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DIABETES MELLITUS Rachel S. Natividad RN, MSN, NP
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Review A&P Review A&P
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Role of Insulin Insulin: – –Counters metabolic activity that would increase blood glucose levels – –Enhances transport of glucose into body cells – –Lowers blood glucose levels
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Physiology Cont: Insulin Basal (continuous) Prandial (Bolus) *Blood glucose increases within 10 minutes of the beginning of a meal*
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Diabetes Mellitus A disorder of carbohydrate, protein, and fat metabolism resulting from an imbalance between insulin availability and insulin need. (Porth, 2002) End Result : HYPERGLYCEMIA
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Physiology Cont.:Glucose Control
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Patho: DM Type 1
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Patho Cont.: DM Type 2
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Normal Physiology
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Pathophysiology-Cont.:DM Type 2
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DM 1&2: The big difference… DM TYPE 1 DM TYPE 2 No endogenous insulin Some endogenous insulin Tx requires insulin injections Tx diet and exercise 1st, then pills and /or insulin Usually < age 30 yrs. Usually over 30 yrs. (peaks at 50) Ketosis prone (DKA) no ketosis Former names: IDDM (Juvenile) Diabetes Type I NIDDM (maturity/adult- onset) Diabetes Type II Thin to normal body weight Usually Overweight Acute metabolic complications (DKA) Chronic vascular complications
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Case Study
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THE 3 POLYs POLYURIA POLYPHAGIA POLYDYPSIA 14 Diabetes: Clinical Manifestations
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Signs and Symptoms Diabetes Clinical Manifestations Cont: Signs and Symptoms Early signs 3 Polys Weight loss Fatigue/Always tired Visual Blurring Late signs Any of the 3 Polys Infections Numbness/ tingling of feet or leg pain Slow healing wounds Chronic Complications
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Diabetes: Dx Tests Diabetes: Dx Tests Fasting Blood Glucose (FBG): <100 mg/dL –Iggy: 70-110 mg/dL *Random/Casual Blood Glucose*:<200 mg/dL Oral Glucose Tolerance Test (OGTT): < 140 mg/dL Glycosylated Hemoglobin (HgbA1C): 4-6% Check MD orders or agency protocol for frequency of BS Monitoring In General: AC&HS if pt able to eat; Q4-6 hours if NPO or tube feedings
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Diabetes: Diagnostic Tests Cont. Glycosylated hemoglobin test – Hemoglobin A1C (HbA1c) – –measures the amount of glycosylated hemoglobin (hemoglobin that is chemically linked to glucose) in blood. –Normal -4-6% –Target range DM patient <7%
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HbA1C Control
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Criteria for the Diagnosis of Diabetes Mellitus Normal –FPG <110 mg per dL –2hr OGTT <140 mg per dL Diabetes- positive findings from any two of the following tests on different days: –Symptoms of diabetes mellitus* plus casual (random) plasma glucose concentration >=200 mg / dL or –FPG >=126 mg per dL or –2hr OGTT >=200 mg per dL after a 75-g glucose load
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Diagnostic Tests – Cont. Is it Diabetes Yet? Impaired Fasting Glucose Impaired Glucose Tolerance <6 100-125 140-200 <100 <140 >126 >200 >6
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Acute Complications Diabetic Ketoacidosis (DKA) BS > 300 mg/dL Classic symptoms Ketosis Hyperglycemic- Hyperosmolar Nonketotic Syndrome (HHNS) BS > 800 mg/dL Similar symptoms No Ketosis Check urine for ketones
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(ADA)
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Chronic Complications of DM
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Effects on Blood Vessels Blood Vessel Lumen
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Chronic Complications - Macrovascular Cardiovascular –heart disease Cerebrovascular –Stroke Peripheral vascular disease DM pts have heart disease and stroke risks 2 to 4 X higher than non-DM pts
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Chronic Complications- Microvascular : Diabetic Retinopathy The leading cause of new cases of blindness in adults ages 20 - 74
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Chronic Complications- Microvascular Nephropathy The leading cause of end-stage renal disease (ESRD), occurs in about 20 - 40% of patients with diabetes
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Chronic Complications-Microvascular Diabetic Neuropathy - Diabetic Neuropathy - the poor blood supply will cause the nervous system to malfunction
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Chronic Complications- Microvascular Amputation of Toes
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Chronic Complications- Microvascular Sexual problems for men erectile dysfunction retrograde ejaculation Sexual problems for women decreased vaginal lubrication decreased sexual response Urologic problems for men and women urinary tract infections neurogenic bladder
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Chronic Complications- Microvascular Gastroparesis Nerve damage to the digestive system most commonly causes constipation. Damage can also cause the stomach to empty too slowly
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MANAGEMENT OF DM Regular Blood Glucose Monitoring Diet Exercise Drug Therapy 32
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Management: Diet & Exercise
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Diet : Diet : Diabetes Food Pyramid
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Diet Cont: What to do???
