Diabetes Mellitus

1
Diabetes Mellitus

• Definition metabolic disorder characterized by
  hyperglycemia due to an absolute or relative lack
  of insulin or to a cellular resistance to insulin
• Major classifications
• 1. Type 1 Diabetes
• 2. Type 2 Diabetes

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Diabetes Mellitus

• Impact on health of American population
• 1. Sixth leading cause of death due to
  cardiovascular effects resulting in
  atherosclerosis, coronary artery disease, and
  stroke
• 2. Leading cause of end stage renal failure
• 3. Major cause of blindness
• 4. Most frequent cause of non-traumatic
  amputations

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Diabetes Mellitus

• 5. Diabetes affects estimated 15.7 million people
  (10.3 million are diagnosed 5.4 million are
  undiagnosed)
• 6. Increasing prevalence of Type 2 Diabetes in
  older adults and minority groups (African
  American, American Indian and Hispanic
  populations)
• 7. Estimated 11 of older U. S. population (65
  74) have diabetes

4
Diabetes Mellitus

• Diabetes Type 1
• Definition
• 1. Metabolic condition in which the beta cells of
  pancreas no longer produce insulin characterized
  by hyperglycemia, breakdown of body fats and
  protein and development of ketosis
• 2. Accounts for 5 10 of cases of diabetes
  most often occurs in childhood or adolescence
• 3. Formerly called Juvenile-onset diabetes or
  insulin-dependent diabetes (IDDM)

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Diabetes Mellitus

• Pathophysiology
• 1. Autoimmune reaction in which the beta cells
  that produce insulin are destroyed
• 2. Alpha cells produce excess glucagons causing
  hyperglycemia
• Risk Factors
• 1. Genetic predisposition for increased
  susceptibility HLA linkage
• 2. Environmental triggers stimulate an autoimmune
  response
• a. Viral infections (mumps, rubella,
  coxsackievirus B4)
• b. Chemical toxins

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Diabetes Mellitus

• Manifestations
• Process of beta cell destruction occurs slowly
  hyperglycemia occurs when 80 90 is destroyed
  often trigger stressor event (e. g. illness)

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Diabetes Mellitus

• 2. Hyperglycemia leads to
• a. Polyuria (hyperglycemia acts as osmotic
  diuretic)
• b. Glycosuria (renal threshold for glucose 180
  mg/dL)
• c. Polydipsia (thirst from dehydration from
  polyuria)
• d. Polyphagia (hunger and eats more since cell
  cannot utilize glucose)
• e. Weight loss (body breaking down fat and
  protein to restore energy source
• f. Malaise and fatigue (from decrease in energy)
• g. Blurred vision (swelling of lenses from
  osmotic effects)

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Diabetes Mellitus

• Diagnosis
• Patient is symptomatic plus
• Casual plasma glucose (non-fasting) is 200 mg/dl
  OR
• Fasting plasma glucose of 126 mg/dl or higher OR
• Two hour plasma glucose level of 200 mg/dl or
  greater during an oral glucose tolerance test

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Diabetes Mellitus

• Diabetic Ketoacidosis (DKA)
• 1. Results from breakdown of fat and
  overproduction of ketones by the liver and loss
  of bicarbonate
• Occurs when Diabetes Type 1 is undiagnosed or
  known diabetic has increased energy needs, when
  under physical or emotional stress or fails to
  take insulin
• Mortality as high as 14
• 3. Pathophysiology
• a. Hypersomolarity (hyperglycemia, dehydration)
• b. Metabolic acidosis (accumulation of ketones)
• c. Fluid and electrolyte imbalance (from osmotic
  diuresis)

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Diabetes Mellitus

• Diagnostic tests
• a. Blood glucose greater than 250 mg/dL
• b. Blood pH less than 7.3
• c. Blood bicarbonate less than 15 mEq/L
• d. Ketones present in blood
• e. Ketones and glucose present in urine
• f. Electrolyte abnormalities (Na, K, Cl)
• G. serum osmolality lt 350 mosm/kg (normal
  280-300)

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Diabetes Mellitus

• DKA
• Signs and symptoms
• Kussmals respirations
• Blow off carbon dioxide to reverse acidosis
• Fruity breath
• Nausea/ abdominal pain
• Dehydration
• Lethargy
• Coma
• Polydipsia, polyuria, polyphagia

