ZEENAT AYAZ Diabetes mellitus. Diabetes mellitus is a group of metabolic diseases characterized by elevated levels of glucose in the blood (hyperglycemia)

ZEENAT AYAZ

Diabetes mellitus

Diabetes mellitus

Diabetes mellitus is a group of metabolic diseases characterized by elevated levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both

Insulin, a hormone produced by the pancreas, controls the level of glucose in the blood by regulating the production and storage of glucose.

• Transports and metabolizes glucose for energy

• Stimulates storage of glucose in the liver and muscle (in the form of glycogen)

Signals the liver to stop the release of glucose

Enhances storage of dietary fat in adipose tissue

Accelerates transport of amino acids (derived from dietary protein) into cells

Also inhibits the breakdown of stored glucose, protein, and fat.

InsulinInsulin and glucagon are hormones secreted by islet cells within thepancreas

Insulin is normally secreted by the beta cells (a type of islet cells) of the pancreas

Stimulus for insulin is high blood glucose levels

Classification

Type 1 diabetes (insulin-dependent diabetes mellitus)

Type 2 diabetes (non-insulindependent diabetes mellitus)

Gestational diabetes mellitus

Type 1 Diabetes Mellitus

Most often occurs in people under 30 years of age

Peak onset between ages 11 and 13Formerly known as “juvenile onset” or

“insulin dependent” diabetes

Type 1 Diabetes MellitusEtiology and Pathophysiology

Progressive destruction of pancreatic cells Autoantibodies cause a reduction of 80% to

90% of normal cell function before manifestations occur


Causes: Genetic predisposition

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

Type 1 Diabetes MellitusOnset of Disease

Manifestations develop when the pancreas can no longer produce insulin Rapid onset of symptoms Present at ER with ketoacidosis


Weight lossPolydipsiaPolyuriaPolyphagia


Diabetic ketoacidosis (DKA) Occurs in the absence of exogenous insulin Life-threatening condition Results in metabolic acidosis

Type 2 Diabetes Mellitus

Accounts for 90% of patients with diabetes

Usually occurs in people over 40 years of age

80-90% of patients are overweight


Pancreas continues to produce some insulin

Insulin produced is either insufficient or poorly utilized by the tissues


Insulin resistance Body tissues do not respond to insulin Results in hyperglycemia


Inappropriate glucose production by the liver Not considered a primary factor in the

development of type 2 diabetes



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Gradual onsetPerson may go many years with

undetected hyperglycemia 75% of type 2 diabetes is detected incidentally

Gestational Diabetes

Develops during pregnancy Detected at 24 to 28 weeks of gestation Risk for cesarean delivery, perinatal

death, and neonatal complications

Secondary Diabetes

Results from another medical condition or due to the treatment of a medical condition that causes abnormal blood glucose levels Cushing syndrome Hyperthyroidism Parenteral nutrition

Clinical ManifestationsDiabetes Mellitus

PolyuriaPolydipsia (excessive thirst)PolyphagiaIn Type I

Weight loss Ketoacidosis

Clinical ManifestationsNon-specific symptoms

Fatigue and weakness Sudden vision changes Tingling or numbness in hands or feet Skin lesions or recurrent infections Prolonged wound healing Visual changes

Clinical Manifestations23

Risk Factors for Diabetes Mellitus

Family history of diabetes (i.e., parents or siblings with diabetes)

Obesity (i.e., ≥20% over desired body weight or BMI ≥27 kg/m2)

Race/ethnicity (e.g., African Americans, Hispanic Americans, Native Americans, Asian Americans, Pacific Islanders)

Age ≥45 years Previously identified impaired fasting

glucose or impaired glucose tolerance

Risk factors (cont.)

