diabetes pdf

8/2/2019 Diabetes PDF

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CH 20Nutrition and

DiabetesMellitus

What is Diabetes Mellitus?Treatment of Diabetes MellitusDiabetes Management throughout Life

2005 Pamela Eccles All Rights Reserved

What isDiabetes Mellitus ?

A group of metabolic

disorders of glucoseregulation and utilization

Characterized by

Elevated glucose

Altered energymetabolism

Caused by

Defective insulin secretion

Defective insulin action

Or

a combination of

10 million in U.S.diagnosed

+ 5.5 million more notdiagnosed..

Types of Diabetes

Type IType 2

Type 1Characteristics Less common

5-10% of cases Pancreas cannot

make insulin Blood glucose rises Without insulin

Glucose cannot enter cell

like it should Insulin must be injected

Type 2

Characteristics

90-95 % of cases

Most likely undiagnosed

Pancreas does produce insulin

Cells not sensitive to (tolerance)

Pancreas makes more insulin Cells in pancreas which make

insulin exhaust

Insulin production falters

Associated w/ obesity

Abdominal fatespecially


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Symptoms

Type 1

Frequent urination

Unusual thirst

Extreme hunger

Unusual weight loss

Extreme fatigue

Irritability

Type 2Any type 1 symptom(s)

PlusFrequent infectionsBlurred visionCuts/bruises - slow to healTingling/numbness in

hands or feetRecurring gum/skin/

bladder infections

People most likely todevelop Type 2diabetes

Are those who

are obese have immediate family

members w/.

are over age 45 are members of high risk

ethnic groups

African Americans

Asian and PacificIslanders

Hispanic Americans

Native Americans

Also

Women who have givenbirth to babies weighingover 9 lbs. or have beendiagnosed w/ gestationaldiabetes while pregnant

Nursing Diagnosis Altered nutrition: more than

body requirements

and

altered nutrition: risk for morethan body requirements

Diagnosis of Diabetes

Random blood glucosesamples

Exceed 200mg/100ml

Or

Blood glucose of 126mg/100ml w/ 8 hour fast

Blood glucose level>200mg/100ml any timeduring a glucose tolerancetest

These suggestdiabetes.

To confirm positive

Second testing Subsequent day


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Acute Complications

of Diabetes

Hyperglycemia, Dehydration,and Glycosuria

Blood glucose -hyperglycemia

Water drawn from tissues intoblood

Kidneys overwhelmed

Glucose excreted w/ fluids andelectrolytes

Glycosuria

Renal threshold The point at which a

blood constituent that isnormally reabsorbed bythe kidneys reaches alevel so high thekidneys cannotreabsorb it

The Nursing Diagnosis:

Fluid volume deficit or riskfor fluid volume deficit

Hyperglycemia

May develop in response to

Carbohydrate eaten

Type

Amount

Improper use of meds

in counterregulatoryhormones

Dawn phenomenon

Early morning hyperglycemia thatdevelops in response to elevated levelsof counterregulatory hormones that actto raise blood glucose after anovernight fast. Without adequateinsulin, the glucose cannot enter cellsand remains in blood

Strenuous exercise

Can cause a sharp rise in bloodglucose

Use of too much insulin

Rebound hyperglycemia

Hyperglycemia resultingfrom excessive secretions ofcounterregulatory hormonesin response to excessiveinsulin and consequent lowblood glucose levels;Somogyi effect

Illness/infection

Ketosis and Coma

Undiagnosed Type 1 diabetes

Cells deprived of glucose forenergy

Breakdown of protein and fatenergy

Liver makes ketone body from fatfragments

Build up of ketones in urine andblood acidosis

Fruity breathacetone

Diabetic coma may follow

Medical emergency

Treated in hospital

IV fluids

Fluid balance

Electrolytes

Acid imbalance


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Nonketotic Coma

(Hyperosmolar hyperglycemicnonketotic coma)

Extremely high blood glucosedehydration

No ketosis

Common in

Elderly w/ Type 2

Dont realize thirstdo notdrink enough

Weight Loss Glucose Ketones

Breakdown of protein for energy

Type 1 diabetes Likely to be thinenergy lost

Type 2 overweight then gradualweight loss

Energy sources lostIn urine

Nursing Diagnosis: alterednutrition: less than body

requirements frequently appliesto person w/ Type 1 diabetes

Hypoglycemia

(insulin reaction/insulin shock)

Inappropriate management of diabetes

Too much insulin

Strenuous physical activity

Skipped/delayed meals

Not enough food

Vomiting

Severe diarrhea

Mental confusion and shakiness

Make it difficult for diabetic to takeaction to correct

The Nursing Diagnosis

Altered nutrition: less than bodyrequirements

Symptoms Hunger

Headache

Sweating

Shakiness

Nervousness

Confusion

Disorientation

Slurred speech

Chronic Complicationsof Diabetes

Chronic hyperglycemia

Damages blood vessels & nerves even before diagnosis

Circulation not good Nerve function

Risk of infections

The Nursing Diagnosis

Risk of infection

Syndrome X

The combination of insulinresistance, hyperinsulinemia,obesity, hypertension, elevatedLDL and triglycerides, andreduced HDL that is frequentlyassociated with type 2 diabetesand cardiovascular disease.Also called Insulin-resistancesyndrome and metabolicsyndrome


