Diabetes

1. Diabetes Irene Owens, MSN, ARNP

2. What Is Diabetes Mellitus? • The inability of the body to produce or respond properly to the hormone insulin • Results in a malfunction of carbohydrate, protein, and fat metabolism • A chronic disease that requires lifelong behavioral changes

3. Types of Diabetes Type 1 diabetes • Called insulin-dependent diabetes mellitus or juvenile-onset diabetes • Usually strikes children and young adults, although disease onset can occur at any age • May account for 5% to 10% of all diagnosed cases of diabetes Type 2 diabetes • Called non-insulin-dependent diabetes mellitus or adult-onset diabetes • Associated with older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity, and race/ethnicity • Increasingly being diagnosed in children and adolescents

4. Diagnosis • Fasting plasma glucose concentration of 126 mg/dL or greater • 2-hour plasma glucose is 200 mg/dL or greater during an oral glucose tolerance test

5. Type 1 vs Type 2 Diabetes Mellitus Type 1 • Insulin deficiency • Abrupt onset • Ketosis prone • Generally not obese • Insulin dependent • Not responsive to oral agents • Onset usually 18 years or younger Type 2 • Insulin resistance • Insidious onset • Not prone to ketosis • Usually obese • Non–insulin dependent • Responsive to oral hypoglycemic medications • Onset usually in adults but seen in obese adolescents

6. Type 1 Diabetes Clinical manifestations • Polyphagia, polydipsia, and polyuria (“3 P’s”) • Unexplained weight loss • Blurred vision • Lack of energy • Diminished reflexes • Irritability • Nausea and vomiting • Fruity odor of breath • Kussmaul respirations

8. Type 1 Diabetes • Incidence: 15 per 100,000 people in North America • Peak ages of onset: between 10 and 12 years of age in girls and 12 to 14 years of age in boys • Risk increases if the child or adolescent has a first-degree relative or identical twin with disease • Type 1 diabetes may show a familial tendency • Theories for disease development include genetic components, environmental influences such as viruses, and an autoimmune response that causes the destruction of insulin-secreting cells of the pancreas in the islets of Langerhans

9. Type 1 Diabetes Pathophysiology • 90% of the insulin-secreting cells (Beta) of the pancreas are progressively destroyed • Absence of insulin available for metabolism causes fats and proteins to be burned • Characterized by chronic hyperglycemia • Ketones are produced as a byproduct of fat metabolism • Ketones cannot be used by the cells in the absence of insulin • Ketones accumulate in the blood, causing metabolic acidosis and ketonuria

10. Insulin Therapy

11. Complications of Insulin Therapy • Lipoatrophy • Lipohypertrophy • Dawn phenomenon • Somogyi’s phenomenon

12. Acute Complications of Diabetes • Diabetic ketoacidosis (DKA) • Hyperglycemic-hyperosmolar state (HHS)- was called Hyperglycemic-hyperosmolar-nonketotic syndrome (HHNS) in the past • Hypoglycemia from too much insulin or too little glucose

13. Insulin Therapy • Divided as two thirds before breakfast and one third before dinner • Two thirds as intermediate, one third as short or rapid • Twice-daily regimen most common

14. Insulin Therapy • Rotation of sites • Mix insulin from clear to cloudy • Inject in subcutaneous tissue • Do not premix any insulin unless advised • Timing of injections in relation to meals • Insulin can be stored at room temperature • Only regular insulin may be administered intravenously

15. Insulin Delivery Systems • Current systems • Syringes • Insulin pens • Insulin pumps

16. Monitoring • Glucose testing is more accurate and is the preferred method of monitoring glucose levels • Glycosylated hemoglobin (hemoglobin A1c) level is usually measured every 3 months to evaluate long-term control • The higher the hemoglobin A1c, the poorer the control has been over the last 3 months

17. Benefits of Regular Physical Activity • Helps the body use glucose more effectively • Weight loss and maintenance • Increases HDL and lowers LDL cholesterol • Lowers blood glucose levels • Muscular strength • Cardiorespiratory (aerobic) fitness • Increases bone mass (through weight-bearing activities) • Relieves anxiety and stress • Increases self-esteem

19. Complications of Diabetes: Hypoglycemia Blood sugar of usually less than 70 mg/dL Clinical manifestations • Shakiness, dizziness • Sweating • Hunger • Headache • Irritability • Pale skin color • Sudden moodiness or behavior changes, such as crying for no apparent reason • Blurred vision • Increased heart rate • Weakness and fatigue

20. Complications of Diabetes: Hypoglycemia Causes • Too little food • Too much insulin • Extra or vigorous exercise Treatment • Severe symptoms may require administration of intramuscular glucagon • Fruit juice, carbonated soda, several hard candies • Follow with some protein and a complex carbohydrate • Test and monitor blood sugar once symptoms subside

22. Complications of Diabetes: Hyperglycemia Blood glucose greater than 180 mg/dL and stays there for several readings Clinical manifestations • Extreme thirst • Frequent urination • Blurred vision • Drowsiness • Nausea • Hunger

