Diabetes Mellitus

Ibrahim R. Ayasreh RN, MSN 2011

Definition
Diabetes mellitus is a group of metabolic diseases characterized by elevated levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both.

Introduction

Sources of glucose in the blood are : absorption of ingested food in the gastrointestinal (GI) tract and formation of glucose by the liver from food substances

Pancreas

Insulin
Insulin, a hormone produced by the pancreas, controls the level of glucose in the blood by regulating the production and storage of glucose.
In the diabetic state, the cells may stop responding to insulin or the pancreas may stop producing insulin entirely. This leads to hyperglycemia. Another pancreatic hormone called glucagon (secreted by the alpha cells of the islets of Langerhans) is released when blood glucose levels decrease and stimulate the liver to release stored glucose.

Functions of insulin
Transports and metabolizes glucose for energy
Stimulates storage of glucose in the liver and muscle (in the form of glycogen). Signals the liver to stop the release of glucose. Enhances storage of dietary fat in adipose tissue. Accelerates transport of amino acids (derived from dietary protein) into cells. Insulin also inhibits the breakdown of stored glucose, protein, and fat.

Regulation of Glucose Level in Blood

Risk factors of DM
Family history of diabetes (ie, parents or siblings with diabetes). Obesity ( BMI 27 kg/m2). Race/ethnicity (eg, African Americans, Hispanic Americans, Native Americans, Asian Americans, Pacific Islanders). Age 45 years. Previously identified impaired fasting glucose or impaired glucose Tolerance. Hypertension (140/90 mm Hg) HDL cholesterol level 35 mg/dL (0.90 mmol/L) and/or triglyceride level 250 mg/dL (2.8 mmol/L) History of gestational diabetes or delivery of babies over 9 lbs

Classifications of insulin
Type 1 diabetes (previously referred to as insulin-dependent diabetes mellitus) Type 2 diabetes (previously referred to as non insulin dependent diabetes mellitus)
Gestational diabetes mellitus. Diabetes mellitus associated with other conditions or syndrome

Nowadays we dont use terms of dependent or non-independent insulin DM. Why ????????????????

Type 1 Diabetes Mellitus

Type 1 diabetes is characterized by destruction of the pancreatic beta cells.
So that no or very little insulin is produced. Require insulin injections to control their blood glucose levels. 5% to 10% of people with diabetes have type 1 diabetes. Type 1 diabetes is characterized by an acute onset, usually before age 30

Causes of Type 1 Diabetes Mellitus

Viral Infections. Genetics predisposition.
Autoimmune response.

Pathophysiology of DM type 1

Pathophysiology of DM type 1

Type 2 Diabetes Mellitus

Results from decreased sensitivity to insulin (called insulin resistance) and impaired beta cell functioning resulting in decreased insulin production.
Approximately 90% to 95% of people with diabetes have type 2 diabetes. Type 2 diabetes occurs more among people who are older than 30 years and obese. Type 2 diabetes is treated with diet and exercise and oral hypoglycemic agents.

Insulin Resistance
Normally Insulin resistance

Clinical Manifestations
Polyuria (increased urination). Polydipsia (increased thirst). Polyphagia (increased appetite). fatigue and weakness. Sudden vision changes. Tingling or numbness in hands or feet, Dry skin, skin lesions or wounds that are slow to heal. Recurrent infections. For type 1 patient is usually thin at diagnosis, whereas for type2 patient is usually obese at diagnosis.

Assessment & Diagnostic Findings

Assessment & Diagnostic Findings

Hgb(A1C)
Is a blood test that reflects average blood glucose levels over a period of approximately 2 to 3 months.
When blood glucose levels are elevated, glucose molecules attach to hemoglobin in the red blood cell. The longer the amount of glucose in the blood remains above normal, the more glucose binds to the red blood cell and the higher the glycosylated hemoglobin level. The normal values differ slightly from test to test and from laboratory to laboratory and normally range from 4% to 6%.

