Diabetes MellitusRevised, May 2007

Disorder of metabolism

Regulated by insulin

FYI:When you eat, your pancreas releases

Insulin into your bloodstream. You allknow by now that every cell in your bodyruns on sugar for energy. Insulin is whatcarries the sugar to and into the cells and makes it usable.

Classifications…

Type 1 (previously known as IDDM or Insulin Dependent Diabetes Mellitus)

Type 2 ( previously known as NIDDM or non-insulin-dependent Diabetes Mellitus)

Role of InsulinRegulates the rate of glucose metabolism

Moves glucose into cells

Reduces blood sugar by ^ utilization of carbohydrates

Synthesis of fatty acids and proteins…Ah Oh!

Symptoms of DM

Hyperglycemia key feature

Classic symptoms are:

Polydipsia

Polyuria

Polyphagia

Criteria for Medical Diagnosis

Symptoms of Diabetes

Fasting serum glucose level of 126mg/dl or greater

Two-hour postprandial glucose above 200mg/dl during OGTT (Pg1009)

Microvascular Complications

Basement membrane of capillaries thickens

Exchange of nutrients, gases and waste is impaired

Related to persistent hyperglycemia and aggravated by hypertension & smoking

Diabetic Retinopathy

Pathological changes in the retina due to DM

Nonproliferative and proliferative

Macula edema ( floaters or spots )

Eye exams should be yearly

NephropathyKidney disease

Caused by high concentrations of glucose in urine, along w/ HTN, destroy capillaries supplying the renal glomeruli.

S/S persistent proteinuria, ^BP & serum creatinine, hematuria, oliguria and anuria

How to reduce the risk of damage……

Macrovascular ComplicationsCauses the development of atherosclerosis

Coronary, cerebral, carotid and peripheral blood vessels are affected

Leading to CAD, CVA and PVD

Trmt is directed at weight loss,exercise and quitting smoking

Neuropathic Complications

Neuropathypathological changes in nerve tissue

Related to poor glucose control and ischemic lesions of nerves

Affects 13% of people w/ diabetes50% chance of having neuropathies if diabetic

for over 25 yrsVariety of symptoms (see pg. 903)

Foot complications

Related to neuropathy or inadequate blood supply

Ulcers, burns or abscess may easily develop and go unnoticed

Best treatment is prevention

Foot Care See table 44-2, pg 904

Acute Emergency Complications

1) Acute Hypoglycemia

2) Diabetic Ketoacidosis ( DKA)

3) Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNKS)

Acute HypoglycemiaS/S shakiness, nervouseness, irritability, tachycardia,

anxiety, lightheadedness, hunger, tingling or numbness of lips or tongue, diaphoresis, confusion, dizziness

Caused by: too much insulin, not eating enough food, not eating at right time, or inconsistent pattern of exercise

Glucose betw. 50-70 are moderately low

Hypoglycemia treatment

Conscious patient 10-15gms of quick acting carbohydrates

EX: 4-6 oz of orange or apple juice, skim milk, 3-4 tbsp. Table sugar or corn syrup, 2-3 glucose tablets. Repeat every 15-30 min until glucose is above 60.

Injectable glucagon should be avail if insulin dependent

Diabetic Ketoacidosis (DKA)Caused by insulin deficiency resulting in the

inability of carbohydrates, proteins and fats to be metabolized.

Pt exhibits hyperglycemia of 300mg/dl, ketonuria and acidosis

Treatment aimed at correcting the 3 main problems: dehydration, electrolyte imbalance and acidosis

S/S of DKA

Early SxAnorexia, headache, and fatigue, f/b polydipsia, polyuria and polyphagia.

If untreated, dehydration, weakness, lethargy, abd. Pain, N,V, tachycardia, blurred vision, fruity breath.

Late Sx Kussmaul’s respirations, coma & shock

Hyperglycemic Hyperosmolar Nonketotic Syndrome ( HHNKS)Extremely high glucose levels (>600mg/dl)

Basic defect is lack of effective insulin or inability to use available insulin

Dehydration and hypernatremia develop

May be caused by IV solutions w/ high concentrations of glucose (TPN or dialysis)

The point is to try and maintain control.

