This action might not be possible to undo. Are you sure you want to continue?
in insulin secretion, or action, or both. Diabetes mellitus, commonly referred to as diabetes (as it will be in this article) was first identified as a disease associated with "sweet urine," and excessive muscle loss in the ancient world. Elevated levels of blood glucose (hyperglycemia) lead to spillage of glucose into the urine, hence the term sweet urine. Normally, blood glucose levels are tightly controlled by insulin, a hormone produced by the pancreas. Insulin lowers the blood glucose level. When the blood glucose elevates (for example, after eating food), insulin is released from the pancreas to normalize the glucose level. In patients with diabetes, the absence or insufficient production of insulin causes hyperglycemia. Diabetes is a chronic medical condition, meaning that although it can be controlled, it lasts a lifetime.
Type-1-Diabetes “Childhood Diabetes” Cause:
Insulin-producing cells are destroyed… Type-1a …by the immune system Type-1b …for unknown reasons Injecting Insulin under the skin
Type 1 diabetes is also called insulin dependent diabetes mellitus (IDDM), or juvenile onset diabetes mellitus. In type 1 diabetes, the pancreas undergoes an autoimmune attack by the body itself, and is rendered incapable of making insulin. Abnormal antibodies have been found in the majority of patients with type 1 diabetes. Antibodies are proteins in the blood that are part of the body's immune system. The patient with type 1 diabetes must rely on insulin medication for survival. In autoimmune diseases, such as type 1 diabetes, the immune system mistakenly manufactures antibodies and inflammatory cells that are directed against and cause damage to patients' own body tissues. In persons with type 1 diabetes, the beta cells of the pancreas, which are responsible for insulin production, are attacked by the misdirected immune system. It is believed that the tendency to develop abnormal antibodies in type 1 diabetes is, in part, genetically inherited, though the details are not fully understood. Type-2-Diabetes “Non-Insulin-dependent Diabetes mellitus” Cause:
Insulin immunity caused by:
Overweight Lack of movement Genetic Conditions Doing sports, dieting and medicines
Type 2 was also referred to as non-insulin dependent diabetes mellitus (NIDDM), or adult onset diabetes mellitus (AODM). In type 2 diabetes, patients can still produce insulin, but do so relatively inadequately for their body's needs, particularly in the face of insulin resistance as discussed above. In many cases this actually means the pancreas produces larger than normal quantities of insulin. A major feature of type 2 diabetes is a lack of sensitivity to insulin by the cells of the body (particularly fat and muscle cells). Type-3-Diabetes Cause:
Caused by several other reasons: Type-3a, genetic damages of the Beta-Cells Type-3b, genetic damages of the Insulin-Secretion Type-3c, ill or destroyed pancreas Type-3d, hormonal distortions Type-3e, chemicals or medicines Type-3f, infections Type-3g, abnormal forms of Type-1-Diabetes Type-3h, other diabetes-related genetic Syndromes
Type-4-Diabetes “Pregnancy Diabetes” Cause:
In pregnancy more glucose must be released Sometimes pancreas cannot produce enough Insulin
easiest: waiting Diets, injections
Gestational diabetes is high blood glucose that develops at any time during pregnancy in a woman who does not have diabetes. Women who have gestational diabetes are at high risk of type 2 diabetes and cardiovascular disease later in life. Causes of Diabetes Mellitus
1. Viral factor: Some forms of viruses known as diabetogenic viruses which attack the pancreas and cause autoimmune destruction of the beta cells are responsible for insulindependent diabetes. 2. Liver disease: Liver disease is known to trigger off diabetes mellitus. Liver diseases such as hepatitis and liver cirrhosis lead to impaired glucose tolerance. The way this happens is not very clear, but they have been linked with the onset of diabetes mellitus. 3. Insulin antagonists: High concentration of certain hormones in the blood stream has been known to cause diabetes mellitus. These hormones include thyroid hormones, growth hormones, gestational hormones, adrenaline and adrenocortical hormones. They are antagonistic to the action of insulin in circulation hence their presence in high concentration in the blood reduces the effectiveness of the insulin in the blood. 4. Genetic factor: Some forms of diabetes are inherited in different families. The way genetics play a role in the inheritance of diabetes is not particularly clear. Diabetes is also known to be passed on from the parents to offspring, or along the family line. 5. Pregnancy: Diabetes mellitus is also known to start during their pregnancy or after pregnancy in some women who had been normal before their pregnancy. The reason may be linkable to the high concentration of gestational hormone which is antagonistic to insulin, or it may be as a result of pregnancy-induced stress. 6. Obesity: Quite a number of persons with adult onset diabetes mellitus are those with obesity. Obesity brings about a decrease in the number of insulin receptor cells in the blood, but increases serum level of insulin. This brings about difficulty in the metabolism of glucose. 7. Drugs: Certain drugs such as thiazide diuretics and corticosteroids are also able to trigger off diabetes mellitus in people who are genetically predisposed. 8. Interference or impairment of glucose metabolism: This impairment can be due to any of the following: Destruction of the beta cells; retarded release of insulin; altered insulin receptors, decrease number of receptors on peripheral cells, or as a result of inactivation of insulin in the blood stream by antibodies or other agents.
