Diabetes Mellitus

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Diabetes Mellitus

• Professor Cynthia Peacock R.N., M.SN.

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Objectives

• Define the assessment findings for a patient with
  Diabetes Type I and Type II.
• Identify the nursing actions to care for a
  patient with Diabetes Type I or Type II.

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Objectives

• Discuss the complications of Diabetes Mellitus
  (DM) and describe the medical treatment of
  complications of DM.
• Name three risk factors that increase the risk
  for developing DM.

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Terms

• Beta Cells
• Carbohydrates
• Calorie
• Gluconegenesis
• Glycogen
• Islets of Langerhans

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Diabetes Mellitus (DM)

• 2004 ADA Group of metabolic diseases
  characterized by increased levels of glucose in
  the blood. (hyperglycemia)
• Results from defect in insulin secretion ,
  insulin action 0r both
• Insulin- hormone produced by the pancreas
  controls the level of glucose in the blood.
• In diabetes, the cells may stop responding to
  insulin or pancreas may stop producing insulin

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Diabetes Mellitus (DM)

• Hyperglycemia may result in
• Diabetic ketoacidosis (DKA)
• Hyperglycemic hyperosmolar nonketo syndrome
  (HHNS)

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Pathophysiology

• Insulin is secreted by beta cells
• One of four types of cells in the islets of
  Langerhans in the pancreas
• Insulin is an anabolic
• hormone
• When a person eats
• a meal?

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Pathophysiology Cont

• Foods provide the body with glucose
• Glucose is a sugar that gives the body energy,
  (the glucose works in the cell)
• Pancreas produces insulin
• Insulin is the key that unlocks the body cells so
  glucose can get inside
• Inside the cells glucose is turned to energy
• Cells uses energy for functions of the body

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Pathophysiology Cont

• Without insulin, the body cannot utilize glucose
  (blood sugar),
• Its principal energy source.
• As a result, the level of glucose circulating in
  the blood is high
• Resulting in retinopathy, nephropathy and
  neuropathy
• Macrovascular and microvascular complications.

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Types of DM

• Major classifications of DM
• Type 1 (5-10)
• Type 2 (90-95)
• Gestational
• Secondary diabetes (other conditions,
  corticosteroids)
• Impaired glucose tolerance
• Prediabetes

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Type 1 Diabetes

• Previously called juvenile-onset or insulin
  dependent diabetes mellitus (IDDM) or Type I
• Develops when the bodys immune system destroys
  pancreatic beta cells,
• The only cells in the body that make the hormone
  insulin to regulate blood glucose

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Type 2 Diabetes Mellitus

• Occurs most often in obese adults older than
  forty
• Insulin resistance and impaired insulin secretion
  
• The pancreas produces more and more.
• Many people with insulin resistance have
  hyperglycemia and high blood insulin levels at
  the same time
• People who are overweight have a higher risk of
  insulin resistance.

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Gestational Diabetes

• Glucose intolerance during pregnancy.
• Hormonal changes can cause the body to be less
  sensitive to the effect of insulin.
• High blood sugar levels in pregnancy are
  dangerous for both mother and baby.

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Clinical Manifestations DM

• Depends on the patients level of hyperglycemia
• Classic signs are 3 Ps
• Polyuria,
• Polydipsia
• Polyphagia
• Fatigue, weakness
• Sudden vision changes
• Tingling and numbness of the hands or feet
• Dry skin, skin lesions, slow healing wounds
• Recurrent infections

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Assessment and Diagnostic

• High blood glucose level is the basic criteria
• Symptoms of diabetes
• Fasting blood glucose level gt126mg/dl
• Random gt200mg/dl
• OGTT
• They all should be repeated for a confirmation of
  diabetes

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Management of DM

• Medical Management of Type 1 and 2 is directed to
  maintaining normal serum glucose levels.
• Nutritional therapy
• Exercise
• Blood and urine glucose monitoring
• Drug therapy
• Education

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Nutritional Exercise Therapy

• Calorie meal plans
• Reasonable body weight
• Caloric distribution
• Food classification systems
• Exercise

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Monitoring Glucose Levels and Ketones

• Blood glucose monitoring is the cornerstone of
  diabetes management.
• Self monitoring of blood glucose (SMBG)
• Continuous glucose monitoring

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Monitoring Glucose Levels and Ketones

