Download Diabetes Mellitus

Diabetes Mellitus
2015, MC
Disorder of metabolism
Regulated by insulin
Pathophysiology & Key Words
• Pg. 1047
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Endogenous
Exogenous
Glycosuria
Hyperglycemia & Hypoglycemia
Effect of Foods
• Food is broken down into chemicals which
include glucose
• Percent of glucose conversion:
• Carbohydrates– 100%
• Protein– 58%
• Fat– 10%
Role of Insulin
• Regulates the rate of glucose metabolism
• Moves glucose into cells
• Reduces blood sugar by ^ utilization of
carbohydrates
• Synthesis of fatty acids and proteins
Role of Insulin (cont’d)
• Moves glucose into cells
• Helps carry glucose into resting muscle
cells
• Helps convert fatty acids into fat
Insulin
• Without adequate insulin, fat stores
breakdown which increases tryglyceride
levels. This increases fatty acid production
of the liver, thus increasing the production
of lipoproteins, which promotes the
development of atherosclerosis.
Classifications…
• Type 1 (previously known as IDDM or
Insulin Dependent Diabetes Mellitus)
• Type 2 ( previously known as NIDDM or
non-insulin-dependent Diabetes Mellitus)
• Gestational
Type I ( IDDM)
• Absence of endogenous insulin
• Most commonly caused by autoimmune
disorder
• Complete destruction of beta cells
• Totally insulin dependent
Type II ( NIDDM )
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Usually adult onset
Showing up in children
Inadequate supply endogenous insulin
Cells become resistant to insulin
Pills are given to increase the sensitivity
Symptoms develop gradually and therefore
often go un-noticed
Risk Factors for type 2 DM
• Review page 1049
• Learn the Risk Factors !
Symptoms of DM
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Hyperglycemia  key feature
FBS @ NCH = 70-99 or 70-110
FBS @ ADA = 70-80-130
There is NO NATIONAL STANDARD
Polydipsia
Polyuria
Polyphagia (hunger)
Criteria for Medical Diagnosis
• Symptoms of Diabetes (3 P’s)
• Fasting serum glucose level of 126mg/dl or
greater
• Two-hour postprandial glucose above
200mg/dl during OGTT (Oral Glucose
Tolerance Test)
• What is “Prediabetes”
DM Complications are
influenced by:
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Duration of DM
Poor glycemic control
Every organ is affected
Classified as:
Microvascular
Macrovascular
Neuropathic
Microvascular Complications
• Basement membrane of capillaries thickens
• Exchange of nutrients, gases and waste is
impaired
• Related to persistent hyperglycemia and
aggravated by hypertension & smoking
• Eyes and kidneys most vulnerable
Diabetic Retinopathy
• Pathological changes in the retina due to
DM
• Nonproliferative and proliferative
• Macula edema ( floaters or spots )
• Causes loss of central vision
• Eye exams should be yearly
Nephropathy
• Kidney 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 Complications
• Causes 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
• Increased complications post surgery d/t
poor circulation
Neuropathic Complications
• Neuropathypathological changes in nerve
tissue
• May not feel or recognize injury
• Related to poor glucose control and ischemic
lesions of nerves
• Affects 13% of people w/ diabetes
• 50% chance of having neuropathies if diabetic for
over 25 yrs
• Classified as: Mono, Poly or Autonomic
• Foot complications
• Related to neuropathy or inadequate blood
supply (PVD)
• Ulcers, burns or abscess may easily
develop and go unnoticed
• Best treatment is prevention
• “Do’s & Don’ts” of foot care ???
Acute Emergency Complications
1) Acute Hypoglycemia
2) Diabetic Ketoacidosis ( DKA)
3) Hyperglycemic Hyperosmolar Nonketotic
Syndrome (HHNKS)
Acute Hypoglycemia
• S/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
• Insulin Shock
• Can happen very fast
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 70.
