advanced theoretical concepts in nursing.dm type2

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Advanced Theoretical

concepts in Nursing

Diabetes Mellitus Type-II

By

Talat RashidDecember 12, 2007


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Objectives

Define the disease in the case study

Discuss the prevalence, significance of Diabetes

Mellitus type II.(DM II)

Describe the etiology, normal and alteredpathology, and s/s of DM II

Explain the prevention/complications of DM II

Review the pharmacological manag. of DM II Discuss nursing management of DM II by

incorporating the appropriate theory.


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Case study 47 yrs old, father.

Appeared in Diabetes consultant clinic on

29-11-07

Presenting features (from last 04 months)

- Sense of heaviness over lowerabdomen

- Retention of urine

- Excessive urination (Polyuria)

- Excessive thirst (Polydipsia)- Excessive eating (Polyphagia)

- Becomes angry on minor issues


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cont

Family Hx:

DM (-), HTN (+), Cardiac dis (+)

Personal/social Hx:

Businessman, normal sleep, Appetite,

feels has lost wt from 01 yr., smokingfrom last 10 yrs


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Vitals

B.P 125/80 mmHg Pulse: 80/min (regular)

RR: 22/min (unlabored)

Wt 85 kg

Ht: 180 cm

Pain score: 1(on pain scale of 1-10)

Allergies: Not known


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General appearance

An adult man with average built walked in

comfortably into the CC (accompanied by his

wife) and sit on the chair with ease. Oriented to

time, place and person, has clear speech &relevant talk but seems to have attention & eye

contact during history taking and gives

incomplete answers occasionally, looks

depressed. Is well groomed and hydrated.


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Physical Examination

Ht 180cm

Wt 85kgs

Body Mass Index (BMI)

BMI = Wt (kgs) / Ht (mxm)

= 85 kgs /1.8m x1.8m

= 85 / 3.24

= 26.23kgs/m2 (n.range= 19-24kgs/m2)

Overweight


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Review of systemsSkin: inspection for breakdown, non healing pustules,

diabetic ulcer or wound, Diabetic foot.

Neurological system: Sensory & motor system. Paralysis, Balance,

response to pain & sensitization of hot or cold application over

limbs for parasthesia to rule out Diabetic Neuropathy,

Cognition status: orientation, alertness, memory status.

Eyes: vision, pain, cataracts, fundoscopy to rule out Diabetic

Retinopathy

Mouth: inspection of gums & teeth for infection, buccal mucosa forsores,


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Cont.CVS: pain, palpitation, heart sounds, dysnea, murmurs,,HTN

PVS: varicose veins, thrombophlebitis, leg cramps

Genito-urinary: frequency of micturation, pressure symtoms,burning

micturation, incontinence of urine, Diabetic Nephropathy

Musculoskeletal system: ROMs, strength, gait & balance

Endocrine: Goiter, change in weight, polyphagia, polidypsia,

polyuria, glycosuria


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Differential Diagnosis

Diabetes Mellitus Type II

Diabetes Mellitus Type I

Hyperlipidemia UTI

BPH

Anxiety


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Investigations FBS 134 mg/dl

RBS 213 mg/dl

Lipid Profile

T. Cholesterol 201 mg/dl (Nor < 250)

Triglycerides 104 mg/dl (Nor < 150)

HDL 40 mg/dl (Nor > 40)

LDL 143 mg/dl (Nor > 100)


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DIABETES MELLITUS TYPE II

(Non Insulin Dependant Diabetes

Mellitus)


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Definition

Type II diabetes is a chronic, common,

complex metabolic disorder characterized

by hyperglycemias, a disease of growing

public health concern


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Significance

INCIDENCE

PREVENTABLE COMPLICATIONS

COMORBIDS

HOSPITAL / TERTIARY CARE

HOSPITAL WORKLOAD / NOSOCOMIAL INFECTIONS

NATIONAL ECONOMY

HEALTHY AND PRODUCTIVE COMMUNITY


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Prevalence

2.9 millionpeople globally died of diabetes

in 2000, about three times its previous

estimate.

