chapter 41 assessment and management of patients with diabetes mellitus

Chapter 41Assessment and Management

of Patients With Diabetes Mellitus

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Diabetes MellitusDefinition


• Is a group of metabolic diseases characterized by increased levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both

• related to:– An endocrine disorder causes Abnormal insulin An endocrine disorder causes Abnormal insulin

productionproduction– Impaired insulin utilization Impaired insulin utilization – Both abnormal production and impaired Both abnormal production and impaired

utilization utilization

• Is a group of metabolic diseases characterized by increased levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both

• related to:– An endocrine disorder causes Abnormal insulin An endocrine disorder causes Abnormal insulin

productionproduction– Impaired insulin utilization Impaired insulin utilization – Both abnormal production and impaired Both abnormal production and impaired

utilization utilization

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• Leading cause of heart disease, stroke, adult blindness, and nontraumatic lower limb amputations

• Leading cause of heart disease, stroke, adult blindness, and nontraumatic lower limb amputations

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Diabetes MellitusEtiology and Pathophysiology

Diabetes MellitusEtiology and Pathophysiology

– Produced by the cells in the islets of Langherans of the pancreas

– Facilitates normal glucose range of 70 to 120 mg/dl

– Produced by the cells in the islets of Langherans of the pancreas

– Facilitates normal glucose range of 70 to 120 mg/dl

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Diabetes Mellitusfunctions of insulin Diabetes Mellitusfunctions of insulin

• 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

• Inhibits breakdown of stored glucose, protein, and fat.

• 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

• Inhibits breakdown of stored glucose, protein, and fat.

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Type 1 Diabetes MellitusType 1 Diabetes Mellitus

• Formerly known as “juvenile onset” or “insulin dependent” diabetes

• 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

• Most often occurs in people under 30 years of age

• Peak onset between ages 11 and 13

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Type 1 Diabetes MellitusEtiology and PathophysiologyType 1 Diabetes Mellitus

Etiology and Pathophysiology

• Progressive destruction of pancreatic cells

• Autoantibodies cause a reduction of 80% to 90% of normal cell function before manifestations occur

• Progressive destruction of pancreatic cells

• Autoantibodies cause a reduction of 80% to 90% of normal cell function before manifestations occur

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• Causes:

– Genetic predisposition

• Related to human leukocyte antigens (HLAs)

– Exposure to a virus

• Causes:

– Genetic predisposition

• Related to human leukocyte antigens (HLAs)

– Exposure to a virus

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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

• Manifestations develop when the pancreas can no longer produce insulin

– Rapid onset of symptoms

– Present at ER with ketoacidosis

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• Weight loss

• Polydipsia

• Polyuria

• Polyphagia

• Weight loss

• Polydipsia

• Polyuria

• Polyphagia

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• Diabetic ketoacidosis (DKA)

– Occurs in the absence of exogenous insulin

– Life-threatening condition

– Results in metabolic acidosis

• Diabetic ketoacidosis (DKA)

– Occurs in the absence of exogenous insulin

– Life-threatening condition

– Results in metabolic acidosis

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Type 2 Diabetes MellitusType 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

• Accounts for 90% of patients with diabetes

• Usually occurs in people over 40 years of age

• 80-90% of patients are overweight

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• Pancreas continues to produce some endogenous insulin

• Insulin produced is either insufficient or poorly utilized by the tissues

• Pancreas continues to produce some endogenous insulin

• Insulin produced is either insufficient or poorly utilized by the tissues

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• Insulin resistance

– Body tissues do not respond to insulin

– Results in hyperglycemia

• Insulin resistance

– Body tissues do not respond to insulin

– Results in hyperglycemia

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• Inappropriate glucose production by the liver

– Not considered a primary factor in the development of type 2 diabetes

• Inappropriate glucose production by the liver

– Not considered a primary factor in the development of type 2 diabetes

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• Gradual onset

• Person may go many years with undetected hyperglycemia

• 75% of type 2 diabetes is detected incidentally

• Gradual onset

• Person may go many years with undetected hyperglycemia

• 75% of type 2 diabetes is detected incidentally

Type 2 Diabetes Mellitus

• Etiology (not well know)

– Genetic factors

– Increased weight.

