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DIABETES MELLITUS

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Title: DIABETES MELLITUS


1
DIABETES MELLITUS
Majuvy L. Sulse MSN, RN, CCRN Lola Oyedele MSN,
RN, CTN
2
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)

3
PANCREAS
  • CELL TYPES AND FUNCTION
  • BETA - INSULIN
  • HYPOGLYCEMIC FACTOR
  • ALPHA - GLUCAGON
  • HYPERGLYCEMIC FACTOR
  • DELTA - SOMASTATIN
  • INHIBITS SECRETION OF BOTH INSULIN AND GLUCAGON

4
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

5
  • 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

6
Critical thinking
  • The process of breaking down material without
    insulin during metabolism is know as
  • A. Ketogenesis
  • B. Lipolysis
  • C. Glycogenesis
  • D. Catabolism

7
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)

8
PITUITARY
  • GROWTH HORMONE
  • ACTH
  • CORTISOL
  • ? GLUCONEOGENESIS
  • ? LIPOLYSIS
  • ? USE OF GLUCOSE BY CELLS
  • ? BLOOD SUGAR

9
RISK FACTORS
  • FAMILY HISTORY
  • HISTORY OF GLUCOSE INTOLERANCE
  • OBESITY
  • HIGH FAT DIET
  • SEDENTARY LIFE STYLE
  • ELDERLY
  • ETHNECITY

10
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

11
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

12
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

13
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.

14
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

15
  • KIDNEY
  • KIDNEY CAN EXCRET 180 MG/DL
  • (GLUSOSURIA)
  • OSMOTIC DIURESIS (POLYURIA)
  • FLUID VOLUME ELECTROLYTE DEPLEATION
  • HYPOVOLEMIA THIRST (POLYDISPIA)
  • ? GLUCOSE TO CELLS STARVATION (POLYPHAGIA)

16
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

17
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

18
MANAGEMENT OUTCOMES
  • PROMOTE PROPER NUTRITION
  • PROMOTE EXERCISE
  • ADMINISTER MEDICATION

19
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

20
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

21
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

22
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23
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

24
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25
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

26
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27
Hyperglycemia
  • Causes
  • Undiagnosed type 1
  • Know type 1
  • Omission of insulin
  • Illness/infection/ trauma/ surgery
  • None DM
  • Cushing's syndrome/ hyperthyroid/ pregnancy
  • Medications ( Dilantin)

28
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29
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30
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31
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

32
Diabetic Ketoacidosis
  • Kidney regulates ? K
  • ? blood glucose ? osmotic pressure
  • Kidney regulates diuresis ? Na
  • Glucosuria, dehydration electrolyte imbalance

33
  • SS
  • Polyuria, polydipsia, polyphagia
  • Headache with blurred vision
  • Nausea/vomiting r/t ? peristalsis
  • ? respirations/ fruity breath
  • Kussmaul's pattern

34
  • 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

35
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

36
Management
  • Rehydration
  • Replace electrolytes
  • Insulin
  • Vital signs hourly
  • Blood sugar hourly
  • Urine output hourly
  • Cardiac monitor

37
Complications
  • Hypovolemic shock
  • Dysrhythmias
  • Myocardial infarction
  • Seizures
  • Coma
  • Acute renal failure

38
Hyperglycemic Hyperosmolar Nonketotic Syndrome
  • Hyperglycemia, Dehydration
  • W/O acidosis ( enough insulin)
  • Insidious onset
  • ( tolerate polyuria, polydipsia, polyphagia
    headache weakness)

39
HHNS
  • Dehydration R/T osmotic diuresis
  • Hypovolemia ? glomerular filtration rate
  • ? glucose retained
  • ? Na retained
  • ? osmolarity.

40
  • 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

41
Management
  • Rehydrate
  • Normal saline X 2 hours ( Isotonic)
  • .45 normal saline (hypotonic)
  • Electrolyte replacement
  • Insulin
  • Hourly vital signs, output,
  • Cardiac monitor

42
Chronic Complications
  • Infections
  • monilia
  • Skin r/t ?glucose moisture
  • Vaginal R/T ?glucose altered Ph

43
Vascular Complications
  • Macrovascular
  • Atherosclerotic changes earlier greater
    frequency
  • Coronary artery disease
  • Cerebral vascular disease
  • peripheral vascular disease

44
  • Microvascular
  • Unique to diabetics
  • Thickening of basement membrane of capillaries
  • Retinopathy -
  • Cataracts
  • Neuropathy
  • Nephropathy

45
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

46
Cataracts
  • Accumulation of sorbitol in the lens
  • Opacity gradual onset
  • Similar to senile cataracts

47
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)

48
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

49
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

50
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

51
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

52
CARE OF THE ELDERLY
  • TEACH AT SIMPELEST LEVEL
  • BARRIERS TO LEARNING
  • ? HEARING
  • ? EYESIGHT
  • ? MEMORY
  • ? EYE HAND COORDINATION
  • ? RESOURCES
  • ? COORDINATION

53
THE FUTURE HOPE
  • PANCREAS TRANSPLANT
  • ISLET CELL TRANSPLANTS

54
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
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