Diabetes MellitusZoya Minasyan RN-MSN-Edu

A chronic multisystem disease related to ◦ Abnormal insulin production◦ Impaired insulin utilization ◦ Or both

7th leading cause of death in the USA Leading cause of adult blindness, end-stage

renal disease, and non traumatic lower limb amputation.

Major contributing factor◦ Heart disease◦ Stroke

Diabetes Mellitus

◦ Genetic◦ Autoimmune◦ Viral◦ EnvironmentalRegardless of it’s cause, Diabetes is primarily a

disorder of glucose metabolism r/t absent or insufficient insulin supply and/or poor utilization of the insulin that is available.

Diabetes MellitusEtiology and Pathophysiology

Two most common types◦ Type 1◦ Type 2

Other types◦ Gestational ◦ Prediabetes◦ Secondary diabetes

Etiology and Pathophysiology

Normal insulin metabolism◦ Produced by the cells

Islets of Langerhans of the pancreas.◦ Released continuously into bloodstream in small

amounts; with larger amounts released after food.◦ Stabilizes glucose range to 70 to 120 mg/dL

Counter regulatory hormones-glucagon, epinephrine, growth hormone and cortisol work to oppose the effect of insulin; work to increase blood glucose level by stimulating glucose production and output by liver, and decreasing the movement of glucose into the cells.

Etiology and Pathophysiology

◦ Promotes glucose transport from bloodstream across cell membrane to cytoplasm of cell Decreases glucose in the bloodstream

◦ ↑ insulin after a meal Stimulates storage of glucose as glycogen in liver

and muscle Inhibits gluconeogenesis Enhances fat deposition ↑ protein synthesis

Insulin

The Pancreas

Pancreas

Exocrine pancreas

releases digestive juices through a

duct

to the duodenum

Endocrine pancreas

releases hormones into the blood

Endocrine pancreas: Islets of

Langerhans

Alpha cells Beta cells Delta cells PP cells

Pancreatic polypeptide

Glucagon Insulin

and amylinSomatostatin

Functions of Pancreatic Hormones

Glucagon: causes cells to release stored food into the blood

Insulin: allows cells to take up glucose from the blood

Amylin: slows glucose absorption in small intestine; suppresses glucagon secretion

Somatostatin: decreases GI activity; suppresses glucagon and insulin secretion

Which pancreatic hormone decreases blood glucose levels?

a. Glucagonb. Insulinc. Amylind. Somatostatin

Question

b. InsulinInsulin allows cells to take glucose from the

blood and use it for energy/to make ATP. Because it stimulates movement of glucose out of the blood and into the cells, blood levels decrease when insulin is released.

Answer

Tell whether the following statement is true or false:

Type 2 DM is more common than Type 1 DM.

Question

TrueType 1 DM is autoimmune (juvenile diabetes

is Type 1), and affects only 5% to 10% of the diabetic population. Type 2 DM is associated with risk factors like obesity, poor diet, and sedentary lifestyle; 90% to 95% of diabetics suffer from this type.

Answer

Skeletal muscle and adipose tissues are Insulin-dependent tissues; have receptors for insulin

Other tissues (brain, liver, blood cells) do not directly depend on insulin for glucose transport; but require adequate glucose for normal fx. Liver has receptor sites for hepatic uptake of glucose and its conversion to glycogen.

Insulin

“juvenile-onset” or “insulin-dependent” diabetes, occurs in people younger than 40 years of age, and in younger children.

• Progressive destruction of pancreatic cells by body’s own T cells

Caused by◦ Genetic predisposition

Related to human leukocyte antigens (HLAs)◦ Exposure to a virus

Manifestations develop when pancreas can no longer produce insulin.