Other Assessment & Diagnostic Tests

Fasting lipid profile Test for microalbuminuria Serum creatinine level Urinalysis Electrocardiogram

Diabetes Management
The main goal of diabetes treatment is to normalize insulin activity and blood glucose levels to reduce the development of vascular and neuropathic complications.

Nutritional Management
50% to 60% of calories should be derived from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein. Focus on starchy food rather than sugar (sucrose) foods.
The recommendations regarding fat content of the diabetic diet include both reducing the total percentage of calories from fat sources to less than 30% of the total calories and limiting the amount of saturated fats to 10% of total calories.

Nutritional Management
The meal plan may include the use of some nonanimal sources of protein (eg, legumes and whole grains) to help reduce saturated fat and cholesterol intake Increasing fiber in the diet may also improve blood glucose levels and decrease the need for exogenous insulin, lowering total cholesterol and low-density lipoprotein cholesterol in the blood.
Soluble fiber - in foods such as legumes, oats, and some fruits - plays more of a role in lowering blood glucose and lipid levels than does insoluble fiber,

Nutritional Management
Soluble fiber is thought to be related to the formation of a gel in the GI tract. This gel slows stomach emptying and the movement of food through the upper digestive tract. Insoluble fiber is found in whole-grain breads and cereals and in some vegetables. This type of fiber plays more of a role in increasing stool bulk and preventing constipation.

Both insoluble and soluble fibers increase satiety, which is helpful for weight loss.

Nutritional Management

Exercise
Exercise lowers the blood glucose level by increasing the uptake of glucose by body muscles and by improving insulin utilization. It also improves circulation and muscle tone.
Exercise also alters blood lipid levels, increasing levels of high-density lipoproteins and decreasing total cholesterol and triglyceride levels. This is especially important to the person with diabetes because of the increased risk of cardiovascular disease.

Exercise Precautions
Patients who have blood glucose levels exceeding 250 mg/dL (14 mmol/L) and who have ketones in their urine should not begin exercising until the urine tests negative for ketones and the blood glucose level is closer to normal. the patient who requires insulin should be taught to eat a 15-g carbohydrate snack (a fruit exchange) or a snack of complex carbohydrate with a protein before engaging in moderate exercise, to prevent unexpected hypoglycemia.

Patients participating in extended periods of exercise should test their blood glucose levels before, during, and after the exercise period, and they should snack on carbohydrates as needed to maintain blood glucose levels

Exercise Precautions

Exercise Precautions
People with diabetes should exercise at the same time and in the same amount each day.
Regular daily exercise, rather than sporadic exercise, should be encouraged. A slow, gradual increase in the exercise period is encouraged. For many patients, walking is a safe and beneficial form of exercise.

Self-Monitoring of Blood Glucose (SMBG)

Frequent SMBG enables people with diabetes to :
1) Adjust the treatment regimen to obtain optimal blood glucose control. 2) Allows for detection and prevention of hypoglycemia and hyperglycemia 3) Reduce the risk of long-term diabetic complications

Types of SMBG devices

Candidates of SMBG
Diabetes patients who treated with intensive treatment therapy.
Patients with unstable diabetes. Patients who suffer severe hypoglycemia without warning signs. Patients with diabetes type 2 , to examine the effect of diet, exercise, and oral antidiabetic agents.

Frequency of SMBG
For most patients who require insulin, SMBG is recommended two to four times daily (usually before meals and at bedtime). For patients not receiving insulin may be instructed to assess their blood glucose levels at least two or three times per week.

Sources of error in SMBG

Improper application of blood (eg, drop too small).
Improper meter cleaning and maintenance (eg, allowing dust or blood to accumulate on the optic window).

Damage to the reagent strips by heat or humidity; use of outdated strips.

