Diabetes Mellitus

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 • 1. Type 1 Diabetes • 2. Type 2 Diabetes

Diabetes Mellitus Impact on health of American population • 1. Sixth leading cause of death due to cardiovascular effects resulting in atherosclerosis, coronary artery disease, and stroke • 2. Leading cause of end stage renal failure • 3. Major cause of blindness • 4. Most frequent cause of non-traumatic amputations • 5. Diabetes affects estimated 15.7 million people (10.3 million are diagnosed; 5.4 million are undiagnosed) • 6. Increasing prevalence of Type 2 Diabetes in older adults and minority groups (African American, American Indian and Hispanic populations) • 7. Estimated 11 % of older U. S. population (65 – 74) have diabetes

Diabetes Mellitus Diabetes Type 1 Definition • 1. 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 • 2. Accounts for 5 – 10 % of cases of diabetes; most often occurs in childhood or adolescence • 3. Formerly called Juvenile-onset diabetes or insulin-dependent diabetes (IDDM)

Diabetes Mellitus Pathophysiology • 1. Autoimmune reaction in which the beta cells that produce insulin are destroyed • 2. Alpha cells produce excess glucagons causing hyperglycemia Risk Factors • 1. Genetic predisposition for increased susceptibility; HLA linkage • 2. Environmental triggers stimulate an autoimmune response • a. Viral infections (mumps, rubella, coxsackievirus B4) • b. Chemical toxins

Diabetes Mellitus Manifestations • Process of beta cell destruction occurs slowly; hyperglycemia occurs when 80 – 90% is destroyed; often trigger stressor event (e. g. illness) 2. Hyperglycemia leads to • a. Polyuria (hyperglycemia acts as osmotic diuretic) • b. Glycosuria (renal threshold for glucose: 180 mg/dL) • c. Polydipsia (thirst from dehydration from polyuria) • d. Polyphagia (hunger and eats more since cell cannot utilize glucose) • e. Weight loss (body breaking down fat and protein to restore energy source • f. Malaise and fatigue (from decrease in energy) • g. Blurred vision (swelling of lenses from osmotic effects)

Diabetes Mellitus Diabetic Ketoacidosis (DKA) 1. Results from breakdown of fat and overproduction of ketones by the liver and loss of bicarbonate 2. 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 3. Pathophysiology • a. Hypersomolarity (hyperglycemia, dehydration) • b. Metabolic acidosis (accumulation of ketones) • c. Fluid and electrolyte imbalance (from osmotic diuresis)

Diabetes Mellitus Diagnostic tests • a. Blood glucose greater than 250 mg/dL • b. Blood pH less than 7.3 • c. Blood bicarbonate less than 15 mEq/L • d. Ketones present in blood • e. Ketones and glucose present in urine • f. Electrolyte abnormalities (Na, K, Cl)

Diabetes Mellitus Treatment • a.Requires immediate medical attention and usually admission to hospital • b.Frequent measurement of blood glucose and treat according to glucose levels with regular insulin (mild ketosis, subcutaneous route; severe ketosis with intravenous insulin administration) • c.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 • d.Correct electrolyte imbalance: client often is hypokalemic and potassium is added to intravenous fluids and levels monitored frequently • e.Monitor cardiac rhythm since hypokalemia puts client at risk for dysrrhythmias • f.Treat underlying condition precipitating DKA

Diabetes Mellitus Diabetes Type 2 • A. Definition: condition of fasting hyperglycemia occurring despite availability of body’s own insulin Pathophysiology • 1. Sufficient insulin production to prevent DKA; but insufficient to lower blood glucose through uptake of glucose by muscle and fat cells • 2. Cellular resistance to insulin increased by obesity, inactivity, illness, age, some medications

Diabetes Mellitus Risk Factors • 1. History of diabetes in parents or siblings; no HLA • 2. Obesity (especially of upper body) • 3. Physical inactivity • 4. Race/ethnicity: African American, Hispanic, or American Indian origin • 5. Women: history of gestational diabetes, polycystic ovary syndrome, delivered baby with birth weight > 9 pounds • 6. Clients with hypertension; HDL cholesterol < 35 mg/dL, and/or triglyceride level > 250 mg/dl.