Type 1 Diabetes Mellitus

Will require insulin Diabetic ketoacidosis (DKA)

◦ Occurs in absence of insulin◦ Life-threatening condition◦ Results in metabolic acidosis

Type 1 Diabetes MellitusOnset of Disease

Individuals already at risk for diabetes Blood glucose is high but not high enough to be

diagnosed as having diabetes Characterized by

◦ Impaired fasting glucose (IFG) ◦ Impaired glucose tolerance (IGT)

IFG: Fasting glucose levels are 100 to 125 mg/dL IGT: 2-Hour plasma glucose levels are between 140 and

199 mg/dL AIC is in range of 5.7% to 6.4%. Must watch for diabetes symptoms

◦ Polyuria◦ Polyphagia◦ Polydipsia

Prediabetes

Usually occurs in ◦ people over 35 years of age,◦ overweight,◦ increases with age,◦ genetic basis.

Type 2 Diabetes MellitusEtiology and Pathophysiology

Four major metabolic abnormalities◦ 1. Insulin resistance

Body tissues do not respond to insulin which results in hyperglycemia.

◦ 2. Pancreas ↓ ability to produce insulin β cells fatigued from compensating β-cell mass lost

◦ 3. Inappropriate glucose production from liver◦ 4. Alteration in production of hormones

Type 2 Diabetes MellitusEtiology and Pathophysiology

Individuals with metabolic syndrome also known as syndrome X or insulin resistance syndrome are at increased risk for type 2 diabetes◦ risk for cardiovascular disease and diabetes

characterized by insulin resistance

Individuals with metabolic syndrome◦ Elevated insulin levels, ↑ triglycerides, LDLs, ↓

HDLs, hypertension◦ Risk factors

Central obesity, sedentary lifestyle, urbanization, certain ethnicities(African Americans, Native Americans, Hispanics, Asians)

Type 2 Diabetes MellitusEtiology and Pathophysiology

Gradual onset Person may go many years with undetected

hyperglycemia. Osmotic fluid/electrolyte loss from

hyperglycemia may become severe.◦ Hyperosmolar coma(will discuss later)

Type 2 Diabetes MellitusOnset of Disease

Develops during pregnancy Detected at 24 to 28 weeks of gestation Usually normal glucose levels at 6 weeks

post partum Increased risk for cesarean delivery, and

neonatal complications Increased risk for developing type 2 in 5 to

10 years Therapy: First- nutritional, second -insulin

Gestational Diabetes

Results from ◦ Another medical condition

Cushing syndrome Hyperthyroidism Pancreatitis Parenteral nutrition Cystic fibrosis

◦ Treatment of a medical condition that causes abnormal blood glucose level Corticosteroids (Prednisone) Thiazides Phenytoin (Dilantin) Atypical antipsychotics (clozapine)

Usually resolves when underlying condition treated Drugs that can alter blood glucose levels are listed in Table

49-8.

Specific Types of Diabetes

Classic symptoms◦ Polyuria (frequent urination)◦ Polydipsia (excessive thirst) ◦ Polyphagia (excessive hunger)

Weight loss Weakness Fatigue

Clinical ManifestationsType 1 Diabetes Mellitus

Nonspecific symptoms ◦ May have classic symptoms of type 1

Fatigue Recurrent infection Recurrent vaginal yeast infection Prolonged wound healing Visual changes

Clinical ManifestationsType 2 Diabetes Mellitus

Four methods of diagnosis1. AIC ≥ 6.5%2. Fasting plasma glucose level >126 mg/dL3. Random plasma glucose measurement ≥200 mg/dL4. Two-hour OGTT(oral glucose tolerance test) level ≥200 mg/dL when

a glucose load of 75 g is used

Hemoglobin A1C test◦ In 2010, recommended to be used as a diagnostic test◦ Useful in determining glycemic levels over time◦ Shows the amount of glucose attached to hemoglobin molecules over

RBC life span, approximately 120 days◦ Ideal goal

ADA ≤7.0% American College of Endocrinology <6.5%

◦ Normal A1C reduces risks of retinopathy, nephropathy, and neuropathy.

