diabetes mellitus

A thorough discussionA thorough discussionabout the Assessment about the Assessment and Management of and Management of

Patients with Diabetes Patients with Diabetes MellitusMellitus

Prepared by: Dave Jay S. Manriquez Prepared by: Dave Jay S. Manriquez RN.RN.

Diabetes MellitusDiabetes Mellitus

A heterogeneous group of disorders A heterogeneous group of disorders characterized by an elevation in the characterized by an elevation in the level of glucose in the blood.level of glucose in the blood.

In Diabetes there may be a In Diabetes there may be a decrease in the body’s ability to decrease in the body’s ability to respond to insulin and/or a respond to insulin and/or a decrease or absence of insulin decrease or absence of insulin produced by the pancreas.produced by the pancreas.

Diabetes MellitusDiabetes Mellitus

The resulting hyperglycemia may The resulting hyperglycemia may lead to acute metabolic complications lead to acute metabolic complications such as diabetic ketoacidosis and such as diabetic ketoacidosis and hyperosmolar nonketotic syndrome. hyperosmolar nonketotic syndrome.

Long term hyperglycemia may Long term hyperglycemia may contribute to chronic microvascular contribute to chronic microvascular complications, neuropathic complications, neuropathic complications, and macrovascular complications, and macrovascular diseases.diseases.

How will you know if How will you know if you are a diabetic? you are a diabetic? If you urinate frequently, experience If you urinate frequently, experience

excessive thirst and unexplained weight excessive thirst and unexplained weight loss. loss.

If your casual blood sugar (plasma If your casual blood sugar (plasma glucose) level is higher than 200mg/dl. glucose) level is higher than 200mg/dl.

If you have fasting plasma glucose level If you have fasting plasma glucose level of not more than 126mg/dl. of not more than 126mg/dl.

Who are at risk of Who are at risk of

diabetes?diabetes? children of diabetics children of diabetics

obese people obese people

people with hypertension people with hypertension

people with high cholesterol levelspeople with high cholesterol levels

people with sedentary lifestyles people with sedentary lifestyles

Types of DiabetesTypes of Diabetes

Type 1 : Insulin-dependent diabetes Type 1 : Insulin-dependent diabetes mellitusmellitus

Type 2 : Non-insulin-dependent diabetes Type 2 : Non-insulin-dependent diabetes mellitusmellitus

Diabetes mellitus associated with other Diabetes mellitus associated with other conditions or syndromesconditions or syndromes

Gestational diabetes mellitusGestational diabetes mellitus

Types of DiabetesTypes of Diabetes

Type 1: About 5% to 10% of people with Diabetes. Type 1: About 5% to 10% of people with Diabetes. A form of diabetes wherein there is inadequate A form of diabetes wherein there is inadequate amounts of insulin are produced by the pancreas, amounts of insulin are produced by the pancreas, resulting in the need for insulin injections to resulting in the need for insulin injections to control the blood glucose. It is also characterized control the blood glucose. It is also characterized by sudden onset usually before the age of 30 by sudden onset usually before the age of 30 years.years.

Type 2: About 90% to 95% of people with Type 2: About 90% to 95% of people with Diabetes. Cause by a decrease in the sensitivity of Diabetes. Cause by a decrease in the sensitivity of the cells to insulin and the decrease in the the cells to insulin and the decrease in the amount of insulin produced. It can be treated with amount of insulin produced. It can be treated with diet, oral hypoglycemic agents and insulin diet, oral hypoglycemic agents and insulin injections. It occurs most frequently in people who injections. It occurs most frequently in people who are over 30 years of age and obese. are over 30 years of age and obese.

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EpidemiologyEpidemiology Diabetes is the third leading cause of death by Diabetes is the third leading cause of death by

disease, mostly because of the high rate of disease, mostly because of the high rate of coronary artery disease among people with coronary artery disease among people with diabetes.diabetes.

Diabetes is the leading cause of new blindness Diabetes is the leading cause of new blindness (among 25 to 74 years old) and nontraumatic (among 25 to 74 years old) and nontraumatic amputations in the United States.amputations in the United States.

25% of patients on dialysis have diabetes.25% of patients on dialysis have diabetes.

Hispanic, black, and some Native American Hispanic, black, and some Native American populations have a higher rate of diabetes than populations have a higher rate of diabetes than the white populations.the white populations.

