, Snyder AL, Cox DJ 1998,Cryer PE 2002).

Assessment:

Each hypoglycaemic episode should be assessed carefully to determine its cause evaluating the insulin action profile (time of insulin administration, peak insulin action and intensity of insulin action). Check the recent food intake (timing and amount of carbohydrates eaten and peak BG effect on recent food. Also check recent physical activity (timing, duration and intensity). Also check and missed signs and symptoms of early hypoglycaemia.

Management:

Management of hypoglycemia involves immediately raising the blood sugar to normal, determining the cause, and taking measures to hopefully prevent future episodes. Initially Glucose 10-20 g is given by mouth either in liquid form or as granulated sugar (2 teaspoons) or sugar lumps (Smeeks FC, 2006). If hypoglycemia causes unconsciousness, or patient is unco-operative, 50 mL of glucose intravenous (IV) infusion 20% can be given. Alternatively, 25 mL of glucose intravenous infusion 50% may be given, but this higher concentration is viscous, making administration difficult; it is also more irritant.

Once the patient regains consciousness oral glucose should be administered as above.

References :

Kitabchi AE, Umpierrez GE, Murphy MB, Kreisberg RA. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care 2006 Dec: 29(12): 2739-48.

Hanas R, Lindgren F, Lindblad B. A 2-yr national population study of pediatric ketoacidosis in Sweden: predisposing conditions and insulin pump use. Pediatr Diabetes 2009 Feb: 10(1): 33-7.

McDonnell CM, Pedreira CC, Vadamalayan B, Cameron FJ, Werther GA. Diabetic ketoacidosis, hyperosmolarity and hypernatremia: are high-carbohydrate drinks worsening initial presentation? Pediatr Diabetes 2005 Jun: 6(2): 90-4.

Rewers A, Klingensmith G, Davis C, Petitti DB, Pihoker C, Rodriguez B, et al. Presence of diabetic ketoacidosis at diagnosis of diabetes mellitus in youth: the Search for Diabetes in Youth Study. Pediatrics 2008 May: 121(5): e1258-66.

Pinies JA, Cairo G, Gaztambide S, et al. Course and prognosis of 132 patients with diabetic non ketotic hyperosmolar state. Diabete Metab 1994; 20: 43-48.

Kovatchev BP, Cox DJ, Kumar A, Gonder-Frederick L, Clarke WL. Algorithmic evaluation of metabolic control and risk of severe hypoglycemia in type 1 and type 2 diabetes using self-monitoring blood glucose data. Diabetes Technol Ther 2003: 5: 817-828.

Kovatchev BP, Cox DJ, Farhy LS, Straume M, Gonder-Frederick L, Clarke WL. Episodes of severe hypoglycemia in type 1 diabetes are preceded and followed within 48 hours by measurable disturbances in blood glucose. J Clin Endocrinol Metab 2000: 85: 4287-4292.

Clarke WL, Gonder-Frederick A, Snyder AL, Cox DJ. Maternal fear of hypoglycemia in their children with insulin dependent diabetes mellitus. J Pediatr Endocrinol Metab 1998: 11(Suppl. 1) : 189-194.

Cryer PE. Hypoglycaemia: the limiting factor in the glycaemic management of type I and type II diabetes. Diabetologia 2002: 45: 937-948.

Strategies for Dealing with the Psychological Issues such as Fear and Anxiety Associated with Diagnosis of Cancer, and How These Can Improve Coping’

A diagnosis of breast cancer is a great shock. Women report that they fear breast cancer more than heart disease, even though they have a better chance of surviving breast cancer, and dying of stroke or heart failure. Breast cancer has been with us since the early Egyptians, and fear of this disease as well as the treatments for it, seems to be inherent in women all across the world.

Normal Emotions and Breast Cancer

Here are some normal emotions that you may experience at diagnosis and during treatment.

