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INTRODUCTION
Diabetes Mellitus
Diabetes mellitus (sometimes called "sugar diabetes") is a condition that occurs when the
body can't use glucose (a type of sugar) normally. Glucose is the main source of energy
for the body's cells. The levels of glucose in the blood are controlled by a hormone called
insulin, which is made by the pancreas. Insulin helps glucose enter the cells.
In diabetes, the pancreas does not make enough insulin (type 1 diabetes) or the body can't
respond normally to the insulin that is made (type 2 diabetes). This causes glucose levels
in the blood to rise, leading to symptoms such as increased urination, extreme thirst, and
unexplained weight loss.
The honeymoon period for patients with Diabetes mellitus type 1 is the period that often
follows diagnosis and initiation of insulin treatment. It is often suggestive of remission,
but it is important to note that the two are unrelated - it is not a cure for type 1 diabetes.
During this period some of the insulin-producing beta cells of the pancreas have not been
completely destroyed yet and produce unpredictable amounts of endogenous insulin. This
period does not occur in all patients. If the honeymoon period does occur, it lasts for
varying lengths of time and can affect diabetics differently.
The islets of Langerhans are destroyed in type I diabetes mellitus. This occurs probably
as a consequence of a genetic susceptibility, followed by the onset of autoimmune
destruction triggered by some environmental factor such as a viral infection. Heavy
lymphocytic infiltrates appear in and around islets. The number and size of islets are
eventually reduced, leading to decreased insulin production and glucose intolerance.
The islets of Langerhans are normal in number or somewhat reduced with type II diabetes
mellitus. Fibrosis and deposition of amylin polypeptide within islets are most
characteristic of the chronic states of type II diabetes.
DEFINITION
DEFINITION
Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia
resulting from defects in insulin secretion, insulin action, or both. The chronic
hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure
of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels.
OR
Diabetes mellitus is a variable disorder of carbohydrate metabolism caused by a
combination of hereditary and environmental factors and usually characterized by
inadequate secretion or utilization of insulin, by excessive urine production, by excessive
amounts of sugar in the blood and urine, and by thirst, hunger, and loss of weight.
also insulin-dependent
diabetes,
insulin-dependent
diabetes
TYPES OF DIABETES
TYPES OF DIABETES
Type 1 diabetes is an auto-immune disease where the body's immune system attacks the
insulin-producing cells of the pancreas. People with type 1 diabetes cannot produce insulin and
require lifelong insulin injections for survival. The disease can occur at any age, although it
mostly occurs in children and young adults. Type 1 diabetes is sometimes referred to as 'juvenile
onset diabetes' or 'insulin dependent diabetes'.
Type 2 diabetes is associated with hereditary factors and lifestyle risk factors including
poor diet, insufficient physical activity and being overweight or obese. People with type 2
diabetes may be able to manage their condition through lifestyle changes; however, diabetes
medications or insulin injections may also be required to control blood sugar levels. Type 2
diabetes occurs mostly in people aged over 40 years old; however, the disease is also becoming
increasingly prevalent in younger age groups.
Gestational diabetes occurs during pregnancy. The condition usually disappears once the
baby is born; however, a history of gestational diabetes increases a woman's risk of developing
type 2 diabetes later in life. The condition may be managed through adopting healthy dietary and
exercise habits, although diabetes medication, including insulin, may also be required to manage
blood sugar levels.
Type 1 Diabetes
Type 1 diabetes is also called insulin-dependent diabetes. It used to be called juvenileonset diabetes, because it often begins in childhood.Type 1 diabetes is an autoimmune
condition. It's caused by the body attacking its own pancreas with antibodies. In people
with type 1 diabetes, the damaged pancreas doesn't make insulin.
This type of diabetes may be caused by a genetic predisposition. It could also be the
result of faulty beta cells in the pancreas that normally produce insulin.
A number of medical risks are associated with type 1 diabetes. Many of them stem from
damage to the tiny blood vessels in your eyes (called diabetic retinopathy), nerves
(diabetic neuropathy), and kidneys (diabetic nephropathy). Even more serious is the
increased risk of heart disease and stroke.