Diabetes Mellitus Manifestations 1. Client usually unaware of diabetes • a. Discovers diabetes when seeking health care for another concern • b. Usually does not experience weight loss 2. Possible symptoms or concerns • a. Hyperglycemia (not as severe as with Type 1) • b. Polyuria • c. Polydipsia • d. Blurred vision • e. Fatigue • f. Paresthesias (numbness in extremities) • g. Skin Infections

Diabetes Mellitus Hypersomolar Hyperglycemic State (HHS) 1. Potential complication of Diabetes Type 2 2. Life threatening medical emergency, high mortality rate 3. Characterized by • a. Plasma osmolarity 340 mOsm/L or greater (normal: 280 -300) • b. Blood glucose severely elevated, 600 - 1000 or 2000 (normal 70-110) • c. Altered level of consciousness 4. Precipitating factors • a. Infection (most common) • b. Therapeutic agent or procedure • c. Acute or chronic illness 5. Slow onset 1 – 14 days

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

Diabetes Mellitus Treatment • a. 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 • b. Correct fluid and electrolyte imbalances giving isotonic or colloid solutions and correct potassium deficits • c. Lower glucose with regular insulin until glucose level drops to 250 mg/dL • d. Treat underlying condition

Diabetes Mellitus Complications of Diabetes A. Alterations in blood sugars: hyperglycemia and hypoglycemia B. Macrocirculation (large blood vessels) • 1. Atherosclerosis occurs more frequently, earlier in diabetics • 2. Involves coronary, peripheral, and cerebral arteries C. Microcirculation (small blood vessels) • 1. Affects basement membrane of small blood vessels and capillaries • 2. Involves tissues affecting eyes and kidneys D. Prevention of complications • 1. Managing diabetes • 2. Lowering risk factors for conditions • 3. Routine screening for complications • 4. Implementing early treatment

Diabetes Mellitus Complications of Diabetes: Alterations in blood sugars A. Hyperglycemia: high blood sugar • 1.DKA (mainly associated with Diabetes Type 1) • 2.HHS (mainly associated with Diabetes Type 2) • 3.Dawn phenomenon: rise in blood sugar between 4 am and 8 am, not associated with hypoglycemia (associated with Diabetes Type 1 and 2) • 4.Somogyi effect: combination of hypoglycemia during night with a rebound morning hyperglycemia that may lead to insulin resistance for 12 to 48 hours B. Hypoglycemia (insulin reaction, insulin shock, “the lows”): low blood sugar • 1.Mismatch between insulin dose, carbohydrate availability and exercise • 2.May be affected by intake of alcohol, certain medications

Three blood glucose phenomena in diabetic clients

Diabetes Mellitus Specific manifestations • a. Cool, clammy skin • b. Rapid heartbeat • c. Hunger • d. Nervousness, tremor • e. Faintness, dizziness • f. Unsteady gait, slurred and/or incoherent speech • g. Vision changes • h. Seizures, coma • 5. Severe hypoglycemia can result in death • 6. Clients taking medications, such as beta-adrenergic blockers may not experience manifestations associated with autonomic nervous system • 7. 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 • a. 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 • b. 15/15 rule: wait 15 minutes and monitor blood glucose; if still low, client should eat another 15 gm of sugar • c. Continue until blood glucose level has returned to normal • d. Client should contact medical care provider if hypoglycemia occurs more that 2 or 3 times per week

Diabetes Mellitus 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 • 1. 25 %– 50% solution of glucose intravenously, followed by infusion of 5% dextrose in water • 2. 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 • 1. Major risk of myocardial infarction in Type 2 diabetics • 2. Most common cause of death for diabetics (40 – 60%) • 3. Diabetics more likely to develop Congestive Heart Failure B. Hypertension • 1. Affects 20 – 60 % of all diabetics • 2. Increases risk for retinopathy, nephropathy C. Stroke: Type 2 diabetics are 2 – 6 times more likely to have stroke 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