WHO (2005)

200 millioncases worldwide(Report of a WHO Meeting, 2004 )


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Prevalence in United States

20.8 million(7 % population) had diabetes in 2005,6.2 millionof them undiagnosed. 90 to 95 %(18.7 million - 19.8million people) of Diabetics had type 2 diabetes.

(U.S. National Institutes of Health-2006)

Prevalence in Pakistan

The prevalence rate of diabetes 16.2% (9% known and 7.2% newlydiagnosed) in men and 11.7% (6.3% known and 5.3% newlydiagnosed) in women. The prevalence increased to almost 30% and21% in 65-74 years old men and women respectively. 79% of

Diabetic men & 96% of Diabetic womenin Pakistan are obese.(Javed, 2003)


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Incidence

Age

Traditionally thought to affect > 40 years

However, Incidence increasing in youngerpersons, in prepubertal children,

teenagers, and young adults.

Type 2 diabetes mellitus is observed evenin some obese children.

Sex; more common in women


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Background

Unlike type 1 diabetes mellitus, patients are notabsolutely dependent upon insulin for life, even thoughmany of these patients are ultimately treated with insulin.

Many people do not realize that they are suffering

from type 2 diabetes as they experience symptoms offatigue, lethargy, extreme thirst, frequent urination,susceptibility to infections and vision changes over aprolonged period of time.

Being overweight can keep your body from making

and using insulin properly. It can also cause high bloodpressure


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Endocrine system

Endocrine glands

release hormones

(chemical messengers)

into the bloodstream to

be transported tovarious organs and

tissues throughout the

body.The pancreas

secretes insulin, whichallows the body to

regulate levels of sugar

in the blood.www.medline.medicine


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Pancreas

The pancreas is located

behind the liver and is

where the hormone

insulin is produced.

Insulin is used by thebody to store and utilize

glucose.

www.medline.medicine


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Islets of Langerhans

Islets of Langerhans

contain beta cells

and are located

within the pancreas.

Beta cells produceinsulin which is

needed to

metabolize glucose

within the body.



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Role of InsulinFood intake

containing CHO

End product of CHO

metabolism GLUCOSE

Insulin is releasedGlucose in the blood

Movement of glucose to

bodys muscle, fat & liver cells

Glucose used by the body

as FUEL for ENERGY


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Path physiology

Production of Insulin (Auto immune) Insulin resistance

by liver, fat & muscle cells

Ineffective movement of Glucose to the cell

no energy available to cells

Blood Levels of Glucose

Hyperglycemia


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Etiology

Presumably, the defects of type 2 diabetes mellitusoccur when a diabetogenic lifestyle (ie, excessivecalories a high-fat diet, inadequate caloric expenditure,obesity) is superimposed upon a susceptible genotypeappears to cause type 2 diabetes mellitus.

Diabetes mellitus may be caused by other conditions.Secondary diabetes may occur in patients takingglucocorticoids or when patients have conditions thatantagonize the actions of insulin (eg, Cushing syndrome,

acromegaly, pheochromocytoma).


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Risk factors of DM

A parent, brother, or sister with diabetes

Obesity ( fat cells become insulin resistant)

Age greater than 45 years

Gestational diabetes or delivering a babyweighing more than 9 pounds

High blood pressure

High blood levels of triglycerides (a type of fatmolecule)

High blood cholesterol level

Not getting enough exercise


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Cardinal characteristics of DM

Hyperglycemia. Abnormally high glucose.

Left untreated to coma or death.

Hypoglycemia. Abnormally low glucose.

Left untreated convulsions,

unconsciousness or brain damage.


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COMPLICATIONS .Microvascular

Diabetic Neuropathyeg; parasthesias and footproblems limb amputations

Diabetic retinopathyeg; glaucoma, cataracts, maculardegeneration and blindness).

MacrovascularCoronary, peripheral- vascular, diabetic nephropathyassociated with BP & albumin in the urine (detectedby urinalysis) kidney failure

Others

Skin disorders and infections. The stomach disorder

Sexual dysfunction..