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Gestational DiabetesGestational Diabetes

• Develops during pregnancy

• Detected at 24 to 28 weeks of gestation Risk for cesarean delivery, perinatal

death, and neonatal complications

• Develops during pregnancy

• Detected at 24 to 28 weeks of gestation Risk for cesarean delivery, perinatal

death, and neonatal complications

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Secondary DiabetesSecondary 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

• 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

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Clinical ManifestationsDiabetes Mellitus

Clinical ManifestationsDiabetes Mellitus

• Polyuria

• Polydipsia (excessive thirst)

• Polyphagia

• In Type I– Weight loss– Ketoacidosis

• Polyuria

• Polydipsia (excessive thirst)

• Polyphagia

• In Type I– Weight loss– Ketoacidosis

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Clinical ManifestationsNon-specific symptoms

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

– Fatigue and weakness– Sudden vision changes– Tingling or numbness in hands or feet– Skin lesions or recurrent infections– Prolonged wound healing– Visual changes

Clinical Manifestations

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Diabetes MellitusDiagnostic StudiesDiabetes MellitusDiagnostic Studies

• Fasting plasma glucose level 126 mg/dl

• Random plasma glucose measurement

200 mg/dl plus symptoms

• Two-hour OGTT level 200 mg/dl using a glucose load of 75 g

• Fasting plasma glucose level 126 mg/dl

• Random plasma glucose measurement

200 mg/dl plus symptoms

• Two-hour OGTT level 200 mg/dl using a glucose load of 75 g

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Assessing the Patient With Diabetes

Assessing the Patient With Diabetes

• History :

• Physical Examination

• Laboratory Examination

• Need for Referrals

• History :

• Physical Examination

• Laboratory Examination

• Need for Referrals

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Diabetes MellitusCollaborative CareDiabetes MellitusCollaborative Care

• Goals of diabetes management:

– Reduce symptoms

– Promote well-being

– Prevent acute complications

– Delay onset and progression of long-term complications

• Goals of diabetes management:

– Reduce symptoms

– Promote well-being

– Prevent acute complications

– Delay onset and progression of long-term complications

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Diabetes MellitusNutritional TherapyDiabetes Mellitus

Nutritional Therapy

– Overall objectives

• Assist people in making changes in nutrition and exercise habits that will lead to improved metabolic control

• Control of total caloric intake to attain or maintain a reasonable body weight, control of blood glucose levels, and normalization of lipids and blood pressure to prevent heart disease.

– Overall objectives

• Assist people in making changes in nutrition and exercise habits that will lead to improved metabolic control

• Control of total caloric intake to attain or maintain a reasonable body weight, control of blood glucose levels, and normalization of lipids and blood pressure to prevent heart disease.

• Obesity is associated with an increased resistance to insulin.

• Some obese patients who have type 2 diabetes and who require insulin or oral agents to control blood glucose levels may be able to reduce or eliminate the need for medication through weight loss.

• A weight loss as small as 10% of total weight may significantly improve blood glucose levels

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Nutritional Therapy

• Type 1 DM

– Meal plan based on the individual’s usual food intake and is balanced with insulin and exercise patterns

• Type 1 DM

– Meal plan based on the individual’s usual food intake and is balanced with insulin and exercise patterns

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Nutritional Therapy

• Type 2 DM

– Emphasis placed on achieving glucose, lipid, and blood pressure goals

– Calorie reduction

• Type 2 DM

– Emphasis placed on achieving glucose, lipid, and blood pressure goals

– Calorie reduction

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Nutritional Therapy

• Food composition

– Individual meal plan developed with a dietitian

– Nutritionally balanced

– Does not prohibit the consumption of any one type of food


– Individual meal plan developed with a dietitian

– Nutritionally balanced

– Does not prohibit the consumption of any one type of food

Diabetes MellitusNutritional Therapy/Caloric Distribution

• Calculate daily caloric requirement.

