Chapter 41 Assessment and Management of Patients With Diabetes Mellitus

1. Chapter 41Assessment and Management of Patients With Diabetes Mellitus

2. Diabetes MellitusDefinition • Is a group of metabolic diseases characterized by increased levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both • related to: • An endocrine disorder causes Abnormal insulin production • Impaired insulin utilization • Both abnormal production and impaired utilization

3. Diabetes MellitusDefinition • Leading cause of heart disease, stroke, adult blindness, and nontraumatic lower limb amputations

4. Diabetes MellitusEtiology and Pathophysiology • Produced by the  cells in the islets of Langherans of the pancreas • Facilitates normal glucose range of 70 to 120 mg/dl

5. Diabetes Mellitusfunctions of insulin • Transports and metabolizes glucose for energy • Stimulates storage of glucose in the liver and muscle (in the form of glycogen) • Signals the liver to stop the release of glucose • Enhances storage of dietary fat in adipose tissue • Accelerates transport of amino acids (derived from dietary protein) into cells • Inhibits breakdown of stored glucose, protein, and fat.

6. Type 1 Diabetes Mellitus • Formerly known as “juvenile onset” or “insulin dependent” diabetes • Most often occurs in people under 30 years of age • Peak onset between ages 11 and 13

7. Type 1 Diabetes MellitusEtiology and Pathophysiology • Progressive destruction of pancreatic  cells • Autoantibodies cause a reduction of 80% to 90% of normal  cell function before manifestations occur

8. Type 1 Diabetes MellitusEtiology and Pathophysiology • Causes: • Genetic predisposition • Related to human leukocyte antigens (HLAs) • Exposure to a virus

9. Type 1 Diabetes MellitusOnset of Disease • Manifestations develop when the pancreas can no longer produce insulin • Rapid onset of symptoms • Present at ER with ketoacidosis

10. Type 1 Diabetes MellitusOnset of Disease • Weight loss • Polydipsia • Polyuria • Polyphagia

11. Type 1 Diabetes MellitusOnset of Disease • Diabetic ketoacidosis (DKA) • Occurs in the absence of exogenous insulin • Life-threatening condition • Results in metabolic acidosis

12. Type 2 Diabetes Mellitus • Accounts for 90% of patients with diabetes • Usually occurs in people over 40 years of age • 80-90% of patients are overweight

13. Type 2 Diabetes MellitusEtiology and Pathophysiology • Pancreas continues to produce some endogenous insulin • Insulin produced is either insufficient or poorly utilized by the tissues

14. Type 2 Diabetes MellitusEtiology and Pathophysiology • Insulin resistance • Body tissues do not respond to insulin • Results in hyperglycemia

15. Type 2 Diabetes MellitusEtiology and Pathophysiology • Inappropriate glucose production by the liver • Not considered a primary factor in the development of type 2 diabetes

16. Type 2 Diabetes MellitusEtiology and Pathophysiology

17. Type 2 Diabetes MellitusOnset of Disease • Gradual onset • Person may go many years with undetected hyperglycemia • 75% of type 2 diabetes is detected incidentally

18. Type 2 Diabetes Mellitus • Etiology (not well know) • Genetic factors • Increased weight.

19. Gestational Diabetes • Develops during pregnancy • Detected at 24 to 28 weeks of gestation •  Risk for cesarean delivery, perinatal death, and neonatal complications

20. Secondary Diabetes • Results from another medical condition or due to the treatment of a medical condition that causes abnormal blood glucose levels • Cushing syndrome • Hyperthyroidism • Parenteral nutrition

21. Clinical ManifestationsDiabetes Mellitus • Polyuria • Polydipsia (excessive thirst) • Polyphagia • In Type I • Weight loss • Ketoacidosis

22. Clinical ManifestationsNon-specific symptoms • Fatigue and weakness • Sudden vision changes • Tingling or numbness in hands or feet • Skin lesions or recurrent infections • Prolonged wound healing • Visual changes

23. Clinical Manifestations

24. Diabetes MellitusDiagnostic Studies • Fasting plasma glucose level 126 mg/dl • Random plasma glucose measurement 200 mg/dl plus symptoms • Two-hour OGTT level 200 mg/dl using a glucose load of 75 g

25. Assessing the Patient With Diabetes • History : • Physical Examination • Laboratory Examination • Need for Referrals

27. Diabetes MellitusCollaborative Care • Goals of diabetes management: • Reduce symptoms • Promote well-being • Prevent acute complications • Delay onset and progression of long-term complications

29. Diabetes MellitusNutritional Therapy • Overall objectives • Assist people in making changes in nutrition and exercise habits that will lead to improved metabolic control • Control of total caloric intake to attain or maintain a reasonable body weight, control of blood glucose levels, and normalization of lipids and blood pressure to prevent heart disease.