Urinary incontinence

Gum disease


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Arteriosclerosis of extremities

Arteriosclerosis of the

extremities is adisease of the bloodvessels characterizedby narrowing and

hardening of thearteriesthat supplythe legs and feet. Thiscauses a decrease in

blood flow that caninjure nerves andother tissues.



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Diabetic retinopathy

Excessive amount

of glucose in the

blood stream may

cause damage to

the blood vessels.Within the eye the

damaged vessels

may leak blood and

fluid into thesurrounding tissues

and cause vision

problems.www.medline.medicine


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Diabetic nephropathy

Uncontrolled diabetescauses thickening andhardening of the internalkidney structures. Akidney biopsy clearlyshows diabeticnephropathy.



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Symptoms of DM II

3 PsPolydypsia (Increased thirst)

Polyuria (Increased urination)

Polyphagia (Increased appetite)

Fatigue

Blurred vision

Slow-healing infections

Impotence in men Mood changes

Sudden reduction in wt


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Diagnostic criteria of DM II

The criteria adopted for the diagnosis of

diabetes & most commonly used is The

American Diabetes Association (1997) :

1. Fasting plasma glucose (FPG) >126 mg/dL

on 2 occasions or random plasma glucose

(RPG) > 200 m g/dl

2. Classic symptoms of diabetes mellitus (ie,

polyuria, polydipsia, polyphagia, weight loss).


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Cont..

Oral glucose tolerance test is +ive ifglucose level is >/= 200 mg/dL a/f 2 hrs ofintake.

Hemoglobin A1c (HbA1c) level >7% is ameasure of average blood glucose duringthe previous 2 to 3 months. It is a veryhelpful way to determine how welltreatment is working.

High triglycerides (>250 mg/dL) or lowHDL (


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Treatment of DM II

Oral antidiabetics*Tab Amaryl Img Bid

*Tab Glucobay 50mg BD

Tab Diabenese 100mg, 250mg

Tab Metformin 500mg OD

Tab Glucophage 500mg OD

Prophylactic drugs*Tab Esso 40 mg OD

*Tab Ascard 70 mg OD


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Tab Amaryl (Glymeperide)1,2&4mg

Action unknown, glucose possibly by stimulatingrelease of insulin from functioning pancreatic

beta cells. May sensitivity of peripheral tissue to

insulin.

Nsg considerations:

-Watch for hypoglycemia (cautiously used in

elderly & malnourished)

-Drug should be taken with first meal of the day

Tab Gl coba (Acarbose) 25 50


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Tab Glucobay (Acarbose) 25,50

&100mg

Alpha glycosidase inhibitor that delays

digestion of CHO, resulting in a smaller

rise in glucose level a/f meal

Nsg considerations:

-Watch for hypoglycemia

-Contraindicated in inflammatory bowel

disease, colonic ulceration, predispositon

to intestinal obstruction.


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Tab Ascard( Aspirin)70mg OD

Salicylate Reduces risk of recurrent transient Ischemic attacks &

stroke in patients at risk, by impeding clotting by blockingprostaglandin synthesis, which prevent formation ofplatelet aggregation substance Thromboxone A2.

Nsg considerations

- Use cautiously in pts with GI lesions, impaired renalfunction, Vit k deficiency, bleeding disorders.

-Should be discontinued , if bleeding from any sightoccurs & 7 days prior surgery

- Pt taught to take drug with food


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Cont

Research in the proposed treatment oftype II diabetes :

Replacement hormones, such as

glucagon-like peptide-1 (GLP-1). Pancreatic cell transplant, (the insulin

producing cells will be transferred to a

diabetic person to achieve a cure) Bariatric surgery

(Christine 2005)


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Complications

Heart attack

Stroke

Renal failure Limb amputation


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Prevention

Exercise

Normal weight control.