EpidemiologyEpidemiologyDiabetes in 2007Diabetes in 2007

• 23.6 million — Number of Americans 23.6 million — Number of Americans who had diabetes who had diabetes

• 12.2 million — Number of Americans 60 12.2 million — Number of Americans 60 and older with diabetes and older with diabetes

• 5.7 million — Number of undiagnosed 5.7 million — Number of undiagnosed cases of diabetes cases of diabetes

• 1.6 million — Number of new cases of 1.6 million — Number of new cases of diabetes in adultsdiabetes in adults

• 186,300 — Number of people younger 186,300 — Number of people younger than 20 with diabetesthan 20 with diabetes

• $174 billion — Economic cost of diabetes$174 billion — Economic cost of diabetesSource: American Diabetes AssociationSource: American Diabetes Association

EpidemiologyEpidemiology

There are 2.8 million Filipinos who were diagnosed with diabetes.

From 1993 to 1997, 2.1 percent of the deaths recorded are due to diabetes and annually the cases of diabetes continue to increase by 2.5 percent.

What is an Insulin?What is an Insulin? Secreted by the beta cells, which are one of four Secreted by the beta cells, which are one of four

types of cells in the islets of langerhans in the types of cells in the islets of langerhans in the pancreas. It is considered to be an anabolic, or pancreas. It is considered to be an anabolic, or storage, hormone. When a meal is eaten, insulin storage, hormone. When a meal is eaten, insulin secretion increases and moves glucose from the secretion increases and moves glucose from the circulation into muscle, liver, and fat cells.circulation into muscle, liver, and fat cells.

During “fasting periods” (between meals and During “fasting periods” (between meals and overnight) there is a lower production of insulin overnight) there is a lower production of insulin accompanied by an increased release of another accompanied by an increased release of another pancreatic hormone the glucagon. The net effect pancreatic hormone the glucagon. The net effect of the balance between insulin and glucagon of the balance between insulin and glucagon levels is to maintain a constant level of glucose in levels is to maintain a constant level of glucose in the blood through release of glucose from the the blood through release of glucose from the liver.liver.

The Pancreas….The Pancreas….

Learn more about Learn more about pancreas with this pancreas with this video presentation….video presentation….

Insulin Functions….Insulin Functions…. Stimulates storage of glucose in the liver Stimulates storage of glucose in the liver

and muscle (in the form of glycogen).and muscle (in the form of glycogen).

Enhances storage of dietary fat in adipose Enhances storage of dietary fat in adipose tissue.tissue.

Accelerates transport of amino acids Accelerates transport of amino acids (derived from dietary protein) into the cells.(derived from dietary protein) into the cells.

Insulin also inhibits the breakdown of Insulin also inhibits the breakdown of stored glucose, protein, and fat. stored glucose, protein, and fat.

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Classification of Diabetes Mellitus and Related Classification of Diabetes Mellitus and Related Glucose IntoleranceGlucose Intolerance

Current ClassificationCurrent Classification Previous ClassificationsPrevious Classifications Clinical CharacteristicsClinical Characteristics

Type 1: Insulin – Type 1: Insulin – dependent diabetes dependent diabetes mellitus (IDDM)mellitus (IDDM)

Juvenile diabetesJuvenile diabetes

Ketosis prone diabetesKetosis prone diabetes

Brittle diabetesBrittle diabetes

Etiology includes genetic, Etiology includes genetic, immunologic, and or immunologic, and or environmental factorsenvironmental factors

Need insulin to preserve Need insulin to preserve lifelife

Acute complication of Acute complication of hyperglycemia: diabetic hyperglycemia: diabetic ketoacidosisketoacidosis

Type 2: Non-insulin-Type 2: Non-insulin-dependent diabetes dependent diabetes (NIDDM)(NIDDM)

Adult onset diabetesAdult onset diabetes

Maturity onset diabetesMaturity onset diabetes

Ketosis resistant diabetesKetosis resistant diabetes

Stable diabetesStable diabetes

Etiology includes obesity, Etiology includes obesity, heredity, and heredity, and environmental factorsenvironmental factors

Oral hypoglycemic agents Oral hypoglycemic agents may improve blood may improve blood glucose levelglucose level

Acute complication: Acute complication: hyperosmolar nonketotic hyperosmolar nonketotic syndromesyndrome



Diabetes mellitus Diabetes mellitus associated with other associated with other conditions or syndromesconditions or syndromes

Secondary diabetesSecondary diabetes Accompanied by Accompanied by conditions known or conditions known or suspected to cause the suspected to cause the disease: pancreatic disease: pancreatic diseases; hormonal diseases; hormonal abnormalities; drug such abnormalities; drug such as glucocorticoids and as glucocorticoids and estrogen containing estrogen containing preparationspreparations

Gestational diabetesGestational diabetes Gestational diabetesGestational diabetes Onset during pregnanacy Onset during pregnanacy 22ndnd and 3 and 3rdrd trimester trimester

Due to hormones secreted Due to hormones secreted by placenta , which inhibit by placenta , which inhibit the action of insulinthe action of insulin