30. Obesity is associated with an increased resistance to insulin. • Some obese patients who have type 2 diabetes and who require insulin or oral agents to control blood glucose levels may be able to reduce or eliminate the need for medication through weight loss. • A weight loss as small as 10% of total weight may significantly improve blood glucose levels

31. Diabetes MellitusNutritional Therapy • Type 1 DM • Meal plan based on the individual’s usual food intake and is balanced with insulin and exercise patterns

32. Diabetes MellitusNutritional Therapy • Type 2 DM • Emphasis placed on achieving glucose, lipid, and blood pressure goals • Calorie reduction

33. Diabetes MellitusNutritional Therapy • Food composition • Individual meal plan developed with a dietitian • Nutritionally balanced • Does not prohibit the consumption of any one type of food

34. Diabetes MellitusNutritional Therapy/Caloric Distribution • Calculate daily caloric requirement. • Carbohydrates • 50% to 60% of caloric intake. • Majority of calories should come from grains • Foods high in carbohydrates, such as sucrose, are not eliminated from the diet but should be eaten in moderation (up to 10% of total calories

35. Diabetes MellitusNutritional Therapy/Caloric Distribution • Fats • 20% to 30% of calories come from fat. • Limit the amount of saturated fats to 10% of total calories • Proteins • 10% to 20% of calories come from protein.

36. Diabetes MellitusNutritional Therapy/Caloric Distribution • Fiber • Lower total cholesterol and LDL in the blood. • Improve blood glucose levels • Decrease the need for exogenous insulin. • Increase satiety, which is helpful for weight loss

37. Diabetes MellitusNutritional Therapy • Food composition • Alcohol • High in calories (lead to weigh gain) • Promotes hypertriglyceridemia • Can cause severe hypoglycemia

38. Diabetes MellitusNutritional Therapy • Diet teaching • Dietitian initially provides instruction • Should include the patient’s family and significant others • Read food labels • Sweetners

40. Diabetes MellitusExercise • Essential part of diabetes management • Increases insulin sensitivity • Lowers blood glucose levels • Decreases insulin resistance • Decreases weight • Reduces cardiovascular risk factors

41. Diabetes MellitusExercise/ Precautions • Don’t exercise if blood glucose > 250 mg/dL or if there is ketone bodies in the urine. • Don’t exercise when the insulin at its peak • Use proper footwear and. • Avoid exercise in extreme heat or cold. • Inspect feet daily after exercise.

42. Diabetes MellitusExercise • Several small carbohydrate snacks can be taken to prevent hypoglycemia • Before exercising • At the end of the exercise with strenuous exercise • At be time with strenuous exercise • Deduce them from total daily calories • May need to reduce inlsulin dose

43. Diabetes MellitusExercise • Best done after meals • Exercise plans should be individualized • Monitor blood glucose levels before, during, and after exercise • Better to exercise at the same time daily when blood sugar at its peak

44. Diabetes MellitusMonitoring Blood Glucose • Self-monitoring of blood glucose (SMBG) • Enables patient to make self-management decisions regarding diet, exercise, and medication

45. Diabetes MellitusMonitoring Blood Glucose • Self-monitoring of blood glucose (SMBG) • Important for detecting episodic hyperglycemia and hypoglycemia • Patient training is crucial

46. Diabetes MellitusDrug Therapy: Insulin • Exogenous insulin: • Required for type 1 diabetes • Prescribed for the patient with type 2 diabetes who cannot control blood glucose by other means

47. Diabetes MellitusDrug Therapy: Insulin • Types of insulin • Human insulin • Most widely used type of insulin • Cost-effective •  Likelihood of allergic reaction

48. Diabetes MellitusDrug Therapy: Insulin • Types of insulin • Insulins differ in regard to onset, peak action, and duration • Different types of insulin may be used in combination therapy

49. Diabetes MellitusDrug Therapy: Insulin • Types of insulin • Rapid-acting: Lispro(onset 15’, peak 60-90’ and last from 2-4 hours) • Short-acting: Regular (Onset is 30-60’, peak in 2-3h and last for 4-6 hours, and Regular insulin is only kind for IV use.

50. Diabetes MellitusDrug Therapy: Insulin • Intermediate-acting: NPH or Lente Onset 3-4h, peak 4-12 hours and lst 16-20 hours. Names include Humulin N, Novolin N, Humulin L, Novolin L • Long-acting: Ultralente, Lantus Onset 6-8h, peak 12-16 h and lasts 20-30h.