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Cardiovascular diseases

Atherosclerosis

Develops early

Progresses rapidly

80% of diabetics die from CVD

Especially heart attacks

Small Blood Vessel Disorders

Capillaries

Nephropathy (loss of kidney function)

Retinopathy (retinal degeneration/vision loss

85%affected

Neuropathy

Nerve tissue deteriorates

Painful prickling

Loss of sensation

Injuries often go unnoticedinfection gangreneamputations of limbs

Toes/feet/legs

Gastric emptying delayed

Nausea

Vomiting

Weight loss

Irregular nutrient control

Treatment ofDiabetes Mellitus

Diagnosis

Devastating

Overwhelming

Change Lifestyle

To control blood glucosesuccessfully, the personmust master the complextask of coordinating diet,physical activity, and

medications.

Treatment Goals

Maintain blood glucosewithin fairly normalrange,

blood lipids optimal

blood pressure controlled

Reduces risk of onset andprogression by 50%

Nephropathy

Retinopathy

Neuropathy

Treatment Plans

Lifestyle changes

Assess and monitor

Diet

Physical activity Meds

Health status

Diabetes education

Medical Nutrition Therapy

for Diabetes

Diet same as for all healthy peopleControlling

Carbohydrates hypo/hyperglycemia

Protein Kidney function

Fats CVD

Coordinate diet w/

Meds

Physical activity


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EnergyAmount

Healthy/realistic bodyweight

Growth children/pregnancy

Type 2 diabetics

Weight loss

10-20 lbs.

Helps w/

Insulin resistance

Blood lipids

Blood pressure

Moderate kcalrestriction

Protein

10-20% of total kcal

Adequate but not excessive helps delay onset orprogression of kidney disease

0.8 g/kg of body weight

Same as RDA for healthypeople

Carbohydrates

Throughout day

Consistent amounts

Affect blood glucose most

Greatest effect on bloodglucose about 1 hour aftereaten

45-60% total kcal

Regular physical activity

Attention to meds

Consistent carbs

Too much hyperglycemia

Too little hypoglycemia

Evening snack

Sustains glucose through night

Frequent hypoglycemia treatsw/ carbs weight gain

Safe amount of glucose

ComplexCarbohydratesVersus SimpleSugars

Encourage Whole-grain breads and

cereals

Legumes

Fruits

Vegetables

Provide Fiber

Vitamins

Minerals

Concentrated sweets

Excluded In past Now - in moderation

Artificial sweeteners Minimal calories

Can be used in place ofsugar


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Fat

If blood lipids Ok


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Treating Hypoglycemia

10-15 g carb w/ notice of symptoms

If on oral agents that interfere w/digestion of sucroseneed glucose

If notany readily available andeasily eaten carb OK

See margin p. 473

Avoid foods w/ fat interferes w/absorption of carb

Check blood glucose within15-20 min.

If risen to acceptablelevelOK

If not - additional 15-20 g ofcarb

Recheck

Continue until blood glucoseto acceptable range

Advise carrying convenientcarb source w/ them

Nocturnal hypoglycemia

People prone to nocturnalhypoglycemia

Wake up during night

Check blood glucose

Snack at bedtime

May

Plan strenuous activitiesfor earlier in day

Reduce insulin dose afterevening activity

both

Hypoglycemia

If severe Disorientation

Many dont recognize

Unable to swallow

IV glucose or Hormone glucagon

Without treatmentshock and death

Enteral and Parental Formulas

Indications same as for other people

Adjustments for carbs formulas

provide Adjust insulin

Formula may need to be more lipidsand less carbohydrate

Specially designed formulas an option

Meal Planning Strategies

Several approachesIndividual

Exchange Lists

Sorts food into 3 groupsProportions of carb, fat,and protein

Carb group Starches Fruit Milk and some milk

products Other carbs Vegetables


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Fat Group Butter

Margarine

Oil salad dressing

Nuts Olives

Bacon

Avocados

Coconut

Cream cheese

Meat and meatsubstitutes group

High protein foods

Fig. 20-2 p. 475examples

Strict portion sizes All foods in exchange

list about same # kcaland nutrients

Any food on listexchanged foranother

HOWTO box p. 477-480

Exchange system a tool

Fat sources and types

Fat free milk - milk

Whole fat exchange

Foods in meat list

Separated into fat categories

Low.

