Diabetes Mellitus Definition: metabolic disorder characterized by hyperglycemia due to an absolute or relative lack of insulin or to a cellular resistance to insulin Major classifications Type 1 Diabetes Type 2 Diabetes

Diabetes Mellitus Diabetes Type 1 Definition Metabolic condition in which the beta cells of pancreas no longer produce insulin; characterized by hyperglycemia, breakdown of body fats and protein and development of ketosis Accounts for 5 – 10 % of cases of diabetes; most often occurs in childhood or adolescence Formerly called Juvenile-onset diabetes or insulin-dependent diabetes (IDDM)

Diabetes Mellitus Pathophysiology Autoimmune reaction in which the beta cells that produce insulin are destroyed Alpha cells produce excess glucagons causing hyperglycemia Risk Factors Genetic predisposition for increased susceptibility; HLA linkage Environmental triggers stimulate an autoimmune response Viral infections (mumps, rubella, coxsackievirus B4) Chemical toxins

Diabetes Mellitus Diabetic Ketoacidosis (DKA) Results from breakdown of fat and overproduction of ketones by the liver and loss of bicarbonate Occurs when Diabetes Type 1 is undiagnosed or known diabetic has increased energy needs, when under physical or emotional stress or fails to take insulin Pathophysiology a. Hypersomolarity (hyperglycemia, dehydration) b. Metabolic acidosis (accumulation of ketones) c. Fluid and electrolyte imbalance (from osmotic diuresis)

Diabetes Mellitus DKA Signs and symptoms Kussmals respirations Blow off carbon dioxide to reverse acidosis Fruity breath Nausea/ abdominal pain Dehydration Lethargy Coma Polydipsia, polyuria, polyphagia

Diabetes Mellitus Treatment Requires immediate medical attention and usually admission to hospital Frequent measurement of blood glucose and treat according to glucose levels with regular insulin (mild ketosis, subcutaneous route; severe ketosis with intravenous insulin administration) Restore fluid balance: initially 0.9% saline at 500 – 1000 mL/hr.; regulate fluids according to client status; when blood glucose is 250 mg/dL add dextrose to intravenous solutions

Diabetes Mellitus DKA Correct electrolyte imbalance: client often is initially hyperkalemic As patient is rehydrated and potassium in pushed back into the cell they become hypokalemic Monitor K levels Monitor cardiac rhythm since hypokalemia puts client at risk for dysrrhythmias Treat underlying condition precipitating DKA Acidosis is corrected with fluid and insulin therapy and rarely needs bicarb

Diabetes Mellitus Diabetes Type 2 Definition: condition of fasting hyperglycemia occurring despite availability of body’s own insulin Was known as non-insulin dependent diabetes or adult onset diabetes Both are misnomers, it can be found in children and type II DM may require insulin

Diabetes Mellitus Pathophysiology Sufficient insulin production to prevent DKA; but insufficient to lower blood glucose through uptake of glucose by muscle and fat cells Cellular resistance to insulin increased by obesity, inactivity, illness, age, some medications

Diabetes Mellitus Risk Factors History of diabetes in parents or siblings; no HLA Obesity (especially of upper body) Physical inactivity Race/ethnicity: African American, Hispanic, or American Indian origin Women: history of gestational diabetes, polycystic ovary syndrome, delivered baby with birth weight > 9 pounds Clients with hypertension; HDL cholesterol < 35 mg/dL, and/or triglyceride level > 250 mg/dl.