Treatment for type 1 diabetes involves taking insulin, which needs to be injected through
the skin into the fatty tissue below. The methods of injecting insulin include:
Syringes
Jet injectors that use high pressure air to send a spray of insulin through the skin
Insulin pumps that dispense insulin through flexible tubing to a catheter under the skin of
the abdomen
A periodic test called the A1C blood test estimates glucose levels in your blood over the
previous three months. It's used to help identify overall glucose level control and the risk
of complications from diabetes, including organ damage.
Having type 1 diabetes does require significant lifestyle changes that include:
Frequent testing of your blood sugar levels
Daily exercise
Type 1 Diabetes
Type 2 Diabetes
By far, the most common form of diabetes is type 2 diabetes, accounting for 95% of
diabetes cases in adults. Some 26 million American adults have been diagnosed with the
disease. Type 2 diabetes used to be called adult-onset diabetes, but with the epidemic of
obese and overweight kids, more teenagers are now developing type 2 diabetes. Type 2
diabetes was also called non-insulin-dependent diabetes.
Type 2 diabetes is often a milder form of diabetes than type 1. Nevertheless, type 2
diabetes can still cause major health complications, particularly in the smallest blood
vessels in the body that nourish the kidneys, nerves, and eyes. Type 2 diabetes also
increases your risk of heart disease and stroke.
With Type 2 diabetes, the pancreas usually produces some insulin. But
either the amount produced is not enough for the body's needs, or the body's cells are
resistant to it. Insulin resistance, or lack of sensitivity to insulin, happens primarily in fat,
liver, and muscle cells.
People who are obese -- more than 20% over their ideal body weight for their height -are at particularly high risk of developing type 2 diabetes and its related medical
problems. Obese people have insulin resistance. With insulin resistance, the pancreas has
to work overly hard to produce more insulin. But even then, there is not enough insulin to
keep sugars normal.
There is no cure for diabetes. Type 2 diabetes can, however, be controlled withweight
management, nutrition, and exercise. Unfortunately, type 2 diabetes tends to progress,
and diabetes medications are often needed.
An A1C test is a blood test that estimates average glucose levels in your blood over the
previous three months. Periodic A1C testing may be advised to see how well diet,
exercise, and medications are working to control blood sugar and prevent organ damage.
The A1C test is typically done a few times a year.
Type 2 Diabetes
Gestational Diabetes
Diabetes that's triggered by pregnancy is called gestational diabetes (pregnancy, to some
degree, leads to insulin resistance). It is often diagnosed in middle or late pregnancy.
Because high blood sugar levels in a mother are circulated through the placenta to the
baby, gestational diabetes must be controlled to protect the baby's growth and
development.
According to the National Institutes of Health, the reported rate of gestational diabetes is
between 2% to 10% of pregnancies. Gestational diabetes usually resolves itself after
pregnancy. Having gestational diabetes does, however, put mothers at risk for developing
type 2 diabetes later in life. Up to 10% of women with gestational diabetes develop type
2 diabetes. It can occur anywhere from a few weeks after delivery to months or years
later.
With gestational diabetes, risks to the unborn baby are even greater than risks to the
mother. Risks to the baby include abnormal weight gain before birth, breathing problems
at birth, and higher obesity and diabetes risk later in life. Risks to the mother include
needing a cesarean section due to an overly large baby, as well as damage to heart,
kidney, nerves, and eye.
Treatment during pregnancy includes working closely with your health care team and:
Careful meal planning to ensure adequate pregnancy nutrients without excess fat and
calories
Daily exercise
GESTATIONAL DIABETES
CAUSES
CAUSES
Genetic Susceptibility
Heredity plays an important part in determining who is likely to develop type 1 diabetes.
Genes are passed down from biological parent to child. Genes carry instructions for
making proteins that are needed for the bodys cells to function. Many genes, as well as
interactions among genes, are thought to influence susceptibility to and protection from
type 1 diabetes.
Environmental Factors
Environmental factors, such as foods, viruses, and toxins, may play a role in the
development of type 1 diabetes, but the exact nature of their role has not been
determined. Some theories suggest that environmental factors trigger the autoimmune
destruction of beta cells in people with a genetic susceptibility to diabetes. Other theories
suggest that environmental factors play an ongoing role in diabetes, even after diagnosis.
