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Diabetes mellitus. Zeenat ayaz. Diabetes mellitus. D iabetes mellitus is a group of metabolic diseases characterized by elevated levels of glucose in the blood ( hyperglycemia ) resulting from defects in insulin secretion, insulin action, or both.
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Diabetes mellitus Zeenat ayaz
Diabetes mellitus Diabetes mellitus is a group of metabolic diseases characterized by elevated levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both
Insulin, a hormone produced by the pancreas, controls the level of glucose in the blood by regulating the production and storage of glucose. • 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 Also inhibits the breakdown of stored glucose, protein, and fat.
Insulin • Insulin and glucagon are hormones secreted by islet cells within the pancreas • Insulin is normally secreted by the beta cells (a type of islet cells) of the pancreas • Stimulus for insulin is high blood glucose levels
Classification Type 1 diabetes (insulin-dependent diabetes mellitus) Type 2 diabetes (non-insulindependentdiabetes mellitus) Gestational diabetes mellitus
Type 1 Diabetes Mellitus • Most often occurs in people under 30 years of age • Peak onset between ages 11 and 13 • Formerly known as “juvenile onset” or “insulin dependent” diabetes
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
Type 1 Diabetes MellitusEtiology and Pathophysiology • Causes: • Genetic predisposition • Related to human leukocyte antigens (HLAs) • Exposure to a virus
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
Type 1 Diabetes MellitusOnset of Disease • Weight loss • Polydipsia • Polyuria • Polyphagia
Type 1 Diabetes MellitusOnset of Disease • Diabetic ketoacidosis (DKA) • Occurs in the absence of exogenous insulin • Life-threatening condition • Results in metabolic acidosis
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
Type 2 Diabetes MellitusEtiology and Pathophysiology • Pancreas continues to produce some insulin • Insulin produced is either insufficient or poorly utilized by the tissues
Type 2 Diabetes MellitusEtiology and Pathophysiology • Insulin resistance • Body tissues do not respond to insulin • Results in hyperglycemia
Type 2 Diabetes MellitusEtiology and Pathophysiology • Inappropriate glucose production by the liver • Not considered a primary factor in the development of type 2 diabetes
Type 2 Diabetes MellitusOnset of Disease • Gradual onset • Person may go many years with undetected hyperglycemia • 75% of type 2 diabetes is detected incidentally
Gestational Diabetes • Develops during pregnancy • Detected at 24 to 28 weeks of gestation • Risk for cesarean delivery, perinatal death, and neonatal complications
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
Clinical ManifestationsDiabetes Mellitus • Polyuria • Polydipsia (excessive thirst) • Polyphagia • In Type I • Weight loss • Ketoacidosis
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
Risk Factors for Diabetes Mellitus Family history of diabetes (i.e., parents or siblings with diabetes) Obesity (i.e., ≥20% over desired body weight or BMI ≥27 kg/m2) Race/ethnicity (e.g., African Americans, Hispanic Americans, Native Americans, Asian Americans, Pacific Islanders) Age ≥45 years Previously identified impaired fasting glucose or impaired glucose tolerance
Risk factors (cont.) Hypertension (≥140/90 mm Hg) HDL cholesterol level ≤35 mg/dL (0.90 mmol/L) and/or tri- glyceride level ≥250 mg/dL (2.8 mmol/L) History of gestational diabetes or delivery of babies over 9 lbs
ASSESSMENT AND DIAGNOSTIC FINDINGS high blood glucose level Fasting plasma glucose (FPG) levels of 126 mg/dL (7.0 mmol/L) or more random plasma glucose levels exceeding 200 mg/dL (11.1 mmol/L) on more than one occasion Plasma glucose values may be 10% to 15% higher than whole
goal The main goal of diabetes treatment is to normalize insulin activity and blood glucose levels to reduce the development of vascular and neuropathic complications.
management There are five components of diabetes management • Nutritional management • Exercise • Monitoring • Pharmacologic therapy • Education
Treatment varies because of changes in lifestyle and physical and emotional status as well as advances in treatment methods. Therefore, diabetes management involves constant assessment and modification of the treatment plan by health professionals and daily adjustments in therapy by the patient.