Diabetes Mellitus 2. Possible symptoms or concerns Hyperglycemia (not as severe as with Type 1) Polyuria Polydipsia Blurred vision Fatigue Paresthesias (numbness in extremities) Skin Infections

Diabetes Mellitus Pathophysiology Hyperglycemia leads to increased urine output and dehydration Kidneys retain glucose; glucose and sodium rise Severe hyperosmolar state develops leading to brain cell shrinkage Manifestations Altered level of consciousness (lethargy to coma) Neurological deficits: hyperthermia, motor and sensory impairment, seizures Dehydration: dry skin and mucous membranes, extreme thirst, tachycardia, polyuria, hypotension

Diabetes Mellitus Treatment Usually admitted to intensive care unit of hospital for care since client is in life-threatening condition: unresponsive, may be on ventilator, has nasogastric suction Correct fluid and electrolyte imbalances giving isotonic or colloid solutions and correct potassium deficits Lower glucose with regular insulin until glucose level drops to 250 mg/dL Monitor for renal failure Treat underlying condition

Diabetes Mellitus Complications of Diabetes Alterations in blood sugars: hyperglycemia and hypoglycemia Macrocirculation (large blood vessels) Atherosclerosis occurs more frequently, earlier in diabetics Involves coronary, peripheral, and cerebral arteries Microcirculation (small blood vessels) Affects basement membrane of small blood vessels and capillaries Involves tissues affecting eyes and kidneys Prevention of complications Managing diabetes Lowering risk factors for conditions Routine screening for complications Implementing early treatment

Diabetes Mellitus Complications of Diabetes: Alterations in blood sugars A. Hyperglycemia: high blood sugar DKA (mainly associated with Diabetes Type 1) HHS (mainly associated with Diabetes Type 2) Dawn phenomenon: rise in blood sugar between 4 am and 8 am, not associated with hypoglycemia Glucose released from the liver in the early AM secondary to growth hormones Altering the time and dose of the insulin (NPH or Ultralente) by 2-3 units stabilizes the blood sugar

Diabetes Mellitus B. Hypoglycemia (insulin reaction, insulin shock, “the lows”): low blood sugar Mismatch between insulin dose, carbohydrate availability and exercise May be affected by intake of alcohol, certain medications

Specific manifestations Cool, clammy skin Rapid heartbeat Hunger Nervousness, tremor Faintness, dizziness Unsteady gait, slurred and/or incoherent speech Vision changes Seizures, coma Severe hypoglycemia can result in death Clients taking medications, such as beta-adrenergic blockers may not experience manifestations associated with autonomic nervous system Hypoglycemia unawareness: clients with Diabetes Type 1 for 4 or 5 years or more may develop severe hypoglycemia without symptoms which can delay treatment

Diabetes Mellitus Treatment for mild hypoglycemia Immediate treatment: client should take 15 gm of rapid-acting sugar (half cup of fruit juice; 8 oz of skim milk, 3 glucose tablets, 3 life savers 15/15 rule: wait 15 minutes and monitor blood glucose; if still low, client should eat another 15 gm of sugar Continue until blood glucose level has returned to normal Client should contact medical care provider if hypoglycemia occurs more that 2 or 3 times per week

Treatment for severe hypoglycemia is often hospitalization a. Client is unresponsive, has seizures, or has altered behavior; blood glucose level is less than 50 mg/dL b. If client is conscious and alert, administer 15 gm of sugar c. If client is not alert, administer 25 %– 50% solution of glucose intravenously, followed by infusion of 5% dextrose in water Glucagon 1 mg by subcutaneous, intramuscular, or intravenous route; follow with oral or intravenous carbohydrate d.Monitor client response physically and also blood glucose level

Diabetes Mellitus Complications Affecting Cardiovascular System, Vision, and Kidney Function A. Coronary Artery Disease Major risk of myocardial infarction in Type 2 diabetics Increased chance of having a silent MI and delaying medical treatment Most common cause of death for diabetics (40 – 60%) Diabetics more likely to develop Congestive Heart Failure

Diabetes Mellitus B. Hypertension 1. Affects 20 – 60 % of all diabetics 2. Increases risk for retinopathy, nephropathy

Diabetes Mellitus C. Stroke: Type 2 diabetics are 2 – 6 times more likely to have stroke as well as Transient Ischemic Attacks (TIA) or mini stroke

Diabetes Mellitus D. Peripheral Vascular Disease 1. Increased risk for Types 1 and 2 diabetics 2. Development of arterial occlusion and thrombosis resulting in gangrene 3. Gangrene from diabetes most common cause of non-traumatic lower limb amputation

