Diabetes Mellitus

By Mark Raphael Barcena and Jerry Ancheta

What is diabetes mellitus?

- Is a disease resulting from a breakdown in the bodys ability to produce or utilize insulin. - Defined as a genetically heterogeneous group of disorders that are characterized by glucose intolerance. - Characterized by disorders in the metabolism of carbohydrates, protein, fat and insulin, as well as the structure and function of blood vessels.

Types of Diabetes Mellitus

Type I - Insulin Dependent Diabetes Mellitus (IDDM) Type II Non-insulin Dependent Diabetes Mellitus (NIDDM) Impaired Glucose Tolerance (IGT) Gestational Diabetes Mellitus (GDM) Diabetes Mellitus associated with other conditions or syndromes

Type 1: Insulin Dependent Diabetes Mellitus Inadequate amount of insulin are produced by
the pancreas. Result from the destruction of the beta cells in the islet of Langerhans in pancreas. Person are deficit in insulin and depend on exogenous insulin to prevent ketoacidosis and to sustain life.

Non Insulin dependent Diabetes Mellitus

May result from a decrease in the amount of insulin produce or an insensitivity of the cells to insulin. Persons do not depend on insulin to sustain life but may be treated with insulin; they are resistant to ketoacidosis except during periods of excessive stress.

Risk Factors
Person with a family history of diabetes Obese persons Those who had an abnormal obstetrical history Persons with early onset of arteriosclerosis Persons with frequent or chronic infections (gallbladder disease, pancreatitis...) Patients inhibiting temporary reduction of glucose tolerance during stress (myocardial infraction, trauma, surgery..) Patients developing glucose intolerance during drug therapy Persons with retinophaty, nephropathy, neuropathy or other vascular manifestations

Manifestations
Type I : Insulin Dependent Diabetes Mellitus (IDDM) Begins in childhood but may occur at any age Onset is abrupt Weight loss Weakness Polyuria (excessive excretion of urine) Polydipsia(excessive thirst) Polyphagia(excessive ingestion of food) Decrease insulin production Hyperglycemia Increase appetite Prone to develop ketosis

Manifestations Cont.
Type II : Non-insulin dependent Diabetes Mellitus (NIDDM) Occurs at the age of 40 Onset is insidious Overweight Suspected as a result of a routine urinalysis Deteriorating vision Pain in lower extremities Fatigue Nocturia Skin wound heals poorly Cramps on the muscles

Management & Treatments

Goal of treatment: try to normalize insulin activity and blood glucose levels in an attempt to reduce the development of the vascular complications. Therapeutic Goal: to lower blood glucose levels as much as possible without seriously disrupting the patients usual activity patterns. -treatment involves constant assessment and modification by health professionals as well as daily adjustments in therapy by patient itself. -the essential components of management is diet and exercise, insulin or oral hypoglycemic agents

Dietary Management
-meals should be measured and spaced at regular intervals -overweight patient should loose weight -control the total calorie intake -high fiber significantly reduces fasting blood glucose levels -the exchange lists are group of foods that are approximately equal in calories and in carbohydrates, and fat content. This exchange list allow for flexibility and variety of meal planning. Includes lists: a) Combination foods (e.g., pizza, chili, chow mien...) b) Foods are occasionally (e.g., ice cream, cookies...) c) Free foods (e.g., seasonings, unsweetened pickles...) -health teaching about diet

Exercise
-exercise lowers blood by increasing uptake of glucose by body muscles -it improves circulation and muscle tones -relation to loose weight. Easing stress and tension and maintaining a feeling of wellbeing -it rises the level of high-density lipoproteins, thereby lowering cholesterol and triglyceride levels -an insulin independent client should be taught to eat a 15gm carbohydrates snacks (fruit) before engaging a moderate exercise -an non-insulin independent client should exercise in addition to dietary management that improves glucose metabolism also enhances loss of body fat -exercise increase the number of insulin receptors in a NIDDM client

Oral Anti diabetic Agents

-these drugs maybe useful to the aged, those with poor vision crippling arthritis of the finger and tremors of the hands -Sulfonylurea's stimulating the pancreas to secrete hormone -for successful treatment with oral anti diabetic agents, diet must be restricted in total calories and carbohydrates, and the patients blood glucose values monitored

Insulin Therapy
-usually taken by persons with insulin-dependent diabetes as well as those with non-insulin dependent diabetes that cannot be adequate controlled by diet alone or by diet or oral agents -insulin had been produced semi-synthetically, this method replaces an amino acid in pork insulin to produce human insulin -insulin preparations: a) short acting insulin b) intermediate acting insulin c) long active insulin -in many patients, combination of short acting insulin and intermediate acting insulin are given to maintain metabolic control -dose of insulin is adjusted according to the level of blood glucose, the degree which the glucose is present, and the time when high glucose levels appear and relation to insulin administration and meals -large doses may be necessary at the onset -factors that affect the doses of insulin includes: the age, diet, amount of insulin secretion -type of insulin delivery system: a) button infuser b) Novopen c) Jet insulin injectors

