Htn & DM

Keara D. Acevedo, PTRP

HYPERTENSION
• The increase in BP c age is most likely d/t complex &
varied factors molded and influenced by the individual
environment & lifestyle.
• Equal or Greater than 140/90 mmHg is a primary risk for:
o Myocardial Infarct
o HF
o CVA
o Kidney Dse
HYPERTENSION
• Classification:
PRIMARY/Essential/Idiopathic = 90-95% of Htn pts
SECONDARY = D/t Renal artery stenosis – “RAAS”
vasoconstriction

• Types:
o Labile/Borderline: Intermittent elevation of BP interspersed
c N readings
o Masked Htn: N in clinic, high @ home
o White Coat Htn: elevated BP in clinic, N outside clinic
HYPERTENSION
• Factors that contributes to Htn:
o >20 y.o. = high BP
o 45 y.o. = M>F
45-64 y.o. = M=F
>65 y.o. = M<F
o Race: African American > Caucasian
o Heredity
o Pregnancy
HYPERTENSION
• Factors that contributes to Htn:
o Lifestyle
➢ Sedentary
➢ Smoking
➢ Heavy Alcohol Consumption
o Activity level
o Obesity
o Diet: High sodium intake
o Comorbidities – Cardiac & Vascular
o Meds: Steroids, NSAIDs, Diet Pills, Cyclosporine, Erythropoietin,
Tricyclic Anti-depressants, MonoAmine Oxidase Inhibitors, Oral
Contraceptives
HYPERTENSION
Factors Causing Increased BP
1. CO: Increased amounts of blood pumped into arteries → Arterial walls
distend --. Higher BP
2. Age:
• Normally rises gradually p birth; Peak @ puberty
• Late adolescence (18-19 y.o.) = adult BP (<120/<80 mmHg)
• 120/80 is PREHYPERTENSION; but is NOT A DISEASE category; A
risk factor for Htn identification
3. Exercise
• Physical Activities → Inc CO → Inc BP (Greater inc in SBP)
• BP increase is proportional to intensity of workload
• 10mmHg drop of SBP → STOP EXERCISE
HYPERTENSION
Factors Causing Increased BP
4. Valsalva Maneuver
• An attempt to exhale forcibly c glottis, nose & mouth closed
• Causes inc intrathoracic pressure c vein collapse of chest wall
• Dec in bf to heart → Dec Venous Return → Drop in BP → Release of
breath → Dec IntraThoracic Pressure → Venous Return is
reestablished (“Overshoot”) → Marked inc in HR & BP →
Bradycardia (vagal slowing of HR)
• Must be avoided by people c Heart dse & Htn
• May result in seeing “black dots” and feeling of dizziness
HYPERTENSION
Factors Causing Increased BP
5. Arm Position
• BP may vary as much as 20 mmHg by altering arm position
• Pt should be sitting c arm in horizontal supported position @
HEART LEVEL
 HYPERTENSION
Anti-Hypertensive Drugs