Diabetes Mellitus Diabetic Retinopathy 1. Definition • a. Retinal changes related to diabetes • b. Leads to retinal ischemia and breakdown of blood-retinal barrier • c. Involves 3 stages 2. Leading cause of blindness ages 25 – 74 • a. Affects almost all Type 1 diabetics after 20 years • b. Affects 60 % of Type 2 diabetics 3. Diabetics should be screened for retinopathy and receive treatment (laser photocoagulation surgery) to prevent vision loss 4. Diabetics also have increased risk for cataract development

Diabetes Mellitus Diabetic Nephropathy • 1. Definition: glomerular changes in kidneys of diabetics leading to impaired renal function • 2. First indicator: microalbuminuria • 3. Diabetics without treatment go on to develop hypertension, edema, progressive renal insufficiency • a. In type 1 diabetics, 10 – 15 years • b. May occur soon after diagnosis with type 2 diabetes since many are undiagnosed for years • 4. Most common cause of end-stage renal failure in U.S. • 5. Kimmelstiel-Wilson syndrome: glomerulosclerosis associated with diabetes

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 • 1. Medications • 2. Dietary management • 3. 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 • 1. Predisposition is combined effect of other complications • 2. Normal inflammatory response is diminished • 3. Slower than normal healing • B. Periodontal disease • C. Foot ulcers and infections: predisposition is combined effect of other complications

Diabetes Mellitus Diagnostic Tests A. To diagnose Diabetes Mellitus, one of the three following tests must be positive and must be confirmed on another day with one of the three tests • 1. Client has symptoms of diabetes and casual plasma glucose > 200 mg/dL (Casual plasma glucose is drawn at any time of day without regard to time of last meal) • 2. Fasting plasma glucose level > 126 mg/dL • 3. During a oral glucose tolerance test (OGTT), the 2 hour plasma glucose > 200 mg/dL

Diabetes Mellitus Diagnostic tests to monitor diabetes management 1. Fasting Blood Glucose (normal: 70 – 110 mg/dL) 2. Glycosylated hemoglobin (c) (Hemoglobin A1C) • a. Considered elevated if values above 7 – 9 % • b. Blood test analyzes glucose attached to hemoglobin. Since rbc lives about 120 days gives an average of the blood glucose over previous 2 to 3 months 3. Urine glucose and ketone levels (part of routine urinalysis)

Diabetes Mellitus • 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) • a. If albumin present, indicates need for workup for nephropathy • b. Typical order is creatinine clearance testing 5. Cholesterol and Triglyceride levels • a. Recommendations • 1. LDL < 100 mg/dl • 2. HDL > 45 mg/dL • 3. Triglycerides < 150 mg/dL • b. Monitor risk for atherosclerosis and cardiovascular complications 6. Serum electrolytes in clients with DKA or HHS

Diabetes Mellitus Medications A. Insulin • 1. 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: • a. All type 1 diabetics since their bodies essentially no longer produce insulin • b. Some Type 2 diabetics, if oral medications are not adequate for control (both oral medications and insulin may be needed) • c. Diabetics enduring stressor situations such as surgery, corticosteroid therapy, infections, treatment for DKA, HHS • d. Women with gestational diabetes who are not adequately controlled with diet • e. Some clients receiving high caloric feedings including tube feedings or parenteral nutrition

Diabetes Mellitus

Diabetes Mellitus • Mixing insulin

Diabetes Mellitus Oral Hypoglycemic Agents • 1. Used to treat Diabetes Type 2 • 2. Client must also maintain prescribed diet and exercise program; monitor blood glucose levels • 3. Not used with pregnant or lactating women • 4. Several different oral hypoglycemic agents and insulin may be prescribed for the client • 5. Specific drug interactions may affect the blood glucose levels

