Download - Adult Medical-Surgical Nursing Endocrine Module: Longterm Complications of Diabetes Mellitus
Adult Medical-Surgical Adult Medical-Surgical NursingNursing
Endocrine Module: Endocrine Module: Longterm Complications of Longterm Complications of
Diabetes MellitusDiabetes Mellitus
Long-term Complications of DMLong-term Complications of DM
Uncontrolled hyperglycaemia gives Uncontrolled hyperglycaemia gives rise to longterm complications within rise to longterm complications within 5 -10 years usually 5 -10 years usually
Long-term Complications of DMLong-term Complications of DM
Macrovascular diseaseMacrovascular disease
Microvascular diseaseMicrovascular disease
NeuropathyNeuropathy
Long-term Complications of DMLong-term Complications of DM
Macrovascular DiseaseMacrovascular Disease
DM: Macrovascular DiseaseDM: Macrovascular Disease
Accelerated atherosclerosis of large Accelerated atherosclerosis of large vessels →vessels →
Coronary artery disease: may include Coronary artery disease: may include ““silent myocardial infarctionsilent myocardial infarction”” (on ECG) (on ECG)
Cerebrovascular disease: TIA, strokeCerebrovascular disease: TIA, stroke Peripheral vascular disease: gradual Peripheral vascular disease: gradual
occlusion of lower arteries, ↓ pulses, occlusion of lower arteries, ↓ pulses, intermittent claudication, ↓ blood flow intermittent claudication, ↓ blood flow to extremities → gangreneto extremities → gangrene
Macrovascular Disease: Macrovascular Disease: ManagementManagement
Close control of blood glucose (diet and Close control of blood glucose (diet and exercise; oral hypoglycaemics or insulin) exercise; oral hypoglycaemics or insulin)
Control of obesityControl of obesity ↓ ↓ hyperlipidaemia (↓ LDL, ↑ HDL)hyperlipidaemia (↓ LDL, ↑ HDL) Control of hypertensionControl of hypertension ↓ ↓ smoking; promote foot care/ hygienesmoking; promote foot care/ hygiene Close monitoring of disease progress and Close monitoring of disease progress and
intervention as necessaryintervention as necessary
Long-term Complications of DMLong-term Complications of DM
Microvascular DiseaseMicrovascular Disease
DM: Microvascular DiseaseDM: Microvascular Disease
Microvascular complications are Microvascular complications are unique to DM, especially type 1unique to DM, especially type 1
Hyperglycaemia thickens the capillary Hyperglycaemia thickens the capillary basement membrane, base for the basement membrane, base for the single layer of endothelial cells (the single layer of endothelial cells (the intima) where exchange of gases and intima) where exchange of gases and nutrients occurs nutrients occurs
Affects microvascular circulation of:Affects microvascular circulation of: The retina (retinopathy)The retina (retinopathy) The kidneys (nephropathy)The kidneys (nephropathy)
Diabetic RetinopathyDiabetic Retinopathy
Diabetic Retinopathy: Diabetic Retinopathy: PathophysiologyPathophysiology
Hyperglycaemia → micro-aneurysms, Hyperglycaemia → micro-aneurysms, small haemorrhages, capillary small haemorrhages, capillary closure, macula oedema and loss of closure, macula oedema and loss of nerve fibres leading to blurred vision nerve fibres leading to blurred vision and gradual loss of central vision and gradual loss of central vision
Proliferation of new capillaries across Proliferation of new capillaries across retina in vitreous humour, which are retina in vitreous humour, which are prone to bleedprone to bleed
Vitreous haemorrhage, fibrous scars, Vitreous haemorrhage, fibrous scars, retinal detachment and blindnessretinal detachment and blindness
Diabetic Retinopathy:Diabetic Retinopathy: Clinical Manifestations Clinical Manifestations
Blurring of visionBlurring of vision Loss of central visionLoss of central vision Spots before the eyesSpots before the eyes No painNo pain Gradually leads to blindnessGradually leads to blindness
Diabetic Retinopathy: DiagnosisDiabetic Retinopathy: Diagnosis
Patient history and clinical Patient history and clinical manifestationsmanifestations
Examination with OphthalmoscopeExamination with Ophthalmoscope
Fluroscein angiography (dye outlines Fluroscein angiography (dye outlines the capillaries)the capillaries)
Diabetic Retinopathy: PreventionDiabetic Retinopathy: Prevention
Control blood glucoseControl blood glucose
Regular eye examinationsRegular eye examinations
Diabetic Retinopathy: ManagementDiabetic Retinopathy: Management
Treatment:Treatment: Intensive regular insulin therapy (6-Intensive regular insulin therapy (6-
hourly) reduces disease progression hourly) reduces disease progression Laser (LA) destroys new and leaking Laser (LA) destroys new and leaking
blood vesselsblood vessels Vitrectomy (advanced): removes Vitrectomy (advanced): removes
vitreous humour replacing with saline; vitreous humour replacing with saline; improves vision but not completelyimproves vision but not completely
Diabetic NephropathyDiabetic Nephropathy
Diabetic Nephropathy: Diabetic Nephropathy: PathophysiologyPathophysiology
Thickened basement membrane in Thickened basement membrane in the glomerulus of the Bowman’s the glomerulus of the Bowman’s Capsule →Capsule →
Elevated pressure affecting Elevated pressure affecting glomerular filtration → glomerular filtration → microalbuminuria/ proteinuriamicroalbuminuria/ proteinuria
Diabetic Nephropathy: Diabetic Nephropathy: Clinical ManifestationsClinical Manifestations