Risk factor: obesity, age Risk factor: obesity, age over 30, family hx of over 30, family hx of diabetes, previous large diabetes, previous large babies (over 9lb)babies (over 9lb)



Impaired glucose Impaired glucose intoleranceintolerance

Borderline diabetesBorderline diabetes

Chemical diabetesChemical diabetes

Subclinical diabetesSubclinical diabetes

Asymptomatic diabetesAsymptomatic diabetes

Blood glucose levels Blood glucose levels between normal and that between normal and that of diabetes 25% of diabetes 25% eventually develop eventually develop diabetesdiabetes

May be obese or May be obese or nonobese; obese should nonobese; obese should reduce weight reduce weight

Previous abnormality of Previous abnormality of glucose toleranceglucose tolerance

Potential abnormality of Potential abnormality of glucose toleranceglucose tolerance

Latent diabetesLatent diabetes

PrediabetesPrediabetes

Previous history of Previous history of hyperglycemia (eg. hyperglycemia (eg. Pregnancy or illness)Pregnancy or illness)

No hx of glucose No hx of glucose intolerance but increase intolerance but increase risk of diabetes due to risk of diabetes due to family hx, obese, racefamily hx, obese, race

Etiology of Type 1 Etiology of Type 1 DiabetesDiabetes

Combination of Genetic, Immunologic, and Combination of Genetic, Immunologic, and possibly Environmental factors contribute possibly Environmental factors contribute to beta cells destruction.to beta cells destruction.

Genetic Genetic – People do not inherit type 1 DM itself; – People do not inherit type 1 DM itself; rather, they inherit a genetic predisposition, or rather, they inherit a genetic predisposition, or tendency, toward developing type 1 DM. This tendency, toward developing type 1 DM. This genetic tendency has been found in people with genetic tendency has been found in people with certain HLA (human leukocyte antigen) types. 95% certain HLA (human leukocyte antigen) types. 95% of patients with type 1 diabetes exhibit specific HLA of patients with type 1 diabetes exhibit specific HLA types (DR3 or DR4). The risk of developing type 1 types (DR3 or DR4). The risk of developing type 1 DM is increased 3-5 times in people who have one of DM is increased 3-5 times in people who have one of these two HLA types.these two HLA types.

Etiology of Type 1 Etiology of Type 1 DiabetesDiabetes

Immunologic Immunologic – Abnormal response in which – Abnormal response in which antibodies are directed against normal antibodies are directed against normal tissues as if they are foreign. Auto tissues as if they are foreign. Auto antibodies against islet cells and against antibodies against islet cells and against endogenous (internal) insulin have been endogenous (internal) insulin have been detected in people at the time of detected in people at the time of diagnosis.diagnosis.

EnvironmentalEnvironmental – Certain viruses or toxins – Certain viruses or toxins may precipitate the autoimmune process may precipitate the autoimmune process that leads to beta cell destruction.that leads to beta cell destruction.

Learn more about Learn more about Diabetes Mellitus Type 1 Diabetes Mellitus Type 1 with this video with this video presentation….presentation….

Etiology of Type 2 Etiology of Type 2 DiabetesDiabetesThe exact mechanisms that lead to insulin resistance and The exact mechanisms that lead to insulin resistance and

impaired insulin secretion in type 2 are still unknown impaired insulin secretion in type 2 are still unknown at this time. But they say Genetic factor play an at this time. But they say Genetic factor play an important role in developing insulin resistance.important role in developing insulin resistance.

There are certain risk factors:There are certain risk factors:

Age (insulin resistance tends to occur with age over Age (insulin resistance tends to occur with age over 65)65)

ObesityObesity

Family historyFamily history

Ethnic group (Hispanic and American Indians)Ethnic group (Hispanic and American Indians)

LearnLearn moremore about about Diabetes Mellitus Type 2 Diabetes Mellitus Type 2 with this video with this video presentations….presentations….

World Health Organization Diagnostic Criteria World Health Organization Diagnostic Criteria for Diabetes Mellitus in Adultsfor Diabetes Mellitus in Adults

On at least two occasions:On at least two occasions:

1.1. Random plasma glucose > 200mg/dlRandom plasma glucose > 200mg/dl

2.2. Fasting plasma glucose > 140mg/dlFasting plasma glucose > 140mg/dl

3.3. 2-hour sample during 75g OGTT (Oral Glucose Tolerance 2-hour sample during 75g OGTT (Oral Glucose Tolerance Test) Test)

> 200mg/dl> 200mg/dl

OGTT OGTT – The patient ingest high CHO (150-300g) meals for 3 – The patient ingest high CHO (150-300g) meals for 3 days preceding the test. After an overnight fast, a blood days preceding the test. After an overnight fast, a blood sample is drawn. Then a 75g CHO load, usually in the form sample is drawn. Then a 75g CHO load, usually in the form of carbonated sugar beverage (Glucola), is given to of carbonated sugar beverage (Glucola), is given to patient. The patient is instructed to sit quietly, avoid patient. The patient is instructed to sit quietly, avoid exercise, smoking, coffee, and any other oral intake exercise, smoking, coffee, and any other oral intake except water. WHO recommends that after 2 hours a except water. WHO recommends that after 2 hours a blood sample is drawn after glucose ingestion. blood sample is drawn after glucose ingestion.