Fear, shock

Denial

Anger

Depression

Sadness

Anxiety

Stress

Guilt

Loneliness, alienation

Hope

Physical Responses to Strong Emotions

As you begin to deal with diagnosis and treatment, your body will be reacting to emotions as well as surgery and drugs. Your physical responses to the overall stress may be:

Fear – trouble sleeping, headaches, body aches

Anger – change in blood pressure

Depression – fatigue, crying, feeling moody

Stress – pain, irritability, tension

Unresolved or Unexpressed Emotions May Lead to Other Problems

You are not alone with your diagnosis – or your emotions. Expressing your feelings can give you quite a bit of relief, helping you move forward in your journey. Not all of us are freely expressive, but there are safe and creative outlets for your feelings. Letting out your emotions will help you get support and heal more quickly. Your bottled-up emotions may lead to:

Loneliness, withdrawal from others

Frustration

Hopelessness

Feeling out of control

Emotional Concerns and Breast Cancer

When you’ve accepted your diagnosis, you may be facing other emotional concerns. The loss of a breast, or part of a breast, has an impact that goes beyond the physical fact. If aggressive treatment is required, it might have long-term impact on your health. It is normal to be concerned about:

Fear of recurrence

Loss of attractiveness

Difficulty with sexual function

Loss of fertility

Coping With and Surviving Breast Cancer

You can improve your emotional health and reduce your physical symptoms with good coping strategies. A study published in the Journal of Psychosocial Oncology reports that women who get help with pain and emotional distress have lower levels of anxiety, fatigue and depression. Here are some ways to cope with your emotions:

Communicate with family and friends

Maintain intimacy (if you have a partner)

Visit with a counselor or spiritual director

Join a support group

Express your needs and ask for help

Report your symptoms to your healthcare team

Keep a log of medical visits, save test results, keep receipts

Educate yourself about your cancer and treatments

Exercise

Make plans for a crisis

Getting Help for Emotions Is Not a Sign of Weakness

You may feel under pressure to “be strong” or “act brave” when you least feel that way. Perhaps you don’t easily share your feelings with others. You may be in a position of responsibility and trust, and feel like you must contain your fears and hide your disease or the effects of treatment. Sharing these feelings and struggles may make you feel vulnerable. A study published in the Journal of Personality shows that women with breast cancer who do express their anger, fear, sadness, and affection in a group setting live longer than women who suppress these emotions. Here are some ways to express your emotions and boost your emotional and physical health:

Make time to talk to family members

Communicate with friends and coworkers

Attend a support group, or join an online support list

Find a good therapist and commit to regular visits

Take-Home Message

Your feelings about breast cancer and its affect on your body, family, relationships, finances, and mortality are valid and normal. Expressing your emotions and needs will help boost your mental and physical health. Letting it out lets you live longer!

Sources:

Journal of the American Geriatric Society. Effect of depression on diagnosis, treatment, and survival of older women with breast cancer. Published January 2004.

Journal of Psychosocial Oncology. Examining the influence of coping with pain on depression, anxiety, and fatigue among women with breast cancer. Published 2005.

National Institute of Health. Women’s Fear of Heart Disease Has Almost Doubled in Three Years, But Breast Cancer Remains Most Feared Disease. Published 2008.

National Cancer Institute. Support for People with Cancer – Taking Time. Published 2005.

California Breast Cancer Research Program. Does Change in Emotional Expression Mediate Cancer Survival? Final Report Published 1999.

Breast cancer is an uninvited and life-altering event frequently associated with a rapid entry into a challenging treatment regimen and a long process of learning to cope with significant physical, practical, and emotional challenges (Boehmke & Dickerson, 2006).

Boehmke, M., & Dickerson, S. (2006). The diagnosis of breast cancer: Transition from health to illness. Oncology Nursing Forum, 33(6), 1121-1127.

Breast cancer can engender negative emotional and interpersonal responses throughout the continuum of cancer care (including the phases of diagnosis, treatment, survivorship, and end of life) (Ganz et al., 1996). Support groups have become central to psychosocial interventions for cancer patients because they provide a confidential atmosphere where cancer patients can discuss their challenges and insights with each other. Compared to control groups, patients who participate in support groups have fewer self-reported physical symptoms, lower cortisol levels, better immune system function and quality of life, and longer survival time (Winzelberg, A. J., Classen, C., Alpers, G. W., Roberts, H., Koopman, C., Adams, R. E., et al. (2003).

Ganz, P. A., Coscarelli, A., Fred, C., Kahn, B., Polinsky, M. L., & Petersen, L. (1996). Breast cancer survivors: Psychosocial concerns and quality of life. Breast Cancer Research and Treatment, 38(2), 183-199.

