1. 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

2. 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)

3. 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

4. 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)

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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.

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

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

22. 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

23. 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

24. Diabetic Foot Ulcer

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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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