Diabetes MellitusDiagnostic Studies

Goals of diabetes management◦ Decrease symptoms◦ Promote well being◦ Prevent acute complications◦ Delay onset and progression of long term

complications◦ Patient teaching

Self-monitoring of blood glucose ◦ Nutritional therapy◦ Drug therapy◦ Exercise

Diabetes Mellitus

◦ Insulin differ with regard to onset, peak action, and duration. Characterized as rapid-acting, short-acting,

intermediate-acting, and long-acting

◦ Rapid-acting: Lispro (Humalog), Aspart (Novolog), and glulisine (Apidra)

◦ Short-acting: Regular◦ Intermediate-acting: NPH ◦ Long-acting: Glargine (Lantus), detemir (Levemir)

Drug Therapy: Insulin

Drug Therapy: Insulin

Insulin preparations◦ Rapid-acting (bolus)

Lispro, aspart, glulisine Injected 0 to 15 minutes before meal Onset of action 15 minutes

◦ Short-acting (bolus) Regular Injected 30 to 45 minutes before meal Onset of action 30 to 60 minutes

◦ Long-acting (basal) Injected once a day at bedtime or in the morning Released steadily and continuously No peak action Cannot be mixed with any other insulin or solution

Drug Therapy: Insulin

Storage of insulin◦ Do not heat/freeze.◦ In-use vials may be left at room temperature up to 4 weeks. ◦ Extra insulin should be refrigerated.◦ Avoid exposure to direct sunlight. ◦ Administration of insulin

Cannot be taken orally Subcutaneous injection for

self-administration IV administration

Fastest absorption from abdomen, followed by arm, thigh, and buttock

Abdomen is the preferred site. Rotate injections within one particular site. Do not inject in site to be exercised.

Drug Therapy: Insulin

Administration of insulin◦ Hand washing◦ Do not recap needle◦ 45- to 90-degree angle, depending on fat

thickness of the patient◦ Insulin pens preloaded with insulin are now

available.

Drug Therapy: Insulin

Drug Therapy:Insulin

Insulin pump◦Continuous subcutaneous infusion; Battery-operated device

◦Connected via plastic tubing to a catheter inserted into subcutaneous tissue in abdominal wall

Drug Therapy:Insulin

Problems with insulin therapy◦ Hypoglycemia◦ Allergic reaction◦ Lipodystrophy(atrophy of SQ tissue)◦ Somogyi effect( during the sleep hrs-decline in

blood glucose in respond to insulin; counterregulatory hormones causes gluconeogenesis which causes rebound hyperglycemia and ketosis at night and in the morning; sweats or nightmares, and high blood glucose in am(recheck BG at 2 and 4 pm again)

◦ Dawn phenomenon( growth hormone and cortisol: hyperglycemia in the morning)

Drug Therapy:Insulin

◦ Sulfonylureas ↑ insulin production from pancreas ↓ chance of prolonged hypoglycemia Ex: glipizide (Glucotrol, Glucotrol XL), glyburide

(Micronase, DiaBeta, Glynase), and glimepiride (Amaryl).

◦ Meglitinides Increase insulin production from pancreas Taken 30 minutes before each meal up to time of

meal Should not be taken if meal skipped Ex: repaglinide (Prandin) and nateglinide (Starlix).

Drug Therapy Oral Agents

◦ Biguanide Reduce glucose production by liver Enhance insulin sensitivity at tissues Improve glucose transport into cells Do not promote weight gain Ex: Metformin (Glucophage)

◦ α-glucosidase inhibitors “Starch blockers” Slow down absorption of carbohydrate in small intestine Ex:Acarbose (Precose) and miglitol (Glyset)

◦Thiazaolidinediones ↑ glucose uptake in muscle and ↓glucose production Ex: pioglitazone (Actos) and rosiglitazone (Avandia).