Winzelberg, A. J., Classen, C., Alpers, G. W., Roberts, H., Koopman, C., Adams, R. E., et al. (2003). Evaluation of an internet support group for women with primary breast cancer. Cancer, 97(5), 1164-1173.

However, face-to-face groups, as noted above, have improved well-being, but often pose barriers to people with limited mobility or who live a distance from where they are held. A growing number of patients use online support groups, which are available anytime in the privacy of one’s home

Eysenbach, G. (2003). The impact of the internet on cancer outcomes. Cancer Journal of Clinicians, 53, 356-371.

Understanding how cancer patients use online support groups is an important factor in determining the value of Internet-based services to support cancer patients. Research that characterizes communication patterns can enhance our understanding of the mechanisms that facilitate positive coping with cancer diagnosis, treatment, survival, or death. A growing body of research on online support group messages suggests that qualitative analysis is a valuable method for categorizing patient cancer-related experiences and concerns, identifying existing gaps in knowledge, and guiding priorities for future research (Eysenbach & Till, 2001)

Eysenbach, G., & Till, J. E. (2001). Ethical issues in qualitative research on internet communities. British Medical Journal, 323(10), 1103-1105.

Belinda has just had her right breast removed, and she is not feeling alright. In fact, she has not been feeling ‘alright’ since the moment the doctor told her she was symptomatic. Even if it turns out the mastectomy was completely successful and she becomes a ‘survivor’, Belinda will probably still continue to feel psychological anxiety about the possible recurrence of her cancer, not to mention embarrassment about the aesthetic change to her body. The key to helping Belinda is a strong social support network, connections to her ordinary life and high quality nursing communication.

Depression Mood Disorder occurs within 10 – 25% of cancer patients, and physical reactions include palpatations, high blood pressure (seen in Belinda), anxiety and depression. Depression and anxiety can lead to social regression, poor medical compliance, and even suicide. If Belinda becomes depressed she is likely to stay in hospital longer, and complain more of adverse drug effects. Depression makes patients highly sensitised, meaning they are more likely to experience vomiting, nausea and anorexia than a patient in a more positive frame of mind, and their discomfort may eventually cause them to stop treatment. Strategies for battling this sensitisation include fully informing patients of adverse drug symptoms ahead of time, explaining that all drugs have adverse symptoms but not all patients experience them, and that having a positive attitude can have a big impact. (Zhou, Duan, Zhou, Cai, Huang, Zeng & Zu, 2010).

Patient fear begins the moment the patient is informed that they have cancer. While being told she was symptomatic, Belinda would have struggled to take in more complex information (Gunderman & Brown, 2010). In most cases it is important to organise a follow-up appointment a few days following so that the cancer can be fully explained. Disbelief can be exacerbated if Belinda was feeling completely healthy at the time. (Gunderman et al., 2010). Additionally, fertility preservation needs to be discussed early in fertile patients, as chemotherapy can lead to infertility – a fact that can be extremely upsetting later on (Wilkes, Coulson, Crosland, Rubin & Stewart, 2010).

For Indigenous patients of Cherbourg, while cancer occurrence in Indigenous Australians is lower than the overall population, cancer mortality is higher because many Indigenous Australians distrust westernised health facilities and will only present when they are very unwell. Many Indigenous Australians link cancer with curses, imminent unstoppable death and contagion, and don’t seek treatment or hide symptoms because they believe they have done wrong, deserve illness, the outcome is already decided, they feel ashamed of their wrong-doing or they fear ostracism. These beliefs are prevalent in urban as well as rural populations (Shahid, Finn, Bessarab & Thompson, 2010) and ‘bush’ medicine is widely used. Encouragingly, Indigenous health care workers can find a successful balance between traditional and westernised medicine. Developing this balance in Indigenous Australian patients will allow them to participate in their own care. Nurses can consciously bring up the subject of traditional medicines and discuss these with the patient and family, as well as provide information about cancer in plain language so that patients can make informed decisions. (Shahid et al., 2010).

