REPORTERS (E5

)
Barcenilla, Deborah Celeste, Rose Paulette Deala, Kathleen Faye Fernandez, Lynch Heldegard Jimenez, Laurene Duls Lay, Felicidade Oliverio, Arnel Jon Rubino, April Glenn Sabellina, Madilou Dimple Sagnoy, Eunice Sumagang, Ernest

Diabetes mellitus is a chronic systemic disease characterized by either a deficiency of insulin or a decreased ability of the body to use insulin.

TYPE I (INSULIN DEPENDENT) TYPEII (NON-INSULIN DEPENDENT)

Comparison of Type I and Type II Diabetes Mellitus
FEATURE
Age at onset

TYPE I

TYPE II
Usually occurs after age 30 but can occur at children ~90% Insidious, may be asymptomatic; body adapts to slow onset of hyper gylcemia Below normal, normal, or above normal

Usually occurs before age 30, but may occur at any age Incidence ~10% Type of onset Usually abrupt, w/ rapid onset of hyperglycemia

Endogenous Little or none Insulin Production Body weight Ideal body weight or thin at onset Ketosis prone to ketosis Manifestations Polyuria, polydipsia, polyphagia, fatigue Oral hypogly Not effective cemic agents Exogenous Dependent on insulin for survival insulin adminis tration

85% are obese: may be of ideal body weight Resistant to ketosis Often none,may be mild symptoms of hyperglycemia Effective 20-30% of clients require insulin

Pathogenesis of Type I Diabetes Mellitus
Genetic Predisposition (susceptibility) Chromosome 6: HDL-DR3 and DR4 increased, HDL-DR2 decreased Environmental Insult -Viral Infection - Toxic chemical agents

Autoimmunity - Lymphocyte infiltration -Insulitis

Immunologic response - Islet cell antibodies - Cell-mediated immunity

ß cell destruction

Lack of insulin release

Insulin-dependent Diabetes Mellitus

Pathogenesis of Type II Diabetes Mellitus
Hereditary Factors Obesity

Delayed or insufficient Insulin secretion

Insulin resistance (receptor defect or other events)

Increased insulin demand

ß Cell exhaustion and dysfunction

Hyperglycemia

Non-insulin dependent diabetes (NIDDM)

HISTORY
- Symptoms r/t the diagnosis of diabetes: Symptoms of hyperglycemia Symptoms of hypoglycemia Frequency, timing, severity, and resolution -Results of blood glucose monitoring -Status, symptoms, & management of chronic complications of diabetes Eye, kidney,nerve, genitourinary & sexual, bladder, & gastrointestinal Cardiac, peripheral vascular, foot complications associated w/ diabetes

-Adherence to/ability to follow prescribed dietary management plan -Adherence to prescribed exercise regimen -Adherence to/ability to follow prescribed pharmacologic treatment -Use of tobacco, alcohol & prescribed & over-thecounter drugs -Lifestyle, cultural, psychosocial, & economic factors that may affect treatment -Effects of diabetes or its complications on functional status

Blood pressure (sitting & standing to detect orthostatic changes) Body mass index ( height & weight) Fundoscopic examination Foot examination ( lesions, signs of infection, pulses} Skin examinations ( lesions & injection sites) Neurologic examination Vibratory & sensory examination using monofilament Deep tendon reflexes Oral examination

Elimination: Polyuria, nocturia, diarrhea or constipation Food and fluid: Hunger, thirst, nausea, weight loss or obesity Neurosensory : Decreased sensation to pain and temperature in the feet, blurred vision, headaches, cataracts, halos around lights Mobility: Muscle weakness, tiredness, wrist-drop, ankledrop Skin: Infection( frequent boils and ulcerations,)

Sexuality: impotence, vaginal discharge, increased susceptibility to vaginal infection Circulation: Cold extremeties, loss of hair in toes; thin, shiny skin, painful calves when walking, numbness and tingling of lower extremeties Psychosocial: verbalizations of inability to cope and change in lifestlye, negative feeling about the body

MAIN GOAL:

To normalize insulin activity and blood glucose levels to reduce the development of vascular and neuropathic conditions

FIVE COMPONENTS OF DIABETES MANAGEMENT

Nutritional Therapy Exercise Monitoring Pharmacologic Therapy Education

NUTRITION THERAPY
CALORIC REQUIREMENTS -Calorie-controlled diets are planned by first calculating a person s energy needs and caloric requirements based on age, gender, height, and weight. CARBOHYDRATES -It should be eaten in moderation to avoid high postprandial blood glucose levels FATS -Include both reducing the total percentage of calories from fat sources to less than 30% of total calories and limiting the amount of saturated fats to 10% of total calories FIBER -Increased fiber in the diet may also improve blood glucose levels and decrease the need for exogenous insulin.

