Dr Ibrahim Bashaireh, RN, PhD

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1 Dr Ibrahim Bashaireh, RN, PhD
Diabetes Mellitus Dr Ibrahim Bashaireh, RN, PhD 13/04/2011

2 Diabetes Mellitus Definition
A multisystem disease related to: Chronic disorder Abnormal metabolism of fuels glucose and fat An endocrine disorder causes Abnormal insulin production Impaired insulin utilization Both abnormal production and impaired utilization 13/04/2011

3 Diabetes Mellitus Definition
Leading cause of heart disease, stroke, adult blindness, and nontraumatic lower limb amputations 13/04/2011

4 Diabetes Mellitus Etiology and Pathophysiology
Normal insulin metabolism Produced by the  cells in the islets of Langherans of the pancreas Facilitates normal glucose range of 70 to 120 mg/dl 13/04/2011

5 Insulin Secretion 13/04/2011 Fig. 47-1

6 Diabetes Mellitus Etiology and Pathophysiology
Normal insulin metabolism Promotes glucose transport from the bloodstream across the cell membrane to the cytoplasm of the cell 13/04/2011

7 Diabetes Mellitus Etiology and Pathophysiology
Normal insulin metabolism  Insulin after a meal: Stimulates storage of glucose as glycogen Inhibits gluconeogenesis 13/04/2011

8 Diabetes Mellitus Etiology and Pathophysiology
Normal insulin metabolism  Insulin after a meal: Enhances fat deposition in adipose tissue Increases protein synthesis 13/04/2011

9 Type 1 Diabetes Mellitus
Formerly known as “juvenile onset” or “insulin dependent” diabetes Most often occurs in people under 30 years of age Peak onset between ages 11 and 13 13/04/2011

10 Type 1 Diabetes Mellitus Etiology and Pathophysiology
Progressive destruction of pancreatic  cells Autoantibodies cause a reduction of 80% to 90% of normal  cell function before manifestations occur 13/04/2011

11 Type 1 Diabetes Mellitus Etiology and Pathophysiology
Causes: Genetic predisposition Related to human leukocyte antigens (HLAs) Exposure to a virus 13/04/2011

12 Type 1 Diabetes Mellitus Onset of Disease
Manifestations develop when the pancreas can no longer produce insulin Rapid onset of symptoms Present at ER with ketoacidosis 13/04/2011

13 Type 1 Diabetes Mellitus Onset of Disease
Weight loss Polydipsia Polyuria Polyphagia 13/04/2011

14 Type 1 Diabetes Mellitus Onset of Disease
Diabetic ketoacidosis (DKA) Occurs in the absence of exogenous insulin Life-threatening condition Results in metabolic acidosis 13/04/2011

15 Type 2 Diabetes Mellitus
Accounts for 90% of patients with diabetes Usually occurs in people over 40 years of age 80-90% of patients are overweight 13/04/2011

16 Type 2 Diabetes Mellitus Etiology and Pathophysiology
Pancreas continues to produce some endogenous insulin Insulin produced is either insufficient or poorly utilized by the tissues 13/04/2011

17 Type 2 Diabetes Mellitus Etiology and Pathophysiology
Insulin resistance Body tissues do not respond to insulin Results in hyperglycemia 13/04/2011

18 Type 2 Diabetes Mellitus Etiology and Pathophysiology
Impaired glucose tolerance (IGT) Occurs when the alteration in  cell function is mild Blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes 13/04/2011

19 Type 2 Diabetes Mellitus Etiology and Pathophysiology
Inappropriate glucose production by the liver Not considered a primary factor in the development of type 2 diabetes 13/04/2011

20 Type 2 Diabetes Mellitus Etiology and Pathophysiology
Insulin resistance syndrome (syndrome X) Cluster of abnormalities that act synergistically to  the risk of cardiovascular disease 13/04/2011

21 Type 2 Diabetes Mellitus Onset of Disease
Gradual onset Person may go many years with undetected hyperglycemia Marked hyperglycemia (500 to 1000 mg/dl) 13/04/2011

22 Gestational Diabetes Develops during pregnancy
Detected at 24 to 28 weeks of gestation  Risk for cesarean delivery, perinatal death, and neonatal complications 13/04/2011

23 Secondary Diabetes Results from another medical condition or due to the treatment of a medical condition that causes abnormal blood glucose levels Cushing syndrome Hyperthyroidism Parenteral nutrition 13/04/2011