Viruses and infections. A virus cannot cause diabetes on its own, but people are
sometimes diagnosed with type 1 diabetes during or after a viral infection, suggesting a
link between the two. Also, the onset of type 1 diabetes occurs more frequently during the
winter when viral infections are more common. Viruses possibly associated with type 1
diabetes include coxsackievirus B, cytomegalovirus, adenovirus, rubella, and mumps.
Infant feeding practices. Some studies have suggested that dietary factors may raise or
lower the risk of developing type 1 diabetes. For example, breastfed infants and infants
receiving vitamin D supplements may have a reduced risk of developing type 1 diabetes,
while early exposure to cows milk and cereal proteins may increase risk. More research
is needed to clarify how infant nutrition affects the risk for type 1 diabetes.
Insulin Resistance
Insulin resistance is a common condition in people who are overweight or obese, have
excess abdominal fat, and are not physically active. Muscle, fat, and liver cells stop
responding properly to insulin, forcing the pancreas to compensate by producing extra
insulin. As long as beta cells are able to produce enough insulin, blood glucose levels stay
in the normal range. But when insulin production falters because of beta cell dysfunction,
glucose levels rise, leading to prediabetes or diabetes.
The symptoms of type 2 diabetes have a gradual onset. They can be easily missed
or mistaken as part of the normal ageing process. They include:
blurred vision
tiredness
urinating more frequently
feeling thirsty all the time
numbness and tingling in the feet or legs
recurrent infections.
SYMPTOMS OF DIABETES
MELLITUS
problems. But for others, the effects may be much more serious. In some cases, diabetes
can also lead to total blindness.
Tingling - burning pain in the feet:
Another important symptom of Diabetes. It may sometimes be the very first symptom of
diabetes.Our hands and feet are supplied by Neurons that due to diabetes blood vessels
become thick, similary is the case with neurons, blood supply to these neurons decreases
due to thickening of blood vessels which leads to degeneration of peripheral nerve fibers
(Neurons) throughout the body which commonly leads to a lack of feeling in the feet,
advances up the legs and then the hands and is the most common reason for lower limb
amputations. It can also be very painful. If there is Loss of motor nerve fibers it leads to
muscular weakness.
A loss of sensory nerve fibers leads to loss of feeling and numbness in hands and feet.
Loss of autonomic fibers cause the loss of functions not normally under conscious control
like digestion, heartbeat, blood pressure, and sweating. Neuropathy symptoms tingling,
burning, aching, prickling, sharp jabs of needle like pain can also be caused by nerves
that are damaged or are healing.
Slow healing sores or frequent infections:
Bacteria love high glucose, Diabetes affects your body's ability to heal and fight
infection. Urinary tract infections and vaginal yeast infections can be a particular problem
for women.
PATHOPHYSIOLOGY
Environmental insult
- Viral infection
- Toxic chemical agents
Autoimmunity
-Lymphocyte infiltration
-Insulitis
Immunologic Response
Islet cell antibodies
Cell- mediated immunity
Diagram I
Pathogenesis of Insulin
Dependent DM (Type 1)
cell destruction
Hereditary Factors
Obesity
Diagram II
cell exhaustion and dysfunction
Hyperglycmia
DIAGNOSTIC TEST
DIAGNOSTIC TEST:
Several blood tests are used to measure blood glucose levels, the primary test for
diagnosing diabetes. Additional tests can determine the type of diabetes and its severity.
Random blood glucose test for a random blood glucose test, blood can be
drawn at any time throughout the day, regardless of when the person last ate. A
random blood glucose level of 200 mg/dL (11.1 mmol/L) or higher in persons
who have symptoms of high blood glucose suggests a diagnosis of diabetes.
Fasting blood glucose test fasting blood glucose testing involves measuring
blood glucose after not eating or drinking for 8 to 12 hours (usually overnight). A
normal fasting blood glucose level is less than 100 mg/dL. A fasting blood
glucose of 126 mg/dL (7.0 mmol/L) or higher indicates diabetes. The test is done
by taking a small sample of blood from a vein or fingertip.