Medium

and

High fat

Carbohydrate counting

Learn to eat consistentamounts of carbohydrates

Monitor blood glucose andkeep records

HOWTO box p. 481

Client must learn to

Plan healthy meals

Eat consistent amounts offoods

Maintain healthy body weight

PhysicalActivity

Carefully evaluate

Appropriate

Type

Amount

Type 2 diabetes

Regular physical activity

Improves blood glucosecontrol

Helps w/ weight loss

Improves blood lipids

blood pressure

Physical Activity andBlood Glucose Levels

Check blood glucose

Before

After

Postpone if

Too low 300 mg/100 ml

Can levels evenhigher


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Physical Activity and FoodIntake

Adequate hydration

Before

During

On insulin Eat

Before

During

After Carbs especially important

Amount depends on

Type

Duration

Individual responses to

Blood testing results

exercise

Drug Therapyfor Diabetes

Type I

Need insulin

Type 2

Sometimes w/out meds

Exercise

Diet

Oral meds

Insulin

Oral Antidiabetic Agents

Many different ones available

Some

stimulate release of insulin from betacells

reduce insulin resistance anddepress manufacture of glucose

reduce rate of complex carbohydrateand sucrose digestion and slow rateof absorption (must use glucose tomanage hypoglycemic episodes)

Insulin and Insulin Analogs

Different forms

Different timings

Rapid (regular)

Intermediate NPH and lente

Long acting ultra-lente

Insulin analog lispro

Acts more quickly

Short duration

risk for hypoglycemia

Insulin and Food Intake

Normally baseline amount w/ moreafter meals

Type I diabetes

NHP (intermediate acting) tomeet baseline needs

Regular (rapid-acting) toprocess nutrients after a meal

Type II diabetes

Insulin alone

Or

Combination of oral and insulin

Insulin and Physical Activity

Insulin taken

More than an hour before

Exercise and temperature

Speed blood flow rate of insulin absorption

Hypoglycemia likely

Reducing insulin dose 30-50%can prevent

[also care w/ injection site andmuscles used in exercise]


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Pancreas Transplants

For those who have serious

trouble managing

Successful

Combined w/ kidney transplant

Can eliminate need for insulinand dialysis

Monitoring

DiabetesManagement

Blood glucose meters

During medical assessmentslook at management makesuggestions

Even when diligenthypoglycemia andhyperglycemia at times

Table 10-6 p. 485

Glycated Hemoglobin

Physicians monitor

Evaluate % of glycated Hb (GHb)

Blood glucose glucoseattaches to amino acids on Hbmolecules

Reflects blood glucosemanagement over past 2-3 months

Urinary Ketones

Monitor

Especially during illness

Predisposed to ketosis andcoma

Other Measures

Weight

Blood lipids

Blood pressure

Reflexes

Diabetes Management

throughout Life

Diabetes Management inChildhood

Energy and nutrient needschange

Difficult w/ children Appetites

Activity

Teens

Difficult when trying tobe the same

New rules

Can manage itthemselves

Meal Plans

Flexible, balanced meals

Snacks

Variety of foods

Carb counting

Snacks at bedtime

Do not force to finish meal

Encourage not to skip meals

Concentrated sweets allowed withinhealthy diet

Meals at about same time each day

Can eat same foods as rest of family


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Family Lifestyles

Incorporate prescribed dietinto existing lifestyle

Child 3 meals/day 2-3 snacks (between meals

and at bedtime)

Vary meals and snacks toprevent boredom

Avoid labeling goodfoods/bad foods

Diabetes Managementin Pregnancy

Pregnancy Elevates blood sugar

Alters insulin resistance

Cells become insulinresistant

Levels of hormonesantagonize

Health Risks Associated withDiabetes During Pregnancy

Uncontrolled Type I or 2

Risk of spontaneous abortion

Macrosomic infant

High blood glucoseoverfeeds

Fetus must also make extrainsulin to handle

After birth hypoglycemic

Important to control diabetesduring pregnancy

Gestational Diabetes

Most common pregnancycomplication

Will screen for at 24-28 weeksunless


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Medical Nutrition Therapy

Individualized diet Additional needs of pregnancy

Insulin therapy

Adequate but not excessive kcals

Carbohydrates moderately restricted

40-45% of total kcal

Frequent small meals

Diabetes ManagementLater in Life

Elderly

Special problems in dealing w/ diabetes

Risk for hyper- and hypoglycemia

Reduced appetite

thirst regulation

Altered organ function

Depression

Mental deterioration

Multiple meds

Medical conditions that complicate

Blood Glucose Control

Type 2

May advance until insulinnecessary

Overwhelming

Vision loss can affect

Drawing meds

Giving injections

Monitoring blood glucose

May make it impossible tolive independently

Financial and SocialConsiderations

Financial

Medication

Supplies

Dr.s visits

Health and nutritionalstatus may deteriorate

Social interaction may

Depression possible

Health care professionalsmust help elderly findsolutions to theseproblems

See Nutrition AssessmentChecklist for People withDiabetes

diabetes pdf

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