SAMPLE MENU
EXCHANGES SAMPLE LUNCH # 1 2 slices of bread 2 oz sliced turkey & 1 oz low fat cheese lettuce, tomato, onion 1 tsp mayonnaise 1 medium apple unsweetened iced tea, mustard, pickle SAMPLE LUNCH # 2 Hamburger bun 3 oz lean beef patty green salad 1 tbsp salad dressing 1 ¼ cup watermelon diet soda, 1 tbsp catsup pickle, onions SAMPLE LUNCH # 3 1 cup cooked pasta 3 oz boiled shrimp ½ cup plum tomatoes 1 tsp olive oil 1 ¼ cup fresh strawberries Ice water w/ lemon, garlic, basil

2 starch 3 meat 1 vegetable 1 fat 1 fruit free items (optional)

EXERCISE
-Exercise is extremely important in diabetes management because of its effect on lowering blood glucose and reducing cardiovascular risk factors. It lowers blood glucose levels by increasing the uptake of glucose by body muscles and by improving insulin utilization. -It also improves circulation and muscle tone -Resistance (strength) training, such as weight lifting, can increase lean muscle mass, thereby increasing the resting metabolic rate. -Exercise also alters blood lipid concentrations, increasing levels of high-density lipoproteins and decreasing total cholesterol and triglyceride levels.

GENERAL PRECAUTIONS FOR EXERCISE

-Use proper footwear and, if appropriate, other protective equipment - Avoid exercise in extreme heat or cold - Inspect feet daily after exercise - Avoid exercise during periods of poor metabolic control

MONITORING GLUCoSE LEVELS AND KETONES

SELF MONITORING OF BLOOD GLUCOSE (SMBG) This allows for detection and prevention of hypoglycemia and hyperglycemia and plays a crucial role in normalizing blood glucose levels, which in turn may reduce the risk of long-term diabetic complications Recommended for patients with: -unstable diabetes (severe swings from very high to very low blood glucose levels w/in a 24-hour day) -a tendency to develop severe ketosis or hypoglycemia -hypoglycemia without warning symptoms

FREQUENCY: SMBG is recommended 2-4 times daily (usually before meals and at bedtime). For patients who take insulin before each meal, SMBG is required at least 3 times daily before meals to determine each dose. Patients not receiving insulin may be instructed to assess their blood glucose levels at least 2-3 times per week .

CONTINUOUS GLUCOSE MONITORING SYSTEM

A sensor attached to an infusion set, which is similar to an insulin pump infusion set, is inserted subcutaneously in the abdomen and connected to the device worn on a belt. After 72 hours, the data from the device are downloaded and blood glucose readings are analyzed.

GLYCATED HEMOGLOBIN

is a blood test that reflects average blood glucose levels over a period of approximately 2-3 months. When blood glucose levels are elevated, glucose molecules attach to hemoglobin in red blood cells. The longer the amount of glucose in the blood remains above normal, the more glucose binds to hemoglobin and the higher the glycated hemoglobin level becomes.

URINE GLUCOSE TESTING

Monitor diabetes on a daily basis
TESTING FOR KETONES

Ketones are byproducts of fat breakdown, and they accumulate in the blood and urine. Ketones in the urine signal that control of type I diabetes is deteriorating, and the risk of DKA is high.

PHARMACOLOGIC THERAPY
INSULIN THERAPY In type I diabetes, exogenous insulin must be administered for life because the body loses the ability to produce insulin. In type II diabetes, insulin may be necessary on a long-term basis to control glucose levels if meal planning and oral agents are ineffective.

CATEGORIES OF INSULIN
TIME COURSE Rapid acting AGENT Lispro Aspart ONSET PEAK DURATION 2-4hr 2-4 hr INDICATIONS Used for rapid reduction of glucose level, to treat postprandial hyperglycemia &/ or to prevent noturnal hypo glycemia usually administered 20-30 min before a meal ;may be taken alone or in combina tion w/ longer-acting insulin usually taken after food

10-15min 1 hr 5-15min 40-50 min

Short-acting

regular(huma log R)

½-1 hr

2-3h

4-6h

IntermediateActing Long-acting Very longActing

NPH(neutral 2-4 hr protamine Ha gedorn) ultralente ( UL ) 6-8hr Glargine(lantus) 1h