Drug Therapy Oral Agents

Dipeptidyl peptidase-4 (DDP-4) inhibitor◦ Slows the inactivation of incretin hormones(Gastric hormones-Ex:gastrin,secretin…)◦ Potential for hypoglycemia◦ Ex: Sitagliptin (Januvia)

Saxagliptin (Onglyza) Amylin analog◦ Hormone secreted by cells of pancreas◦ Administered subcutaneously: thigh or abdomen◦ Slows gastric emptying◦ Ex: Pramlintide (Symlin)

Incretin mimetic◦ Synthetic peptide ◦ Stimulates release of insulin from cells◦ Subcutaneous injection◦ Suppresses glucagon secretion ◦ Reduces food intake◦ Slows gastric emptying◦ Not to be used with insulin◦ Ex: Byetta

-adrenergic blockers◦ Mask symptoms of hypoglycemia

Thiazide/loop diuretics◦ Can potentiate hyperglycemia

By inducing potassium loss

Drug Therapy Oral Agents

American Diabetes Association (ADA)◦ Overall goal

Assist people in making changes in nutrition and exercise habits that will lead to improved metabolic control.

◦ Meal plan is based on individual’s usual food intake and is balanced with insulin and exercise patterns.

Diabetes: Nutritional Therapy

Carbohydrates◦ Sugars, starches, and fiber◦ minimum of 130 g/day; whole grains, along with fruits, vegetables, and low-fat milk,

should be included. Fats

◦ Less than 200 mg/day of cholesterol and trans fats Protein Alcohol

◦ High in calories◦ No nutritive value◦ Detrimental effects on liver◦ Can cause severe hypoglycemia

• Alcohol inhibits gluconeogenesis (breakdown of glycogen to glucose) by the liver. This can cause severe hypoglycemia in patients on insulin or oral hypoglycemic medications that increase insulin secretion.

• Moderate alcohol consumption can sometimes be safely incorporated into the meal plan if blood glucose levels are well controlled, and if the patient is not taking medications that will cause adverse effects.

Diabetes: Nutritional Therapy

Exercise◦ Essential part of diabetes management◦ ↑ insulin receptor sites ◦ Lowers blood glucose levels◦ Contributes to weight loss• The ADA recommends that individuals with diabetes should perform

at least 150 minutes per week of a moderate-intensity aerobic physical activity.

• The ADA also encourages those with type 2 diabetes to perform resistance training 3 times a week in the absence of contraindications.

◦ Several small carbohydrate snacks can be taken every 30 minutes during exercise to prevent hypoglycemia.

◦ Best done after meals◦ Exercise plans should be started after medical clearance◦ Slowly with gradual progression◦ Should be individualized◦ Monitor blood glucose levels before, during, and after exercise.

Diabetes

Past health history◦ Viral infections◦ Medications◦ Recent surgery

Obesity Weight loss Thirst Hunger Poor healing• Kussmaul respirations (Rapid, deep breathing)

Nursing ManagementNursing Assessment

Ineffective self-health management Risk for injury Risk for infection Powerlessness Imbalanced nutrition: More than body

requirements

Nursing ManagementNursing Diagnoses

Overall goals◦ Active patient participation◦ Few or no episodes of acute hyperglycemic

emergencies or hypoglycemia ◦ Maintain normal blood glucose levels.◦ Prevent or delay chronic complications.◦ Lifestyle adjustments with minimal stress

Nursing ManagementPlanning

Health promotion◦ Identify those at risk, routine screening

Acute intervention for◦ Hypoglycemia; Diabetic ketoacidosis; Hyperosmolar

hyperglycemic nonketotic syndrome.◦ Stress of illness and surgery

↑ blood glucose level Continue taking oral agents and insulin. Frequent monitoring of blood glucose Patients undergoing surgery or radiologic procedures requiring

contrast medium should hold their metformin on day of surgery and to 48 hour

Ambulatory and home care◦ Overall goal is to reach an optimal level of independence ◦ Insulin therapy and oral agents◦ Personal hygiene ◦ Medical identification and travel card◦ Patient and family teaching

Educate on disease process, physical activity, medications, monitoring blood glucose, diet, resources.