Diabetes Mellitus Classifications and action a. Sulfonylureas • 1. Action: Stimulates pancreatic cells to secrete more insulin and increases sensitivity of peripheral tissues to insulin • 2. Used: to treat non-obese Type 2 diabetics • 3. Example: Glipizide (Glucotrol) b. Meglitinides • 1. Action: stimulates pancreatic cells to secret more insulin • 2. Example: Repaglinide (Prandin) c. Biguanides • 1. Action: decreases overproduction of glucose by liver and makes insulin more effective in peripheral tissues • 2. Example: Metformin (Glucophage) d. Alpha-glucoside Inhibitors • 1. Action: Slow carbohydrate digestion and delay glucose absorption • 2. Example: Acarbose (Precose)

Diabetes Mellitus Thizaolidinediones • 1. Action: Sensitizes peripheral tissues to insulin • 2. Example: Rosiglitazone (Avandia) D-pheylalanine (Amino Acid) Derivative • 1. Action: Stimulates very rapid and short insulin secretion to decrease spikes in glucose following meals; reduces overall glucose level • 2. Example: Nateglinide (Starlix) Aspirin Therapy: daily dose recommended to decrease risk of cardiovascular complications

Diabetes Mellitus Role of Diet in Diabetic Management A. Goals for diabetic therapy include • 1. Maintain as near-normal blood glucose levels as possible with balance of food with medications • 2. Obtain optimal serum lipid levels • 3. Provide adequate calories to attain or maintain reasonable weight B. Diet Composition • 1. Carbohydrates: 60 – 70% of daily diet • 2. Protein: 15 – 20% of daily diet • 3. Fats: No more than 10% of total calories from saturated fats • 4. Fiber: 20 to 35 grams/day; promotes intestinal motility and gives feeling of fullness • 5. Sodium: recommended intake 1000 mg per 1000 kcal • 6. Sweeteners approved by FDA instead of refined sugars • 7. Limited use of alcohol: potential hypoglycemic effect of insulin and oral hypoglycemics

Diabetes Mellitus Care of diabetic older clients • A. 40% of all clients with diabetes are over age of 65 • B. Need to include spouse, members of family in teaching who may assist with client meeting medical needs • C. Diet changes may be difficult to implement since client has established eating habits • D. Exercise programs may need adjustment to meet individual’s abilities (such as physical limitations from other chronic illnesses) • E. Individual reluctance to accept assistance to deal with chronic illness, assist with hygiene • F. Limited assets for medications, supplies, dietary • G. Visual deficits or learning challenges to learn insulin administration, blood glucose monitoring

Diabetes Mellitus Nursing Care • A. Assessment, planning, implementation with client according to type and stage of diabetes • B. Prevention, assessment and treatment of complications through client self-management and keeping appointments for medical care • C. Client and family teaching for diabetes management • D. Health promotion includes education of healthy life style, lowering risks for developing diabetes for all clients • E. Blood glucose screening at 3 year intervals starting at age 45 for persons in high risk groups

Diabetes Mellitus Common Nursing Diagnoses and Specific Teaching Interventions A. Risk for impaired skin integrity: Proper foot care • 1. Daily inspection of feet • 2. Checking temperature of any water before washing feet • 3. Need for lubricating cream after drying but not between toes B. Risk for infection • 1. Frequent hand washing • 2. Early recognition of signs of infection and seeking treatment • 3. Meticulous skin care • 4. Regular dental examinations and consistent oral hygiene care C. Risk for injury: Prevention of accidents, falls and burns D. Sexual dysfunction • 1. Effects of high blood sugar on sexual functioning, • 2. Resources for treatment of impotence, sexual dysfunction E. Ineffective coping • 1. Assisting clients with problem-solving strategies for specific concerns

Diabetes Mellitus • 2. Providing information about diabetic resources, community education programs, and support groups • 3. Utilizing any client contact as opportunity to review coping status and reinforce proper diabetes management and complication prevention

Diabetes Mellitus