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.
Oral glucose tolerance test Oral glucose tolerance testing (OGTT) is the most
sensitive test for diagnosing diabetes and pre-diabetes. However, the OGTT is not
routinely recommended because it is inconvenient compared to a fasting blood
glucose test.
The standard OGTT includes a fasting blood glucose test. The person then drinks a 75
gram liquid glucose solution (which tastes very sweet, and is usually cola or orangeflavored). Two hours later, a second blood glucose level is measured.
TREATMENT
MEDICATIONS:
When diet, exercise and maintaining a healthy weight arent enough, you may need the
help of medication. Medications used to treat diabetes include insulin. Everyone with
type 1 diabetes and some people with type 2 diabetes must take insulin every day to
replace what their pancreas is unable to produce. Unfortunately, insulin cant be taken in
pill form because enzymes in your stomach break it down so that it becomes ineffective.
For that reason, many people inject themselves with insulin using a syringe or an insulin
pen injector,a device that looks like a pen, except the cartridge is filled with insulin.
Others may use an insulin pump, which provides a continuous supply of insulin,
eliminating the need for daily shots.
The most widely used form of insulin is synthetic human insulin, which is chemically
identical to human insulin but manufactured in a laboratory. Unfortunately, synthetic
human insulin isnt perfect. One of its chief failings is that it doesnt mimic the way
natural insulin is secreted. But newer types of insulin, known as insulin analogs, more
closely resemble the way natural insulin acts in your body. Among these are lispro
(Humalog), insulin aspart (NovoLog) and glargine (Lantus).
A number of drug options exist for treating type 2 diabetes, including:
or kidney function.
Meglitinides- These medications, such as repaglinide (Prandin), have effects
similar to sulfonylureas, but youre not as likely to develop low blood sugar.
your cells. One advantage of metformin is that is tends to cause less weight gain than do
other diabetes medications. Possible side effects include a metallic taste in your mouth,
loss of appetite, nausea or vomiting, abdominal bloating, or pain, gas and diarrhea. These
effects usually decrease over time and are less likely to occur if you take the medication
with food. A rare but serious side effect is lactic acidosis, which results when lactic acid
builds up in your body. Symptoms include tiredness, weakness, muscle aches, dizziness
and drowsiness. Lactic acidosis is especially likely to occur if you mix this medication
damage.
Thiazolidinediones- These drugs make your body tissues more sensitive to insulin and
keep your liver from overproducing glucose. Side effects of thiazolidinediones, such as
rosiglitazone (Avandia) and pioglitazone hydrochloride (Actos), include swelling, weight
gain and fatigue. A far more serious potential side effect is liver damage. The
thiazolidinedione troglitzeone (Rezulin) was taken off the market in March 2000 because
it caused liver failure. If your doctor prescribes these drugs, its important to have your
liver checked every two months during the first year of therapy. Contact your doctor
immediately if you experience any of the signs and symptoms of liver damage, such as
nausea and vomiting, abdominal pain, loss of appetite, dark urine, or yellowing of your
skin and the whites of your eyes (jaundice).
INSULIN
ADMINISTRATION
BY SYRINGE
gently rolled in the palms of the hands (not shaken) to resuspend the insulin. An amount
of air equal to the dose of insulin required should first be drawn up and injected into the
vial to avoid creating a vacuum. For a mixed dose, putting sufficient air into both bottles
before drawing up the dose is important. When mixing rapid- or short-acting insulin with
intermediate- or long-acting insulin, the clear rapid- or short-acting insulin should be
drawn into the syringe first.
After the insulin is drawn into the syringe, the fluid should be inspected for air bubbles.
One or two quick flicks of the forefinger against the upright syringe should allow the
bubbles to escape. Air bubbles themselves are not dangerous but can cause the injected
dose to be decreased.
Injection procedures
Injections are made into the subcutaneous tissue. Most individuals are able to lightly
grasp a fold of skin and inject at a 90 angle. Thin individuals or children can use short
needles or may need to pinch the skin and inject at a 45 angle to avoid intramuscular
injection, especially in the thigh area. Routine aspiration (drawing back on the injected
syringe to check for blood) is not necessary. Particularly with the use of insulin pens, the
needle should be embedded within the skin for 5 s after complete depression of the
plunger to ensure complete delivery of the insulin dose.