Clinical manifestations may be due to the following two main factors:
A. Disorder of metabolism. B. Disorder of structure and function of blood vessels.
Clinical features of diabetes mellitus:
1. Excessive urination which may be troublesome at night. 2. Excessive thirst, due to dehydration.
3. Loss of weight and weakness, due to loss of glucose in the urine and breakdown of tissue protein. 4. Itching around the external genitalia due to local infection by sugar-loving organisms. 5. Pain in the legs at night. 6. Increased appetite. 7. Failing vision. 8. Recurrent boils. 9. Loss of sexual vigour. 10. Coma. 11. Repeated abortions. 12. Angina pectoris. 13. Cardiovascular insufficiency. 14. Delayed healing of wounds. 15. Swarming of ants at urine. OTHERS:
The early symptoms of untreated diabetes are related to elevated blood sugar levels, and loss of glucose in the urine. High amounts of glucose in the urine can cause increased urine output and lead to dehydration. Dehydration causes increased thirst and water consumption. The inability of insulin to perform normally has effects on protein, fat and carbohydrate metabolism. Insulin is an anabolic hormone, that is, one that encourages storage of fat and protein.
Other Disorders or Complications that May be Related to Diabetes Mellitus Diabetes Mellitus does come with a number of complications, and other many other disorders tend to be more prevalent in those people who are already diagnosed. Poor circulation, slow healing as well as eye problem are very common on people with diabetes. Other related disorders and complications include:
ACUTE COMPLICATIONS OF DM Hypoglycemia - too much insulin, too little food and excessive physical activity. Diabetic ketoacidosis Hyperglycemic hyperosmolar non-ketotic syndrome (HHNS) CHRONIC COMPLICATIONS OF DM Macrovascular complications- MI, Stroke, Atherosclerosis, CAD, and Peripheral vascular disease Microvascular complications- micro-angiopathy, retinopathy, nephropathy Peripheral neuropathy Retino damage to the retina of the eye Necrobiosis – a skin disorder associated with diabetes Mastopathy – lumps in the breast Musculoskeletal conditions. Assessment: -assess the level of knowledge and ability to perform self care of the patient. - assess what type of DM. - Clinical status of the client and plans for treatment are also important assessments. - ask clients whether they take any vitamins, mineral or herbal supplements to decrease blood Glucose levels or for other purposes. Test procedures Most diabetes tests require blood samples. Generally, a band is tightened around your upper arm to slow blood flow and cause the veins below the band to stand out. The intended injection site is swabbed with alcohol. The hypodermic needle is inserted into the vein and the blood is directed into a collection tube. The band may be removed from your arm while the blood is being taken. You may need more than one collection tube, depending on the test. After the blood is taken, you are asked to press a cotton ball or gauze against the injection site. Once bleeding has stopped, the injection site is covered with a sticking plaster. Types of tests Tests to diagnose diabetes include:
Fasting blood glucose test – blood glucose levels are checked after fasting for between 12 and 14 hours. You can drink water during this time, but should strictly avoid any other beverage. Patients with diabetes may be asked to delay their diabetes medication or insulin dose until the test is completed. Random blood glucose test – blood glucose levels are checked at various times during the day, and it doesn’t matter when you last ate. Blood glucose levels tend to stay constant in a person who doesn’t have diabetes. Oral glucose tolerance test – a high-glucose drink is given. Blood samples are checked at regular intervals for two hours.
The most common test for diagnosis of diabetes is the fasting blood glucose test. Glucose tolerance tests are used when the results of the fasting blood glucose are borderline. They are also used to diagnose diabetes in pregnancy (gestational diabetes). Immediately after the procedure The fasting blood glucose test will confirm that the person has diabetes if it shows that the level of glucose in their blood is higher than normal when they are fasting. Sometimes the test result of the fasting blood glucose test is borderline. If this is the case, a glucose tolerance test may be performed. This test will confirm diabetes if the person’s blood sugar levels stay high for a long time after the tests. If a person doesn’t have diabetes, the results of the glucose tolerance test will show that their blood sugar levels fall within the normal range.