Monitoring for Glucose and Ketones

SELF MONITORING BLOOD GLUCOSE provides direct measurement of blood glucose levels -it is important for those who are having the following circumstances: a) unstable diabetes b) pregnancy complicated with diabetes c)a tendency to severe ketosis of hypoglycemia URINE TESTING FOR GLUCOSE useful for the obese type II patient because of increase motivation to loose weight -should be performed by insulin dependent patients who cannot use blood glucose testing URINE TESTING FOR KETONES Ketones in the urine signal that control diabetes is deteriorating and that body has started to breakdown stored fat for energy. -test for ketone are done where there is persistent glocosuria or elevated blood glucose levels, or the patient is not feeling well -test can be done by the patient to determine the presence of acetone (ketone bodies) in the urine -testing the urine for ketones is very important to IDDM patients who test their blood for glucose, because ketones signals a dangerous condition ketosis

Hypoglycemia
-abnormally low blood glucose level -caused by too much insulin, too little food, or excessive physical activity -most episodes occur before meals, but may occur at any time of the day and night -it is prevented by following a pattern and time table for eating, administering insulin, and engaging in daily exercises -between meals and bedtime snacks are often needed to counteract the maximum insulin effect

Diabetic Ketocidosis & Coma

- Caused by an absence or inadequate amount of insulin, which results in hyperglycemie and leads to a series of biochemical disorders - Result of insulin deficiency affecting many aspects of the metabolism of carbohydrate, protein and fats - Maybe participated by failure to take insulin, by insufficient insulin intake or by resistance to insulin - A rapid physical examination is carried out to detect evidence of the infection, myocardial infiltration, stroke and other disease. - Insulin is given to reduce blood glucose - As blood glucose level decrease glucose is added to the infusion, and the insulin concentration is decreases to reduce the risk of hypoglycemia

Hyperosmosalar Non Ketotic Coma

- Syndrome in which hyperglycemia and hyperosmolarity predominate with possible alterations of sensorium ( sense of awareness ) - Ketosis is a minimal or absent - Management is to correct the volume depletion and hyperosmolar state

Long Term Complications

DIABETIC RETINOPATHY - Caused by changes in the small blood vessels in the retina of the eye NEPHROPATHY - Kidney disease or renal failure - As renal function decreases, the patient frequently experiences multiple renal failure declining visual acuity, impotence, congestive heart failure

Long Term Complications

NEUROPATHY - It refers to a group of diseases that affect the peripheral nerves (motor, sensory and autonomic) - Increases with the age of the patient and duration of disease - It manifest itself in the lower extremities - Pain and parasthesia are outstanding manifestations

Diagnostic Evaluation
- Blood glucose levels are elevated above 120mg/dl on more than one occasion suggests a diagnosis of diabetes. If fasting glucose levels are normal or nearly normal, diagnosis must be based on a glucose tolerance test - Glucose Tolerance Test- administration of a simple carbohydrate solution. Patient ingests high-carbohydrate meals for three days preceding the test, a blood sample is drawn. Blood samples drawn hour, 1 hour, and 2 hours after glucose ingestion. - Gerontological considerations elevate blood glucose levels appear to be age-related and occur in both men and women. Possibilities include poor diet, physical inactivity, altered insulin secretion and insulin resistance. - Screening test for diabetes- mass screening test for diabetes in general use are 2 hour post-prandial blood glucose test based on the capillary blood sample.

Nursing Intervention
Health Education for diabetes - the education program is started at the time of diagnosis and must be continued throughout the life of the patient - is necessary for better control of the disease and for greater selfreliance of the patient - diagnose patient include understanding of: 1. the pathophysiology of diabetes 2. basic concepts of dietary management 3. administration of insulin 4. exercise regimen 5. urine and blood testing 6. recall of signs and symptoms

Maintaining Normoglycemia
- Close daily attention to meal planning, exercise, medication, prevention of acute episodes of illness. And self monitoring blood glucose - Meal plan needs to be realistic and to take in consideration the patients food preferences, culture, and socioeconomic status - Proper spacing for meals, and types and amounts of food, are important for all patient - Exercise should be done daily

Maintaining Skin Integrity

- Paying close attention to dry skin, cuts, bruises and infections by detection and prompt treatment can help to prevent serious problems in the future - Patients management and care of the skin and feet can also be assessed

Adherence to the Therapeutic Regiment

- Teaching of the knowledge and skills needed by the patient with diabetes will enhance adherence to the prescribe regimen - Motivation must be assessed by the patient but throughout the course of the disease - Simplification and flexibility of the treatment regimen will increase adherence

Disorders
Degenerative brain disorders - Are diseases that selectively affect one or more functional systems of neurons while leaving the others intact. - Generally produce symmetric and progressive involvement of the CNS, affect similar areas of the brain and produced similar symptoms - Those affecting basal produce extra pyramidal movement disorder Dementia - Syndrome of intellectual deterioration - Disturbance in memory, language use, perception, and motor skills and think abstractly and make judgments.