DIABETES MELLITUS

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DIABETES MELLITUS
Majuvy L. Sulse MSN, RN, CCRN Lola Oyedele MSN,
RN, CTN
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DIABETES MELLITUS

• DEFINE
• CHRONIC SYSTEMIC DISEASE CHARACTERIZED BY EITHER
• A DEFICIENCY OF INSULIN
• OR A DECREASED ABILITY OF THE BODY TO USE INSULIN
  (insulin resistant)

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PANCREAS

• CELL TYPES AND FUNCTION
• BETA - INSULIN
• HYPOGLYCEMIC FACTOR
• ALPHA - GLUCAGON
• HYPERGLYCEMIC FACTOR
• DELTA - SOMASTATIN
• INHIBITS SECRETION OF BOTH INSULIN AND GLUCAGON

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ROLE OF INSULIN

• SKELETAL MUSCLE
• INCREASE UPTAKE OF GLUCOSE, CONVERT TO GLYCOGEN
• Liver
• Increase uptake of glucose from blood and convert
  to glycogen
• Inhibits production of glycogenolysis
• Inhibits gluconeogenesis

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• CARBOHYDRATES
• BREAKS DOWN TO GLUCOSE, INSULIN TRANSPORTS ACROSS
  CELL MEMBRANE
• ENZYMES BREAKS DOWN FOR ENERGY OR STORED AS
  GLYCOGEN
• PROTEIN
• INSULIN ENHANCES AMINO ACIDS TO PROTEIN
• FATS
• FREE FATTY ACIDS TO ADIPOSE

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Critical thinking

• The process of breaking down material without
  insulin during metabolism is know as
• A. Ketogenesis
• B. Lipolysis
• C. Glycogenesis
• D. Catabolism

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REGULATION

• INSULIN
• ? BLOOD SUGAR INSULIN SECRETED FOR TRANSPORT
  INTO CELLS
• GLUCAGON
• ? BLOOD SUGAR GLUCAGON SECRETED
• STIMULATES LIVER TO BREAKDOWN GLYCOGEN TO GLUCOSE
  RELEASE ( GLYCOGENESIS)
• METABOLISE AMINO ACIDS TO GLUCOSE
• LIPOLYSIS TO GLYCEROL
  ( GLUCONEOGENESIS)

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PITUITARY

• GROWTH HORMONE
• ACTH
• CORTISOL
• ? GLUCONEOGENESIS
• ? LIPOLYSIS
• ? USE OF GLUCOSE BY CELLS
• ? BLOOD SUGAR

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RISK FACTORS

• FAMILY HISTORY
• HISTORY OF GLUCOSE INTOLERANCE
• OBESITY
• HIGH FAT DIET
• SEDENTARY LIFE STYLE
• ELDERLY
• ETHNECITY

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TYPES

• TYPE 1
• IDDM ( 5-10)
• TYPE 2
• NIDDM ( 90)
• GLUCOSE INTOLERANCE
• FBS ? 110 BUT ? 126
• SECONDARY DIABETES
• 2ND TO DISEASE OR DISORDER
• GESTATIONAL DIABETES
• DURING PREGNANCY

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TYPE 1 (IDDM)

• DEFINE
• BETA CELL DESTRUCTION
• ( AUTOIMMUNE, VIRAL, GENETIC)
• INSULIN INSUFFICIENT TO SUSTAIN LIFE
• REQUIRES EXOGENOUS INSULIN
• REVERTS TO LIPOLYSIS GLUCONEOGENESIS
• ETIOLOGY
• ? 30 YEARS, THIN, ABRUPT ONSET
• SS
• POLYURIA, POLYDIPSIA, POLY PHASIA

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TYPE 2 (NIDDM)

• DEFINE
• DEFECIENT INSULIN TO MEET BODY DEMANDS
• INSULIN RESISTENCE
• DOES NOT REVERT TO LIPOLYSIS OR GLUCONEOGENESIS
• ETIOLOGY
• ? 30 YEARS, OBESE, GRADUAL ONSET
• SS
• VAGUE, FATIGUE, IRRITABILITY, GRADUAL POLYURIA,
  POLYDIPSIA, POLYPHASIA

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Critical Thinking

• Which of the following is true regarding
  Diabetes?
• Diabetes is an acute disorder that responds only
  to insulin
• Diabetes is curable
• Diabetes is characterized by an abnormality of
  carbohydrate metabolism
• Diabetes is not a significant cause of death.