Patients should be aware that air bubbles in an insulin pen can reduce the rate of insulin
flow from the pen; underdelivery of insulin can occur when air bubbles are present, even
if the needle remains under the skin for as long as 10 s after depressing the plunger. Air
can enter the insulin pen reservoir during either manufacture or filling if the needle is left
on the pen between injections. To prevent this potential problem, avoid leaving a needle
on a pen between injections and prime the needle with 2 units of insulin before injection.
If an injection seems especially painful or if blood or clear fluid
is seen after withdrawing the needle, the patient should apply pressure for 58 s without
rubbing. Blood glucose monitoring should be done more frequently on a day when this
occurs. If the patient suspects that a significant portion of the insulin dose was not
administered, blood glucose should be checked within a few hours of the injection. If
bruising, soreness, welts, redness, or pain occur at the injection site, the patients injection
technique should be reviewed by a physician or diabetes educator. Painful injections may
be minimized by the following:
1. Injecting insulin at room temperature.
2. Making sure no air bubbles remain in the syringe before injection.
3. Waiting until topical alcohol (if used) has evaporated completely before injection.
4. Keeping muscles in the injection area relaxed, not tense, when injecting.
5. Penetrating the skin quickly.
6. Not changing direction of the needle during insertion or withdrawal.
7. Not reusing needles.
Some individuals may benefit from the use of prefilled syringes (e.g., the visually
impaired, those dependent on others for drawing their insulin, or those traveling or eating
in restaurants). Prefilled syringes are stable for up to 30 days when kept in a refrigerator. If
possible, the syringes should be stored in a vertical position, with the needle pointing
upward, so that suspended insulin particles do not clog the needle. The predrawn syringe
should be rolled between the hands before administration. A quantity of syringes may be
premixed and stored. The effect of premixing of insulins on glycemic control should be
assessed by a physician, based on blood glucose results obtained by the patient. When
premixing is required, consistency of technique and careful blood glucose monitoring are
especially important.
INJECTION TECHNIQUE
Injection site
Insulin may be injected into the subcutaneous tissue of the upper arm and the anterior and
lateral aspects of the thigh, buttocks, and abdomen (with the exception of a circle with a
2-inch radius around the navel). Intramuscular injection is not recommended for routine
injections. Rotation of the injection site is important to prevent lipohypertrophy or
lipoatrophy. Rotating within one area is recommended (e.g., rotating injections
systematically within the abdomen) rather than rotating to a different area with each
injection. This practice may decrease variability in absorption from day to day. Site
selection should take into consideration the variable absorption between sites. The
abdomen has the fastest rate of absorption, followed by the arms, thighs, and buttocks.
Exercise increases the rate of absorption from injection sites, probably by increasing
blood flow to the skin and perhaps also by local actions. Areas of lipohypertrophy usually
show slower absorption. The rate of absorption also differs between subcutaneous and
intramuscular sites. The latter is faster and, although not recommended for routine use,
can be given under other circumstances (e.g., diabetic ketoacidosis or dehydration).
NURSING
MANAGEMENT
NURSING MANAGEMENT
Nursing Diagnosis for Diabetes Mellitus
Intervention / Implementation:
1. Measure body weight per day as indicated.
R: Knowing eating adequate income.
2. Determine the diet program and diet of patients compared with food that can be spent
on the patient.
R: Identify deviations from the requirements.
3. Auscultation of bowel sounds, record the presence of abdominal pain / abdominal
bloating, nausea, vomiting, keep fasting as indicated.
R: Influence of intervention options.
4. Observation of the signs of hypoglycemia, such as changes in level of consciousness,
cold / humid, rapid pulse, hunger and dizziness.
R: Potentially life-threatening, which must be multiplied and handled appropriately.
5. Collaboration in the delivery of insulin, blood sugar tests and diet.
R: It is useful to control blood sugar levels.
Intervention / Implementation
1. Observation for signs of infection and inflammation such as fever, redness, pus in the
wound, purulent sputum, urine color cloudy and foggy.