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Diet Cont. Carb-Counting
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Diet Cont: Diet Cont: Glycemic Index
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Diet Cont.: Getting the balance right Get your portions right!!
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Management: Exercise Helps regulate blood glucose Increases insulin effectiveness and sensitivity in the body. Must monitor insulin and food intake to match exercise regimen.
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Drug Therapy Insulin& Oral Antidiabetic Agents
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Drug Therapy: Insulin Types Fast-acting insulin – –Rapid Acting Insulin AnalogsRapid Acting Insulin Analogs Aspart, Lispro, Glulisine – –Regular Human InsulinRegular Human Insulin Intermediate-acting insulin – –NPH Human InsulinNPH Human Insulin – –Pre-Mixed InsulinPre-Mixed Insulin Humulin 70/30, Humalog 75/25 Long-acting insulin – –Insulin Glargine, Insulin Detemir BASAL Used to lower blood sugar throughout the day and night BOLUS Used to lower blood sugar after eating a meal
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Drug Therapy Cont.: Insulin Onset - how soon it starts to work in the blood Peak - when the insulin has the greatest effect on blood sugar levels Duration – how long it keeps working
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Drug Therapy Cont: Goal of Insulin Therapy Basal and Bolus Insulin Coverage
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Drug Therapy Cont: Sample Insulin Regimen (NPH & Regular insulin)
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Drug Therapy-Insulin Cont: Rapid Acting “Logs” Humalog (insulin lispro) Novolog (insulin aspart) Bolus insulin Onset 15 min; peaks 1-2 hrs; lasts 4-6 hours Ideal for meal coverage “Give the shot while the plate is hot!”
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Drug Therapy-Insulin Cont: Short Acting: Regular Insulin Regs Bolus insulin Onset ½-1 hr; peaks 2-4 hrs; lasts 6-8 hrs Give 30 minutes to 1 hour before a meal
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Drug Therapy-Insulin Cont: Short Acting: Regular Insulin ♪ It’s time give you your regular insulin ♪ ♪ It’s time to give it 30 minutes before your plate is in ♪ ♪ Come back to check you in 2 (hours) ♪ ♪ Watch out for shakes and sweats too ♪ ♪ If your lucky you’ll have no clue!!!! ♪
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Drug Therapy-Insulin Cont: Drug Therapy-Insulin Cont: Rapid Acting (Humalog/Novolog) VS. Short Acting (Regular Insulin) Rapid onset 1-2 hour peak Limited duration Delayed onset Peaks in 2-4 hr Lasts 6-8 hours
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Drug Therapy-Insulin Cont: Intermediate acting: NPH Insulin Basal insulin: covers blood sugar between meals Satisfies overnight insulin requirement Onset 1-2 hrs, peaks 6-10 hrs, lasts 12+ hrs Need snack if NPH given at 5 pm (only) Ideal to be given at 9 pm (HS) to address Dawn Phenomenon
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Drug Therapy-Insulin Cont: L ong-Acting: Peakless Insulins!!! L antus (insulin glargine) L evimir (insulin detimir) Basal Insulin Onset 1.5 hrs; no peak (max effect in 5 hrs); lasts 24 hours No risk for hypoglycemia Do not mix with other insulins – becomes inactivated when mixed with other insulins
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Lantus
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Drug Therapy- Insulin Cont: Hypoglycemia BS < 60-70 mg/dL An acute complication of insulin administration Tx: (15/15 or 20/20 Rule) –Give 15/20 g simple carb and recheck BG in 15/20 minutes
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Synthetic injectables Byetta: Synthetic incretin mimetic hormone – –Indicated for patients with type 2 diabetes who don’t use insulin Symlin: Synthetic analogue of human amylin – –Approved for use with insulin in adults with type 1 and type 2 diabetes
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Drug Therapy Cont: Other Methods of Administration For Uncontrolled DM 1 0r 2 Rapid-acting insulin
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Continuous IV insulin infusion Used to maintain glycemic control in hospitalized patients with high blood glucose levels; in DKA and HHNS Regular insulin may be used IV May also be given preoperatively or postoperatively More frequent BS monitoring ( q1- 2 hours per agency protocol)
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Drug Therapy Cont: Drug Therapy Cont: Oral Antidiabetic agents (see handout)
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New Oral Med Januvia (Sitagliptin) – –An oral drug that reduces blood sugar levels in patients with type 2 diabetes.diabetes – – Sitagliptin is the first approved member of a class of drugs that inhibit the enzyme, dipeptidyl peptidase-4 (DPP-4).
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Oral Agents: How do they work?
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Acute Complication of Insulin and (some) Oral Meds Hypoglycemia Acute Complication of Insulin and (some) Oral Meds Hypoglycemia
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Hyperglycemia
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Critical Thinking Exercises Course Packet pp. 81-84
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Diabetic Teaching Needs Disease process S/S of hyperglycemia and hypoglycemia Blood sugar monitoring DietExercise Drug therapy Sick Day Rules Complications (acute and chronic) Prevention: Foot care, eye exam etc.
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DIABETES can be controlled!!!
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