DIABETES MELLITUS

DIABETES MELLITUS
-was used in the 1st century by Aretacus, who describe the disorder as a “melting down of the flesh limbs into urine” Diabetes= “running through” or “siphon Large urine volume Mellitus= “sweet” Glucose in urine

Definition
• Is a group of metabolic diseases characterized by elevated levels of glucose in the blood (hyperglycemia) resulting from abnormal endocrine secretion by the pancreas

• Diabetes mellitus is a condition in which the pancreas no longer produces enough insulin or cells stop responding to the insulin that is produced, so that glucose in the blood cannot be absorbed into the cells of the body. • The four general components of diabetes are hyperglycemia, large blood vessel (macrovascular) dse., small blood vessel (microvascular) dse., and neuropathy. • A useful definition of diabetes is symptomatic (polyuria, polydipsia, and polyphagia) or asymptomatic state of altered CHON, CHO, and fat metabolism.

Glucose is our body’s primary energy source. After digestion, glucose passes into the bloodstream where it is used by cells for growth and energy.
Insulin, a hormone that is produced by the pancreas, must be present in order for glucose to get into our cells. When we eat, the pancreas produces the right amount of insulin to act as carriers to deliver glucose to our cells.

• In people with diabetes, the pancreas produces either little or no insulin, or the cells do not respond appropriately to the insulin being produced.
• Glucose builds up in the blood, overflows into the urine and passes out of the body, thus, the body loses its main energy fuel. The cause of diabetes continues to be investigated, and both genetic and environmental factors such as obesity and sedentary lifestyle appear to play a role.

Causes
• Hereditary • Viral Infection (Pancreatitis) • Trauma

Individuals who are at high risk of developing Type II diabetes mellitus include people who:

• • • •

• •

obesity have a relative with diabetes mellitus belong to a high-risk ethnic have been diagnosed with gestational diabetes or have delivered a baby weighing more than 9 lbs (4 kg) have high blood have a high density lipoprotein cholesterol level and/or triglyceride have had impaired glucose tolerance or impaired fasting glucose on previous testing Physiologic or emotional stress

Signs and Symptoms
 polyuria, polydipsia and polyphagia

 Fatigue and weakness
 Slow wound healing  Dry skin  Sudden vision changes  Tingling / numbness of the hand and feet  Feeling of tiredness much of the

times

CLASSIFICATIONS: ☺Type 1 Diabetes (insulin dependent diabetes mellitus) ☺Type 2 Diabetes (non insulin dependent diabetes mellitus) ☺Gestational diabetes mellitus ☺Diabetes mellitus associated with other conditions or syndrome.

Diagnostic tests
♠ ♠ ♠ ♠ ♠ ♠ Random blood sugar Fasting blood sugar Post Randial blood sugar Oral glucose tolerance test IV glucose tolerance test Hemoglobin A1C test (A1C) — The A1C blood test measures the average blood glucose level during the past two to three months. It is used to monitor blood glucose control in people with known diabetes, but is not normally used to diagnose diabetes. Normal values for A1C are 4 to 6 percent. The test is done by taking a small sample of blood from a vein or fingertip.

Anatomy and Physiology

12

CONFIDENTIAL

13

CONFIDENTIAL

Pancreas The pancreas is a gland organ in the digestive and endocrine system of vertebrates. It is both an endocrine gland producing several important hormones, including insulin, glucagon, and somatostatin, as well as an exocrine gland, secreting pancreatic juice containing digestive enzymes that pass to the small intestine. These enzymes help in the further breakdown of the carbohydrates, protein, and fat in the chyme.

Structure

Appearance Lightly staining, large, spherical clusters

Function Hormone production and secretion (endocrine pancreas)

Islets of Langerhans

Pancreatic acini

Darker staining, small, berry-like clusters

Digestive enzyme production and secretion (exocrine pancreas)

Pathophysiology
Precipitating factors: Predisposing factors: 1. 2. 3. family history of DM Obesity Age above 40

1. 2. 3.