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CONSEQUENCE OF INSULIN DEFECIENCY

• LIVER
• CANNOT STORE GLUCOSE AS GLYCOGEN
• FREE FATTY ACIDS BREAK DOWN KETONE BODIES
• HYPERTRIGLYCERIDEMIA
• SKELETAL MUSCLE
• NO GLUCOSE FOR ENERGY, METABOLISE PROTEINS
• ADIPOSE TISSUE
• LIPOLYSIS FREE FATTY ACIDS

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• KIDNEY
• KIDNEY CAN EXCRET 180 MG/DL
• (GLUSOSURIA)
• OSMOTIC DIURESIS (POLYURIA)
• FLUID VOLUME ELECTROLYTE DEPLEATION
• HYPOVOLEMIA THIRST (POLYDISPIA)
• ? GLUCOSE TO CELLS STARVATION (POLYPHAGIA)

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Critical thinking

• A diagnosis of diabetes suggests that a clients
  symptom of polyuria is most likely caused by
• A. Increased insulin levels promote a diuretic
  effect
• B. Glucose acting as a hypertonic agent, draws
  water from the intracellular fluid into the renal
  tubules
• C. Electrolyte changes lead to the retention of
  sodium and potassium
• D. Microvascular changes alter the effectiveness
  of the kidney

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DIAGNOSTIC STUDIES

• FASTING BLOOD SUGAR ? 126
• RANDOM BLOOD SUGAR ? 200
• POST PRANDIAL BLOOD SUGAR ? 200
• GLYCOSYLATED HgB. (HgA1c) ? 7
• (life of RBC 120 days)
• GLYCOSYLATED ALBUMIN 1.52.7nmol/L

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MANAGEMENT OUTCOMES

• PROMOTE PROPER NUTRITION
• PROMOTE EXERCISE
• ADMINISTER MEDICATION

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ORAL ANTIDIABETIC MEDICATIONS

• SULFONYLURES
• INCREASE RELEASE OF INSULIN
• ORINASE, TOLINASE
• GLUTROL, DIABETA
• WEIGHT GAIN, HYPOGLYCEMIA
• MEGLITINIDES
• INCREASE RELEASE OF INSULIN
• PRANDIN, STARLIX
• WEIGHT GAIN, HYPOGLYCEMIA

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ORAL ANTIDIABETIC MEDICATIONS

• BIGUANIDES
• REDUCE GLUCOSE BY LIVER, INCREASED INSULIN
  SENSATIVITY.
• GLUCOPHAGE
• DIRRHEA, LACTIC ACIDOSIS
• A-GLUCOSIDASE INHIBITORS
• DECREASE ABSORPTION OF CARBOHYDRATES
• ACARBOSE,
• DIRRHEA, ABD PAIN
• THIAZOLIDINEDIONES
• INCREASE GLUCOSE UPTAKE
• ACTOSE, AVANDIA
• WEIGHT GAIN, EDEMA

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ALTERED HEALTH MAINTENANCE

• R/T LACK OF KNOWLEDGE OF DIETARY MANAGEMENT
  DIABETES
• OUTCOME
• CLIENT WILL STATE RELATIONSHIP OF DIETARY
  MANAGEMENT TO BLOOD GLUCOSE CONTROL
• CLIENT WILL CHOOSE FOODS THAT MEET CALORC NEEDS
  AND OFFER A WELL BALANCED DIET

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Dietary Proportions

• Carbohydrates 50-60
• Fats ? 30
• 10 saturated ( animal fats)
• 10 polysaturated ( fish)
• 10 monounsaturated ( olive oil)
• Protein 10-20
• Fiber 40 gms daily

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Acute Complications of Diabetes Mellitus

• Hypoglycemia BS below 60
• Causes
• Insufficient food
• Missed meal, nausea/vomiting, interrupted enteral
  feeding
• Increased insulin
• ? dose, NPO exam, peak action of insulin
• Categories
• Adrenergic
• Neuroglycopenic

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Hyperglycemia

• Causes
• Undiagnosed type 1
• Know type 1
• Omission of insulin
• Illness/infection/ trauma/ surgery
• None DM
• Cushing's syndrome/ hyperthyroid/ pregnancy
• Medications ( Dilantin)

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Diabetic Ketoacidosis

• Criteria Blood sugar greater than 250
• Arterial Ph less than 7.30
• HCO3 less than 18
• Pathology
• ? cellular glucose gluconeogenesis
  glycogenolysis
• Free fatty acids metabolized ketone bodies
• Ketones release hydrogen ions
• Hydrogen ions exchanged for K at cell wall
• ? K

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Diabetic Ketoacidosis

• Kidney regulates ? K
• ? blood glucose ? osmotic pressure
• Kidney regulates diuresis ? Na
• Glucosuria, dehydration electrolyte imbalance

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• SS
• Polyuria, polydipsia, polyphagia
• Headache with blurred vision
• Nausea/vomiting r/t ? peristalsis
• ? respirations/ fruity breath
• Kussmaul's pattern

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• Labs
• Blood sugar 300-800
• Na ? ( reflect level of dehydration)
• K first ? (hydrogen ions exchanged for K at cell
  wall
• then ? (kidney regulates)
• ? Bun Creatinine
• ABGs metabolic acidosis