23. Complications of Diabetes: Hyperglycemia Causes • Not enough insulin • Larger food intake than usual • Less exercise than usual • Illness such as cold or flu • Stresses from family, school, or personal situations Treatment • Push sugar-free liquids • Insulin • Activity

24. Illness Management • Continue insulin treatment Patients with type 1 diabetes need insulin to live. Illness often increases the amount of insulin the body needs. Insulin should never be withheld. • Stay close to the meal planIf a patient has an upset stomach and cannot eat, give clear liquids that contain carbohydrates (sports drinks, juices, gelatin, broth, frozen fruit bars). • Give plenty of liquidsEncourage the patient to drink as much water and other noncaffeinated beverages as possible.

25. Illness Management Choose medications wisely • Many over-the-counter medications contain sugar and/or alcohol. • Glucose in medications can rapidly add up; patients should look for a glucose-free version of the medication. If unavailable, carbohydrates must be accounted for in the meal plan. • Alcohol-free medicines are best. • Many decongestants can raise blood glucose levels.

26. Food for Sick Days Fluids • 1 double-stick popsicle • 1 cup electrolyte sports drink • 1 cup soup • 1/2 cup fruit juice • 1/2 cup regular soft drink (not diet) Solids • Crackers • Vanilla wafers • Graham crackers • 1 slice dry toast (not light bread) • Mashed potatoes • Regular gelatin dessert • Patients may not want to eat when sick • They must eat to keep the body from burning fats for fuel and to speed healing. • Food ideas for sick days for patients with diabetes include:

27. Long-Term Complications of Diabetes • Microvascular problems • Neuropathy • Retinopathy • Nephropathy • Macrovascular problems • Peripheral vascular disease • Atherosclerosis

28. Developmental Issues Infants • Very rapid growth • Continuing brain development • Trusting relationships with the parents • Erratic eating habits (food can become a power struggle) • Erratic sleep patterns • Treatment schedule is difficult to keep because of feeding and sleeping patterns

29. Developmental Issues Toddlers • Can participate in some self-care • Look for parental approval while they test their limits • Show decreased appetite and picky eating habits (easily distracted from eating) • Begin to show more regular sleep patterns • Difficult to distinguish a low blood sugar reaction from a normal temper tantrum

30. Developmental Issues Preschool • Peer issues begin to emerge • Can understand rules • Can perform more self-care, including blood tests under parental supervision • Eating behavior is less erratic • Very energetic, so hypoglycemia can be a problem • Regular sleep patterns • May be more challenging to provide snacks and meals that match what siblings and friends eat

31. Developmental Issues School age • Fear of being different from other children • Can perform most self-care, including blood tests and insulin injections • Eager to learn • Beginning to understand consequences of their actions • Tests independent decision making • Most time spent away from home

32. Developmental Issues Early adolescence • Erratic growth, which affects insulin requirements • Glucose control may be erratic in spite of everyone’s best efforts • Concerned about body image • Greatly influenced by friends • May challenge authority • Development of self-esteem • Beginning to understand abstract concepts

33. Developmental Issues Adolescence • Puberty is well underway • Concerned with physical appearance • Clearer sense of self (can set goals) • Increased autonomy • Risk-taking behaviors, including not taking insulin and not performing blood sugar tests • Many social activities are unpredictable • Counseling regarding contraception, alcohol, and smoking

34. Proper Foot Care • Foot injury is the most common complication of diabetes leading to hospitalization • Prevention of high-risk conditions • Peripheral sensation management • Footwear • Foot care

35. Chronic Pain • Neuropathic pain results from damage to the nervous system anywhere along the nerve • Pharmacologic agents • Nonpharmacologic interventions

36. Ineffective Tissue Perfusion: Renal • Interventions include: • Control of blood glucose levels • Yearly evaluation of kidney function • Control of blood pressure levels • Prompt treatment of UTIs • Avoidance of nephrotoxic drugs • Diet therapy • Fluid and electrolyte management

37. Risk for Injury Related to Disturbed Sensory Perception: Visual • Interventions include: • Blood glucose control • Environmental management: • Incandescent lamp • Coding objects • Syringes with magnifiers • Use of adaptive devices

38. Potential for Hypoglycemia • Blood glucose level <70 mg/dL • Diet therapy—carbohydrate replacement • Drug therapy—glucagon, 50% dextrose, diazoxide, octreotide • Prevention strategies for: • Insulin excess • Deficient food intake • Exercise • Alcohol

39. Resources for Parents and Children • American Diabetes Association www.diabetes.org/home.jsp • Children with Diabeteswww.childrenwithdiabetes.com/index_cwd.htm • KidsHealthkidshealth.org • The Lawson Wilkins Pediatric Endocrine Society www.lwpes.org • The Magic Foundationwww.magicfoundation.org • The US National Library of Medicine National Institutes of Healthwww.nlm.nih.gov/medlineplus/encyclopedia.html