Diabetes Mellitus I

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Diabetes Mellitus I II
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What is diabetes?

• Normal Blood Glucose 80-120 mg/dL
• What are the 3 key symptoms of diabetes?
• When the body does not produce or properly
  utilize insulin
• What does insulin do?
• 2 kinds
• Type 1 Insulin dependent
• Type 2 Non - insulin dependent
• Gestational diabetes mellitus (GDM)

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What does insulin do?

• Transports metabolizes glucose
• Stimulates the liver muscle to convert glucose
  into glycogen
• Enhances storage of fat in adipose tissue
• Accelerates transport of amino acids into cell

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Type 1 Diabetes

• Classified as requiring insulin injections to
  control blood sugar levels
• Acute onset before the age of 30
• Approximately 5 10 population due to
  autoimmune destruction of the insulin producing
  pancreatic beta cells
• Usually genetic (most common), immunological or
  environmental (ie virus, etc)
• Genetic is that the patients carry HLA (human
  leukocyte antigen)
• Patients are usually thin when diagnosed

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• When the blood glucose level exceeds 180 200
  glucosuria occurs
• Insulin also prevent glycogenolysis
  glucogenesis
• Without it, fat is broken for energy producing
  ketones
• S S
• Wasting away of muscle and/or subcutaneous fat
• Polydipsia
• Polyphagia
• Polyuria
• N V
• Joint pain

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DKA

• Diabetic KetoAcidosis
• The level of ketones are so high in the blood
  that it disrupts the acid- base balance
• S S
• Abdominal pain
• N V
• Hyperventilation
• Fruity odor of the breath
• Altered level of consciousness
• coma
• Treatment lower blood sugar levels with
  insulin acid base balance

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Hypoglycemia

• Too low of glucose in the blood
• May result of too much insulin by the body or
  given in the treatment of DM

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Type 2

• Approximately 90 95 of diabetes patients
• Results from a decreased sensitivity to insulin
  (insulin resistance) or decrease in production
• First line of treatment Diet exercise
• Most common in individuals over 30 or obese
• Ketosis does not occur due to the presence of
  insulin (just not enough to lower blood sugar
  levels)

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S S

• Fatigue
• Irritability
• Polyuria
• Polydipsia
• Poor wound healing
• Vaginal infections
• Blurred vision

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Treatment

• Weight loss
• Exercise (enhances the effectiveness of insulin)
• Oral anti-diabetic meds

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Gestational Diabetes

• Occurs during pregnancy
• Hyperglycemia is a result of placental hormones
  that are secreted
• Screening between the 24 28 weeks gestation
• Initial management diet changes (usually ADA)
• Usually resolves after delivery

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Testing for DM

• Random glucose level equal to or above 200 mg/dL
• Fasting blood sugar level equal to or greater
  than 126 mg/dL
• Blood glucose level at or above 200 on the 2nd
  hour of a glucose tolerance test
• Urinalysis showing acetone in the urine

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Screening guidelines

• Adults over the age of 45 should be screened
  every 3 years
• Fasting glucose level greater or equal to 126
  mg/dL on at least 2 occurrences
• Patients at high risk should be tested more
  frequently. Patient groups such as
• Native Americans
• African Americans
• Asian
• Hispanics
• Anyone overweight
• HTN
• Strong family history of DM

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Diagnosing DM

• Symptoms present
• Random blood sugar readings at 200 mg/dL or
  greater
• Fasting plasma glucose level equal or greater 126
  mg/dL
• Glucose tolerance test 2nd hour reading of 200
  or higher
• Others
• Urinalysis for acetone
• Ophthalmologic exam showing diabetic retinopathy

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Treatments

• Diet Weight Control
• Provide needed nutrients
• Achieve reasonable weight
• Meet energy needs
• Prevent wide fluctuating blood glucose levels
• Decrease cholesterol
• American Diabetes Association Diet Plan
• Exercise
• Increases the uptake of insulin promotes sugar
  to be utilized by the muscles
• Increases HDLs lowers LDLs
• Should not exercise if blood sugar is above 250
  (spilling ketones)

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Foods recommended by the ADA

• Eat lots of vegetables and fruits. Try picking
  from the rainbow of colors available to maximize
  variety.
• Eat non-starchy vegetables such as spinach,
  carrots, broccoli or green beans with meals.
• Choose whole grain foods over processed grain
  products. Try brown rice with your stir fry or
  whole wheat spaghetti with your favorite pasta
  sauce.
• Include dried beans (like kidney or pinto beans)
  and lentils into your meals.
• Include fish in your meals 2-3 times a week.
• Choose lean meats like cuts of beef and pork that
  end in "loin" such as pork loin and sirloin.
  Remove the skin from chicken and turkey.
• Choose non-fat dairy such as skim milk, non-fat
  yogurt and non-fat cheese.
• Choose water and calorie-free "diet" drinks
  instead of regular soda, fruit punch, sweet tea
  and other sugar-sweetened drinks.
• Choose liquid oils for cooking instead of solid
  fats that can be high in saturated and trans
  fats. Remember that fats are high in calories. If
  you're trying to lose weight, watch your portion
  sizes of added fats.
• Cut back on high calorie snack foods and desserts
  like chips, cookies, cakes, and full-fat ice
  cream.
• Eating too much of even healthful foods can lead
  to weight gain. Watch your portion sizes.

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Self glucose Monitoring

• Allows patients to know their blood glucose
  levels at any point time adjust treatment as
  necessary
• Education of patients is key to accurate readings
• Patients usually check their blood sugars on a
  schedule (2 4 times a day) usually prior to
  meals at bedtime

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Medication Management

• Insulin therapy
• Rapid acting - Humalog
• Short acting - Regular
• Intermediate acting - NPH
• Long acting Lente or Ultralente
• Insulin is usually kept refrigerated
• Injection dosage is determined by the blood
  glucose level
• Usually based on a scale

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Example of a Sliding scale

• 0-60 Initiate Hypoglycemic Protocol (see below)
• 61-150 1No Insulin
• 151-200 13 units SQ
• 201-250 15 units SQ
• 251-300 18 units SQ
• 301-350 10 units SQ
• 351-400 12 units SQ
• gt400 15 units SQ and call MD

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Insulin Pen

• Looks like a pen with 150 300 units in a
  pre-filled syringe
• Disposable needle is attached at the end for
  injections
• All insulin is Injected SQ
• What are the locations for injecting SQ?

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Insulin Pump

• Continuous infusion of insulin into the
  subcutaneous tissue
• 3 ml syringe attached to tubing with a needle
  under the skin (needle is changed q 3 days)
• Usually contains Regular insulin
• Usually rate is .5 2 units /hour
• Prior to meals, the patient pushes a button to
  deliver a bolus

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Oral Medications

• Glucophage (metformin)
• Category biguanides
• Usually used in insulin resistance Type 2
• Must have insulin present in blood to work
• Complication Lactic Acidosis
• Other uses aids in treatment of Polycystic
  Ovary Disease