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Critical Thinking

• Which terms would best describe the condition of
  a ketoacidotic client on admission?
• A. warm, flushed, dry
• B. Cool and clammy
• C. cool and dry
• D. Warm, pale and clammy

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Management

• Rehydration
• Replace electrolytes
• Insulin
• Vital signs hourly
• Blood sugar hourly
• Urine output hourly
• Cardiac monitor

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Complications

• Hypovolemic shock
• Dysrhythmias
• Myocardial infarction
• Seizures
• Coma
• Acute renal failure

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Hyperglycemic Hyperosmolar Nonketotic Syndrome

• Hyperglycemia, Dehydration
• W/O acidosis ( enough insulin)
• Insidious onset
• ( tolerate polyuria, polydipsia, polyphagia
  headache weakness)

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HHNS

• Dehydration R/T osmotic diuresis
• Hypovolemia ? glomerular filtration rate
• ? glucose retained
• ? Na retained
• ? osmolarity.

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• At risk
• Elderly, type 2 or mild type 1
• Burns, infection, renal heart disease
• Acute illness
• Dialysis, hyperalimentation
• SS
• Profound dehydration
• Blood sugar 600-2000
• ? BUN Creatinine
• glycosuria

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Management

• Rehydrate
• Normal saline X 2 hours ( Isotonic)
• .45 normal saline (hypotonic)
• Electrolyte replacement
• Insulin
• Hourly vital signs, output,
• Cardiac monitor

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Chronic Complications

• Infections
• monilia
• Skin r/t ?glucose moisture
• Vaginal R/T ?glucose altered Ph

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Vascular Complications

• Macrovascular
• Atherosclerotic changes earlier greater
  frequency
• Coronary artery disease
• Cerebral vascular disease
• peripheral vascular disease

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• Microvascular
• Unique to diabetics
• Thickening of basement membrane of capillaries
• Retinopathy -
• Cataracts
• Neuropathy
• Nephropathy

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Retinopathy

• R/t vascular fragility
• Stages
• Early - ? capillary permeability intra-retinal
  hemorrhage
• Moderate- macular edema, micro hemorrhage
• Progressive retinal ishemia, exudate, cotton-wool
  patches
• Advanced - neo-vascularization, retinal
  detachment, blind

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Cataracts

• Accumulation of sorbitol in the lens
• Opacity gradual onset
• Similar to senile cataracts

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Neuropathy

• Most commonly affects peripheral nervous system
• Most common complication
• ? sensation ? motor function
• Parasthesia ( tingle- burn, numbness)
• Mononephropathy
• Sporadic, single focal area
• Symmetrical polyneuropathy
• Distal symmetrical pattern ( stocking, glove)
• Autonomic nephropathy
• Cardiac, GI ( gastroparesis) , GU ( neurogenic
  bladder)

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NEPHROPATHY

• Most common cause of end-stage renal disease
• Type 1 45, Type 2 20
• Damage to capillaries of glomeruli
• Concomitant hypertension
• Dx glycosylated albumin
• Rx hypertension, maintain even blood sugar

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SICK DAY MANAGEMENT

• TEST BLOOD SUGAR Q 2-4 HRS
• TEST URINE FOR KETONES Q 2-4 HRS
• TAKE INSULIN EVEN IF N/V
• 10-15 GMS CARBOHYDRATES Q 1-2 HRS.
• EX. 1 POPSICLE, 1/2 CUP JELLO
• FLUIDS Q 30 MINS
• EX. ICE CHIPS, GATORADE

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FOOT PROBLEMS

• 75 OF ALL LOWER EXTREMITY AMPUTATIONS
• 3 FOLD PROBLEM
• NEUROPATHY
• ? SENSATION (INJURY)
• PERIPHERAL VASCULAR DISEASE
• ? CIRCULATION ( POOR WOUND HEALING)
• IMMUNOCOMPROMISED
• ? ABILITY OF LEUKOCYTES
• ?RESISTANCE TO INFECTION

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Critical thinking

• The goals of management of diabetes are based
  entirely on the patient's ability for self care.
  The general focus of short term goals then is
• A. cure of the disease
• B. Control of the disease
• C. prevention of the disease
• D. Recognition of complications

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CARE OF THE ELDERLY

• TEACH AT SIMPELEST LEVEL
• BARRIERS TO LEARNING
• ? HEARING
• ? EYESIGHT
• ? MEMORY
• ? EYE HAND COORDINATION
• ? RESOURCES
• ? COORDINATION

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THE FUTURE HOPE

• PANCREAS TRANSPLANT
• ISLET CELL TRANSPLANTS

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Islet cell transplant

• Edmonton procedure
• Utilizes cadaver donors
• Requires 1 million cells
• 80 success rate
• Cells injected into liver
• Pt carefully monitored while cells attach
  themselves to blood vessels and begin insulin
  production
• Requires Immunosuppression drugs for life