Urine Testing for Glucose

The advantages of urine glucose testing are that it is less expensive than SMBG and it is not invasive. Disadvantages of urine testing include the following: - Results do not accurately reflect the blood glucose level at the time of the test. - The renal threshold for glucose is 180 to 200 mg/dL (9.9 to 11.1 mmol/L), far above target blood glucose levels. - Hypoglycemia cannot be detected because a negative urine glucose result may occur when the blood glucose level ranges from 0 to 180 mg/dL (9.9 mmol/L) or higher. - Patients may have a false sense of being in good control when results are always negative. -Various medications (eg, aspirin, vitamin C, some antibiotics) may interfere with test results. - In elderly patients and patients with kidney disease, the renal threshold (the level of blood glucose at which glucose starts to appear in the urine) is raised; thus, false-negative readings may occur at dangerously elevated glucose levels.

Pharmacologic Therapy

Insulin therapy.

Oral hypoglycemic drugs.

Insulin Therapy
Insulin therapy is necessary for:
- Type 1 diabetes patients.

- Type 2 diabetes patients in which diet and oral agents fail to control blood glucose.
- Temporarily for type 2 diabetes who is usually controlled by diet alone or by diet and an oral agent may require insulin during illness, infection, pregnancy, surgery, or some other stressful even

Categories of Insulin

Insulin Species
Animal insulins were obtained from beef (cow) and pork (pig) pancreases. Human insulins are now widely available.

Insulin Regimens (Conventional Approach)

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. 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 selfmanagement activities.

Insulin Regimens (Intensive Approach)

Intensive treatment (three or four injections of insulin per day) reduced the risk of 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.

Complications of insulin therapy (Local allergic reactions)

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.
The physician may prescribe an antihistamine to be taken 1 hour before the injection if such a local reaction occurs.

Complications of insulin therapy (Systemic allergic reactions)

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.

These rare reactions are occasionally associated with generalized edema or anaphylaxis.

Complications of insulin therapy (Lipodystrophy)

Lipoatrophy is loss of subcutaneous fat and appears as slight dimpling or more serious pitting of subcutaneous fat.
Lipohypertrophy, the development of fibrofatty masses at the injection site, is caused by the repeated use of an injection site.

Rotation of injection sites is so important

Lipoatrophy

Lipohypertrophy

Rotation is the solution

Complications of insulin therapy (Insulin Resistance)

Clinical insulin resistance has been defined as a daily insulin requirement of 200 units or more.
This may occur for various reasons, the most common being obesity, which can be overcome by weight loss. It may be related to formation of autoantibodies against insulin, but it is rarely occur.

Complications of insulin therapy (Morning Hyperglycemia)

Oral Antidiabetic Agents

Oral antidiabetic agents may be effective for patients who have type 2 diabetes that cannot be treated by diet and exercise alone. They cannot be used during pregnancy.
Oral antidiabetic agents include the sulfonylureas, biguanides, alpha glucosidase inhibitors, thiazolidinediones, and meglitinides

Sulfonylureas
Directly stimulating the pancreas to secrete insulin. Therefore, a functioning pancreas is necessary for these agents to be effective. They cannot be used in patients with type 1 diabetes. The sulfonylureas can be divided into first- and secondgeneration categories. The most common side effects of these medications are GI symptoms and dermatologic reactions. Hypoglycemia may occur when an excessive dose of a sulfonylurea is used or when the patient omits or delays meals, reduces food intake, or increases activity.

Biguanides
Metformin (Glucophage) produces its antidiabetic effects by facilitating insulins action on peripheral receptor sites. It can be used only in the presence of insulin. Biguanides have no effect on pancreatic beta cells. Lactic acidosis is a potential and serious complication of biguanide therapy

Metformin is contraindicated in patients with renal impairment (serum creatinine level more than 1.4) or those at risk for renal dysfunction (eg, those with acute myocardial infarction).

Alpha glucosidase inhibitors

Acarbose (Precose) and miglitol (Glyset) are oral alpha glucosidase inhibitors used in type 2 diabetes management.
They work by delaying the absorption of glucose in the intestinal system, resulting in a lower postprandial blood glucose level. As a consequence of plasma glucose reduction, hemoglobin A1C levels drop.