• Glycated hemoglobin AKA glycosated hemoglobin or
  HgbA1c
• (gt 7 poorly controlled diabetes)
• Urine glucose testing (are not used anymore)
• Testing for ketones
• Body looking for energy
• Artificial energy sources
• Broken down fats (ketones), building up in the
  blood and the urine
• High levels are deadly

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Management of Type 1

• Prescribing the hormone insulin
• Regulating the amount of fats, carbohydrates and
  proteins in the diet
• Planned daily exercise activity

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Pharmacologic Therapy for Type 1

• Insulin Therapies (High Alert Drug)
• Rapid Insulin
• Novolog, humalog
• Onset 5-15 minutes
• Taken 15 minutes before meals
• Regular
• Soluble and rapidly absorbed (IV use only)
• Onset lt1h, peak 2-3h
• Used in emergencies e.g. DKA
• NPH
• Onset 2-4h, peak 4-10h
• Available as pre-mixed 70 NPH/30 Reg. 50/50
• Can be mixed in the syringe with reg.

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Pharmacologic Therapy Cont

• Lente (long-acting)
• Onset 3-4 h peak 6-12h
• Duration 16-20h
• Pump Therapy
• Continuous Therapy
• Regular insulin
• Inhaled Insulin
• Exubera
• Enters the blood stream more rapidly than SQ

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Management of Type 2

• Oral medications
• Controlling or reducing body weight
• Exercise
• Cholesterol lt200
• Prevent macrovascular and microvascular
  complications.

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Major Long-Term Complications of DM (Both Types)

• Macrovascular (atherosclerotic plaque)
• Coronary arteries ? (MIs)
• Cerebral arteries ? (strokes)
• Peripheral vessels ? (ulcers, amputations)
• Microvascular (capillary damage)
• Retinopathy
• Neuropathy
• Nephropathy

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Sulfonylureas

• Diabenese, Tolinase, Glipizide
• First second generation drugs
• Used when diet and exercise fail to keep blood
  glucose in acceptable range
• Stimulates the pancreas to secrete insulin
• Certain Medications can cause hypoglycemia
• Salycylates, propranolol, MAO inhibitors and
  pentamidine.

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Biguanides

• Metformin (Glucophage) most common used
• Inhibits the production of glucose by the liver,
  ?body tissue sensitivity to insulin.
• Contraindicated in patients with renal failure

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Alpha-Glucosidases Inhibitors

• Acarbose (Precose), Miglitol (Glyset)
• Work in delaying the absorption of glucose in the
  intestinal system
• Result in lower postprandial blood glucose level
• Do not enhance insulin secretion
• They are not systemically absorbed
• Must be taken immediately before a meal.

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Thiazolidinediones (TDZs)

• Rosiglitazone (Avandia), Pioglitazone (Actos)
• Taken in conjunction with insulin for type 2
  diabetes or
• Uncontrolled BG, A1C gt8.5
• Enhance insulin action at the receptor site
  without ?ing secretion from the beta cells.
• Impair liver function
• ?the effectiveness of contraceptive therapy

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Meglitinides

• Repaglinide (Prandin)
• Stimulate pancreas to secrete insulin
• Effectiveness depends on the function of the
  pancreas
• Has a fast action and short duration
• Should be taken before each meal
• Side effect is hypoglycemia

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Nursing Management of Diabetes

• Patient Education
• Assess readiness to learn
• Diet meal plan
• Number of calories and use of exchange list or
  carbohydrate counting
• Eat meals at the same time everyday

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Nursing Management of Diabetes

• Exercise (walking, swimming, biking)
• Verbalization of proper use of oral meds
• Proper use of blood glucose monitor
• Testing blood, documentation, interventions

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Nursing Management of Diabetes

• Testing blood for Hgb A1C
• Target blood fat levels
• Total cholesterol lt200
• LDL cholesterol lt100
• HDL cholesterol gt40
• Triglycerides lt150

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Nursing Management of Diabetes

• Preparation of insulin and injection
• Insulin delivery devices
• Needle and syringe
• Insulin pens
• Insulin jet injectors
• External insulin pumps
• Implantable pumps
• Insulin inhalers
• Islet cell transplantation

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References
Smeltzer, S., Bare, b. (2007). Textbook of
Medical-Surgical Nursing, 11th ed. Philadelphia
Lippincott, Williams Wilkins Company Miami-Dade
College, Nursing Curriculum