4-12h

16-20h

12-16h

20-30h

conti 20-30 h nuous (no peak

Used primarily to control fasting glucose level used for basal dose

ALTERNATIVE METHODS OF INSULIN DELIVERY

-INSULIN PENS -JET INJECTORS -INSULIN PUMPS -IMPLANTABLE AND INHALANT INSULIN DELIVERY

NURSING IMPLICATIONS FOR PHARMACOLOGY:INSULIN NURSING RESPONSIBILITIES -Discard vials of insulin that have been open for several weeks or whose expiration date has passed. -Refrigerate extra insulin vials not currently in use, but do not freeze them. -Store insulin in a cool place, and avoid exposure to temperature extremes or sunlight. -Store compatible mixtures of insulin for no longer than 1 month at room temp. Or three mo. at 36-46 F -Discard any vial w/ discoloration, clumping, granules or solid deposits on the sides -Monitor and maintain a record of blood glucose readings 30 min before each meal and bedtime -If breakfast is delayed, also delay the administration of rapid-acting insulin -monitor food intake, and notify the physician if food is not being consumed -monitor electrolytes, BUN levels and creatinine

Observe injection sites for manifestations of hypersensitivity lipodystrophy, and lipoatrophy -If symptoms of hypoglycaemia occur, confirm by testing blood glucose level, and administer an oral source of a fast-acting CHO, such as juice, milk or crackers -If symptoms of hyperglycemia occur, confirm by testing blood glucose level, and notify the physician CLIENT AND FAMILY TEACHING - The manifestations of DM to patient -Self administration of insulin w/ a return demonstration: a. Wash hands carefully b. Have a vial of insulin, the insulin syringe w/ needle, and alcohol pads ready to use. c. Remove the cover from the needle

d. Fill the syringe w/ an amount of air equal to the # of units of insulin, and insert the needle into the vial e. Push air into the vial, invert the vial, and withdraw the prescribed units of insulin f. Replace the cover over the needle g. Wipe the selected site w/ alcohol h. pinch up a fold of skin, and insert the needle into the tissue at the recommended angle i. Insert the insulin j. Withdraw the needle; if desired, apply firm pressure to the site for a few seconds k. Recap the needle and dispose

-Follow instructions for mixing insulins -Always keep an extra vial of insulin available -Be aware of the signs of hypersensitivity responses, hypoglycaemia and hyperglycemia -Keep candy or a sugar source available at all times to treat hypooglycemia, if it occurs -Vision may be blurred during the first 6-8 weeks of insulin -therapy because of fluid changes in the eye -Avoid alcoholic beverages w/c may cause hypoglycaemia

-Follow guidelines for sick days: a. Never omit insulin b. Always monitor blood glucose and/or urine ketones at least every 2-4 hours c. Always drink plenty of fluids d. Get as much rest as possible e. Contact the physician if there is persistent fever, vomiting, SOB, severe pain in the abdomen, DHN, loss of vision, chest pain, [persistent diarrhea, blood glucose levels above 250 or ketones in the urine. -Establish a plan for rotating injection sites, and observe closely for changes in tissues

CONCENTRATIONS OF INSULIN: Insulin is dispense in 3 concentrations: 40 U/mL, 100 U/mL, and 500 U/mL. Each of the basic types of insulin is available in both U-40 and U-100 concentrations. Only regular insulin is also dispensed in U-500 concentrations TYPES OF INSULIN: 1. Regular insulin -unmodified crystalline insulin, clear in appearance and is the only type that can be given by IV route, used to treat DKA 2. NPH and protamine Zinc insulin suspension -preparations in w/c the insulin has been conjugated w/ protamine, a large protein. -these preparations appear cloudy when properly mixed prior to injection

3. SEMILENTE, LENTE, and ULTRALENTE INSULINS -have altered solubility as a result of a modification of the insulin itself; no foreign proteins are added ROUTES OF ADMINISTRATION All insulins are given parenterally. Only regular insulin is given by both subcutaneous and IV routes; all others are given only subcutaneously. If the IV route is not available, regular insulin may also be administered intramuscularly in an emergency situation.

SYRINGE AND NEEDLE SELECTION: Insulin is administered in sterile, single-use, disposable insulin syringes, calibrated in U/ml. Syringes for administering U-100 insulin can be purchased in either 0.3 ml (30 U), 0.5 ml(50 U) or 1.0 ml (100 U ) size. Most insulin syringes are manufactured w/ a needle permanently attached in a 25-36 gauge, 0.5 inch size. If these type of syringe is not available, an insulin syringe and a 25 gauge, 0.5 inch or 0.75 inch needle should be used. SITES OF INJECTION: -Abdomen- site that allows the most rapid absorption -Deltoid muscle -thigh -hip

MIXING INSULINS: When a person w/ diabetes requires more than 1 type of insulin , mixing is required to avoid administering 2 injections/dose. 2 different concentrations are administered because a single dose of intermediate-acting or long-acting insulin rarely provides adequate control of blood glucose levels.