Nursing Management Nursing Implementation

Medical Alert

Knowledge Balance of nutrition Immune status Health benefits No injuries

Nursing ManagementEvaluation

Diabetic ketoacidosis (DKA) Hyperosmolar hyperglycemic syndrome

(HHS) Hypoglycemia Table 49-17 compares the manifestations,

causes, management, and prevention of hyperglycemia and hypoglycemia(page 1242)

Acute Complications

◦ Caused by profound deficiency of insulin Characterized by

Hyperglycemia, Ketosis, Acidosis, Dehydration Most likely occurs in type 1

◦ Precipitating factors Illness, Infection, Inadequate insulin dosage,

Undiagnosed type 1, Poor self-management, and Neglect

◦ When supply of insulin insufficient Glucose cannot be properly used for energy. Body breaks down fat stores.

Ketones are by-products of fat metabolism. Alter pH balance, causing metabolic acidosis Ketone bodies excreted in urine Electrolytes become depleted.

Diabetic ketoacidosis (DKA)

◦ Signs and symptoms Lethargy/weakness: early symptoms Dehydration

Poor skin turgor Dry mucous membranes Tachycardia

Orthostatic hypotension Abdominal pain Anorexia, vomiting Kussmaul respirations

Rapid deep breathing Attempt to reverse metabolic acidosis Sweet fruity odor

◦ Serious condition Must be treated promptly

DKA (cont’d)

Acute Complications◦ Airway management

Oxygen administration◦ Correct fluid/electrolyte imbalance

IV infusion 0.45% or 0.9% NaCl Restore urine output. Raise blood pressure.

When blood glucose levels approach 250 mg/dL 5% dextrose added to regimen Prevent hypoglycemia. Potassium replacement Sodium bicarbonate

◦ Insulin therapy Withheld until fluid resuscitation has begun. Bolus followed by insulin drip

DKA (cont’d)

◦ Life-threatening syndrome◦ Less common than DKA◦ Often occurs in patients older than 60 years with type 2 DM◦ Patient has enough circulating insulin that ketoacidosis does

not occur.◦ Neurologic manifestations occur because of ↑ serum osmolality.◦ Usually history of

Inadequate fluid intake Increasing mental depression Polyuria

◦ Laboratory values Blood glucose >400 mg/dL Increase in serum osmolality Absent/minimal ketone bodies

◦ Medical emergency; high mortality rate◦ Therapy similar to DKA, except HHS requires greater fluid

replacement

Hyperosmolar hyperglycemic syndrome (HHS)

Administration IV fluids Insulin therapy Electrolytes

Assessment Renal status Cardiopulmonary status Level of consciousness

Signs of potassium imbalance Cardiac monitoring Vital signs

Nursing management DKA/HHS

◦ Low blood glucose Blood glucose level less than 70 mg/dL

◦ Common manifestations Confusion Irritability Diaphoresis Tremors Hunger Weakness Visual disturbances

◦ Untreated can progress to loss of consciousness, seizures, coma, and death

• The balance between blood glucose and insulin can be disrupted by the administration of too much insulin or medication, the ingestion of too little food, delaying the time of eating, and performing unusual amounts of exercise.

Hypoglycemia

Check blood glucose If <70 mg/dL, begin treatment If >70 mg/dL, investigate further for cause of

signs/symptoms If monitoring equipment not available, treatment should

be initiated If alert enough to swallow

15 to 20 g of a simple carbohydrate 4 to 6 oz fruit juice Regular soft drink

Avoid foods with fat Decrease absorption of sugar Gels or tablets containing specific amounts of glucose

are convenient for carrying.• Avoid large quantities of quick-acting carbohydrates, so that

rapid fluctuation to hyperglycemia does not occur.