R: incoming patients with infections that normally might have been able to trigger a state
ketosidosis or nosocomial infections.
2. Increase prevention efforts by performing good hand washing, each contact on all
items related to the patient, including his or her own patients.
R: prevention of nosocomial infections.
3. Maintain aseptic technique in invasive procedures (such as infusion, catheter folley,
etc.).
R: Glucose levels in the blood will be the best medium for the growth of germs.
4. Attach catheter / perineal care do well.
R: Reduce the risk of urinary tract infection.
5. Give skin care with regular and earnest. Massage depressed bone area, keep skin dry,
dry linen and tight (not wrinkled).
R: peripheral circulation can be impaired which puts patients at increased risk of damage
to the skin / eye irritation and infection.
6. Position the patient in semi-Fowler position.
R: Makes it easy for the lung to expand, lowering the risk of hypoventilation.
4 . Knowledge Deficit
Expected outcomes:
Perform the necessary procedures and explain the rationale of an action.
Initiate the necessary lifestyle changes and participate in treatment regimen.
Intervention / Implementation:
1. Assess the level of knowledge of the client and family about the disease.
R: Find out how much experience and knowledge of the client and family about the
disease.
2. Give an explanation to the client about diseases and conditions now.
R: By knowing the diseases and conditions now, clients and their families will feel calm
and reduce anxiety.
3. Encourage clients and families to pay attention to her diet.
R: Diet and proper diet helps the healing process.
4. Ask the client and reiterated family of materials that have been given.
R: Knowing how much understanding of clients and their families and assess the success
of the action taken.
EDUCATION OF
DIABETIC PATIENT
glycemic targets are being achieved. Results of SMBG can be useful in preventing
hypoglycemia and adjusting medications, MNT, and physical activity.
The frequency and timing of SMBG should be dictated by the particular needs and goals of
the patients. Daily SMBG is especially important for patients treated with insulin to monitor
for and prevent asymptomatic hypoglycemia. For most patients with type 1 diabetes and
pregnant women taking insulin, SMBG is recommended three or more times daily. The
optimal frequency and timing of SMBG for patients with type 2 diabetes is not known, but
should be sufficient to facilitate reaching glucose goals. When adding to or modifying
therapy, type 1 and type 2 diabetic patients should test more often than usual. The role of
SMBG in stable diet-treated patients with type 2 diabetes is not known.
Because the accuracy of SMBG is instrument- and user-dependent , it is important
for health care providers to evaluate each patients monitoring technique, both initially and at
regular intervals thereafter. In addition, optimal use of SMBG requires proper interpretation
of the data. Patients should be taught how to use the data to adjust food intake, exercise, or
pharmacological therapy to achieve specific glycemic goals. Health professionals should
evaluate at regular intervals the patients ability to use SMBG data to guide treatment.
Recommendations
Instruct the patient in SMBG and routinely evaluate the patients technique and
ability to use data to adjust therapy.
PHYSICAL ACTIVITY
Regular exercise has been shown to improve blood glucose control, reduce cardiovascular
risk factors, contribute to weight loss, and improve well-being. Furthermore, regular exercise
may prevent type 2 diabetes in high-risk individuals.
Before beginning a physical activity program, the patient with diabetes should have a
detailed medical evaluation with appropriate diagnostic studies. This examination should
screen for the presence of macro- and micro vascular complications that may be worsened by
the physical activity program (see next section regarding coronary heart disease [CHD]
screening). Identification of areas of concern will allow the design of an individualized
physical activity plan that can minimize risk to the patient.
All levels of physical activity, including leisure activities, recreational sports, and
competitive professional performance, can be performed by people with diabetes who do not
have complications and have good glycemic control. The ability to adjust the therapeutic
regimen (insulin therapy and MNT) to allow safe participation is an important management
strategy.
Recommendations
Optimal glycemic control can substantially reduce the risk and progression of
diabetic retinopathy.
Optimal blood pressure control can reduce the risk and progression of diabetic
retinopathy.
Aspirin therapy does not prevent retinopathy or increase the risks of hemorrhage.
Treatment
Laser therapy can reduce the risk of vision loss in patients with HRCs.