Hypertension (≥140/90 mm Hg) HDL cholesterol level ≤35 mg/dL (0.90

mmol/L) and/or triglyceride level ≥250 mg/dL (2.8 mmol/L)

History of gestational diabetes or delivery of babies over 9 lbs

ASSESSMENT AND DIAGNOSTIC FINDINGS

high blood glucose levelFasting plasma glucose (FPG) levels of 126

mg/dL (7.0 mmol/L) or more random plasma glucose levels exceeding 200

mg/dL (11.1 mmol/L) on more than one occasion

Plasma glucose values may be 10% to 15% higher than whole

goal

The main goal of diabetes treatment is to normalize insulin activity and blood glucose levels to reduce the development of vascular and neuropathic complications.

management

There are five components of diabetes management

• Nutritional management• Exercise• Monitoring• Pharmacologic therapy• Education

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Treatment varies because of changes in lifestyle and physical and emotional status as well as advances in treatment methods.

Therefore, diabetes management involves constant assessment and modification of the treatment plan by health professionals and daily adjustments in therapy by the patient.

Diabetes MellitusAcute Complications

HypoglycemiaDiabetic ketoacidosis (DKK)Hyperosmolar hyperglycemic nonketotic

syndrome (HHNS)

hypoglycemia

Type 1 or type 2 diabetesBlood glucose < 50-60 mg/dLCauses

Too much insulin Overdose of oral antidiabetic agents Too little food Excess physical activity

May experience S & S of hypoglycemia if there is sudden decrease in BS

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hypoglycemia

Treatment Mild

Immediate treatment 15 g rapid-acting sugar

Severe Hospitalized Intravenous glucose

Teach patients to carry simple sugar with them

Life-threatening illness in type 1 Hyperglycemia Dehydration and electrolyte loss Acidosis

Causes of DKA Decreased or missed dose of insulin, Illness or infection, Undiagnosed and untreated diabetes

Without insulin, the amount of glucose entering the cells is reduced, and production and release of glucose by the liver is increased (lead to hyperglycemia).

Excess glucose leads to polyuria (6.5 L/day) dehydration, sodium and potassium loss

Burning of fat leads to ketosisKidneys unable to excrete ketones, leads to

ketoacidosis

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Diagnosis: Blood glucose (300 and 800 mg/dL)

Treatment Rehydration (0.9-0.45% saline) Restoring Electrolytes (K+)

loss of potassium from body stores and an intracellular-to-extracellular shift of potassium

Reversing Acidosis (reversed with insulin) Regular insulin infusion (5 units/hr) Hourly blood glucose monitoring

Hyperosmolar hyperglycemic nonketotic syndrome (HHNS)39

Is a serious condition most frequently seen in older persons.

HHNS is usually brought on by something else, such as an illness or infection, dialysis, drugs that increase BS.

Blood sugar levels rise resulting into glycosuria, polyuria, thirst.

Severe dehydration will lead to seizures, coma and eventually death.

HHNS may take days or even weeks to develop. Know the warning signs of HHNS.

HHNS/ clinical manifestations 40

Hypotension, profound dehydration (dry mucous membranes, poor skin turgor), tachycardia, and variable neurologic signs (eg, alteration of sensorium, seizures, hemiparesis).

Blood glucose level (600 to 1200 mg/dL)Treatment: fluid replacement, correction of

electrolyte imbalances, and insulin.

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Diabetes MellitusChronic Complications

Macrovascular (atherosclerotic plaque) Coronary arteries → (MI’s) Cerebral arteries → (strokes) Peripheral vessels → (ulcers, amputations, infection)

Microvascular (capillary damage) Retinopathy Neuropathy Nephropathy

Macrovascular Complications43

Macrocirculation Blood vessel walls thicken, sclerose, and

become occluded by plaque that adheres to the vessel walls. finally, blood flow is blocked.

Complications Coronary artery disease Stroke Peripheral vascular disease

Complication: CAD44

CAD account for 50% to 60% of all deaths among patients with diabetes.

High cholesterol and high triglyceridesMI is twice as common in men and three

times in women with diabetes, compared to people without diabetes.

Silent MIHigher risk for a second infarction

Complication: Stroke45

People with diabetes have twice the risk of developing cerebrovascular disease.

There is a greater likelihood of death from cerebrovascular disease.

Recovery is slower with high BS.Hypertension plays a role

Complication: Peripheral Vascular Disease46

Diabetes-induced arteriosclerosis2-3 times higher than in nondiabetic

peopleS & S: diminished peripheral pulses and

intermittent claudication (pain in the buttock, thigh, or calf during walking)

Can lead to leg ulcers and gangrene and amputation.