Usual symptoms of renal disease: Usual symptoms of renal disease: oliguria, oedema and weight gain, oliguria, oedema and weight gain, hypertension, fatigue, anaemiahypertension, fatigue, anaemia
Usually other systems failing: poor Usually other systems failing: poor vision, impotence, neuropathy and vision, impotence, neuropathy and maybe “diabetic foot” ulcers, maybe “diabetic foot” ulcers, dyspnoea (CHF), nocturnal diarrhoea dyspnoea (CHF), nocturnal diarrhoea (autonomic neuropathy) (autonomic neuropathy)
Diabetic Nephropathy: DiagnosisDiabetic Nephropathy: Diagnosis
Lab test for albumen in urine Lab test for albumen in urine (albumen in urine indicates (albumen in urine indicates nephropathy in 85% diabetics)nephropathy in 85% diabetics)
24 hour urine save for albumen24 hour urine save for albumen KFT KFT Creatinine clearance test Creatinine clearance test
Diabetic Nephropathy: Diabetic Nephropathy: ManagementManagement
Control blood glucoseControl blood glucose ACE inhibitors to control BP (These ACE inhibitors to control BP (These
will reduce proteinuria also)will reduce proteinuria also) Low salt dietLow salt diet Treat infection early (UTI)Treat infection early (UTI) Adjust medications with kidney Adjust medications with kidney
functionfunction DialysisDialysis Renal TransplantRenal Transplant
DM: Longterm ComplicationsDM: Longterm Complications
Diabetic NeuropathyDiabetic Neuropathy
Diabetic NeuropathyDiabetic Neuropathy
Hyperglycaemia leads to demyelination of Hyperglycaemia leads to demyelination of the nerves and reduced conduction of the nerves and reduced conduction of impulsesimpulses
Classification:Classification: Peripheral neuropathy (sensory or motor) Peripheral neuropathy (sensory or motor)
is most common. Usually affects lower is most common. Usually affects lower extremities symmetricallyextremities symmetrically
AutonomicAutonomic Spinal nerveSpinal nerve
Peripheral Diabetic Neuropathy: Peripheral Diabetic Neuropathy: Clinical ManifestationsClinical Manifestations
Paraesthesia: heightened sensation Paraesthesia: heightened sensation with tingling, burning at night → with tingling, burning at night → numbness with disease progressionnumbness with disease progression
↓ ↓ proprioception; deep tendon reflexproprioception; deep tendon reflex Unsteady gait: ↓ sensation to touch; ↑ Unsteady gait: ↓ sensation to touch; ↑
risk of injury and infection risk of injury and infection Joint deformities (weight distribution Joint deformities (weight distribution
effect)effect) Painful lower extremities (lactic acid)Painful lower extremities (lactic acid)
Diabetic Peripheral Neuropathy: Diabetic Peripheral Neuropathy: DiagnosisDiagnosis
Patient history and clinical picturePatient history and clinical picture Neurological examination and tendon Neurological examination and tendon
reflexesreflexes Nerve conduction studiesNerve conduction studies Corresponding assessment of blood Corresponding assessment of blood
supply to extremitiessupply to extremities
Diabetic Peripheral Neuropathy: Diabetic Peripheral Neuropathy: ManagementManagement
Control blood glucose; frequent Control blood glucose; frequent monitoringmonitoring
Control painControl pain Careful regular foot care/ hygieneCareful regular foot care/ hygiene Splints to prevent/ correct deformitySplints to prevent/ correct deformity Exercises to improve circulationExercises to improve circulation Vitamin B complex and B12Vitamin B complex and B12
Diabetic Neuropathy: Autonomic Diabetic Neuropathy: Autonomic Nervous System and Spinal NervesNervous System and Spinal Nerves
Autonomic Diabetic Neuropathy: Autonomic Diabetic Neuropathy: Clinical Manifestations Clinical Manifestations
Silent MI; orthostatic hypotension Silent MI; orthostatic hypotension (↓ sympathetic activity)(↓ sympathetic activity)
Delayed gastric emptying, nausea, Delayed gastric emptying, nausea, constipation, nocturnal diarrhoea, swings constipation, nocturnal diarrhoea, swings in blood glucose as inconsistent absorptionin blood glucose as inconsistent absorption
Neurogenic bladder (retention)Neurogenic bladder (retention) Adrenal disorder: inability to sense and Adrenal disorder: inability to sense and
respond to hypoglycaemia (dangerous)respond to hypoglycaemia (dangerous)
Diabetic Spinal Neuropathy: Diabetic Spinal Neuropathy: Clinical ManifestationsClinical Manifestations
Neurogenic bladder (flaccid bladder: Neurogenic bladder (flaccid bladder: retention overflow incontinence); retention overflow incontinence); chronic infection riskchronic infection risk
Sexual impotenceSexual impotence Problems with mobilityProblems with mobility
Diabetic Autonomic and Spinal Diabetic Autonomic and Spinal Neuropathy: DiagnosisNeuropathy: Diagnosis
Patient history and clinical picturePatient history and clinical picture ECG ECG Bladder function studies (micturating Bladder function studies (micturating
cystogram)cystogram) Reflexes and nerve conduction testsReflexes and nerve conduction tests
Diabetic Neuropathy (Autonomic Diabetic Neuropathy (Autonomic and Spinal): Managementand Spinal): Management
Control blood glucoseControl blood glucose Avoid strenuous exerciseAvoid strenuous exercise Monitor BP, ECGMonitor BP, ECG Elastic stockings (Elastic stockings (↑ ↑ venous return)venous return) Small frequent meals; Small frequent meals; ↓↓ salt, salt, ↓ ↓ fat fat Ensure bladder emptying/ hygieneEnsure bladder emptying/ hygiene Prevention/ prompt treatment of UTIPrevention/ prompt treatment of UTI Skin care (pressure); counsellingSkin care (pressure); counselling