Promptly refer patients with any level of macular edema, severe NPDR, or any
PDR to an ophthalmologist who is knowledgeable and experienced in the
management and treatment of diabetic retinopathy.
DIABETIC RETINOPATHY
FOOT CARE
Amputation and foot ulceration are one of the most common consequences of diabetic
neuropathy and a major cause of morbidity and disability in people with diabetes. Early
recognition and management of independent risk factors can prevent or delay adverse
outcomes.
The risk of ulcers or amputations is increased in people who have had diabetes >10 years,
are male, have poor glucose control, or have cardiovascular, retinal, or renal
complications. The following foot-related risk conditions are associated with an increased
risk of amputation:
Bony deformity.
A multidisplinary approach is recommended for persons with foot ulcers and highrisk feet, especially those with a history of prior ulcer or amputation.
The foot examination can be accomplished in a primary care setting and should
include the use of a tuning fork, palpation, and a visual examination.
Educate all patients, especially those with risk factors or prior lower-extremity
complications, about the risk and prevention of foot problems and reinforce self-care
behavior.
Refer high-risk patients to foot care specialists for ongoing preventive care
and life-long surveillance.
TREATMENT:The treatment of foot problems depends upon the presence and severity of foot
ulcers.Treatment of superficial ulcers (involving only the top layers of skin) usually
includes cleaning the ulcer and removing dead skin and tissue (debridement) by a
healthcare provider. There are a number of debridement techniques available.If the foot is
infected, antibiotics are generally prescribed. The patient (or someone in his or her
household) should clean the ulcer and apply a clean dressing twice daily. The patient
should keep weight off the foot ulcer as much as possible, meaning that they should not
walk with the affected foot. The foot should be elevated when sitting or lying down. The
ulcer should be checked by a healthcare provider at least once per week to make sure that
the ulcer is improving.
Ulcers that extend into the deeper layers of the foot, involving muscle and bone, usually
require hospitalization. More extensive laboratory testing and x-rays may be done, and
intravenous antibiotics are often necessary. Surgery may be necessary to remove infected
bone or to place a cast on the foot to take pressure off the ulcer.If part of the toes or foot
become severely damaged, causing areas of dead tissue (gangrene), partial or complete
amputation may be required.
DIABETIC FOOT
DIETARY ADVICE
Eat three meals a day. Avoid skipping meals and space breakfast, lunch and evening meal
out over the day.
At each meal include starchy carbohydrate foods, eg bread, pasta, chapatis, potatoes,
yam, noodles, rice and cereals. Eat more slowly absorbed (low glycaemic index) foods, eg
pasta, basmati or easy cook rice, grainy breads such as granary, pumpernickel and rye, new
potatoes, sweet potato and yam, porridge oats, All-Bran and natural muesli.
Reduce the fat in the diet, especially saturated fats. Use unsaturated fats or oils, especially
monounsaturated fats, eg olive oil and rapeseed oil.
Eat more fruit and vegetables. Aim for at least five portions a day.
Eat more beans and lentils, eg kidney beans, butter beans, chickpeas or red and green
lentils.
Eat at least two portions of oily fish a week, eg mackerel, sardines, salmon and pilchards.
Limit sugar and sugary foods.
Don't use diabetic foods or drinks (they are expensive and of no benefit).
Diabetes is a condition in which the amount of glucose (sugar) in the blood is too high
due to a lack of insulin. Eating the right food at regular intervals during the day helps to
keep blood glucose at satisfactory levels.
It is important to AVOID HIGH SUGAR FOODS. The majority of high sugar foods have
suitable replacements for diabetics, some of which are included in the table below.
A starchy food MUST be included at every meal and preferably in similar amounts each
day. If possible choose starches that are high in fibre.
It is important to limit the amount of fat in your diet, as too much fat can cause weight
gain, increase blood fat levels and affect blood sugar control.
DIET PLAN
Items
Carbohydrate
Dont Eat
Maida , Sujee, Noodles, White
Healthy Eat
Atta, Whole Wheat , Brown Bread,
Vegetable
Fruits
Protein
Seetaphal
Meat- Red Meat, Yellow Egg
Pomograine
Whole Dal, Black Channa, White
Drinks
Others
Drinks
Fast Food, Pizza, Burger, Chips,
DIET CHART
TIME
Morning- 7 A.M.