• Carbohydrates– 50% to 60% of caloric intake. – Majority of calories should come from grains– Foods high in carbohydrates, such as sucrose,

are not eliminated from the diet but should be eaten in moderation (up to 10% of total calories

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• Fats– 20% to 30% of calories come from fat. – Limit the amount of saturated fats to 10% of

total calories

• Proteins– 10% to 20% of calories come from protein.

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• Fiber – Lower total cholesterol and LDL in the blood. – Improve blood glucose levels – Decrease the need for exogenous insulin.– Increase satiety, which is helpful for weight

loss

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Nutritional Therapy


– Alcohol

• High in calories (lead to weigh gain)

• Promotes hypertriglyceridemia

• Can cause severe hypoglycemia


– Alcohol

• High in calories (lead to weigh gain)

• Promotes hypertriglyceridemia

• Can cause severe hypoglycemia

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Nutritional Therapy

• Diet teaching

– Dietitian initially provides instruction

– Should include the patient’s family and significant others

– Read food labels

– Sweetners

• Diet teaching

– Dietitian initially provides instruction

– Should include the patient’s family and significant others

– Read food labels

– Sweetners

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Diabetes MellitusExercise


– Essential part of diabetes management

– Increases insulin sensitivity

– Lowers blood glucose levels

– Decreases insulin resistance

– Decreases weight

– Reduces cardiovascular risk factors

– Essential part of diabetes management

– Increases insulin sensitivity

– Lowers blood glucose levels

– Decreases insulin resistance

– Decreases weight

– Reduces cardiovascular risk factors

Diabetes MellitusExercise/ Precautions

• Don’t exercise if blood glucose > 250 mg/dL or if there is ketone bodies in the urine.

• Don’t exercise when the insulin at its peak

• Use proper footwear and.

• Avoid exercise in extreme heat or cold.

• Inspect feet daily after exercise.

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– Several small carbohydrate snacks can be taken to prevent hypoglycemia

• Before exercising

• At the end of the exercise with strenuous exercise

• At be time with strenuous exercise

• Deduce them from total daily calories

– May need to reduce inlsulin dose

– Several small carbohydrate snacks can be taken to prevent hypoglycemia

• Before exercising

• At the end of the exercise with strenuous exercise

• At be time with strenuous exercise

• Deduce them from total daily calories

– May need to reduce inlsulin dose

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– Best done after meals

– Exercise plans should be individualized

– Monitor blood glucose levels before, during, and after exercise

– Better to exercise at the same time daily when blood sugar at its peak

– Best done after meals

– Exercise plans should be individualized

– Monitor blood glucose levels before, during, and after exercise

– Better to exercise at the same time daily when blood sugar at its peak

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Diabetes MellitusMonitoring Blood Glucose


• Self-monitoring of blood glucose (SMBG)

– Enables patient to make self-management decisions regarding diet, exercise, and medication


– Enables patient to make self-management decisions regarding diet, exercise, and medication

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– Important for detecting episodic hyperglycemia and hypoglycemia

– Patient training is crucial


– Important for detecting episodic hyperglycemia and hypoglycemia

– Patient training is crucial

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Diabetes MellitusDrug Therapy: Insulin


• Exogenous insulin:

– Required for type 1 diabetes

– Prescribed for the patient with type 2 diabetes who cannot control blood glucose by other means

• Exogenous insulin:

– Required for type 1 diabetes

– Prescribed for the patient with type 2 diabetes who cannot control blood glucose by other means