In the case of younger Cherbourg cancer patients, teenaged and young adult cancer patients often feel quite out of place as they are either the oldest in paediatric unit or the youngest in an adult unit at the hospital. Additionally they are developing into independent adults, but are suddenly thrown back into a dependent role as cancer patients. They require high levels of social networking support. These dilemmas have been battled by a hospital in Denmark where teenaged and young adult (15 – 22 years) cancer patients are placed in a dedicated ‘youth unit’ and are involved in specialised care appropriate to their age and needs. This includes network meetings involving the patient, family, friends the patient selects, and health care workers involved in the patient’s care. These meetings allow the nurse to ‘be the voice’ for the patient, letting friends know the patient needs support and might find it hard to ask, and letting the parents know the patient may need some ‘parent-free hours’. The nurse can also make the space youth friendly, offering friends chips and soft drink when they visit so that they will return and helping them schedule so that at least one friend visits each week. (Olsen & Harder, 2011).

Generally, the key with all cancer patients, including Belinda, is to encourage a strong social support network, encourage them to be involved in their normal lives as much as possible, and communicate both information and empathy. Getting patients involved in their own treatment, such as encouraging them to research their disease, and encouraging them to return to work if they can are also positive strategies. (Gunderamn et al., 2010).

Interesting Topics for Further Exploration:

Honesty, particularly with late or terminally ill patients, is a controversial issue as some families may want to withhold information, while generally health workers support full disclosure. (Locatelli, Piselli, Cicerchia, Raffaele, Abbatecola and Repetto, 2010).

The psychological affect of treatment-induced infertility or sexual impotence

Anticipatory grieving in parents of children with cancer

Religious coping and it’s advantages and pitfalls

The psychology and struggles of cancer ‘survivors’

Coping With and Surviving Breast Cancer

You can improve your emotional health and reduce your physical symptoms with good coping strategies. A study published in the Journal of Psychosocial Oncology reports that women who get help with pain and emotional distress have lower levels of anxiety, fatigue and depression. Here are some ways to cope with your emotions:

Communicate with family and friends

Maintain intimacy (if you have a partner)

Visit with a counselor or spiritual director

Join a support group

Express your needs and ask for help

Report your symptoms to your healthcare team

Keep a log of medical visits, save test results, keep receipts

Educate yourself about your cancer and treatments

Exercise

Make plans for a crisis

Getting Help for Emotions Is Not a Sign of Weakness

You may feel under pressure to “be strong” or “act brave” when you least feel that way. Perhaps you don’t easily share your feelings with others. You may be in a position of responsibility and trust, and feel like you must contain your fears and hide your disease or the effects of treatment. Sharing these feelings and struggles may make you feel vulnerable. A study published in the Journal of Personality shows that women with breast cancer who do express their anger, fear, sadness, and affection in a group setting live longer than women who suppress these emotions. Here are some ways to express your emotions and boost your emotional and physical health:

Make time to talk to family members

Communicate with friends and coworkers

Attend a support group, or join an online support list

Find a good therapist and commit to regular visits

Take-Home Message

Your feelings about breast cancer and its affect on your body, family, relationships, finances, and mortality are valid and normal. Expressing your emotions and needs will help boost your mental and physical health. Letting it out lets you live longe

Eliza, you have given a prefect picture of emotion and stress which Belinda is facing. Now a day’s diagnosis of breast cancer is a great shock. Today women fear breast cancer more than heart diseases, even though they have a better chance of surviving cancer than dying to stoke or heart failure (National institute of Health 2008).

As the women being to deal with diagnosis and treatment of breast cancer, their body automatically start reacting to emotions. Their physical response to overall stress may be fear (trouble sleeping, headaches or body aches), Anger (Change of blood pressure), Depression (fatigue, crying. Feeling moody), stress (pain, irrtability, tension). Also once women accept her diagnosis, they may also face another emotional concern. The loss of breast or part of breast has a deep impact that goes beyond the physical fact. Moreover if aggressive treatment is required, it may also be long term impact on the health. The fear of recurrence. Loss of attractiveness, difficulty in sexual function and loss of fertility also plays important role to increase the stress.

Every woman who is facing this situation should understand that getting help for emotion is not the sign of weakness. There are certain ways to cope with this emotion. The best is communicate with family and friend, maintaining intimacy with your partner, visiting the counselor or spiritual person, joining the support team are some of the sign which will make great difference to tackle emotions. In term of health care practice, Report any symptoms or change to the healthcare team. Always maintain a log of health visit, test result etc. educating yourself about the cancer and the treatment and having regular exercise along with plan for crisis make a huge impact.