Breakfast
FOOD STATUS
Tea/ Milk ( without sugar)
1. Milk chach
2. Daliya
3. Poha ( namkeen)
QUANTITY
1 Cup
1 Cup
1 katori
4.
5.
6.
7.
Daliya Rabdi
Sparouts
Idli / Simple Dosa
Rote / Bread + fruits
1 katori
1 katori
1 katori
1 katori
Lunch
Evening Tea
Dal
1 katori
1 katori
Rice
1 katori
1 chapati
Vegetables
1 katori
1 katori
Salad
Tea / Milk / Chach (without sugar)
1 katori
1 Cup/ 1 glass
1 katori
1 katori
EXERCISE
Regular physical activity improves insulin resistance and lipid profile (reduction in
triglyceride and increase in high-density lipoprotein (HDL)) and lowers blood pressure
(although blood pressure will rise during exercise).
The metabolic benefits in type 2 diabetes are lost within 3-10 days of stopping regular
exercise.
Physical activity also protects against the development of type 2 diabetes.
Diabetes recommendations
The recommended minimum amount of activity for:
It is essential to find activities that are enjoyable, achievable and sustainable, eg walks,
dancing, swimming, bowling, cycling, golf, playing with the children, DIY.
Glycemic control
Several long-term studies have demonstrated a consistent beneficial effect of regular
exercise training on carbohydrate metabolism and insulin sensitivity, which can be
maintained for at least 5 years. These studies used exercise regimens at an intensity of 50
80% Vo2max three to four times a week for 3060 min a session. Improvements in
HbA1c were generally 1020% of baseline and were most marked in patients with mild
type 2 diabetes and in those who are likely to be the most insulin resistant. It remains true,
unfortunately, that most of these studies suffer from inadequate randomization and
controls, and are confounded by associated lifestyle changes. Data on the effects of
resistance exercise are not available for type 2 diabetes although early results in normal
individuals and patients with type 1 disease suggest a beneficial effect.
It now appears that long-term programs of regular exercise are indeed feasible for patients
with impaired glucose tolerance or uncomplicated type 2 diabetes with acceptable
adherence rates. Those studies with the best adherence have used an initial period of
supervision, followed by relatively informal home exercise programs with regular,
frequent follow-up assessments. A number of such programs have demonstrated sustained
relative improvements in Vo2maxover many years with little in the way of significant
complications.
Hyperlipidemia
Regular exercise has consistently been shown to be effective in reducing levels of
triglyceride-rich VLDL. However, effects of regular exercise on levels of LDL cholesterol
have not been consistently documented. With one major exception, most studies have
failed to demonstrate a significant improvement in levels of HDL in patients with type 2
diabetes, perhaps because of the relatively modest exercise intensities used.
EXERCISES
Fibrinolysis
Many patients with type 2 diabetes have impaired fibrinolytic activity associated with
elevated levels of plasminogen activator inhibitor-1 (PAI-1), the major naturally
occurring inhibitor of tissue plasminogen activator (TPA). Studies have demonstrated an
Obesity
Data have accumulated suggesting that exercise may enhance weight loss and, in
particular, weight maintenance when used along with an appropriate calorie-controlled
meal plan. There are few studies specifically dealing with this issue in type 2 diabetes,
and much of the available data is complicated by the simultaneous use of unusual diets
and other behavioral interventions. Of particular interest are studies suggesting a
disproportionate effect of exercise on loss of intra-abdominal fat, the presence of which
has been associated most closely with metabolic abnormalities.
Internet
1.
2.
3.
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5.
http://library.med.utah.edu/WebPath/Tutorial/Diabetes/Diabetes.html
http://www.nlm.nih.gov/medlineplus/diabetes.html
wikipedia.org/wiki/Honeymoon period_(diabetes)
http://www.disabled-world.com/artman/publish/diabetesmellitus.shtml
http://rnspeak.com/pathophysiology/diabetes-pathophysiology-diseases-processdiagram.