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
DKA and Stress
• Sympathetic response detects need for cell
fuel
• Converts stored glycogen to glucose
• Elevates BS even more
• Body is depleted of glycogen and starts to
burn fats and proteins
• Leads to DKA and metabolic acidosis
Patient becomes dehydrated
• What do you treat it with
• IV fluids
• Patient is hemo-concentrated and is now at
risk for what?
• Blood clots
S/S of DKA
• Early SxAnorexia, 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
• Rapid and deep respirations
Hyperglycemic Hyperosmolar
Nonketotic Syndrome (
HHNKS)
Extremely high glucose levels (>600mg/dl)
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• Basic defect is lack of effective insulin or
inability to use available insulin
• Dehydration and hypernatremia develop
• Caused by hyperglycemia, increased osmotic
pressure
• Kussmaul resp and GI symptoms are absent
• May be caused by IV solutions w/ high
concentrations of glucose (TPN or dialysis)
Medical Treatment for Diabetes
Mellitus
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4)
Nutritional Management
Exercise
Insulin Therapy
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; employ a dietitian to help teach.
• Always consider personal & ethnic choices
• Emphasis on total carbs not type
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 exercise if glucose are elevated
• Regular exercise helps to control glucose
• Insulin is absorbed quickly when injected into
abdomen
Insulin Therapy
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Time Course of Action Table 46-1 pg. 1059
Novolog is the most rapid acting
Route (No oral forms yet)
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
Common Therapy Types
• Conventional Therapy
• Intensive Therapy
• Basal Bolus Therapy
QBrittle Diabetes would require what type
of therapy ??
Subcutaneous Insulin Infusion
• Continuous 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
Sliding Scale Dosage
Blood Sugar:
>150
3 units
200-299 6 units
300-400 9 units
>400
12 units
Pre-Operative Dosing
• Pts instructed to give just ½ dose at regular
time
• BS value on admission and serial BS as
needed
• May run background D5W as needed
PostOp
• Stress of surgery may cause ^ in BS
• Type II patients may need insulin
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
• NPH (Neutral Protamine Hagedorn) is
cloudy, needs warming
• Regular is given prior to meals
Insulin Injection
• See Figure 46-3 pg. 1061
• Site rotation helps prevent lipohypertrophy
or lipoatrophy
• Abdomen absorption is 50% faster
• ADA recommends rotating sites within one
anatomic area
Oral Hypoglycemic Agents
• See Table 46-2 & 46-3
• 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
• Metformin
Class Activity
• Acute Hypoglycemia
• Diabetic Ketoacidosis
Self Monitoring of Blood
Glucose (SMBG)
• 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*
Complications of Therapy
• Hypoglycemia
• Somogyi Phenomenon
• Dawn’s Phenomenon
Dawn Phenomenon
• FBS to >180 between 5-9 am
• Treat with bedtime snack and delay
evening insulin intermediate insulin until
10pm so it will peak around 5-9 am
Assessment of the patient with
Diabetes
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See Box 46-2 pg. 1068
Health History ???
PMHx ???
Review of Systems??
Functional Assessment??
Interventions are ???
Class Activity
• A 44-year-old obese man is admitted with a blood
glucose level of 400 mg/dl and a blood pH of 7.28. The
patient experienced increasing fatigue, headaches, and
weakness. He is diagnosed with diabetes mellitus type 2
and DKA. The patient works part-time at night as a
security guard. He tells the nurse that he had no idea he
had diabetes and says that he loves to eat while at work.
He also says that he sleeps all day and doesn’t exercise.
The patient is very concerned about how his new
diagnosis will affect his life.
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
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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
• *Remember Hypoglycemia associated with
treatment of diabetes uses different guidelines for
treatment
Class Activity
• A 75-year-old woman with diabetes
mellitus type 2 who receives insulin
therapy lives in a long-term care center and
tells the nurse that she is tired of living this
way. She says that she wants to eat
whatever she likes and doesn’t want to take
her insulin anymore. The patient has
several complications related to diabetes,
including polyneuropathy and retinopathy.
WOW, We Did It
• Remember, you must recycle this
knowledge!!!!!