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• Types of insulin

– Human insulin

• Most widely used type of insulin

• Cost-effective Likelihood of allergic reaction


– Human insulin

• Most widely used type of insulin

• Cost-effective Likelihood of allergic reaction

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– Insulins differ in regard to onset, peak action, and duration

– Different types of insulin may be used in combination therapy


– Insulins differ in regard to onset, peak action, and duration

– Different types of insulin may be used in combination therapy

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• Types of insulin– Rapid-acting: Lispro (onset 15’, peak 60-90’ and last

from 2-4 hours)

– Short-acting: Regular (Onset is 30-60’, peak in 2-3h and last for 4-6 hours, and Regular insulin is only kind for IV use.

• Types of insulin– Rapid-acting: Lispro (onset 15’, peak 60-90’ and last

from 2-4 hours)

– Short-acting: Regular (Onset is 30-60’, peak in 2-3h and last for 4-6 hours, and Regular insulin is only kind for IV use.

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– Intermediate-acting: NPH or LenteOnset 3-4h, peak 4-12 hours and lst 16-20 hours. Names include

Humulin N, Novolin N, Humulin L, Novolin L

– Long-acting: Ultralente, LantusOnset 6-8h, peak 12-16 h and lasts 20-30h.

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• Administration of insulin

– Cannot be taken orally

– SQ injection for self-administration

– IV administration

• Administration of insulin

– Cannot be taken orally

– SQ injection for self-administration

– IV administration

Insulin Strengths

• Insulin Strengths– 100 U per mL or 500 U per mL– Administered in a sterile, single-use,

disposable syringe– All insulin given parenterally– Regular insulin: either subcutaneous or

intravenous

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Injection Sites

• Process: pinch skin, inject needle at 90-degree angle

• Do not inject into muscle; do not massage after injecting

• Rotate injection sites

• Minimize painful injections

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Injection SitesInjection Sites

Fig. 47-5

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• Complications of insulin therapy

– Hypoglycemia

– Allergic reactions

• Lipodystrophy : is a medical condition characterized by abnormal or degenerative conditions of the body's adipose tissue– Includes lipoatrophy or lipohypertrophy


– Hypoglycemia

– Allergic reactions

• Lipodystrophy : is a medical condition characterized by abnormal or degenerative conditions of the body's adipose tissue– Includes lipoatrophy or lipohypertrophy


(Morning hyperglycemia)• Insulin Waning (Progressive rise in blood

glucose from bedtime to morning)– Increase evening’ NPH (predinner or bedtime)

dose

• Dawn Phenomenon (Relatively normal blood glucose until about 3 AM, when the level begins to rise)– Change time of injection of evening NPH from

dinnertime to bedtime.58

Complications of insulin therapy(Morning hyperglycemia)

• Somogyi Effect (Normal or elevated blood glucose at bedtime, a decrease at 2–3 AM to hypoglycemic levels, and a subsequent increase caused by the production of counterregulatory hormones– Decrease evening (predinner or bedtime) dose of

intermediate-acting insulin, or increase bedtime snack.

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Complications of insulin therapy

• Resistance to Injected Insulin– Most patients have some degree of insulin

resistance at one time or another. – The most common is obesity.

• Local Allergic Reactions– Redness swelling, tenderness and induration or a 2-

to 4-cm wheal

• Systemic Allergic Reactions (rare)– Immediate local skin reaction that gradually

spreads into generalized urticaria (hives). 60

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Diabetes MellitusDrug Therapy: Oral Agents


• Used only in type II DM

• They increases the secretion of insulin by the pancreatic beta cells, may improve binding between insulin and insulin receptors or increase the number of insulin receptors

• Used only in type II DM

• They increases the secretion of insulin by the pancreatic beta cells, may improve binding between insulin and insulin receptors or increase the number of insulin receptors

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• Used along with (but not a substitute to) nutrition and exercise.

• In time, they may no longer be effective in controlling the patient's diabetes because of decline of beta cells. In such cases, the patient is treated with insulin.

