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Diabetes Mellitus

I. Definition:

Diabetes is a metabolic disorder affecting the way the body uses digested food for
growth and energy. As a person eats, digestive juices break down the food into a simple sugar
called glucose. Glucose is the main source of fuel for the body.

After digestion, glucose passes into the bloodstream to be used by body cells for
growth and energy. In order for glucose to get into the cells, insulin must be present. Insulin is a
hormone produced by the beta cells of the pancreas, an organ behind the stomach.

As food passes through the stomach, the pancreas is designed to automatically


produce the right amount of insulin to move the glucose from the bloodstream into cells. In
some people with diabetes the pancreas produces little to no insulin and in others the body
cells do not respond to the available insulin. Still others have both defects. As a result glucose
builds up in the blood, overflows into the urine, and passes out of the body. The body loses its
main source of fuel even though the blood contains large amounts of glucose.

Diabetes Mellitus is a group of metabolic disease characterized by elevated


levels of glucose in the blood (Hyperglycemia) resulting from defects in insulin secretion,
insulin action, or both. Normally, a certain amount of glucose circulates in the blood. The major
sources of this glucose are absorption of ingested food in the gastrointestinal (GI) tract and
formation of glucose from the liver from food substances.

Insulin, a hormone produced by the pancreas, controls the levels of glucose in the
body by regulating the production and storage of glucose. In diabetic state, the cells may stop
responding to insulin or the pancreas may stop producing insulin entirely. This leads to
hyperglycemia which may result in acute metabolic complications such as diabetic
ketoacidosis (DKA) (a metabolic derangement in type 1 diabetes that results from a
deficiency of insulin.) , hyperglycemic hyperosmolar nonketotic syndrome(HHNS) (a
metabolic disorder of type 2 diabetes resulting from a relative insulin deficiency initiated by
inter-current illness that raises the demand for insulin; associated with polyuria and severe
dehydration.). Long-term effects of hyperglycemia contribute to macrovascular complications
(coronary artery disease, cerebrovascular disease and peripheral vascular disease), chronic
microvascular complications (kidney and eye disease), and neuropathic complications (disease
of the nerves).

Classification of Diabetes:

 Type 1 diabetes - previously referred to as juvenile-onset or insulin-dependent diabetes


mellitus (IDDM), usually develops during childhood, adolescence, or during early
adulthood and affects approximately 5 percent to 10 percent of all people with diabetes.
Type 1 diabetes is characterized by a partial or complete loss of insulin producing beta
cells as a result of an autoimmune disorder. Patients with Type 1 diabetes require daily
injections of insulin. Although this disease affects only a small percentage of all people
with diabetes, it is associated with a greater prevalence of premature complications and
mortality than other forms of the disease.

 Type 2 diabetes - previously defined as non-insulin-dependent diabetes mellitus


(NIDDM) is the most common form, affecting 90 percent to 95 percent of all people who
develop diabetes (1). An insulin deficiency or resistance characterizes type 2 diabetes.
The symptoms of this disorder develop gradually and are often overlooked. The Centers
for Disease Control and Prevention (CDC) estimates that nearly 30 percent of the people
with type 2 diabetes are undiagnosed.

 Gastrointestinal diabetes mellitus (GDM) - is defined as a carbohydrate intolerance


that normally develops during the 24th through the 32nd week of pregnancy. This
condition affects 2 percent to 5 percent of all pregnant women and is the most common
disease affecting pregnancy (2). Gestational diabetes often can be controlled by diet, but
insulin is sometimes necessary to maintain glycemic control. An elevated blood glucose
level during pregnancy is associated with an increase in complications for both mother
and child. Following pregnancy, normal blood glucose tolerance usually returns. Women
who have had gestational diabetes have a 20% to 50% chance of developing diabetes in
the next 5-10 years.