Medication MOA Action Example SE
Diuretics “Water Pills” Inhibits reabsorption of Dec peripheral vascular Thiazide
water in kidneys resistance Furosemide (Lasix)
Bumex
Beta-Blockers Beta 1: Inc Heart Cxn “olols”
Beta 2: Bronchioles Relaxation
Non-Selective Beta- Inhibits (B) Beta 1 & 2 Propanolol CI in COPD
Blockers Nadolol
Penbutolol
Selective Beta Blockers Inhibits Beta 1 Atenolol
Metaprolol
Beta Agonist Stimulates Beta 1 & 2 Asthma Px Palpitations
For relaxation of
Bronchioles
 HYPERTENSION
Anti-Hypertensive Drugs
Medication MOA Action Example SE
Ca Channel Blockers Inihibits the influx of Ca Dec HR “dipine”
in myocardium Vasodilation Amlodipine
Felodipine
Nisoldipine
Verapamil
Alpha-1 Blocker Alpha 1: Inhibits “zocin” Dizziness
Vasoconstriction Vasocontraction Terazocin Postural Hypotension
Alpha 2: Vasodilation Promotes Vasodilation Prazocin
Dexazocin
DIABETES MELLITUS
• Chronic disorder caused by deficient insulin or
defective insulin in the body
• Characterized by HYPERGLYCEMIA and disruption of
the metabolism of carbohydrate, fat and protein
• Main organ involved: PANCREAS
o “GABIDS”: Glucagon = Alpha Cell
Beta Cell = Insulin
Delta Cell = Somatostatin
DIABETES MELLITUS
• s/sx:
o Hyperglycemia, Glycosuria, Ketonuria
o 3 Ps (Polyuria, Polydipsia, Polyphagia)
o Unexplained Wt Loss
o Fatigue
o Blurred Vision, h/a
DIABETES MELLITUS
FACTORS TYPE 1 TYPE 2
Age of Onset < 30 y.o. >35 y.o.
Type of Onset Abrupt Gradual
Insulin Production Little-to-None Below/Above Normal
Incidence 5% - 10% 90% -95%
KetoAcidosis May Pccurs Unlikely
Insulin Injections Requires 20% - 30% of clients only
Body Weight Normal-toThin 80% obese
Management Diet, Exercise, Insulin Diet, insulin, oral hypoglycemics,
exercise
Etiology AutoImmune, Viral Obesity assoc to insulin receptor
resistance
Hereditary Yes Yes
DIABETES MELLITUS:
• TYPE I DM = Insulin-Dependent DM
o AutoImmune Dse (inhibits Beta Cell, no
release of Insulin)
o (-) Insulin
o New Source of ATP: tryglycerides → Ketone
Acid → Atherosclerosis
o Ectomorph (d/t Triglycerides)
o “Ketone Prone DM”
DIABETES MELLITUS:
• TYPE II DM = Non-Insulin Dependent DM
o Dec Insulin Production/Dec Insulin Receptors
sensitivity
o Obese
o Mx: diet/exercise
o “Ketone Resistant DM”
DIABETES MELLITUS RFs:
• Obesity (non-obese c inc body fat
% in Abdominal Region)
• Family Hx of Diabetes
• Unhealthy eating patterns
• Lack of Physical Activity
DIABETES MELLITUS RFs:

Abdominal
Triglycerides Low HDL
Obesity

Elevated BP FBS High LDL

DIABETES MELLITUS
Criteria for Clinical Diagnosis of Metabolic Syndrome:
Any three of these five components constitute a diagnosis of metabolic
syndrome:
• Elevated waist circumference (in US: >40 inches [102 cm] in men &
>35 inches [88cm] in women; lower values are recommended for
Asian, Middle Eastern, South American, and African groups)
• Reduced levels of HDL (good or “healthy” cholesterol): < 40 mg/dL
in men, <50 mg/dL in women
• Inc BP of 130/85 mmHg or greater
• Elevated fasting blood glucose level of 100 mg/dL or greater
• Elevated serum triglyceride levels of 150 mg/dL or greater
DIABETES MELLITUS
Diagnostic Criteria
• Casual Plasma Glucose:
o >200mg/dL (N: 80-120mg/dL)

• Fasting Plasma Glucose:

o >=126mg/dL or higher on 2 different days
o >100-125 mg/dL “prediabetic”

• 2-hour postload glucose during OGTT

o >200 mg/dL (N:<139mg/dL)
DIABETES MELLITUS
DIABETES MELLITUS
HypoGlycemia
• Blood Glucose: <70 mg/dL (DON’T EXERCISE)
• S/sx:
o shakiness, sweating, excessive hunger, tachycardia,
fainting, dizziness, weakness, poor coordination and
unsteady gait
o Post exercise hypoglycemia may last as long as 48 hrs.
o 15 g of carbohydrates every 30 mins of exercise
 DIABETES MELLITUS
Diabetic KetoAcidosis (DKA)
• Fasting blood glucose: >300mg/dL (DO NOT EXERCISE)
• Seek immediate medical attention
• S/sx:
o Weakness
o Inc Thirst
o Polyuria
o Confusion
o Flushed face, hot & dry skin
o Deep rapid respirations
o Fruity odor breath (acetone breath)
o Hyperglycemic Coma
DIABETES MELLITUS
HyperGlycemia vs HypoGlycemia
HYPERGlycemia HYPOGlycemia
> 250 mg/dL <50 mg/dL
Onset Gradual (Days) Rapid (Minutes)
Mood Lethargic Labile, Irritable, Nervous, Weepy
Mental Status Dulled sensorium, confused Difficulty concentrating,
speaking, focusing
Skin Flushed, Dehydrated Pallor, Sweaty
Mucous Dry, Crusty Normal
Membrane
Respiration Deep, rapid; Kussmaul’s Shallow
Pukse Decreased Increased
Breath Fruity, Acetone Normal
Neuro Signs Hyporeflexia, Glove & Tremors, Dilated Pupils,
Stocking Paresthesia Convulsions
DIABETES MELLITUS
Primary tx for DM:

1.Diet
2.Exercise
3.Medication
DIABETES MELLITUS
Insulin Reaction Time:

ONSET: How long it takes before the insulin reaches the

bloodstream and starts to lower glucose

PEAK: Time when insulin reaches its maximum strength

DURATION: How long the insulin continues to lower blood

glucose
DIABETES MELLITUS
Type of Insulin (Action):

Rapid-Acting: work 5” p injection (Humulin R, Novolin R)

Regular or Short-Acting: reaches bloodstream in first 30”
p injection (Humulin R, Novolin R)
Intermediate-Acting: reaches bloodstream in about 2-4
hrs p injection (Humulin N,L; Novolin N,L)
Long-Acting: reaches bloodstream 6-10 hrs p injection
(Humulin U)
 DIABETES MELLITUS
REHAB CONSIDERATIONS
• Sudden hypoglycemia
• Inconsistent management of insulin intake
• Proper skin care and shoe evaluation
• Do not inject short-acting insulin in exercising muscles (abdominal
injection is preferred)
• Do not exercise …
 ALONE
 without adequate hydration
 In extreme Temps
 Between 2-4 hours after insulin injection
 DIABETES MELLITUS
REHAB CONSIDERATIONS
• Goals of therapy:
➢ Young (Type I DM): 90-130 mg/dL
➢ Adult (Type II DM): 90-150 mg/dL
• BEST TIME to Exercise: 1 hour p meal
• Check Blood Glucose prior to exercise:
 >250 mg/dL: NO EXERCISE!
✓ 100-200 mg/dL: Safe level (non-fasting)
 80-100 mg/dL: eat carbs snacks (retest p 15”)
 60-80 mg/dL: liquid glucose (juice / honey)
 <60 mg/dL: IV glucose
• Avoid LATE NIGHT Exercises
 DIABETES MELLITUS
REHAB CONSIDERATIONS
• a Exercise
o Drink at least 16 oz / 2 glasses of WATER
o Check ketones
o Do not use drugs that may contribute to exercise-induced hypoglycemia such as beta-blockers,
alcoholic beverages, diuretics, estrogen , phenytoin)
o Menstruating women need to increase insulin
• During Exercise
o Best Frequency = 5x /wk (every other day)
o Duration of continuous Aerobics: 20-30” (beneficial)
40-60” (optimal)
o During prolonged exercise
• p Exercise
o Monitor glucose 15” p
o Increase carbs / calorie intake at least 12-24 hrs a & p exercise
o Reduce insulin (which peaks in the evening)
DIABETES MELLITUS
RELATED DISEASES
• Diabetic Neuropathy
• Charcot’s Joint
• CRPS
• Periarthritis
• Frozen Shoulder
• Dupuytren’s Contracture
• Metabolic Syndrome