Their side effects are diarrhea and flatulence. These effects may be minimized by starting at a very low dose and increasing the dose gradually.

Thiazolidinediones.
Rosiglitizone (Avandia) and pioglitozone (Actos) are oral diabetes medications categorized as thiazolidinediones. Thiazolidinediones enhance insulin action at the receptor site without increasing insulin secretion from the beta cells of the pancreas. These medications may affect liver function; therefore, liver function studies must be performed at baseline and at frequent intervals(monthly for the first 12 months of treatment).

Meglitinides
Repaglinide (Prandin), an oral glucose-lowering agent of the class of oral agents called meglitinides, lowers the blood glucose level by stimulating insulin release from the pancreatic beta cells. Its effectiveness depends on the presence of functioning beta cells. Therefore, repaglinide is contraindicated in patients with type 1 diabetes. The principal side effect of repaglinide is hypoglycemia; however, this side effect is less severe and frequent than for a sulfonylurea because repaglinide has a short half-life (approximately 1 hour).

Self-administration of insulin
Storing Insulin:
- Cloudy insulins should be thoroughly mixed by gently inverting the vial or rolling it between the hands before drawing the solution into a syringe. - Whether insulin is the short- or long-acting preparation, the vials not in use should be refrigerated and extremes of temperature should be avoided; insulin should not be allowed to freeze and should not be kept in direct sunlight or in a hot car.

Self-administration of insulin
The insulin vial in use should be kept at room temperature to reduce local irritation at the injection site, which may occur when cold insulin is injected.
Patients should be instructed to always have a spare vial of the type or types of insulin they use.

Self-administration of insulin
Selecting Syringes:

Self-administration of insulin
Mixing Insulins:
When rapid- or short-acting insulins are to be given simultaneously with longer-acting insulins, they are usually mixed together in the same syringe. the longer-acting insulins must be mixed thoroughly before use While there are varying opinions regarding which type of insulin (short- or longer-acting) should be drawn up into the syringe first when they are going to be mixed, the ADA recommends that the regular insulin be drawn up first. The most important issue isthat patients not inject one type of insulin into the bottle containing a different type of insulin.

Self-administration of insulin
The ratio of 70/30 (70% NPH and 30% regular insulin in one bottle) is the most common.
Most (if not all) of the printed materials available on insulin dose preparation instruct patients to inject air into the bottle of insulin equivalent to the number of units of insulin to be withdrawn.

Self-administration of insulin
Selecting and rotating injection site:
- The four main areas for injection are the abdomen, arms (posterior surface), thighs (anterior surface), and hips. - The speed of absorption is greatest in the abdomen and decreases progressively in the arm, thigh, and hip. - Systematic rotation of injection sites within an anatomic area is recommended to prevent localized changes in fatty tissue (lipodystrophy).

- Patients should try not to use the same site more than once in 2 to 3 weeks. I
- if the patient is planning to exercise, insulin should not be injected into the limb that will be exercised

Sites of insulin injections

Self-administration of insulin
Preparing the skin:
- Use of alcohol to cleanse the skin is not recommended, but patients who have learned this technique often continue to use it. - If alcohol is used to cleanse the injection area, patients should be cautioned to allow the skin to dry after cleansing with alcohol. If the skin is not allowed to dry before the injection.

Pinching is preferable

Acute complications of DM

Hypoglycemia.

Diabetic Ketoacidosis (DKA).

Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS).

Hypoglycemia
Hypoglycemia (abnormally low blood glucose level) occurs when the blood glucose falls to less than 50 to 60 mg/dL (2.7 to 3.3 mmol/L).

Causes of hypoglycemia
Too much insulin. Too much oral hypoglycemic agents. Too little food. Excessive physical activity

Clinical manifestations of hypoglycemia

They can be categorized into: - Adrenergic symptoms. - Central nervous system (CNS) symptoms.