Management of Macrovascualr changes

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Prevention and treatment of risk factors for atherosclerosis. obesity, hypertension, and hyperlipidemia (exercise,

stop smoking). Control of blood glucose levels may reduce

triglyceride concentrations and can significantly reduce the incidence of complications.

Microvascular Complications48

Microcirculation Eyes Kidneys Nerves

Complication: Diabetic Retinopathy49

Leading cause of blindness in people ages 20 to 74 in US

Almost all patients with type 1 diabetes and more than 60% of patients with type 2 diabetes have some degree of retinopathy after 20 years

Diabetic Retinopathy50

Changes in the retinal capillaries; lead to retinal ischemia.

Changes include microaneurysms, intraretinal hemorrhage, hard exudates, and focal capillary closure.

Yearly eye exams are recommended

Complication: Diabetic Nephropathy

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Disease of the kidneys (50% of RF due to DM)Characterized by albumin in the urine,

hypertension, edema, renal insufficiencyDM is the most common cause of renal failureFirst indication: microalbuminuriaTreatment: ACE inhibitors, control BP and BS,

prevent & treat UTI, low Na & protein diet.

Complication: Diabetic Neuropathy52

Disorder of the peripheral nerves, spinal cord, and autonomic nervous system

Results: sensory and motor impairments, postural hypotension, delayed gastric emptying, diarrhea, impaired GU function

Result from the thickening of the capillary membrane and destruction of myelin sheath which disrupt nerve conductions.

Complication: Diabetic Neuropathy53

Bilateral sensory disorders Appear first in toes, feet, and progress upward to

fingers and hands Tingling, decrease in proprioception , and a

decreased sensation of light touch Treatment

Controlling BS delay the onset. Analgesics to control pain

Complication: Autonomic Neuropathy54

Involves numerous body systems such as: Cardiovascular (slight tachycardia, orthostatic

hypotension & silent MI). Gastrointestinal (Delayed gastric emptying , N&V,

early satiety, variation of BS absorption) Genitourinary (urinary symptoms of neurogenic

bladder, UTI, erectile dysfunction) Hypoglycemic unawareness (DM diminish function

of adrenal medulla)

Foot and Leg Problems55

50% -75% of lower extremity amputations are performed on people with diabetes.

More than 50% of these amputations are thought to be preventable.

Foot and Leg ProblemsContributing factors

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• Neuropathy• Peripheral

vascular disease • Immunocompromi

se• Injuries could be:

Chemical Thermal Traumatic

Foot Care 57

1. Take care of your diabetes.2. Inspect your feet every day.3. Wash your feet every day (dry between

toes well).4. Keep the skin soft and smooth.5. Smooth corns and calluses gently.6. Trim your toenails each week or when

needed.7. Wear shoes and socks at all times.8. Protect your feet from hot and cold.9. Keep the blood flowing to your feet.10.Check with your health care provider.

Special Issues in Diabetes Care58

Patients with diabetes who are undergoing surgery Hyperglycemia (due to stress hormones) Hypoglycemia (being NPO)

Hold morning insulin unless it is > 200 mg/dL. Diuresis leads to fluid and electrolytes imbalance

Nursing Diagnoses59

Risk for fluid volume deficit related to polyuria and dehydration

Imbalanced nutrition related to imbalance of insulin, food, and physical activity

Deficient knowledge about diabetes self-care skills/information

Nursing Diagnoses60

Deficient knowledge about diabetes self-care skills/information

Potential self-care deficit related to physical impairments or social factors

Anxiety related to loss of control, fear of inability to manage diabetes, misinformation related to diabetes, fear of diabetes complications

Collaborative Problems/ Potential Complications

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Fluid overload, pulmonary edema, and heart failure

HypokalemiaHyperglycemia and ketoacidosisHypoglycemiaCerebral edema

Documents

ZEENAT AYAZ Diabetes mellitus. Diabetes mellitus is a group of metabolic diseases characterized by elevated levels of glucose in the blood (hyperglycemia)