Learn more about Blood Learn more about Blood Glucose Monitoring with Glucose Monitoring with this video presentation….this video presentation….

Complications of Complications of DiabetesDiabetesAcute Complications: result from an Acute Complications: result from an

imbalance in the treatment regimen.imbalance in the treatment regimen.

Hypoglycemia (low blood sugar), which is Hypoglycemia (low blood sugar), which is also called insulin reaction or insulin shock.also called insulin reaction or insulin shock.

Hyperglycemia (high blood sugar), which, if Hyperglycemia (high blood sugar), which, if uncontrolled, may lead to diabetic uncontrolled, may lead to diabetic ketoacidosis (DKA) in type 1 diabetes or ketoacidosis (DKA) in type 1 diabetes or hyperosmolar nonketotic syndrome (HNKS) hyperosmolar nonketotic syndrome (HNKS) in type 2 diabetes. in type 2 diabetes.

Complications of Complications of DiabetesDiabetesChronic Complications of type 1 and type 2 diabetes Chronic Complications of type 1 and type 2 diabetes

generally occur 10 to 15 years after the onset of generally occur 10 to 15 years after the onset of diabetes.diabetes.

Macrovascular (large vessel) disease – affecting Macrovascular (large vessel) disease – affecting coronary peripheral vascular, and cerebrovascular coronary peripheral vascular, and cerebrovascular circulations.circulations.

Microvascular (small vessel) disease – affecting the Microvascular (small vessel) disease – affecting the eyes (retinopathy) and kidneys (nephropathy).eyes (retinopathy) and kidneys (nephropathy).

Neuropathic diseases – affecting sensorimotor and Neuropathic diseases – affecting sensorimotor and autonomic nerves and contributing to such problems autonomic nerves and contributing to such problems aqs impotence and foot ulcers.aqs impotence and foot ulcers.

Learn more about Learn more about Chronic Complications Chronic Complications of Diabetes with this of Diabetes with this video presentation….video presentation….

Misconceptions Related to Diabetes and Its Misconceptions Related to Diabetes and Its TreatmentTreatment

MisconceptionMisconception Nurse’s ResponseNurse’s Response Diabetes is caused by Diabetes is caused by eating too much sugar.eating too much sugar.

Sugar is found only in Sugar is found only in dessert foods.dessert foods.

The reason that diabetes The reason that diabetes develops initially is that there develops initially is that there is a decrease in the amount of is a decrease in the amount of insulin in the body or a insulin in the body or a decrease in the ability of decrease in the ability of insulin to control the blood insulin to control the blood glucose level.glucose level. There are several different There are several different types of sugars (simple types of sugars (simple carbohydrates) that increase carbohydrates) that increase blood glucose level. Dessert blood glucose level. Dessert foods often contain sucrose. foods often contain sucrose. Even if the juice is labeled Even if the juice is labeled “unsweetened”, there is still “unsweetened”, there is still natural fruit sugar in the natural fruit sugar in the product, which causes product, which causes elevations in the glucose elevations in the glucose level.level.


MisconceptionMisconception Nurse’s ResponseNurse’s Response The only diet change The only diet change needed in the treatment of needed in the treatment of diabetes is to stop eating diabetes is to stop eating sugar.sugar.

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

It is important for the It is important for the patient to realize that it is not patient to realize that it is not feasible or advisable to feasible or advisable to remove all sources of sugar remove all sources of sugar from the diet. There are from the diet. There are nutritious foods such as fruit nutritious foods such as fruit that contain sugar and that that contain sugar and that should be included in the should be included in the meal plan.meal plan.

During period of acute During period of acute stress (such as stress (such as illness/surgery) or when illness/surgery) or when receiving certain medications receiving certain medications that cause elevations in blood that cause elevations in blood glucose, some patients with glucose, some patients with type 2 diabetes will require type 2 diabetes will require insulin.insulin.


MisconceptionMisconception Nurse’s ResponseNurse’s Response If increasing doses of If increasing doses of insulin are needed to control insulin are needed to control the blood glucose, the the blood glucose, the diabetes must be getting diabetes must be getting “worse”.“worse”.

Blood glucose levels remain Blood glucose levels remain the same throughout the day.the same throughout the day.