4. 5. 6.

frequent or chronic infections eating too much sweets development of glucose intolerance during drug therapy delivery of over 9 lbs infants Diet sedentary lifestyle

Insulin resistance

Impaired insulin secretion

Exhaustion of beta cells  Insulin production/ decrease secretion of insulin  Absorption of glucose by the cell ↑Serum glucose level HYPERGLYCEMIA

Cell starvation Stimulation of hunger Mechanism via hypothalamus

INCREASE VISCOSITY OF BLOOD

Kidney filtration mechanism impaired ↑ Hunger GLYCOSURIA POLYPHAGIA Excess glucose excreted in urine

Excess fluid loss

MACROVASCULAR COMPLICATIONS
Thickening of blood vessel walls Occlusion of plaque Blood flow blocked Atherosclerosis POLYURIA Tissue dehydration POLYDIPSIA

MICROVASCULAR COMPLICATIONS
Capillary basement membrane thickening Abnormal retinal vascular permeability RETINOPATHY Kidney filtration mechanism is stressed

NEUROPATHIC DISEASE
Nerve Demyelinization NEUROPATHY Sensorimotor
Polyneuropathy

Autonomic Neuropathies
Slowing of nerve conduction or blocked nerve impulse transmission.

Stages Coronary Artery Disease
Cerebrovascular Disease

Allowing blood protein to leak into the urine

(Peripheral Neuropathy)

Peripheral Vascular Disease Diminished peripheral pulse

Paresthesias & numbness Impaired pain sensation NON-HEALING ULCERS

1. Non Proliferative 2. Pre Proliferative 3. Proliferative
New blood vessels growing from retina Wide spread vascular changes & loss of nerve

Pressure in blood vessels of kidney ↑

Early warning sign of ↓coronary blood flow and MI is asymptomatic.

Formation of an embolus elsewhere in vasculature that lodges in cerebral blood vessel

NEPHROPATHY

Cardiovascular symptoms: Orthostathic hypotension and painless Myocardial Ischemia

fibers.

Renal failure Delayed wound healing End-Stage Renal Disease Gangrene
GI→ Delayed gastric emptying: Bloating, Nausea &Vomiting

Myocardial ischemia
Vitreous hemorrhage

Blurry vision

Myocardial infarction

Stroke

Resorption of blood in vitreous

Vitreous become clouded & cannot transmit light

Scarring

Renal System→ Urinary retention→ UTI

Blindness

Complications
1. Acute Complications • Hypoglycemia • Diabetic Ketoacidosis (DKA) • Hyperglycemic hyperosmolar nonketotic syndrome (HHNS)

Diabetic ketoacidosis is a complication of diabetes that occurs when the body cannot use sugar (glucose) as a fuel source because the body has no insulin or not enough insulin, and fat is used instead. By products of fat breakdown, called ketones, build up in the body.

Symptoms • The warning signs that you are becoming very sick might include: • Deep, rapid breathing • Dry skin and mouth • Flushed face • Fruity breath (breath odor) • Nausea and vomiting • Stomach pain

 Nonketotic Syndrome (HHNS) is an emergency condition in which one’s blood glucose level is very high and ketones are not present in the blood or urine. If HHNS is not treated, it can lead to coma or death.

Symptoms • Blood glucose level over 600 mg/dl • Dry, parched mouth • Extreme thirst (which may gradually disappear) • Warm, dry skin that does not sweat • High fever (>101 degrees Fahrenheit) • Sleepiness or confusion • Loss of vision • Hallucinations (seeing/hearing things that aren't there) • Weakness on one side of the body

2. a)    b)   c)  

Long-Term Complications Macrovascular Complication CAD Cerebrovascular dse. Peripheral vascular dse. Microvascular Complication Retinopathy Nephropathy Diabetic Neuropathies Peripheral Neuropathy Autonomic Neuropathy

Management in DM type 1
1. Pharmacologic Therapy (Insulin) 2. Nutritional management (Small Frequent Meal) 3. Monitoring Glucose Levels (SMBG) 4. Exercise

Management in DM type 2
1. Healthy Eating Habits  CARBOHYDRATES should provide 50 60% of total daily calories. The type and amount of carbohydrate are both important. Best choices are vegetables, fruits, beans, and whole grains. These foods are also high in fiber. Patients with diabetes should monitor their carbohydrate intake either through carbohydrate counting or meal planning exchange lists.