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Diabetes Mellitus

• Treatment
• a. Requires immediate medical attention and
  usually admission to hospital
• B .Frequent measurement of blood glucose and
  treat according to glucose levels with regular
  insulin (mild ketosis, subcutaneous route severe
  ketosis with intravenous insulin administration)
• c. Restore fluid balance initially 0.9 saline
  at 500 1000 mL/hr. regulate fluids according
  to client status when blood glucose is 250 mg/dL
  add dextrose to intravenous solutions

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Diabetes Mellitus

• DKA
• d.Correct electrolyte imbalance client often is
  initially hyperkalemic
• As patient is rehydrated and potassium in pushed
  back into the cell they become hypokalemic
• Monitor K levels
• e. Monitor cardiac rhythm since hypokalemia puts
  client at risk for dysrrhythmias
• f. Treat underlying condition precipitating DKA
• G. Acidosis is corrected with fluid and insulin
  therapy and rarely needs bicarb

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Diabetes Mellitus

• Diabetes Type 2
• A. Definition condition of fasting hyperglycemia
  occurring despite availability of bodys own
  insulin
• B. Was known as non-insulin dependent diabetes
  or adult onset diabetes
• Both are misnomers, it can be found in children
  and type II DM may require insulin

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Diabetes Mellitus

• Pathophysiology
• 1. Sufficient insulin production to prevent DKA
  but insufficient to lower blood glucose through
  uptake of glucose by muscle and fat cells
• 2. Cellular resistance to insulin increased by
  obesity, inactivity, illness, age, some
  medications

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Diabetes Mellitus

• Risk Factors
• 1. History of diabetes in parents or siblings no
  HLA
• 2. Obesity (especially of upper body)
• 3. Physical inactivity
• 4. Race/ethnicity African American, Hispanic,
  or American Indian origin
• 5. Women history of gestational diabetes,
  polycystic ovary syndrome, delivered baby with
  birth weight gt 9 pounds
• 6. Clients with hypertension HDL cholesterol lt
  35 mg/dL, and/or triglyceride level gt 250 mg/dl.

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Diabetes Mellitus

• Syndrome X or Metabolic Syndrome
• Chronic, low grade inflammatory process
• Gives rise to diabetes type 2, ischemic heart
  disease, left ventricular hypertrophy
• Group of disorders with insulin resistance as the
  main feature
• Includes
• Obesity especially around the waist and abdomen
• Low levels of physical activity
• High blood pressure
• Increased blood cholesterol (high LDL, low HDL,
  high triglycerides

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Diabetes Mellitus

• Manifestations
• 1. Client usually unaware of diabetes
• a. Discovers diabetes when seeking health care
  for another concern
• b. Most cases arent diagnosed for 5-6 years
  after the development of the disease
• c. Usually does not experience weight loss

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Diabetes Mellitus

• 2. Possible symptoms or concerns
• a. Hyperglycemia (not as severe as with Type 1)
• b. Polyuria
• c. Polydipsia
• d. Blurred vision
• e. Fatigue
• f. Paresthesias (numbness in extremities)
• g. Skin Infections

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Diabetes Mellitus

• Hypersomolar Hyperglycemic Nonketotic Syndrome
  (HHNS)
• 1. Potential complication of Diabetes Type 2
• Life threatening medical emergency, high
  mortality rate, as high as 50
• Enough insulin is secreted to prevent ketosis,
  but not enough to prevent hyperglycemia
• High blood sugar causes an extreme diuresis with
  severe electrolyte and fluid loss

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• Characterized by
• Plasma osmolarity 340 mOsm/l or greater- normal
  280-300
• Blood glucose severely elevated, 800-1000
• Altered level of consciousness

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Diabetes Mellitus

• 4. Precipitating factors
• a. Infection (most common)
• pneumonia
• b. Therapeutic agent or procedure
• c. Acute or chronic illness
• MI
• Stroke
• Pancreatitis
• pregnancy
• 5. Slow onset 1 14 days