Hypoglycemia (cont’d)

◦ Treatment If alert enough to swallow

Recheck blood sugar 15 minutes after treatment. Repeat until blood sugar >70 mg/dL. Patient should eat regularly scheduled meal/snack to

prevent rebound hypoglycemia. Check blood sugar again 45 minutes after treatment.

Patient not alert enough to swallow Administer 1 mg of glucagon IM or subcutaneously.

Side effect: Rebound hypoglycemia Have patient ingest a complex carbohydrate after

recovery. In acute care settings

20 to 50 mL of 50% dextrose IV push

Hypoglycemia (cont’d)

◦ Macrovascular Diseases of large and medium-sized blood vessels one of the leading causes of diabetes-related deaths Tight glucose control may delay atherosclerotic

process. Risk factors

Obesity Smoking Hypertension High fat intake Sedentary lifestyle

Angiopathy

◦ Microvascular Result from thickening of vessel membranes in

capillaries and arterioles In response to chronic hyperglycemia

Is specific to diabetes, unlike macrovascular ◦ Areas most noticeably affected

Eyes (retinopathy) Kidneys (nephropathy) Skin (dermopathy)

◦ Clinical manifestations usually appear after 10 to 20 years of diabetes.

◦ Microvascular damage to retina Result of chronic hyperglycemia

Angiopathy

Diabetic retinopathy (cont’d) Most common form Partial occlusion of small blood vessels in retina

Causes development of microaneurysms Capillary fluid leaks out.

Retinal edema and eventually hard exudates or intr-aretinal hemorrhages occur

◦ Proliferative Most severe form Involves retina and vitreous When retinal capillaries become occluded

Body forms new blood vessels Vessels are extremely fragile and hemorrhage easily

Produce vitreous contraction Retinal detachment can occur

Angiopathy

◦ Treatment Laser photocoagulation

Most common Laser destroys ischemic areas of retina

Prevents further visual loss Vitrectomy

◦ Aspiration of blood, membrane, and fibers inside the eyedamage to small blood vessels that supply the glomeruli of the kidney

◦ Leading cause of end-stage renal disease Risk factors for the development of diabetic

nephropathy include hypertension, genetic predisposition, smoking, and chronic hyperglycemia.

Diabetic retinopathy (cont’d)

More than 60% of nontraumatic amputations in the United States occur in people with diabetes.

• Sensory versus autonomic neuropathy◦ Sensory neuropathy

Distal symmetric Most common form Affects hands and/or feet bilaterally Characteristics include

Loss of sensation, abnormal sensations, pain. The pain is often described as burning, cramping, crushing, or tearing.

Usually worse at night Foot injury and ulcerations can occur without the patient

having pain. Can cause atrophy of small muscles of hands/feet

Diabetic neuropathy

Diabetic neuropathy

◦ Autonomic Can affect nearly all body systems Complications

Gastroparesis Delayed gastric emptying

Cardiovascular abnormalities

◦ Foot complications Most common cause of hospitalization in diabetes Result from combination of microvascular and

macrovascular diseases

Diabetic neuropathy

Necrotic Toe Before and After Amputation

◦ Risk factors Sensory neuropathy Peripheral arterial disease

◦ Other contributors Smoking Clotting abnormalities. Impaired immune function Autonomic neuropathy

Complications of foot and lower extremity (cont’d)

◦ Diabetic individuals more susceptible to infection◦ Defect in mobilization of inflammatory cells ◦ Impairment of phagocytosis by neutrophils and

monocytes◦ Loss of sensation may delay detection.

Infection

• process of aging is associated with a reduction in β-cell function, decreased insulin sensitivity, and altered carbohydrate metabolism.

• diabetes has been found to contribute to a greater rate of decline in cognitive function. Recognize limitations in physical activity

and visual acuity Education based on individual’s needs,

using slower pace .

Gerontologic Considerations