 FATS should provide 20 - 30% of daily calories. Monounsaturated (olive, peanut, and canola oils; avocados; nuts) and omega-3 polyunsaturated (fish, flaxseed oil, and walnuts) fats are the best types. Limit saturated fat (red meat, butter) to less than 7% of daily calories. Choose nonfat or low-fat dairy instead of whole milk products. Limit trans-fats (hydrogenated fat found in snack foods, fried foods, commercially baked goods) to less than 1% of total calories.

 PROTEIN should provide 10 - 20% of daily calories, although this may vary depending on a patient’s individual health requirements. Patients with kidney disease should limit protein intake to less than 10% of calories. Fish, soy, and poultry are better protein choices than red meat.

2. Achieve healthy weight and Lifestyle changes  A reasonable weight is usually defined as a weight that is achievable and sustainable, rather than one that is culturally defined as desirable or ideal.  Patients should lose weight if their body mass index (BMI) is 25 - 29 (overweight) or higher (obese).  aim for a small but consistent weight loss of ½ - 1 pound per week

 follow a diet that supplies at least 1,000 1,200 kcal/day for women and 1,200 -

1,600 kcal/day for men

 Regular exercise, even of moderate intensity (such as brisk walking), improves insulin sensitivity and may play a significant role in preventing type 2 diabetes  even a modest weight loss of 10 - 15 pounds can significantly reduce the risk of progressing to diabetes.

 Patients should have an exercise goal of 30 - 60 minutes, at least 5 days a week, and follow a low-fat, high-fiber diet.  Quitting smoking is also essential.  It is also important to have your doctor check your cholesterol and blood pressure levels on a regular basis. Your doctor should also check your fasting blood glucose and microalbuminuria levels every year, and your hemoglobin A1c and lipids every 6 months

3. Oral hypoglycemic agents • Metformin • The first oral agent used should be metformin. – decrease hepatic glucose output – enhance hepatic & muscle insulin sensitivity without a direct effect on b-cell function • Sulfonylureas: chlorpropamide, gliclazide, glimepiride, glipizide, tolazamide, & tolbutamide – promote insulin secretion from islet cells

• Diapenease • Minidiapenease - Stimulate betacells of pancreas therefore it will release insulin

NURSING INTERVENTIONS (General) • Advice patient about the importance of an individualized meal plan in meeting weekly weight loss goals and assist with compliance. • Assess patients for cognitive or sensory impairments, which may interfere with the ability to accurately administer insulin. • Demonstrate and explain thoroughly the procedure for insulin self-injection. Help patient to achieve mastery of technique by taking step by step approach.

• Review dosage and time of injections in relation to meals, activity, and bedtime based on patients individualized insulin regimen. • Instruct patient in the importance of accuracy of insulin preparation and meal timing to avoid hypoglycemia. • Explain the importance of exercise in maintaining or reducing weight. • Advise patient to assess blood glucose level before strenuous activity and to eat carbohydrate snack before exercising to avoid hypoglycemia.

• Assess feet and legs for skin temperature, sensation, soft tissues injuries, corns, calluses, dryness, hair distribution, pulses and deep tendon reflexes. • Maintain skin integrity by protecting feet from breakdown. • Advice patient who smokes to stop smoking or reduce if possible, to reduce vasoconstriction and enhance peripheral flow.

Thank You!!! =)
BY: A.D.S. R.N

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