Mild hypoglycemia
In mild hypoglycemia, as the blood glucose level falls, the sympathetic nervous system is stimulated, resulting in an increase of epinephrine and norepinephrine. Sweating. Tremor. Tachycardia. Palpitation. Nervousness. hunger

Moderate hypoglycemia
In moderate hypoglycemia, the fall in blood glucose level deprives the brain cells of needed fuel for functioning. Signs of impaired function of the CNS may include:

- inability to concentrate. - lightheadedness. - memory lapses. - slurred speech. - emotional changes. - double vision. - drowsiness.

- headache. - confusion. - numbness of the lips and tongue. - impaired coordination, - irrational or combative behavior.

Severe hypoglycemia
In severe hypoglycemia, CNS function is so impaired that the patient needs the assistance of another person for treatment of hypoglycemia. Symptoms may include: - Disoriented behavior. - Seizures. - Difficulty arousing from sleep. - Loss of consciousness

Management of hypoglycemia
For patients who are unconscious and cannot swallow, an injection of glucagon 1 mg can be administered either subcutaneously or intramuscularly. A concentrated source of carbohydrate followed by a snack should be given to the patient on awakening to prevent recurrence of hypoglycemia.

In the hospital or emergency department, patients who are unconscious or cannot swallow may be treated with 25 to 50 mL 50% dextrose in water (D50W) administered intravenously. The effect is usually seen within minutes.

Glucagon injection

Prevention of hypoglycemia
DM patients must carry some form of simple sugar with them at all times. Patients are advised to refrain from eating highcalorie, high fat dessert foods (eg, cookies, cakes, doughnuts, ice cream) to treat hypoglycemia. The high fat content of these foods may slow the absorption of the glucose.

Diabetic Ketoacidosis
DKA is caused by an absence or markedly inadequate amount of insulin. This deficit in available insulin results in disorders in the metabolism of carbohydrate, protein, and fat. The three main clinical features of DKA are: - Hyperglycemia - Dehydration and electrolyte loss - Acidosis.

Clinical manifestations
Polyuria and polydipsia. Blurred vision, Weakness, and headache. Orthostatic hypotension. GI symptoms such as anorexia, nausea, vomiting, and abdominal pain. Patients may have acetone breath (a fruity odor), which occurs with elevated ketone levels. Hyperventilation. Patients may be alert, lethargic, or comatose.

Kussmaul respirations

Assessment and Diagnostic Findings

Blood glucose levels may vary from 300 to 800 mg/dL (16.6 to 44.4 mmol/L). low serum bicarbonate (0 to 15 mEq/L) and low pH (6.8 to 7.3). low PCO2 level (10 to 30 mm Hg). Elevated levels of creatinine, blood urea nitrogen (BUN), hemoglobin, and hematocrit may also be seen with dehydration.

Medical management (Rehydration)

Patients may need up to 6 to 10 liters of IV fluid to replace fluid losses caused by polyuria, hyperventilation, diarrhea, and vomiting. Initially, 0.9% sodium chloride (normal saline) solution is administered at a rapid rate, followed by 0.45% sodium chlorise solution. When the blood glucose level reaches 300 mg/dL (16.6 mmol/L) or less, the IV fluid may be changed to dextrose 5% in water (D5W) to prevent a precipitous decline in the blood glucose level.

Medical management (Restoring electrolytes)

The major electrolyte of concern during treatment of DKA is Potassium. Why ???????????
Cautious but timely potassium replacement is vital to avoid dysrhythmias that may occur with hypokalemia. Up to 40 mEq per hour may be needed for several hours. Frequent (every 2 to 4 hours initially) electrocardiograms and laboratory measurements of potassium are necessary during the first 8 hours of treatment. Potassium replacement is withheld only if hyperkalemia is present or if the patient is not urinating

Medical management (Reversing acidosis)

The acidosis that occurs in DKA is reversed with insulin, which inhibits fat breakdown, thereby stopping acid buildup.
Insulin is usually infused intravenously at a slow, continuous rate. Dextrose water such as (D5NS or D50.45NS), are administered when blood glucose levels reach 250 to 300 mg/dL (13.8 to 16.6 mmol/L) to avoid too rapid a drop in the blood glucose level

Hyperosmolar
Hyperglycemic Nonketotic Syndrome (HHNS)

Long-term complications of DM
Macrovascular complications. Microvascular complications.