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Diabetes Mellitus

• Pathophysiology
• a. Hyperglycemia leads to increased urine output
  and dehydration
• b. Kidneys retain glucose glucose and sodium
  rise
• c. Severe hyperosmolar state develops leading to
  brain cell shrinkage
• Manifestations
• a. Altered level of consciousness (lethargy to
  coma)
• b. Neurological deficits hyperthermia, motor and
  sensory impairment, seizures
• c. Dehydration dry skin and mucous membranes,
  extreme thirst, tachycardia, polyuria, hypotension

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Diabetes Mellitus

• Treatment
• a. Usually admitted to intensive care unit of
  hospital for care since client is in
  life-threatening condition unresponsive, may be
  on ventilator, has nasogastric suction
• b. Correct fluid and electrolyte imbalances
  giving isotonic or colloid solutions and correct
  potassium deficits
• c. Lower glucose with regular insulin until
  glucose level drops to 250 mg/dL
• Monitor for renal failure
• d. Treat underlying condition

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Diabetes Mellitus

• Complications of Diabetes
• A. Alterations in blood sugars hyperglycemia and
  hypoglycemia
• B. Macrocirculation (large blood vessels)
• 1. Atherosclerosis occurs more frequently,
  earlier in diabetics
• 2. Involves coronary, peripheral, and cerebral
  arteries
• C. Microcirculation (small blood vessels)
• 1. Affects basement membrane of small blood
  vessels and capillaries
• 2. Involves tissues affecting eyes and kidneys
• D. Prevention of complications
• 1. Managing diabetes
• 2. Lowering risk factors for conditions
• 3. Routine screening for complications
• 4. Implementing early treatment

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Diabetes Mellitus

• Complications of Diabetes Alterations in blood
  sugars
• A. Hyperglycemia high blood sugar
• 1.DKA (mainly associated with Diabetes Type 1)
• 2.HHS (mainly associated with Diabetes Type 2)
• 3.Dawn phenomenon rise in blood sugar between 4
  am and 8 am, not associated with hypoglycemia
• Glucose released from the liver in the early AM
  secondary to growth hormones
• Altering the time and dose of the insulin (NPH or
  Ultralente) by 2-3 units stabilizes the blood
  sugar

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Diabetes Mellitus

• 4. Somogyi effect combination of hypoglycemia
  during night with a rebound morning hyperglycemia
  that may lead to insulin resistance for 12 to 48
  hours

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Diabetes Mellitus

• B. Hypoglycemia (insulin reaction, insulin shock,
  the lows) low blood sugar
• 1.Mismatch between insulin dose, carbohydrate
  availability and exercise
• 2.May be affected by intake of alcohol, certain
  medications

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Diabetes Mellitus

• Specific manifestations
• a. Cool, clammy skin
• b. Rapid heartbeat
• c. Hunger
• d. Nervousness, tremor
• e. Faintness, dizziness
• f. Unsteady gait, slurred and/or incoherent
  speech
• g. Vision changes
• h. Seizures, coma
• 5. Severe hypoglycemia can result in death
• 6. Clients taking medications, such as
  beta-adrenergic blockers may not experience
  manifestations associated with autonomic nervous
  system
• 7. Hypoglycemia unawareness clients with
  Diabetes Type 1 for 4 or 5 years or more may
  develop severe hypoglycemia without symptoms
  which can delay treatment

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Diabetes Mellitus

• Treatment for mild hypoglycemia
• a. Immediate treatment client should take 15 gm
  of rapid-acting sugar (half cup of fruit juice 8
  oz of skim milk, 3 glucose tablets, 3 life savers
• b. 15/15 rule wait 15 minutes and monitor blood
  glucose if still low, client should eat another
  15 gm of sugar
• c. Continue until blood glucose level has
  returned to normal
• d. Client should contact medical care provider if
  hypoglycemia occurs more that 2 or 3 times per
  week

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Diabetes Mellitus

• Treatment for severe hypoglycemia is often
  hospitalization
• a. Client is unresponsive, has seizures, or has
  altered behavior blood glucose level is less
  than 50 mg/dL
• b. If client is conscious and alert, administer
  15 gm of sugar
• c. If client is not alert, administer
• 1. 25 50 solution of glucose intravenously,
  followed by infusion of 5 dextrose in water
• 2. Glucagon 1 mg by subcutaneous, intramuscular,
  or intravenous route follow with oral or
  intravenous carbohydrate
• d. Monitor client response physically and also
  blood glucose level