Prolonged time with these types of complications leads to PVD, CVA,and CAD.

And of course the host of problems causedby each

Medical Treatment for Diabetes Mellitus

1) Nutritional Management

2) Exercise

3) Insulin Therapy

4) Oral Hypoglycemic Drugs

Nutritional Management

Weight control important component

Emphasis is on a well-balanced diet

Carbohydrate counting is useful with use of insulin therapy or pumps

Considerable education and support to learn guidelines

Always consider personal & ethnic choices

Exercise

Combine aerobic & anaerobic exercise

Type 1 hyperglycemia may occur w/ exercise if insulin is inadequate

Type 2 exercise makes receptor sites more sensitive to insulin & lowers glucose levels

Avoid excessive exercise if glucose are elevated

Insulin is absorbed quickly when injected into abdomen

Insulin Therapy

Time Course of Action (Table 46-2)

Route

Concentrations

( U-100 ) has a concentration of 100 units/ml & is most commonly used

Premixed easier to prepare and less risk of error when mixing 2 insulins in 1 syringe

Dosing Schedules

Conventional Therapy uses a combination of insulins. Admin in AM and PM. Doses are fixed.Monitor BS before meals, twice a day.

Intensive Therapy designed for tight control. 3-4 injections/day. Glucose monitoring is essential 3-5x/day

Subcutaneous Insulin InfusionContinuous subcutaneous insulin infusion

Delivers regular insulin continuously and a bolus of insulin at mealtimes

Contains 2-3 day supply of insulin

Advantages no need to use intermediate or long acting insulin and more flexibility regarding travel and exercise

Insulin Mixing

Remember “clear to cloudy”

When mixing short-acting “clear” and longer-acting (cloudy) insulin, draw the “clear” (short-acting) insulin into the syringe first

Insulin Injection See Figure 1014

Site rotation helps prevent lipohypertrophy or lipoatrophy

Abdomen absorption is 50% faster

ADA recommends rotating sites within one anatomic area

Oral Hypoglycemic Agents

See 1016

Not insulin substitutes

Some patients may need one dose of insulin at night and then are able to control serum glucose during the day with oral agents

Euglycemia

Self blood glucose monitoring (SBGM)

• Reduces complications of long term diabetes

• Helps normalize blood glucose levels

• Glycosylated Glucose Levels drawn every 2-3 mos. Helps MD and patients determine how well blood glucose levels are regulated

Health history and PE

Review nursing diagnosis related outcome criteria and teaching plan pgs 1020

Hypoglycemia

• Syndrome that develops when blood glucose levels drop below 45-50mg/dl

• Symptoms can occur at different blood levels based on individual tolerances

• Divided into 3 categories:

1)Exogenous 2) Endogenous 3) Functional

Exogenous hypoglycemia

Caused by outside factors that act on body to produce low blood glucose

1) Insulin

2) Oral hypoglycemic agents

3) Alcohol

4) exercise

Endogenous hypoglycemia

Caused by excessive secretion of insulin or an increase in glucose metabolism

Usually the result of a tumor or genetics

Functional hypoglycemia

• Has a variety of causes

1) gastric surgery (post gastrectomy)

2) fasting

3) malnutrition

Signs and Symptoms

• weakness

• hunger, diaphoresis,

• tremors, anxiety

• irritability,headache

• pallor

• tachycardia

• Confusion, dizziness

Medical Diagnosis

• Whipple’s Triad

1) Presence of symptoms

2) Documentation of blood glucose when symptoms occur

3) Improvement of symptoms when blood glucose rises

Medical treatment

• Depends on cause of problem

• Prevention based upon proper food intake is an important treatment component

• Hypoglycemia associated with treatment of diabetes uses different guidelines for treatment

Nursing care, diagnosis and related Interventions

• Review pg 921-922