Explain to the patient that, Explain to the patient that, unlike other medications that unlike other medications that are given in standard doses, are given in standard doses, there is not a standard dose there is not a standard dose of insulin that is effective for of insulin that is effective for all patients. It is imp’t to all patients. It is imp’t to instruct patients that many instruct patients that many diff. factors may affect the diff. factors may affect the ability of insulin to lower ability of insulin to lower glucose such as glucose such as obesity,puberty,illness.obesity,puberty,illness. Explain to patients that Explain to patients that there is normally a variation there is normally a variation in blood glucose levels, with in blood glucose levels, with the lowest level before meals the lowest level before meals and the highest 1 to 2 hours and the highest 1 to 2 hours after eating.after eating.


MisconceptionMisconception Nurse’s ResponseNurse’s Response Insulin causes blindness (or Insulin causes blindness (or other diabetic complications.other diabetic complications.

Urine and blood glucose Urine and blood glucose testing are interchangeable. testing are interchangeable. (they provide the same (they provide the same information)information)

It must be explained to the It must be explained to the patient that factors such as patient that factors such as elevated blood glucose and elevated blood glucose and elevated blood pressure elevated blood pressure levels (and not insulin levels (and not insulin therapy) contribute to some therapy) contribute to some of the diabetic complications.of the diabetic complications. Explain to the patient that Explain to the patient that directly testing the blood is directly testing the blood is the most accurate method of the most accurate method of measuring the glucose level. measuring the glucose level. The urine glucose test, w/c The urine glucose test, w/c measures the amt. of glucose measures the amt. of glucose that has spilled into the urine that has spilled into the urine since the bladder last since the bladder last emptied, is only indirect way emptied, is only indirect way of determining glucose level of determining glucose level in the blood. in the blood.


MisconceptionMisconception Nurse’s ResponseNurse’s Response Insulin must be injected Insulin must be injected directly into the vein.directly into the vein.

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

The patient must be The patient must be reassured that insulin is reassured that insulin is injected into the fat tissue on injected into the fat tissue on the back of the arm (or on the the back of the arm (or on the abdomen, thigh, or hip) and abdomen, thigh, or hip) and that the needle is much that the needle is much shorter than that used for shorter than that used for venipuncture.venipuncture.

This maybe related to This maybe related to misconception that insulin is misconception that insulin is injected directly to the vein. injected directly to the vein. Reassure patients that the Reassure patients that the main danger in having air main danger in having air bubbles in the insulin syringe bubbles in the insulin syringe is that the amount of insulin is that the amount of insulin being injected is less than the being injected is less than the required dosage.required dosage.

Morning HyperglycemiaMorning HyperglycemiaA.A. Insulin WaningInsulin Waning – Progressive rise in blood glucose – Progressive rise in blood glucose

from bedtime to morning. from bedtime to morning. TTTT: Increase evening : Increase evening dose of intermediate or long acting insulin.dose of intermediate or long acting insulin.

B.B. Dawn PhenomenonDawn Phenomenon – Relatively normal blood – Relatively normal blood glucose until about 3am when the level begins to glucose until about 3am when the level begins to rise. rise. TTTT: Change time of injection of evening : Change time of injection of evening intermediate acting insulin from dinner time to intermediate acting insulin from dinner time to bedtime.bedtime.

C.C. Somogyi EffectSomogyi Effect – Normal or elevated glucose at – Normal or elevated glucose at bedtime, a decrease at 2-3am to hypoglycemic bedtime, a decrease at 2-3am to hypoglycemic levels, and a subsequent increase caused by the levels, and a subsequent increase caused by the production of counter regulatory hormones. production of counter regulatory hormones. TTTT: : Decrease dose of evening intermediate acting Decrease dose of evening intermediate acting insulin or increase evening snack.insulin or increase evening snack.

Foot and Leg Problems in Foot and Leg Problems in DiabetesDiabetes

55% to 75% of lower extremity amputations are 55% to 75% of lower extremity amputations are performed on people with Diabetes. 50% of these performed on people with Diabetes. 50% of these amputations are preventable, provided patients amputations are preventable, provided patients are taught preventive foot care measures and are taught preventive foot care measures and practice preventive foot care on a daily basis.practice preventive foot care on a daily basis.

Three diabetic complications contribute to the Three diabetic complications contribute to the increased risk of foot infections. They are:increased risk of foot infections. They are:

A. NeuropathyA. Neuropathy – Sensory neuropathy leads to loss – Sensory neuropathy leads to loss of pain and pressure sensation, and autonomic of pain and pressure sensation, and autonomic neuropathy leads to increased dryness and neuropathy leads to increased dryness and fissuring of the skin (secondary to decreased fissuring of the skin (secondary to decreased sweating).sweating).