 Diabetes mellitus associated with other conditions or syndromes


There are several rare causes of diabetes mellitus that do not fit into type 2, or
gestational diabetes:

➢ Genetic defects in beta cells (autosomal or mitochondrial)


➢ Genetically-related insulin resistance, with or without lipodystrophy (abnormal
body fat deposition)
➢ Diseases of the pancreas (e.g. chronic pancreatitis, cystic fibrosis)
➢ Hormonal defects
➢ Chemicals or drugs

II. Clinical manifestations:

Clinical manifestations of all types of diabetes include the “three Ps”:

 Polyuria (increased urination)


 Polydipsia (increased thirst) – occur as a result of the excess loss of fluid
associated with osmotic diuresis .

 Polyphagia (increased appetite) – resulting from the catabolic state induced by


insulin deficiency and the break down of proteins and fats.

Other symptoms include:

• Fatigue and weakness, dry skin, skin lesions or wounds that are slow to heal, and
recurrent infections.

• The onset type 1 diabetes may also be associated with sudden weight loss or
nausea , vomiting, or abdominal pains, if DKA has developed.

III. Nursing Management and Responsibilities:

Nursing management of the patient with diabetes can involve treatment of a wide
variety of physiologic disorders, depending on the patients health status and whether the
patient is newly diagnosed or seeks care for an unrelated health problem. Because all diabetic
patient must master the concept and skills necessary for long-term management of diabetes
and its potential complications, a solid educational foundation is necessary for competent self-
care and is ongoing focus of nursing care.
Key areas for Prevention and Control

• Maintain body weight and prevent obesity through proper nutrition and physical activity
or exercise.

• Encourage proper nutrition – Eat more dietary fiber, reduce salt and fat intake, avoid
simple sugars like cakes and pastries; avoid junk foods.

• Promote regular physical activity and exercise to prevent obesity, hypercholesterolemia


and enhance insulin action in the body.

• Advice smoking cessation for active smokers and prevent exposure to second hand
smoke. Smoking along diabetics increases risk for heart attack and stroke.

IV. Medical Management:

Before the discovery of insulin in 1921, all people with type 1 diabetes died within a
few years after the appearance of the disease. Although insulin is not a cure for diabetes, it was
the first major breakthrough in diabetes treatment.
Today, daily injections of insulin are the basic therapy for type 1 diabetes. Insulin
injections must be balanced with meals and daily activities, and glucose levels must be closely
monitored through frequent blood sugar testing.
Diet, exercise and blood testing for glucose are also the basis for management of type
2 diabetes. In addition, some people with type 2 diabetes take oral drugs and insulin to lower
their blood glucose levels.
People with diabetes must take responsibility for their day-to-day care. Much of the daily
care involves trying to keep blood sugar levels from going too low or too high. When blood
sugar levels drop too low -- a condition known as hypoglycemia -- a person can become
nervous, shaky and confused. Judgment can be impaired and the person may lose
consciousness. The treatment for low blood sugar is to eat or drink something with sugar in it.
A person also can become very ill if blood sugar levels raise too high, a condition known
as hyperglycemia. Hypoglycemia and hyperglycemia can occur in people with type 1 or type 2
diabetes and both are potentially life-threatening emergencies.
Doctors knowledgeable in diabetes therapy, blood sugar control and complications
should monitor people with the disease. Some people see doctors who specialize in diabetes
called endocrinologists or diabetologists. People with diabetes often visit ophthalmologists for
eye examinations, podiatrists for routine foot care, dietitians for help in planning meals,
diabetes educators for instruction in day-to-day care, and psychologists or counselors to help
deal with the emotional burdens of chronic disease.
The goal of diabetes management is to keep blood glucose levels as close to the
normal range as safely possible. A government study, sponsored by the National Institute of
Diabetes and Digestive and Kidney Diseases (NIDDK), proved that keeping blood sugar levels
as close to normal as safely possible reduces the risk of developing major complications of
diabetes.
The 10-year study, called the Diabetes Control and Complications Trial (DCCT), was
completed in 1993 and included 1,441 people with type 1 diabetes. The study compared the
effect of two treatment approaches, intensive management and standard management, on the
development and progression of eye, kidney and nerve complications of diabetes. Researchers
found that study participants who maintained lower levels of blood glucose through intensive
management had significantly lower rates of these complications.