Macrovascualr complications
Coronary artery disease, cerebrovascular disease, and peripheral vascular disease are the three main types of macrovascular complications.
Myocardial infarction is twice as common in diabetic men and three times as common in diabetic women, cerebrovascular disease includes transient ischemic attacks and strokes.

Signs and symptoms of peripheral vascular disease include diminished peripheral pulses and intermittent claudication (pain in the buttock, thigh, or calf during walking). The severe form of arterial occlusive disease in the lower extremities is largely responsible for the increased incidence of gangrene leading to diabetic foot.

Microvascualr complications
Diabetic microvascular disease (or microangiopathy) is characterized by capillary basement membrane thickening. The basement membrane surrounds the endothelial cells of the capillary.
Two areas affected by these changes are the retina and the kidneys.

Normal Retina

Background Retinopathy

Early stage, asymptomatic retinopathy. Blood vessels within the retina develop microaneurysms that leak fluid, causing swelling and forming deposits (exudates).

Preproliferative Retinopathy

Represents increased destruction of retinal blood vessels

Proliferative Retinopathy

Abnormal growth of new blood vessels on the retina. New vessels rupture, bleeding into the vitreous and blocking light. Ruptured blood vessels in the vitreous form scar tissue, which can pull on and detach the retina.

Nephropathy
The earliest detectable change in the course of diabetic nephropathy is a thickening in the glomerulus. At this stage, the kidney may start allowing more serum albumin( plasma protein) than normal in the urine( albuminuria ,)and this can be detected by sensitive medical tests for albumin. This stage is called" microalbuminuria "

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

Peripheral Neuropathy
Initial symptoms include paresthesias and burning sensations (especially at night). As the neuropathy progresses, the feet become numb.

In addition, a decrease in proprioception (awareness of posture and movement of the body and of position and weight of objects in relation to the body).
Decreased sensation of light touch may lead to an unsteady gait. Decreased sensations of pain and temperature place patients with neuropathy at increased risk for injury and undetected foot infections.

Autonomic Neuropathies
Neuropathy of the autonomic nervous system results in a broad range of dysfunctions affecting almost every organ system of the body. Three manifestations of autonomic neuropathy are related to the cardiac, GI, and renal systems. Cardiovascular symptoms range from fixed, slightly tachycardic heart rate; orthostatic hypotension; and silent, or painless, myocardial ischemia and infarction. GI symptoms include: Delayed gastric emptying may occur with the typical symptoms of early satiety, bloating, nausea. Urinary retention, a decreased sensation of bladder fullness, and other urinary symptoms of neurogenic bladder result from autonomic neuropathy.

Sudomotor Neuropathy
This neuropathic condition refers to a decrease or absence of sweating (anhidrosis) of the extremities.

Foot and Leg ulcers

From 50% to 75% of lower extremity amputations are performed on people with diabetes. Complications of diabetes that contribute to the increased risk of foot infections include: - Neuropathy: Sensory neuropathy leads to loss of pain and pressure sensation, and autonomic neuropathy leads to increased dryness and fissuring of the skin (secondary to decreased sweating). Motor neuropathy results in muscular atrophy, which may lead to changes in the shape of the foot. - Peripheral vascular disease: Poor circulation of the lower extremities contributes to poor wound healing and the development of gangrene. - Immunocompromise: Hyperglycemia impairs the ability of specialized leukocytes to destroy bacteria. Thus, in poorly controlled diabetes, there is a lowered resistance to certain infections.

Foot and Leg ulcers

Foot and Leg ulcers

High-risk characteristics include: - Duration of diabetes more than 10 years - Age older than 40 years - History of smoking - Decreased peripheral pulses - Decreased sensation - Anatomic deformities or pressure areas (eg, bunions, calluses, hammer toes) - History of previous foot ulcers or amputation