Foot and Leg Problems in Foot and Leg Problems in DiabetesDiabetesB. Peripheral vascular diseaseB. Peripheral vascular disease – Poor circulation of – Poor circulation of

the lower extremities contributes to poor wound the lower extremities contributes to poor wound healing and the development of gangrene.healing and the development of gangrene.

C. ImmunocompromiseC. Immunocompromise – Hyperglycemia impairs the – Hyperglycemia impairs the ability of specialized leukocytes to destroy ability of specialized leukocytes to destroy bacteria. Thus, in poorly controlled diabetes there bacteria. Thus, in poorly controlled diabetes there is a lowered resistance to certain infections.is a lowered resistance to certain infections.

Diabetic foot ulcer begins with a soft tissue injury Diabetic foot ulcer begins with a soft tissue injury of the foot, the injury or fissure may go unnoticed of the foot, the injury or fissure may go unnoticed until a serious infection has developed. Drainage, until a serious infection has developed. Drainage, swelling, redness (from cellulitis) of the leg, or swelling, redness (from cellulitis) of the leg, or gangrene may be the first sign of foot problems gangrene may be the first sign of foot problems that the patient notices that the patient notices

Foot and Leg Problems in DiabetesFoot and Leg Problems in Diabetes Treatment of foot ulcers involves bed rest, antibiotics, Treatment of foot ulcers involves bed rest, antibiotics,

and debridement.and debridement. In peripheral vascular diseases, foot ulcers may not heal In peripheral vascular diseases, foot ulcers may not heal

because of the decreased ability of oxygen, nutrients, because of the decreased ability of oxygen, nutrients, and antibotics to reach the injured tissue. Amputation and antibotics to reach the injured tissue. Amputation may be necessary to prevent further spread of infection.may be necessary to prevent further spread of infection.

Foot Assessment and Foot Care instruction are most Foot Assessment and Foot Care instruction are most important in dealing with patient who are high risk of important in dealing with patient who are high risk of developing foot ulcers.developing foot ulcers.

• Duration of diabetes over 10 yearsDuration of diabetes over 10 years• Age over 40 yearsAge over 40 years• History of smokingHistory of smoking• Decreased peripheral pulsesDecreased peripheral pulses• Decreased sensationDecreased sensation• Anatomic deformities or pressure areas (such as calluses)Anatomic deformities or pressure areas (such as calluses)• History of previous foot ulcers or amputation History of previous foot ulcers or amputation

Foot Care….Foot Care…. Preventive foot care includes properly bathing, Preventive foot care includes properly bathing,

drying, and lubricating feet (care must be taken drying, and lubricating feet (care must be taken not to allow moisture to accumulate from water not to allow moisture to accumulate from water or lotion between the toes.)or lotion between the toes.)

Feet must be inspected on a daily basis for any Feet must be inspected on a daily basis for any redness, blisters, fissures, calluses or redness, blisters, fissures, calluses or ulcerations.ulcerations.

The interior surface of the shoes should be The interior surface of the shoes should be inspected for any rough spots or foreign objects.inspected for any rough spots or foreign objects.

Feet should be examined on a regular basis by a Feet should be examined on a regular basis by a podiatrist, physician, or nurse.podiatrist, physician, or nurse.

Foot Care….Foot Care…. Patients with thick toenails should see the Patients with thick toenails should see the

podiatrist routinely for shaving of calluses podiatrist routinely for shaving of calluses and trimming of nails.and trimming of nails.

Patients should be taught to wear well-Patients should be taught to wear well-fitting, closed toe shoes.fitting, closed toe shoes.

High risk behaviors should be avoided, such High risk behaviors should be avoided, such as walking barefoot, using heating pads on as walking barefoot, using heating pads on the feet, wearing open toed shoes, and the feet, wearing open toed shoes, and shaving calluses.shaving calluses.

Toenails should be trimmed straight across Toenails should be trimmed straight across without rounding the corners.without rounding the corners.

Types (Levels) of Types (Levels) of AmputationsAmputations

Amputations can be divided into two types: minor Amputations can be divided into two types: minor and major. and major.

Minor or limited amputationsMinor or limited amputations are amputations where are amputations where only a toe or part of the foot is removed.only a toe or part of the foot is removed.

A A ray amputationray amputation is a particular form of minor is a particular form of minor amputation where a toe and part of the amputation where a toe and part of the corresponding metatarsal bone is removed; and corresponding metatarsal bone is removed; and the wound is usually left open to heal. This sort of the wound is usually left open to heal. This sort of operation is performed frequently for foot operation is performed frequently for foot infections in patients with diabetes. A partial foot infections in patients with diabetes. A partial foot amputation through the metatarsal bones is called amputation through the metatarsal bones is called transmetatarsal (TM) amputation.transmetatarsal (TM) amputation.

