Individuals Experiencing Diabetes Mellitus

1. Individuals Experiencing Diabetes Mellitus NURS2016

2. Diabetes Mellitus • A multisystem disease related to • Abnormal insulin production • Impaired insulin utilization • Both

3. Diabetes Mellitus • Leading cause of heart disease, stroke, adult blindness, and non-traumatic limb amputation • In Canada, 7th leading cause of death • Hospitalization rates are 2.4 and 5.3 X greater for adult and child than general population • Diabetes higher in Algoma and Cochrane • The number of Ontarians with diabetes has increased by 69 per cent over the last 10 years – and is projected to grow from 900,000 to 1.2 million by 2010

4. Local Reality (2007) • NELHIN 7.5% • Nipissing & Parry Sound 6.7 % • Timiskaming 10% • Ontario as a whole 6.1 %

5. Type 1 • Formerly known as ‘juvenile diabetes’ • Most often occurs under 30 years of age • Peak onset 11-13 years

6. Type 1Onset of Disease • Manifestations develop when the pancreas can no longer produce insulin • Rapid onset of symptoms • Present in ER with ketoacidosis

7. Type 1 • Weight loss • Polydipsia • Polyuria • Polyphagia

8. Type 1 • Diabetic Ketoacidosis • Occurs in the absence of exogenous insulin • Life threatening • Results in metabolic acidosis

9. Type 2 • Formerly called ‘adult onset diabetes’ • Accounts of 90% of patients with diabetes • Usually >40 years of age • Recently seen in children as young as 10 • 80-90% are overweight

10. Type 2 • Onset of disease is gradual • May be undetected for years

11. Recommended blood glucose targets for people with diabetes* • HB AIC** • Fasting blood glucose/ blood glucose before meals (mmol/L) Blood glucose two hours after eating (mmol/L) • Target for most patients with diabetes ≤7.0% 4.0 to 7.0 5.0 to 10 Normal range ≤6.0% 4.0 to 6.0 5.0 to 8.0 * This information is based on the Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada and is a guide. Talk to your doctor about YOUR blood glucose target ranges. ** A1C is a blood test that indicates an average of your overall blood glucose levels over the past 120 days. A1C targets for pregnant women and children 12 years of age and under are different.

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

13. Clinical Manifestations

15. Diabetic Ketoacidosis • A medical emergency • Sometimes brought on by stress, surgery, pregnancy, puberty, infection • #1 cause: person with diabetes not taking his/her insulin (fed up or non-compliance) • S & S: • ketosis • dehydration • electrolyte and acid-base imbalance

16. DKA • Abd pain • Nausea • Vomiting • Hyperventilation • Fruity odor to breath • If untreated, • Altered LOC • Coma • death

17. Diabetic Coma • Bicarbonate buffering system fails to compensate for ketosis • Respirations increase in rate and depth (Kussmaul’s respirations) & breath has fruity or acetone odour • Renal system attempts to excrete ketones which leads to hemoconcentration • Hemoconcentration impedes blood circulation & leads to tissue anoxia & lactic acid production • The rise in lactic acid production further acidifies blood pH • Rising ketones eventually overwhelms the body’s defenses against the acid & the body succumbs to coma

18. Hypoglycemia • To treat low blood sugar the 15/15 rule is usually applied. Eat 15 grams of carbohydrate and wait 15 minutes. The following foods will provide about 15 grams of carbohydrate: • 3 glucose tablets • Half cup (4 ounces) of fruit juice or regular soda • 6 or 7 hard candies • 1 tablespoon of sugar • After the carbohydrate is eaten, the person should wait about 15 minutes for the sugar to get into their blood. If the person does not feel better within 15 minutes more carbohydrate can be consumed. Their blood sugar should be checked to make sure it has come within a safe range.

20. Diabetes MellitusCollaborative Care • Patient teaching • Nutritional therapy • Drug therapy • Exercise • Self-monitoring of blood glucose

21. Complications: Acute Acute • Hypoglycemia: sweating, tremor, tachycardia, palpitations, nervousness, hunger, -- confusion, numbness lips/tongue, slurred speech, -- irrational/combative behaviour – disoriented, seizures, loss of consciousness • Immediate Treatment: 15gm of fast-acting carb

22. Complications: Acute • Diabetic Ketoacidosis • Hyperglycemia – dehydration and electrolyte loss, acidosis • Polyuria, polydipsia, blurred vision, dehydration, weakness, headache • Tx: rehydration, electrolyte balance, reversing acidosis • Monitoring fld/electrolyte status, glucose levels, administering insulin drip – blood glucose is usually corrected before acidosis

23. Complications: Long-Term • Angiopathy • Retinopathy • Nephropathy • Neuropathy • Skin problems • Infection

24. Nutritional Therapy • Overall goal: assist people in making changes in nutrition and exercise habits that will lead to improved metabolic control • Canada’s Food Guide Exchange System

25. Nutritional therapy • Type 1 • Meal plan based on the individual’s usual food intake and is balanced with insulin and exercise patterns • Type 2 • Emphasis placed on achieving glucose, lipid, and blood pressure goals • Caloric reduction

26. Nutritional therapy • Food composition • Individual meal plan developed with a dietician • Nutritionally balanced • Does not prohibit the consumption of any one type of food • Dietician provides initial support

27. Exercise • Essential part of diabetes management • Increases insulin sensitivity • Lowers blood glucose levels • Decreases insulin resistance • Several small complex carbohydrate snacks can be taken q30m during exercise

28. Exercise • Best done after meals • Monitor blood glucose levels before, during and after exercise

29. Blood Glucose Monitoring • Enables patient to make self-management decisions • Important for detecting episodic hypo or hyperglycemic events

30. Nursing Management • Assessment • Weight loss/gain • Thirst • Hunger • Healing pattern

31. Nursing Management • Nursing diagnosis • Ineffective therapeutic regime management • Fatigue • Risk for infection • Powerlessness

32. Nursing Management • Goals • Active patient participation • No episodes of acute hypo or hyperglycemia • Maintaining normal blood glucose levels • Prevent complications • Lifestyle adjustment with minimal stress

33. Ontario Launches Diabetes Strategy • $741 Million Plan Will Make Patients Partners In Care July 22, 2008 • Ontario is investing $741 million in new funding on a comprehensive diabetes strategy over four years to prevent, manage and treat diabetes. 

34. Diabetes Strategy • The strategy includes an online registry that will enable better self-care by giving patients access to information and educational tools that empower them to manage their disease. The registry will also give health care providers the ability to easily check patient records, access diagnostic information and send patient alerts.  

35. Key elements of the strategy include : • Improving access to insulin pumps and supplies for more than 1300 adults with type 1 diabetes by funding these services for people over the age of 18. • Expanding chronic kidney disease services, including greater access to dialysis services. • Implementing a strategy to expand access to bariatric surgery.  • Educational campaigns to prevent diabetes by raising awareness of diabetes risk factors in high risk populations, such as the Aboriginal and South Asian communities. • Increasing access to team-based care closer to home by mapping the prevalence of diabetes across the province and the location of current diabetes programs in order to align services and address service gaps. • Ontario’s diabetes strategy will help tackle a growing – and expensive – health care challenge.. Treatment for diabetes and related conditions such as heart disease, stroke, and kidney disease currently cost Ontario over $5 billion each year.