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

Diabetes Mellitus • 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)

Diabetes Mellitus 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 • Diagnosis • Patient is symptomatic plus • Casual plasma glucose (non-fasting) is 200 mg/dl OR • Fasting plasma glucose of 126 mg/dl or higher OR • Two hour plasma glucose level of 200 mg/dl or greater during an oral glucose tolerance test

Diabetes Mellitus Diabetic Ketoacidosis (DKA) 1. 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 • Mortality as high as 14% 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) • G. serum osmolality < 350 mosm/kg (normal 280-300)

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

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

Diabetes Mellitus • DKA • d.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 • e. Monitor cardiac rhythm since hypokalemia puts client at risk for dysrrhythmias • f. Treat underlying condition precipitating DKA • G. Acidosis is corrected with fluid and insulin therapy and rarely needs bicarb

Diabetes Mellitus Diabetes Type 2 • A. Definition: condition of fasting hyperglycemia occurring despite availability of body’s own insulin • B. 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

Diabetes Mellitus 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 • Syndrome X or Metabolic Syndrome • Chronic, low grade inflammatory process • Gives rise to diabetes type 2, ischemic heart disease, left ventricular hypertrophy • Group of disorders with insulin resistance as the main feature • Includes • Obesity especially around the waist and abdomen • Low levels of physical activity • High blood pressure • Increased blood cholesterol (high LDL, low HDL, high triglycerides

Diabetes Mellitus Manifestations 1. Client usually unaware of diabetes • a. Discovers diabetes when seeking health care for another concern • b. Most cases aren’t diagnosed for 5-6 years after the development of the disease • c. Usually does not experience weight loss

Diabetes Mellitus 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 Nonketotic Syndrome (HHNS) 1. Potential complication of Diabetes Type 2 • Life threatening medical emergency, high mortality rate, as high as 50% • Enough insulin is secreted to prevent ketosis, but not enough to prevent hyperglycemia • High blood sugar causes an extreme diuresis with severe electrolyte and fluid loss

Characterized by • Plasma osmolarity 340 mOsm/l or greater- normal 280-300 • Blood glucose severely elevated, 800-1000 • Altered level of consciousness

Diabetes Mellitus 4. Precipitating factors • a. Infection (most common) • pneumonia • b. Therapeutic agent or procedure • c. Acute or chronic illness • MI • Stroke • Pancreatitis • pregnancy 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, tachycardia, polyuria, hypotension

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 • Monitor for renal failure • 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 • 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

Diabetes Mellitus • 4. Somogyi effect: combination of hypoglycemia during night with a rebound morning hyperglycemia that may lead to insulin resistance for 12 to 48 hours

Diabetes Mellitus 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

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 • Increased chance of having a silent MI and delaying medical treatment • 2. Most common cause of death for diabetics (40 – 60%) • 3. Diabetics more likely to develop Congestive Heart Failure

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

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

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

Diabetic Foot Ulcer

Diabetes Mellitus Diabetic Retinopathy 1. Definition • a. Retinal changes related to diabetes • Hemorrhage, swelling, decreased vision • b. Leads to retinal ischemia and breakdown of blood-retinal barrier 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 • Diabetics should be screened for retinopathy and receive treatment (laser photocoagulation surgery) to prevent vision loss • Should be sent immediately to ophthalmologist upon diagnosis because may already have damage 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 • Male erectile dysfunction • Half of all diabetic men have erectile dysfunction

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 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% • b. 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 )

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) • a. If albumin present, indicates need for workup for nephropathy • b. Typical order is creatinine clearance testing

Diabetes Mellitus 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 withDKA or HHNS

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, HHNS • 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 • Injection sites • Abdominal areas is the most preferred because of rapid absorption • Do not aspirate insulin injections • Administration covered in the lab

Diabetes Mellitus

Diabetes Injection Sites

Diabetes Mellitus • When rapid acting or short acting insulin is mixed with longer acting insulin, draw the short acting insulin into the syringe first. • Prevents contamination of the shorter acting insulin with the longer acting insulin • Draw up clear, then cloudy • Insuling glargine (Lantus) should not be mixed with any other insulin

Diabetes Mellitus • Mixing insulin

Diabetes Mellitus