Hypertension
I. Definition:
Hypertension, also referred to as high blood pressure, HTN or HPN, is a medical condition
in which the blood pressure is chronically elevated. In current usage, the word
"hypertension".without a qualifier normally refers to arterial hypertension.
Hypertension can be classified either essential (primary) or secondary. Essential
hypertension indicates that no specific medical cause can be found to explain a patient's
condition. Secondary hypertension indicates that the high blood pressure is a result of (i.e.,
secondary to) another condition, such as kidney disease or tumours (pheochromocytoma and
paraganglioma). Persistent hypertension is one of the risk factors for strokes, heart attacks,
heart failure and arterial aneurysm, and is a leading cause of chronic renal failure. Even
moderate elevation of arterial blood pressure leads to shortened life expectancy. At severely
high pressures, defined as mean arterial pressures 50% or more above average, a person can
expect to live no more than a few years unless appropriately treated.
In individuals older than 50 years, hypertension is considered to be present when a
person's systolic blood pressure is consistently 140 mm Hg or greater or when the diastolic
blood pressure is consistently 90 mm Hg or greater. Beginning at a systolic pressure of 115 and
diastolic pressure of 75 (commonly written as 115/75 mm Hg), cardiovascular disease (CVD)
risk doubles for each increment of 20/10 mmHg. Prehypertension is defined as blood pressure
from 120/80 mm Hg to 139/89 mm Hg. Prehypertension is not a disease category; rather, it is a
designation chosen to identify individuals at high risk of developing hypertension. The Mayo
Clinic specifies blood pressure is "normal if it's below 120/80". Patients with blood pressures
over 130/80 mm Hg along with Type 1 or Type 2 diabetes, or kidney disease require further
treatment.

II. Clinical Manifestations:

If your blood pressure is extremely high, there may be certain symptoms to look out for,
including severe head ache, fatigue or confusion, vision problems, chest pain, difficulty in
breathing, irregular heart beat and blood in the urine. Other clinical efffects are absent until
complications develop from vascular changes.

III. Nursing Responsibilities:

Key areas for Prevention of Hypertension:

• Encourage proper nutrition – reduce salt and fat intake.


• Prevent becoming overweight or obese – weight reduction through proper nutrition and
exercise.
• Smoking cessation – tobacco use promotes atherosclerosis that may contribute to
hypertension; quiting smoking anytime is beneficial; this refers to both active and
passive smokers.
• Identify people with risk factors and encourage regular check-ups for possible
hypertension and modification of risk factors.

IV. Medical Management:


The goal of hypertension treatment is to prevent death and complications by achieving
and maintaining the arterial blood pressure at 140/90 mmHg or lower. Although essential
hypertension has no cure, drugs and modifications in diet and lifestyle can control it.
Drug therapy usually begins with a diuretic alone. Examples of diuretic drugs are
Thiazide Diuretics (Diuril) which promotes renal excretion of sodium, water and potassium,
Loop Diuretics (Lasix) which act on Loop of Henle to minimize sodium and water reabsorption
and Potassium-Sparing Diuretics (Aldactone: Spirinolactone) which blocks action of Aldactone
promoting excretion of sodium and water and retention of potassium.
Beta-blockers such as Propranolol (Inderal), Metoprolol (Lopressor), and Nadolol
(Corgard) are block beta receptors in the heart and peripheral vessels to reduce peripheral
vascular resistance.
Vasodilators are added as needed such as Hydralazine (Apresoline) which has a direct
action on smooth muscles of arterioles causing dilation.
Lifestyle and dietary changes may include weight loss, relaxation techniques, regular
exercise, and restriction of sodium unsaturated fat intake.
Treatment of secondary hypertension includes correcting the underline cause and
controlling hypertensive effects.

Prepared by:
Geofel C. Abejero
dice_147@yahoo.com
February 20, 2009
Health Care 1 (SY 2008-2009)