Physical activity Healthy diet

Strict blood glucose control


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Integration of Theory in patient with DM

Banduras Self-Efficacy Theory


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Model of triade resiprocality


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Background of theory

Self-Efficacy theory is an important

component of Banduras social cognitive

theory (1986), which suggests high inter-

relation b/w individuals Behavior,Environment and Personal( cognitive,

affective, & biological events) factors.

(Graham & Winner, 1996)


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Assumptions

The reciprocal nature of the determinants of

human functioning in social cognitive theorymakes it possible for therapeutic & counseling

effortsto be directed at personal, environmental

or Behavioral factors.

Hence strategies for well-being can be aimed at

improving emotional, cognitive, or motivational

processes, increasing behavioral competencies,or altering the social conditions under which

people live & work.


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Cont.. Self-efficacy beliefs provide the foundation for

human motivation, well-being and personalaccomplishment.

People who regard themselves as highly

efficacious act, think & feel differently from those

who perceive themselves as inefficacious.

Because individuals operate collectively as wellas individually, selfefficacy is both a personal &

social construct.


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Self-Efficacy

Self-efficacy is the belief in ones

effectiveness in performing specific tasks.(Bandura, 1986)

Self efficacy in DM type II


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Selfefficacy in DM type IISelf- monitoring of

Blood glucose,

Compliance with Rx

Follow Dietary restriction.Control weight

Regular exercise.

Regular follow ups in cc.

Health outcome (improved health)

Develop habits ofpositive thinking,

willingness to do

Actions and

self-reflection

Treatment

Nurse

Health Educator.Persuader

Counselor

Family

HEALH CARE PROGRAMS


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Nursing diagnosis

Fear r/t diagnosis of chronic illness

Knowledge deficit r/t control of disease/

prevention of complications.

Risk of ineffective coping r/t chronic

disease

Risk of noncompliance r/t the complexity

of the prescribed regime and follow up.


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Nsg interventions

Explain to the patient that the disease is controllable and

the symptoms can be reduced by improving behaviorslike:

-Control on weight through a weight reduction programand exercise. Use of stairs instead of elevators, and aregular program of walk, starting from small distance togradually increasing the distance.

-Reduction of calories in diet. Limit fat intake to about 25percent of total calories. For example, if the food choicesadd up to about 2,000 calories a day, should eat no

more than 56 grams of fat.-Diet can be planed with the dietition. The patient can beasked to check food labels for fat content too.


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Cont.. Avoid taking saturated fats coming from

animals meats & dairy products like milk,cheese and ice cream; and in some kinds of

cooking oils.

Reduce serving sizes of foods (such as meat,

desserts, and foods high in fat). Increase the

amount of fruits and vegetables in the diet.

Controlling carbohydrates in diet, such as:

pasta, bread, rice, potatoes


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Cont.

The patient is allowed to choose activitieshe/she enjoys. Some ways to work extra activityinto daily routine:

Take the stairs rather than an elevator orescalator.

Park at the far end of the plot and walk.

Get off the bus a few steps early and walk the

rest of the way. Walk or ride bicycle instead of drive whenever

he/she can.


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Cont.

Compliance with Rx. The medicine must

be taken as prescribed by the physician, at

the right time in the right dose.

Regular follow ups in cc, once in three

months, with raflo checks and lipid profile

and review of risk of appearance of 3

cardinal pathies.


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Acknowledgements

Miss Salma Jaffer

Ms Saleema Moiz

Ms Zubaida ( Diabetic cc nurse)

All Collegues


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References

Anne.J., Diabetes Causes and Prevention,retrieved from http://www.a1articles.com on

9/12/2007

Author: Bandura.A. (1986), Social foundation of

thought and action: a social cognitive

theory, England cliffs NJ, Prentice Hall- Diabetic diet information, what should you

eat,retr. From http://www.a1articles.com on

7/12/2007

- Pajares F., Overview of Social Cognitive Theory And of

Self-Efficacy, retrieved from www.healthology.comon 7/12/2007

- Porth, C. M. (2004). Pathophysiology: Concepts of altered

health states (7th ed.). New York: Lippincott.


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