DIABETES MELLITUS TREATMENT AND THERAPHY MEDICAL MANGAMENT
Includes restoring and maintaining blood glucose levels to as near normal as possible by what? o o o Balance diet Exercise Use of oral hypoglycemic agents and insulin
! However, complication may develop in some clients with diabetes mellitus despite their vigorous effects to carefully control the disease
1. Promote Proper Nutrition o Improves metabolic control by making changes in their diet goals. 1. Improve the blood glucose and lipid levels 2. Improve consistency in day-to-day food intake for Type 1 Diabetes mellitus 3. Facilitate weight management for Type 2 Diabetes mellitus 4. Provide adequate nutrition for all stages of life 2. Alcohol Consumption o Does not require insulin for absorption and it generally absorbed before other nutrients Alcohol can impair the process of gluceogenesis, especially if the alcohol is consumed on an empty stomach Gluceogenesis – is a metabolic pathway that results in the generation of glucose from non-carbohydrate carbon substrates such as lactate, glycerol, and glucogenic amino acids
Can also impair the client’s ability to recognize and treat the hypoglycemia • Recommended consumption: 1 Drink for female and not more than 2 drinks for male with food ingestion is recommended
3. Artificial Sweeteners o There are two types of sweeteners Nutritive and Non-nutritive: Nutritive sweeteners : contains calories these includes fructose, sorbitol and xylitol that is similar to sucrose (table sugar) , they cause less blood glucose elevation. Sorbitol can also have laxative effects Non-nutritive sweeteners : contains minimal or no calories at all these includes Saccharin (contains no calories), Aspartame (contains 4 calories per packet), Acesulfame-K (contains 1 calorie per packet) and Sucralose , they produce minimal or no elevation in blood glucose
4. Promote regular physical activity o o o o o o Lowers blood glucose level Fosters weight reduction and maintenance Increases insulin sensitivity Increases high-density lipoprotein level Decreases triglyceride level Decreases the blood pressure Primary side effect of acute physical activity is hypoglycemia Occasionally, hyperglycemia and ketosis can occur in clients with Type 1 DM Adjustments are needed to prevent hypoglycemia who exercise and taking insulin at the same time Hepatic glucose production is blocked or partially inhibited by exogenous insulin Meal planning and physical activity will have no risk of hypoglycemia for Type 2 DM patients
5. Oral Anti Diabetic Drugs o Major classes of oral anti diabetic : Sulfonylureas – primary action is by directly stimulate the pancreas to produce insulin, cannot use for Type 1 DM and can also decrease glucose production of the liver Biguanides – keeps the liver from releasing too much glucose Alpha-glucosidase inhibitors – slows the digestion of some carbohydrates: after meal blood glucose peaks are not as high, and delaying the the absorption of glucose in the intestinal system Thiazolidinediones – make muscle cells more sensitive to insulin, decreasing blood glucose levels
D-phenylalanine derivatives – stimulate the release of insulin from beta cells Meglitinides – same effect as Sulfonylureas • ! aimed only on one aspect of the underlying pathogenesis of Type 2 DM, multiple medication are often needed to achieve optimal glycemic control
6. Insulin therapy o o Type 1 DM – they do not produce insulin Type 2 DM – insulin for adequate glucose control especially in times of stress and illness Types of Insulin : there are Rapid, Short, Intermediate and Long – acting insulin • Rapid – Acting o Minimize the absorption limitations of regular human insulin Foundation of type 1 and type 2 DM Both analogs provide many benefits in achieving glucose control and may ultimately prevent or delay diabetes – related complications
Source of Insulin – in the past insulin were obtained from beef and pork and other animals but now human insulin are widely used from DNA recombinant technology Insulin Regimen Conventional Regimen - One approach is to simplify the insulin regimen as much as possible, with the aim of avoiding the acute complications of diabetes (hypoglycemia and symptomatic hyperglycemia). With this type of simplified regimen (eg, one or more injections of a mixture of short- and intermediate-acting insulins per day), patients may frequently have blood glucose levels well above normal. The exception is the patient who
never varies meal patterns and activity levels. This approach would be appropriate for the terminally ill, the frail elderly with limited self-care abilities, or any patient who is completely unwilling or unable to engage in the self-management activities that are part of a more complex insulin regimen. Intensive Regimen - The second approach is to use a more complex insulin regimen to achieve as much control over blood glucose levels as is safe and practical. The results of the landmark DCCT study (1993) and the UKPDS study (1998) have demonstrated that maintaining blood glucose levels as close to normal as possible prevents or slows the progression of long-term diabetic complications. Another reason for using a more complex insulin regimen is to allow patients more flexibility to change their insulin doses from day to day in accordance with changes in their eating and activity patterns, with stress and illness, and as needed for variations in the prevailing glucose level. Although the DCCT found that intensive treatment (three or four injections of insulin per day) reduced the risk of complications, not all people with diabetes are candidates for very tight control of blood glucose. The patient needs to be involved in the decision regarding which insulin regimen to use. Patients need to compare the potential benefits of different regimens with the potential costs (eg, time involved, number of injections or finger sticks for glucose testing, amount of record-keeping). There are no set guidelines as to which insulin regimen should be used for which patients. It must not be assumed that an elderly patient or a patient with visual impairment should automatically be given a simplified regimen. Likewise, it must not be assumed that all people will want to be involved in a complex treatment regimen. Nurses play an important role in educating patients about the different approaches to insulin therapy. Nurses should refer patients to diabetes specialists or diabetes education centers, when available, for further training and education in the various insulin treatment regimens.