A Gangrene Foot….A Gangrene Foot….

Transmetatarsal (TM) Transmetatarsal (TM) amputationamputation

Types (Levels) of Types (Levels) of AmputationsAmputations

Major amputations are amputations where part of the Major amputations are amputations where part of the leg is removed. leg is removed.

These are usually: These are usually: • below the knee, called below the knee, called transtibial (TT) amputation, transtibial (TT) amputation,

or or • above the knee, called above the knee, called transfemoral (TF) transfemoral (TF)

amputation.amputation.

Occasionally an amputation of just the foot can be Occasionally an amputation of just the foot can be performed with a cut through the ankle joint. performed with a cut through the ankle joint.

Below the knee operation (transtibial amuptation), Below the knee operation (transtibial amuptation), the bone in the lower leg (tibia) is divided about 12-the bone in the lower leg (tibia) is divided about 12-15 cm below the knee joint. This produces a good 15 cm below the knee joint. This produces a good size stump to which a prosthesis can be fitted. size stump to which a prosthesis can be fitted.

BELOW KNEE AMPUTATION DUE TO ISCHEMIA BELOW KNEE AMPUTATION DUE TO ISCHEMIA NECROSISNECROSIS

Learn more about Learn more about Diabetic Foot Care with Diabetic Foot Care with this video presentation….this video presentation….

What can you do to control What can you do to control your blood sugar?your blood sugar?1. Diet Therapy 1. Diet Therapy

* Avoid simple sugars like cakes and * Avoid simple sugars like cakes and chocolates. Instead have complex chocolates. Instead have complex carbohydrated like rice, pasta, cereals and carbohydrated like rice, pasta, cereals and fresh fruits.fresh fruits.* Do not skip or delay meals. It causes * Do not skip or delay meals. It causes fluctuations in blood sugar levels.fluctuations in blood sugar levels.* Eat more fiber-rich foods like vegetables.* Eat more fiber-rich foods like vegetables.* Cut down on salt.* Cut down on salt.* Avoid alcohol. Dietary guidelines * Avoid alcohol. Dietary guidelines recommend no more than two drinks for recommend no more than two drinks for men and no more than one drink per day for men and no more than one drink per day for women.women.

2. Exercise2. Exercise

Regular exercise is an important part of diabetes Regular exercise is an important part of diabetes control.control.

Daily exercise . . .Daily exercise . . .

* Improves cardiovascular fitness* Improves cardiovascular fitness* Helps insulin to work better and lower blood * Helps insulin to work better and lower blood sugarsugar* Lowers blood pressure and cholesterol levels* Lowers blood pressure and cholesterol levels* Reduces body fat and controls body weight* Reduces body fat and controls body weight

Exercise at least 3 time a week for ate least 30 Exercise at least 3 time a week for ate least 30 minutes each session. Always carry quick sugar minutes each session. Always carry quick sugar sources like candy or softdrink to avoid sources like candy or softdrink to avoid hypoglycemia (low blood sugar) during and after hypoglycemia (low blood sugar) during and after exercise.exercise.

3. Control your weight 3. Control your weight

If you are overweight or obese, start If you are overweight or obese, start weight reduction by diet and exercise. weight reduction by diet and exercise. This improves your cardiovascular risk This improves your cardiovascular risk profile.profile.

* It lowers your blood sugar* It lowers your blood sugar* It improves your lipid profile* It improves your lipid profile* It improves your blood pressure * It improves your blood pressure controlcontrol

4. Quit smoking.4. Quit smoking.

Smoking is harmful to your health.Smoking is harmful to your health.

5. Maintain a normal blood 5. Maintain a normal blood pressure.pressure.

Since having hypertension Since having hypertension puts a person at high risk of puts a person at high risk of cardiovascular disease, cardiovascular disease, especially if it is associated especially if it is associated with diabetes, reliable BP with diabetes, reliable BP monitoring and control is monitoring and control is recommended.recommended.

There are drug therapies using oral There are drug therapies using oral hypoglycemic agents. Your doctor can hypoglycemic agents. Your doctor can prescribe one or two agent, depending on prescribe one or two agent, depending on which is appropriate for you.which is appropriate for you.

1. Sulfonylurea – Glibenclamide, Gliclazide, 1. Sulfonylurea – Glibenclamide, Gliclazide, Glipizide, Glimepiride, RepaglinideGlipizide, Glimepiride, Repaglinide

2. Biguanide – Metformin2. Biguanide – Metformin

3. Alpha-glucosidase Inhibitors – Acarbose3. Alpha-glucosidase Inhibitors – Acarbose

4. Thiazolidindione – Troglitazone, 4. Thiazolidindione – Troglitazone, Rosiglitazone, Proglitazone. Rosiglitazone, Proglitazone.