Diabetic Foot Ulcer

Diabetes Mellitus Male erectile dysfunction Half of all diabetic men have erectile dysfunction

Diabetes Mellitus Collaborative Care A. Based on research from 10-year study of Type 1 diabetics conducted by NIH focus is on keeping blood glucose levels as close to normal by active management interventions; complications were reduced by 60% B. Treatment interventions are maintained through Medications Dietary management Exercise C. Management of diabetes with pancreatic transplant, pancreatic cell or Beta cell transplant is in investigative stage

Diabetes Mellitus Other Complications from Diabetes A. Increased susceptibility to infection Predisposition is combined effect of other complications Normal inflammatory response is diminished Slower than normal healing B. Periodontal disease C. Foot ulcers and infections: predisposition is combined effect of other complications

Diabetes Mellitus Diagnostic tests to monitor diabetes management 1. Fasting Blood Glucose (normal: 70 – 110 mg/dL) 2. Glycosylated hemoglobin (c) (Hemoglobin A1C) Considered elevated if values above 7% Blood test analyzes excess glucose attached to hemoglobin. Since rbc lives about 120 days gives an average of the blood glucose over previous 2 to 3 months Not a fasting test, can be drawn any time of the day % of glycated (glucose attached) hemoglobin measures how much glucose has been in the bloodstream for the past 3 months

Diabetes Mellitus 3. Urine glucose and ketone levels (part of routine urinalysis) a. Glucose in urine indicates hyperglycemia (renal threshold is usually 180 mg/dL) b. Presence of ketones indicates fat breakdown, indicator of DKA; ketones may be present if person not eating 4. Urine albumin (part of routine urinalysis) If albumin present, indicates need for workup for nephropathy Typical order is creatinine clearance testing

2. Clients who need insulin as therapy: Medications A. Insulin Sources: standard practice is use of human insulin prepared by alteration of pork insulin or recombinant DNA therapy 2. Clients who need insulin as therapy: All type 1 diabetics since their bodies essentially no longer produce insulin Some Type 2 diabetics, if oral medications are not adequate for control (both oral medications and insulin may be needed) Diabetics enduring stressor situations such as surgery, corticosteroid therapy, infections, treatment for DKA, HHNS Women with gestational diabetes who are not adequately controlled with diet Some clients receiving high caloric feedings including tube feedings or parenteral nutrition

Diabetes Mellitus Role of Diet in Diabetic Management A. Goals for diabetic therapy include Maintain as near-normal blood glucose levels as possible with balance of food with medications Obtain optimal serum lipid levels Provide adequate calories to attain or maintain reasonable weight

Care of diabetic older clients 40% of all clients with diabetes are over age of 65 Need to include spouse, members of family in teaching who may assist with client meeting medical needs Diet changes may be difficult to implement since client has established eating habits Exercise programs may need adjustment to meet individual’s abilities (such as physical limitations from other chronic illnesses) Obesity worsens diabetes Minimum of 30 minutes of moderate exercise like walking or swimming most days of the week

Diabetes Mellitus Care of diabetic older clients Individual reluctance to accept assistance to deal with chronic illness, assist with hygiene Limited assets for medications, supplies, dietary Visual deficits or learning challenges to learn insulin administration, blood glucose monitoring

A. Risk for impaired skin integrity: Proper foot care Daily inspection of feet Checking temperature of any water before washing feet Need for lubricating cream after drying but not between toes Patients should be followed by a podiatrist Early reporting of any wounds or blisters B. Risk for infection Frequent hand washing Early recognition of signs of infection and seeking treatment Meticulous skin care Regular dental examinations and consistent oral hygiene care

Diabetes Mellitus C. Risk for injury: Prevention of accidents, falls and burns D. Sexual dysfunction Effects of high blood sugar on sexual functioning, Resources for treatment of impotence, sexual dysfunction E. Ineffective coping Assisting clients with problem-solving strategies for specific concerns

Diabetes Mellitus Providing information about diabetic resources, community education programs, and support groups Utilizing any client contact as opportunity to review coping status and reinforce proper diabetes management and complication prevention