Diabetes MellitusAcute Complications • Hypoglycemia • Diabetic ketoacidosis (DKK) • Hyperosmolar hyperglycemic nonketotic syndrome (HHNS)
hypoglycemia • Type 1 or type 2 diabetes • Blood glucose < 50-60 mg/dL • Causes • Too much insulin • Overdose of oral antidiabetic agents • Too little food • Excess physical activity • May experience S & S of hypoglycemia if there is sudden decrease in BS
hypoglycemia • Treatment • Mild • Immediate treatment • 15 g rapid-acting sugar • Severe • Hospitalized • Intravenous glucose • Teach patients to carry simple sugar with them
Life-threatening illness in type 1 • Hyperglycemia • Dehydration and electrolyte loss • Acidosis • Causes of DKA • Decreased or missed dose of insulin, • Illness or infection, • Undiagnosed and untreated diabetes
Without insulin, the amount of glucose entering the cells is reduced, and production and release of glucose by the liver is increased (lead to hyperglycemia). • Excess glucose leads to polyuria (6.5 L/day) dehydration, sodium and potassium loss • Burning of fat leads to ketosis • Kidneys unable to excrete ketones, leads to ketoacidosis
Diagnosis: Blood glucose (300 and 800 mg/dL) • Treatment • Rehydration (0.9-0.45% saline) • Restoring Electrolytes (K+) • loss of potassium from body stores and an intracellular-to-extracellular shift of potassium • Reversing Acidosis (reversed with insulin) • Regular insulin infusion (5 units/hr) • Hourly blood glucose monitoring
Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) • Is a serious condition most frequently seen in older persons. • HHNS is usually brought on by something else, such as an illness or infection, dialysis, drugs that increase BS. • Blood sugar levels rise resulting into glycosuria, polyuria, thirst. • Severe dehydration will lead to seizures, coma and eventually death. • HHNS may take days or even weeks to develop. Know the warning signs of HHNS.
HHNS/ clinical manifestations Hypotension, profound dehydration (dry mucous membranes, poor skin turgor), tachycardia, and variable neurologic signs (eg, alteration of sensorium, seizures, hemiparesis). Blood glucose level (600 to 1200 mg/dL) Treatment: fluid replacement, correction of electrolyte imbalances, and insulin.
Diabetes MellitusChronic Complications • Macrovascular (atherosclerotic plaque) • Coronary arteries → (MI’s) • Cerebral arteries → (strokes) • Peripheral vessels → (ulcers, amputations, infection) • Microvascular (capillary damage) • Retinopathy • Neuropathy • Nephropathy
Macrovascular Complications • Macrocirculation • Blood vessel walls thicken, sclerose, and become occluded by plaque that adheres to the vessel walls. finally, blood flow is blocked. • Complications • Coronary artery disease • Stroke • Peripheral vascular disease
Complication: CAD CAD account for 50% to 60% of all deaths among patients with diabetes. High cholesterol and high triglycerides MI is twice as common in men and three times in women with diabetes, compared to people without diabetes. Silent MI Higher risk for a second infarction
Complication: Stroke People with diabetes have twice the risk of developing cerebrovascular disease. There is a greater likelihood of death from cerebrovascular disease. Recovery is slower with high BS. Hypertension plays a role
Complication: Peripheral Vascular Disease • Diabetes-induced arteriosclerosis • 2-3 times higher than in nondiabetic people • S & S: diminished peripheral pulses and intermittent claudication (pain in the buttock, thigh, or calf during walking) • Can lead to leg ulcers and gangrene and amputation.
Management of Macrovascualr changes • Prevention and treatment of risk factors for atherosclerosis. • obesity, hypertension, and hyperlipidemia (exercise, stop smoking). • Control of blood glucose levels may reduce triglyceride concentrations and can significantly reduce the incidence of complications.
Microvascular Complications • Microcirculation • Eyes • Kidneys • Nerves
Complication: Diabetic Retinopathy Leading cause of blindness in people ages 20 to 74 in US Almost all patients with type 1 diabetes and more than 60% of patients with type 2 diabetes have some degree of retinopathy after 20 years
Diabetic Retinopathy Changes in the retinal capillaries; lead to retinal ischemia. Changes include microaneurysms, intraretinal hemorrhage, hard exudates, and focal capillary closure. Yearly eye exams are recommended