• Used along with (but not a substitute to) nutrition and exercise.

• In time, they may no longer be effective in controlling the patient's diabetes because of decline of beta cells. In such cases, the patient is treated with insulin.

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• Sulfonylureas: Glipizide, Glyburide and Glimepiride, Chlorpropamide (Diabinese)

• Meglitinides: Prandin & Starlix

• Biguanides: Metformin-Glucosidase inhibitors: Acarbose. Delay

absorption of CHO

• Thiazolidinediones: Pioglitazone (Actos)

• Sulfonylureas: Glipizide, Glyburide and Glimepiride, Chlorpropamide (Diabinese)

• Meglitinides: Prandin & Starlix

• Biguanides: Metformin-Glucosidase inhibitors: Acarbose. Delay

absorption of CHO

• Thiazolidinediones: Pioglitazone (Actos)

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• Other drugs affecting blood glucose levels: -Adrenergic blockers

– Adrenaline

– Corticosteoids

• Other drugs affecting blood glucose levels: -Adrenergic blockers

– Adrenaline

– Corticosteoids

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Diabetes MellitusPancreas Transplantation

Diabetes MellitusPancreas Transplantation

Used for patients with type 1 diabetes who have end-stage renal disease and who have had or plan to have a kidney transplant

Used for patients with type 1 diabetes who have end-stage renal disease and who have had or plan to have a kidney transplant

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Diabetes MellitusNew Developments in Diabetic

Therapy

Diabetes MellitusNew Developments in Diabetic

Therapy

• New insulin delivery systems not yet approved by the FDA:

– Inhaled insulin

– Skin patch

– Oral spray

• New insulin delivery systems not yet approved by the FDA:

– Inhaled insulin

– Skin patch

– Oral spray

Diabetes MellitusPatient education

1. Simple pathophysiology– Basic definition of diabetes (having a high

blood glucose level)– Normal blood glucose ranges– Effect of insulin and exercise (decrease glucose)– Effect of food and stress, including illness and

infections (increase glucose)– Basic treatment approaches

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2. Treatment modalities– Administration of medications– Meal planning (food groups, timing of meals)– Monitoring of blood glucose and urine ketones

3. Recognition, treatment, and prevention of acute complications– Hypoglycemia– Hyperglycemia

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4. Pragmatic information– Where to buy and store insulin, syringes, and

glucose monitoring supplies– When and how to contact the physician

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• Planning In-Depth and Continuing Education– Foot care– Eye care– General hygiene (eg, skin care, oral hygiene)– Risk factor management (eg, control of blood

pressure and blood lipid levels, normalizing blood glucose levels)

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Diabetes Mellitus Misconceptions Related to Insulin Treatment

1. Once insulin injections are started (for treatment of type 2 diabetes), they can never be discontinued

2. If increasing doses of insulin are needed to control the blood glucose, the diabetes must be getting “worse”

3. Insulin causes blindness (or other diabetic complications)

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Diabetes Mellitus Misconceptions Related to Insulin Treatment

4. Insulin must be injected directly into the vein

5. There is extreme danger in injecting insulin if there are any air bubbles in the syringe

6. Insulin always causes people to have bad (hypoglycemic) reactions

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Diabetes MellitusAcute ComplicationsDiabetes Mellitus

Acute Complications

• Hypoglycemia

• Diabetic ketoacidosis (DKK)

• Hyperosmolar hyperglycemic nonketotic syndrome (HHNS)

• 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 75

Hypoglycemia

• Treatment– Mild

• Immediate treatment

• 15 g rapid-acting sugar

– Severe• Hospitalized

• Intravenous glucose

– Teach patients to carry simple sugar with them

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Diabetes Ketoacidosis (DKA)

• 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

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DKA

• 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 79

DKA

• 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 81

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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.

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chapter 41 assessment and management of patients with diabetes mellitus

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