Insulin Therapy….Insulin Therapy….Insulin preparation vary according to four main characteristics: Insulin preparation vary according to four main characteristics:

time course of action, concentration, species (source), and time course of action, concentration, species (source), and manufacturer.manufacturer.

Time course Time course – Insulin may be grouped into 3 main – Insulin may be grouped into 3 main categories based on onset, peak, duration of action.categories based on onset, peak, duration of action.

Concentration Concentration – Most common concentration of insulin in – Most common concentration of insulin in the united states is U-100. Means that there are 100 the united states is U-100. Means that there are 100 units of insulin per 1 cubic centimeter. 100 units of U-units of insulin per 1 cubic centimeter. 100 units of U-100 is 1 ml, 50 units of U-100 is 1/2ml. 100 is 1 ml, 50 units of U-100 is 1/2ml.

Species Species – Derived from pancreas of cows and pigs and – Derived from pancreas of cows and pigs and conversion of this insulin to human insulin. conversion of this insulin to human insulin.

Manufacturer Manufacturer – Lilly human insulin – “Humulin” and Novo – Lilly human insulin – “Humulin” and Novo Nordisk human insulin – “Novolin”Nordisk human insulin – “Novolin”

Insulin Therapy….Insulin Therapy….ONSETONSET PEAKPEAK DURATIONDURATION CONSISTENCYCONSISTENCY

Short acting Short acting insulininsulin• RegularRegular

•SemilenteSemilente

½ to 1 hour½ to 1 hour

1 to 2 hours1 to 2 hours




8 to 12 8 to 12 hourshours

ClearClear

ClearClear

IntermediatIntermediate acting e acting insulininsulin• NPHNPH

• LenteLente


SameSame


SameSame


SameSame

CloudyCloudy

CloudyCloudy

Long acting Long acting insulininsulin

• UltralenteUltralente 6 to 8 hours6 to 8 hours 14 to 20 14 to 20 hourshours

30 to 36 30 to 36 hours or hours or greatergreater

CloudyCloudy

Learn more about Insulin Learn more about Insulin Preparation and Injecting Preparation and Injecting Insulin with this video Insulin with this video presentation….presentation….

RememberRememberIf you have the classic symptoms of diabetes:If you have the classic symptoms of diabetes:

* See your doctor for blood sugar testing* See your doctor for blood sugar testing* Start dieting* Start dieting* Eat plenty of vegetables* Eat plenty of vegetables* Avoid sweets such as chocolates and * Avoid sweets such as chocolates and cakescakes* Cut down on fatty foods* Cut down on fatty foods* Exercise regularly* Exercise regularly* If you are obese, try to lose some weight* If you are obese, try to lose some weight* Avoid alcohol drinking and stop smoking* Avoid alcohol drinking and stop smoking* If you are hypertensive, consult your * If you are hypertensive, consult your doctor for advice and managementdoctor for advice and management

DOH Calendar of DOH Calendar of EventsEvents

July 2008July 2008

> National Blood Donors Month> National Blood Donors Month> Nutrition Month> Nutrition Month> National Disaster Consciousness Week (1-7)> National Disaster Consciousness Week (1-7)> World Population Day (11)> World Population Day (11)> National Disability Prevention and > National Disability Prevention and Rehabilitation Week (14-20)Rehabilitation Week (14-20)> National Diabetes Awareness Week (14-20)> National Diabetes Awareness Week (14-20)

DOH Calendar of DOH Calendar of EventsEvents

November 2008November 2008

> Cancer Pain Awareness Month> Cancer Pain Awareness Month> Filariasis Awareness Month> Filariasis Awareness Month> Malaria Awareness Month> Malaria Awareness Month> Traditional and Alternative Health Care Month> Traditional and Alternative Health Care Month> Chronic Obstructive Pulmonary Disease (COPD) > Chronic Obstructive Pulmonary Disease (COPD) Awareness Week (3-9) Awareness Week (3-9) > National Skin Disease Detection and Prevention > National Skin Disease Detection and Prevention Week (10-16)Week (10-16)> National Food Fortification Day (7)> National Food Fortification Day (7)> Deaf Awareness Week (10-16)> Deaf Awareness Week (10-16)> World Diabetes Day (14)> World Diabetes Day (14)> Drug Abuse Prevention and Control Week (17-23)> Drug Abuse Prevention and Control Week (17-23)> Population and Development Week (23-29)> Population and Development Week (23-29)

Doctor’s View about Doctor’s View about Diabetes Mellitus 1 & 2 Diabetes Mellitus 1 & 2 thru video thru video presentations….presentations….

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