Complications of Insulin Therapy Allergic Reaction - A local allergic reaction (redness, swelling, tenderness, and induration or a 2- to 4-cm
wheal) may appear at the injection site 1 to 2 hours after the insulin administration. These reactions, which usually occur during the beginning stages of therapy and disappear with continued use of insulin, are becoming rare because of the increased use of human insulins. Systemic Allergic Reaction - Systemic allergic reactions to insulin are rare. When they do occur, there is an immediate local skin reaction that gradually spreads into generalized urticaria (hives) the treatment is desensitization, with small doses of insulin administered in gradually increasing amounts using a desensitization kit. Insulin Lipodystrophy - Lipodystrophy refers to a localized reaction, in the form of either lipoatrophy or lipohypertrophy, occurring at the site of insulin injections. Lipoatrophy is loss of subcutaneous fat and appears as slight dimpling or more serious pitting of subcutaneous fat. The use of human insulin has almost eliminated this disfiguring complication. Insulin Resistance - Most patients at one time or another have some degree of insulin resistance. This may occur for various reasons, the most common being obesity, which can be overcome by weight loss. Morning Hyperglycemia - An elevated blood glucose level upon arising in the morning may be caused by an insufficient level of insulin due to several causes: the dawn phenomenon, the Somogyi effect, or insulin waning. The dawn phenomenon is characterized by a relatively normal blood glucose level until approximately 3 a.m., when blood glucose levels begin to rise. The phenomenon is thought to result from nocturnal surges in growth hormone secretion that create a greater need for insulin in the early morning hours in patients with type 1 diabetes. It must be distinguished from insulin waning (the progressive increase in blood glucose from bedtime to morning) or the Somogyi effect (nocturnal hypoglycemia followed by rebound hyperglycemia). Insulin waning is frequently seen if the evening NPH dose is administered before dinner and is prevented by moving the evening dose of NPH insulin to bedtime.
Alternative Methods of Insulin Delivery Insulin Pens - These devices use small (150- to 300-unit) prefilled insulin cartridges that are loaded into a penlike holder. A disposable needle is attached to the device for insulin injection. Insulin is delivered by dialing in a dose or pushing a button for every 1- or 2-unit increment administered. Jet Injectors - As an alternative to needle injections, jet injection devices deliver insulin through the skin under pressure in an extremely fine stream. These devices are more expensive than other alternative devices mentioned above and require thorough training and supervision when first used.
Insulin Pumps - Continuous subcutaneous insulin infusion involves the use of small, externally worn devices that closely mimic the functioning of the normal pancreas. Insulin pumps contain a 3-mL syringe attached to a long (24- to 42-in), thin, narrow-lumen tube with a needle or Teflon catheter attached to the end. The patient inserts the needle or catheter into the subcutaneous tissue (usually on the abdomen) and secures it with tape or a transparent dressing. The needle or catheter is changed at least every 3 days. The pump is then worn either on a belt or in a pocket. Some women keep the pump tucked into the front or side of the bra or wear it on a garter belt on the thigh.
Implantable and Inhalant Insulin Delivery Research into mechanical delivery of insulin has involved implantable insulin pumps that can be externally programmed according to blood glucose test results. Clinical trials with these devices are continuing. In addition, there is research into the development of implantable devices
that both measure the blood glucose level and deliver insulin as needed. Methods of administering insulin by the oral route (oral spray or capsule), skin patch, and inhalation are undergoing intensive study. Transplantation of Pancreatic Cells - Transplantation of the whole pancreas or a segment of the pancreas is being performed on a limited population (mostly diabetic patients receiving kidney transplantations simultaneously). One main issue regarding pancreatic transplantation is weighing the risks of antirejection medications against the advantages of pancreas transplantation. Another approach under investigation is the implantation of insulin-producing pancreatic islet cells. This latter approach involves a less extensive surgical procedure and a potentially lower incidence of immunogenic problems. However, thus far, independence from exogenous insulin has been limited to 2 years after transplantation of islet cells. A recent study of patients with islet cell transplants using less toxic antirejection drugs has shown promise.