GENERAL GUIDELINES: -Commercially mixed insulins are recommended if the insulin ratio is appropriate for the requirements of the client. -Only insulins of like concentrations should be mixed. -Regular insulin maybe mixed w/ all other types of insulin; It may be injected immediately after mixing or stored for future use. -NPH insulin and PZI insulin maybe mixed only w/ regular insulin. -Lente insulin preparations maybe mixed with each other, mixing w/ regular insulin or w/ PZI and NPH insulin is not recommended. -Do not mix human and animal insulins. -Always withdraw regular insulin first to avoid contaminating the regular insulin w/ intermediate-acting insulin.

MIXING INSULINS: 10 Units of regular and 20 units of NPH 1. Wash hands. 2. Inspect regular insulin for clarity. 3. Gently rotate NPH insulin to mix well. 4. Wipe off the top of both vials with an alcohol pad. 5. Draw 20 U of air into the syringe and inject air into the NPH vial. Withdraw needle. 6. Draw 10 U of air into the syringe and inject air into the regular vial. 7. Invert the vial and withdraw 10 U of regular insulin. 8. Insert the needle into the NPH vial, and carefully withdraw 20 U of NPH insulin. 9. Administer the insulin. 10. Wash hands and properly dispose of the syringe.

HYPERSENSITIVITY RESPONSES Manifestations of local reactions are a hardening and reddening of the area that develops over several hours. Local reactions result from a contaminant in the insulin and are more likely to occur when less purified insulin products are used. -Systemic reactions occur rapidly and are characterized by widespread red, intensely pruritic welts. Systemic responses are due to an allergy to the insulin itself and are most common with beef insulin. The client can be desensitized by administering small doses of purified pork or human insulin, followed by progressively larger doses.

OTHER DIETARY CONSIDERATIONS: SODIUM The recommended daily intake is 1000mg of sodium per 1000kcal, not to exceed 3000mg. Table salt and processed foods high in sodium must be avoided in the diabetes meal plan. SWEETENERS Commercially produced non-nutritive sweeteners are approved for use by the Food and Drug Administration. Sweeteners include saccharine, aspartame, and acesulfame potassium. The non-nutritive sweeteners have neglidient amounts of kcal or no kcal and produced very little or no changes in blood glucose levels. Nutritive sweeteners are also used by diabetics. This includes fructose, sorbitol, and xylitol. The kcal content of these substances is similar to that of table sugar but they cause less elevation in blood glucose.

ALCOHOL -Alcohol consumption may potentiate the hypoglycemic effects of insulin and oral agents. The American Diabetes Association recommends that men w/ diabetes consume no more than 2 drinks and women w/ diabetes no more than 1 drink per day. NEEDS OF THE CLIENT WITH TYPE 2 DM There are no specific guidelines for the type 2 diet, but in addition to decreasing kcal, it is recommended that the client consume 3 meals of equal size, evenly spaced approximately 4-5 hrs apart, w/ 1 or 2 snacks. The person with type 2 DM should also decrease. It should also decrease fat intake. If the exchange list is difficult to use, calorie counting or designing the diet by grams of fat maybe more useful.

NEEDS OF A CLIENT WITH TYPE 1 DM: -Diet and insulin prescription must be integrated for optimal energy metabolism and the prevention of hyperglycemia or hypoglycaemia. STRATEGIES IN MEETING GOALS: -Glucose regulation requires correlating eating patterns with insulin Onset and peak of actions. -meals, snacks, and insulin regimens should be based on a person¶s lifestyle. -meal planning depends on the specific insulin regimen prescribed -Snacks are an important consideration in relation to the amount and timing of exercise -The diet plan must consider the availability of foods based on occupational, financial, religious, and ethnic constraints. -Self-monitoring of blood glucose levels helps the client make adjustments for planned and unplanned changes in routines.