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Diabetes Mellitus

• Complications Affecting Cardiovascular System,
  Vision, and Kidney Function
• A. Coronary Artery Disease
• 1. Major risk of myocardial infarction in Type 2
  diabetics
• Increased chance of having a silent MI and
  delaying medical treatment
• 2. Most common cause of death for diabetics (40
  60)
• 3. Diabetics more likely to develop Congestive
  Heart Failure

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Diabetes Mellitus

• B. Hypertension
• 1. Affects 20 60 of all diabetics
• 2. Increases risk for retinopathy, nephropathy

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Diabetes Mellitus

• C. Stroke
• Type 2 diabetics are 2 6 times more likely to
  have stroke as well as Transient Ischemic Attacks
  (TIA) or mini stroke

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Diabetes Mellitus

• D. Peripheral Vascular Disease
• 1. Increased risk for Types 1 and 2 diabetics
• 2. Development of arterial occlusion and
  thrombosis resulting in gangrene
• 3. Gangrene from diabetes most common cause of
  non-traumatic lower limb amputation

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Diabetic Foot Ulcer
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Diabetes Mellitus

• Diabetic Retinopathy
• 1. Definition
• a. Retinal changes related to diabetes
• Hemorrhage, swelling, decreased vision
• b. Leads to retinal ischemia and breakdown of
  blood-retinal barrier
• 2. Leading cause of blindness ages 25 74
• a. Affects almost all Type 1 diabetics after 20
  years
• b. Affects 60 of Type 2 diabetics
• Diabetics should be screened for retinopathy and
  receive treatment (laser photocoagulation
  surgery) to prevent vision loss
• Should be sent immediately to ophthalmologist
  upon diagnosis because may already have damage
• 4. Diabetics also have increased risk for
  cataract development

38
Diabetes Mellitus

• Diabetic Nephropathy
• 1. Definition glomerular changes in kidneys of
  diabetics leading to impaired renal function
• 2. First indicator microalbuminuria
• 3. Diabetics without treatment go on to develop
  hypertension, edema, progressive renal
  insufficiency
• a. In type 1 diabetics, 10 15 years
• b. May occur soon after diagnosis with type 2
  diabetes since many are undiagnosed for years
• 4. Most common cause of end-stage renal failure
  in U.S.
• 5. Kimmelstiel-Wilson syndrome
  glomerulosclerosis associated with diabetes

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Diabetes Mellitus

• Male erectile dysfunction
• Half of all diabetic men have erectile
  dysfunction

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Diabetes Mellitus

• Collaborative Care
• A. Based on research from 10-year study of Type 1
  diabetics conducted by NIH focus is on keeping
  blood glucose levels as close to normal by active
  management interventions complications were
  reduced by 60
• B. Treatment interventions are maintained through
• 1. Medications
• 2. Dietary management
• 3. Exercise
• C. Management of diabetes with pancreatic
  transplant, pancreatic cell or Beta cell
  transplant is in investigative stage

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Diabetes Mellitus

• Other Complications from Diabetes
• A. Increased susceptibility to infection
• 1. Predisposition is combined effect of other
  complications
• 2. Normal inflammatory response is diminished
• 3. Slower than normal healing
• B. Periodontal disease
• C. Foot ulcers and infections predisposition is
  combined effect of other complications

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Diabetes Mellitus

• Diagnostic tests to monitor diabetes management
• 1. Fasting Blood Glucose (normal 70 110 mg/dL)
• 2. Glycosylated hemoglobin (c) (Hemoglobin A1C)
• a. Considered elevated if values above 7
• b. Blood test analyzes excess glucose attached to
  hemoglobin. Since rbc lives about 120 days gives
  an average of the blood glucose over previous 2
  to 3 months
• Not a fasting test, can be drawn any time of the
  day
• of glycated (glucose attached) hemoglobin
  measures how much glucose has been in the
  bloodstream for the past 3 months
• )

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Diabetes Mellitus

• 3. Urine glucose and ketone levels (part of
  routine urinalysis)
• a. Glucose in urine indicates hyperglycemia
  (renal threshold is usually 180 mg/dL)
• b. Presence of ketones indicates fat breakdown,
  indicator of DKA ketones may be present if
  person not eating
• 4. Urine albumin (part of routine urinalysis)
• a. If albumin present, indicates need for workup
  for nephropathy
• b. Typical order is creatinine clearance testing