SICK DAY MANAGEMENT: -Monitor blood glucose at least four times a day throughout an illness -Testing urine for ketones if blood glucose is greater than 240 mg/dl -continue to take the usual insulin dose or oral hypoglycaemic agent -Sipping 8-12 oz of fluid each hour -Substitute easily digested liquids or soft foods if solid foods are not tolerated -call the physician if client is unable to eat for more than 24 hours or if vomiting and diarrhea last for more than 6 hours

GENERAL GUIDELINES FOR TYPE 1 DM EXERCISE PROGRAMS:

-People who have frequent hyper or hypoglycaemia should avoid prolonged exercise until glucose control improves -The risk of exercise induced hypoglycaemia is lowest before breakfast, when free-insulin levels tend to be lower, than they are before meals later in the day or At bedtime -Low-impact aerobic exercises are encourage -Exercise should be, moderate and regular; brief, intense exercise causes mild hyperglycemia,and prolonged exercise causes hypoglycaemia -Exercising at a peak insulin action time may lead to hypoglycaemia -Self-monitoring of blood glucose levels is essential both before and after an exercise -Food intake may need to be increased to compensate for the activity -Fluid intake, especially water is essential

FOR TYPE 2: -before the client begins the program, carefully assessed for previously undiagnosed hypertension, neuropathy, retinopathy, nephropathy, and cardiac ischemia -Begin the [program w/ mild exercises, and gradually increase intensity and duration -Self monitoring of blood glucose levels before and after exercise is essential -Exercise at least 3 times a week or every other day, for at least 20-30 minutes -Include muscle strengthening and low impact aerobic exercises in the program

Long Term Complications of Diabetes: a. Macrovascular complications b. Microvascular complications Diabetic retinopathy Diabetic nephropathy c. Neuropathy

a. Macrovascular complications
- result from changes in the medium to large blood vessels. Blood vessel walls thicken, sclerose, and become occluded by plaque that adheres to the vessel walls. - blood flow is blocked.

b. Microvascular complications ( microangiopathy)
- characterized by capillary basement membrane thickening.

‡ Diabetic retinopathy
- caused by changes in the small blood vessels in the retina, the area of the eye that receives images and sends information anout the images to the brain. - major cause of blindness among clients with diabetes

‡ nephropathy
- renal disease secondary to diabetic icrovascular changes in kidney. - damage to or and eventual obliteration of the capillaries that supply the glomeruli of the kidney.

- common complication in diabetes.

c. Diabetic neuropathies

-refers to a group of diseases that affect all types of nerves, including peripheral (sensorimotor), autonomic, and spinal nerves.

Diabetic ketoacidosis is caused by an absence or markedly inadequate amount of insulin. This deficit in available insulin results in disorders in the metabolism of carbohydrates, protein, and fat.

THREE MAIN FEATURES OF DKA

Hyperglycemia Dehydration and electrolyte loss Acidosis

Lack of insulin
-Decreased utilization of glucose by muscle, fat and liver -Increased production of glucose by liver Hyperglycemia Blurred vision Polyuria -Acetone breath -Poor appetite -Nausea Increased breakdown of fat Increased fatty acids Increased ketone bodies

-Weakness -Headache

Dehydration

Increased thirst (polydipsia)

-Nausea -Vomiting -Abdominal pain

Acidosis

Increasingly rapid respiration

ASSESSMENT AND DIAGNOSTIC FINDINGS

-Blood glucose level may vary from 300 and 800 mg/dl -Low serum bicarbonate: 0 to 15 mEq/L -Low ph values: 6.8 to 7.3 -Low partial pressure of CO2 (PCO2 10 to 30 mmHg) -Accumulation of ketone bodies -Na+ and K+ concentration may be low, normal or high -Increased levels of creatinine, BUN, and hematocrit seen with dehydration

GUIDELINES TO FOLLOW DURING PERIODS OF ILLNESS (SICK DAY RULES)

-Take insulin or oral antidiabetic agents as usual -Test blood glucose and test urine ketones every 3 to 4 hours -Report elevated glucose levels ( > 300 mg/dL or others as specified) or urine ketones to your health care provider -If you take insulin, you may need supplemental doses of regular insulin every 3 to 4 hours -if you cannot follow your usual meal plan, substitute soft foods ( e.q. 1/3 cup regular gelatin, 1 cup cream soup, ½ cup custard, 3 squares graham crackers) six to eight times per day

-If vomiting, diarrhea, or fever persists, take liquids (e.q. ½ cup regular cola or orange juice, ½ cup broth, 1 cup gatorade) every ½ to 1 hour to prevent dehydration and to provide calories -Report nausea and vomiting and diarrhea to your health care provider, extreme fluid loss may be dangerous -If you¶re unable to retain oral fluids, you may require hospitalization to avoid diabetic ketoacidosis and possibly coma.

-Monitoring fluid, electrolyte and hydration status, glucose level -Administering fluids, insulin, and other medication -Monitor I and O to ensure adequate renal function before administering potassium to prevent hyperkalemia -Monitor ECG for dysrhythmias -Monitor vital signs ( especially BP and pulse), arterial blood gases, breath sounds and mental status

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