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Diabetes Mellitus

• 5. Cholesterol and Triglyceride levels
• a. Recommendations
• 1. LDL lt 100 mg/dl
• 2. HDL gt 45 mg/dL
• 3. Triglycerides lt 150 mg/dL
• b. Monitor risk for atherosclerosis and
  cardiovascular complications
• 6. Serum electrolytes in clients with DKA or HHNS

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Diabetes Mellitus

• Medications
• A. Insulin
• 1. Sources standard practice is use of human
  insulin prepared by alteration of pork insulin or
  recombinant DNA therapy
• 2. Clients who need insulin as therapy
• a. All type 1 diabetics since their bodies
  essentially no longer produce insulin
• b. Some Type 2 diabetics, if oral medications are
  not adequate for control (both oral medications
  and insulin may be needed)
• c. Diabetics enduring stressor situations such as
  surgery, corticosteroid therapy, infections,
  treatment for DKA, HHNS
• d. Women with gestational diabetes who are not
  adequately controlled with diet
• e. Some clients receiving high caloric feedings
  including tube feedings or parenteral nutrition

46
Diabetes Mellitus

• Injection sites
• Abdominal areas is the most preferred because of
  rapid absorption
• Do not aspirate insulin injections
• Administration covered in the lab

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Diabetes Mellitus
48
Diabetes Injection Sites
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Diabetes Mellitus

• When rapid acting or short acting insulin is
  mixed with longer acting insulin, draw the short
  acting insulin into the syringe first.
• Prevents contamination of the shorter acting
  insulin with the longer acting insulin
• Draw up clear, then cloudy
• Insuling glargine (Lantus) should not be mixed
  with any other insulin

50
Diabetes Mellitus

• Mixing insulin

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Diabetes Mellitus

• Alternative insulin administration
• Insulin pump
• Continuous subcutaneous infusion of a basal dose
  with increases at meal times
• Implanted pumps
• Implanted into the peritoneal cavity
• Inhaled insulin
• Under development

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Insulin Pump
53
Internal Insulin Pump
54
Diabetes Mellitus

• Oral Hypoglycemic Agents
• 1. Used to treat Diabetes Type 2
• 2. Client must also maintain prescribed diet and
  exercise program monitor blood glucose levels
• 3. Not used with pregnant or lactating women
• 4. Several different oral hypoglycemic agents and
  insulin may be prescribed for the client
• 5. Specific drug interactions may affect the
  blood glucose levels
• 6. Must have some functioning beta cells

55
Diabetes Mellitus

• Classifications and action
• a. Sulfonylureas
• 1. Action Stimulates pancreatic cells to secrete
  more insulin and increases sensitivity of
  peripheral tissues to insulin
• 2. Used to treat non-obese Type 2 diabetics
• 3. Example Glipizide (Glucotrol), Chlorpropamide
  (Diabinese), Tolazamide (Tolinase)

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Diabetes Mellitus

• b. Meglitinides
• 1. Action stimulates pancreatic cells to secret
  more insulin
• 2. Taken just before meals, rapid onset, limited
  duration of action
• 3. Major adverse effects is hypoglycemia
• 4. Used in non-obese diabetics
• 5. Example Repaglinide (Prandin), Nateglinide
  (Starlix)

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Diabetes Mellitus

• c. Biguanides
• 1. Action decreases overproduction of glucose by
  liver and makes insulin more effective in
  peripheral tissues
• 2. Used in obese diabetics
• 3. Does not stimulate insulin release
• 4. Metabolized by the kidney, do not use with
  renal patients
• 5. Example Metformin (Glucophage

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Diabetes Mellitus

• d. Alpha-glucoside Inhibitors
• 1. Action Slow carbohydrate digestion and delay
  rate of glucose absorption
• 2. Take with first bite of the meal or 15 min.
  after
• 3. Adjunct to diet to decrease blood glucose
  levels
• 4. Example Acarbose (Precose), Miglitol
  (Glyset)

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Diabetes Mellitus

• Thizaolidinediones (Glitazones)
• 1. Action Sensitizes peripheral tissues to
  insulin
• 2. Used in obese diabetics
• 3. Inhibits glucose production
• 4. Improves sensitivity to insulin in muscle,
  and fat tissue
• 5. Example Rosiglitazone (Avandia), Pioglitazone
  (Actos)

60
Diabetes Mellitus

• Patients with Type 2 DM who are obese have
  insulin resistance, they produce enough insulin
• Should use Glucophage, Actos or Avandia
• Enhances insulin secretion in tissue, but does
  not increase amount of insulin secreted

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Diabetes Mellitus

• Patients with Type 2 DM who are thin do not
  produce enough insulin, they are not insulin
  resistant
• Need sulfonylurea agents like Diabinese,
  Tolinase, Glucotrol, Diabeta

62
Diabetes Mellitus

• Role of Diet in Diabetic Management
• A. Goals for diabetic therapy include
• 1. Maintain as near-normal blood glucose levels
  as possible with balance of food with medications
• 2. Obtain optimal serum lipid levels
• 3. Provide adequate calories to attain or
  maintain reasonable weight

63
Diabetes Mellitus

• B. Diet Composition
• 1. Carbohydrates 60 70 of daily diet
• Carbohydrates convert quickly to sugars
• Advice patient to consume a similar amount of
  carbs at each meal
• Medications can work on a consistent glucose
  response from foods
• 2. Protein 15 20 of daily diet
• 3. Fats No more than 10 of total calories from
  saturated fats

64
Diabetes Mellitus

• 4. Fiber 20 to 35 grams/day promotes
  intestinal motility and gives feeling of fullness
• 5. Sodium recommended intake 1000 mg per 1000
  kcal
• 6. Sweeteners approved by FDA instead of refined
  sugars
• 7. Limited use of alcohol potential hypoglycemic
  effect of insulin and oral hypoglycemics

65
Diabetes Mellitus

• Diet
• Look for more dietary information online at
  http//www.diabetes.org/nutrition-and-receipes/nut
  rition/overview.jsp

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Diabetes Mellitus

• Care of diabetic older clients
• A. 40 of all clients with diabetes are over age
  of 65
• B. Need to include spouse, members of family in
  teaching who may assist with client meeting
  medical needs
• C. Diet changes may be difficult to implement
  since client has established eating habits
• D. Exercise programs may need adjustment to meet
  individuals abilities (such as physical
  limitations from other chronic illnesses)
• Obesity worsens diabetes
• Minimum of 30 minutes of moderate exercise like
  walking or swimming most days of the week

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Diabetes Mellitus

• E. Individual reluctance to accept assistance to
  deal with chronic illness, assist with hygiene
• F. Limited assets for medications, supplies,
  dietary
• G. Visual deficits or learning challenges to
  learn insulin administration, blood glucose
  monitoring

68
Diabetes Mellitus

• Nursing Care
• A. Assessment, planning, implementation with
  client according to type and stage of diabetes
• B. Prevention, assessment and treatment of
  complications through client self-management and
  keeping appointments for medical care
• C. Client and family teaching for diabetes
  management
• D. Health promotion includes education of healthy
  life style, lowering risks for developing
  diabetes for all clients
• E. Blood glucose screening at 3 year intervals
  starting at age 45 for persons in high risk groups

69
Diabetes Mellitus

• Common Nursing Diagnoses and Specific Teaching
  Interventions
• A. Risk for impaired skin integrity Proper foot
  care
• 1. Daily inspection of feet
• 2. Checking temperature of any water before
  washing feet
• 3. Need for lubricating cream after drying but
  not between toes
• 4. Patients should be followed by a podiatrist
• 5. Early reporting of any wounds or blisters
• B. Risk for infection
• 1. Frequent hand washing
• 2. Early recognition of signs of infection and
  seeking treatment
• 3. Meticulous skin care
• 4. Regular dental examinations and consistent
  oral hygiene care

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Diabetes Mellitus

• C. Risk for injury Prevention of accidents,
  falls and burns
• D. Sexual dysfunction
• 1. Effects of high blood sugar on sexual
  functioning,
• 2. Resources for treatment of impotence, sexual
  dysfunction
• E. Ineffective coping
• 1. Assisting clients with problem-solving
  strategies for specific concerns

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Diabetes Mellitus

• 2. Providing information about diabetic
  resources, community education programs, and
  support groups
• 3. Utilizing any client contact as opportunity to
  review coping status and reinforce proper
  diabetes management and complication prevention