24 Clinical Manifestations Type 1 Diabetes Mellitus
Polyuria Polydipsia (excessive thirst) Polyphagia Weight loss Weakness and fatigue Ketoacidosis 13/04/2011

25 Clinical Manifestations Type 2 Diabetes Mellitus
Non-specific symptoms Fatigue Recurrent infections Prolonged wound healing Visual changes 13/04/2011

26 Diabetes Mellitus Diagnostic Studies
Fasting plasma glucose level 126 mg/dl Random plasma glucose measurement 200 mg/dl plus symptoms Two-hour OGTT level 200 mg/dl using a glucose load of 75 g 13/04/2011

27 Diabetes Mellitus Diagnostic Studies
Impaired glucose tolerance (IGT) Fasting blood glucose level 110 mg/dl but less than 126 mg/dl Hemoglobin A1C test: Measures blood levels over 2-3 months (per text) High levels of glucose will attach to hemoglobin Helps to ensure that the patient’s gluco-meter is accurate. 13/04/2011

28 Diabetes Mellitus Collaborative Care
Goals of diabetes management: Reduce symptoms Promote well-being Prevent acute complications Delay onset and progression of long-term complications 13/04/2011

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30 Diabetes Mellitus Collaborative Care
Patient teaching Nutritional therapy Drug therapy Exercise Self-monitoring of blood glucose 13/04/2011

31 Diabetes Mellitus Drug Therapy: Insulin
Exogenous insulin: Required for type 1 diabetes Prescribed for the patient with type 2 diabetes who cannot control blood glucose by other means 13/04/2011

32 Diabetes Mellitus Drug Therapy: Insulin
Types of insulin Human insulin Most widely used type of insulin Cost-effective  Likelihood of allergic reaction 13/04/2011

33 Diabetes Mellitus Drug Therapy: Insulin
Types of insulin Insulins differ in regard to onset, peak action, and duration Different types of insulin may be used for combination therapy 13/04/2011

34 Diabetes Mellitus Drug Therapy: Insulin
Types of insulin Rapid-acting: Lispro (onset 15’, peak 60-90’ and last from 2-4 hours) Short-acting: Regular (Onset is 30-60’, peak in 2-3h and last for 4-6 hours, and Regular insulin is only kind for IV use. 13/04/2011

35 Diabetes Mellitus Drug Therapy: Insulin
Intermediate-acting: NPH or Lente Onset 3-4h, peak 4-12 hours and lst hours. Names include Humulin N, Novolin N, Humulin L, Novolin L Long-acting: Ultralente, Lantus Onset 6-8h, peak h and lasts 20-30h. 13/04/2011

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37 Diabetes Mellitus Drug Therapy: Insulin
Administration of insulin Cannot be taken orally SQ injection for self-administration IV administration 13/04/2011

38 Insulin Strengths Insulin Strengths 100 U per mL or 500 U per mL
Administered in a sterile, single-use, disposable syringe All insulin given parenterally Regular insulin: either subcutaneous or intravenous 13/04/2011

39 Injection Sites Process: pinch skin, inject needle at 90-degree angle
Do not inject into muscle; do not massage after injecting Rotate injection sites Minimize painful injections 13/04/2011

40 Injection Sites 13/04/2011 Fig. 47-5

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42 Diabetes Mellitus Drug Therapy: Insulin
Problems with insulin therapy Hypoglycemia Allergic reactions Lipodystrophy Somogyi effect: The tendency of the body to react to extremely low blood sugar (hypoglycemia) by overcompensating, resulting in high blood sugar. nocturnal hypoglycemia followed by rebound hyperglycemia-decrease evening dose of insulin 13/04/2011

43 Problems with Insulin Injections
Lipodystrophy: is a medical condition characterized by abnormal or degenerative conditions of the body's adipose tissue Lipoatrophy: is the term describing the localized loss of fat tissue. 13/04/2011

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45 Diabetes Mellitus Drug Therapy: Oral Agents
Not insulin Work to improve the mechanisms in which insulin and glucose are produced and used by the body 13/04/2011

46 Diabetes Mellitus Drug Therapy: Oral Agents
Sulfonylureas: Glipizide, Glyburide and Glimepiride Meglitinides: Prandin & Starlix Biguanides: Metformin -Glucosidase inhibitors: Acarbose. Delay absorption of CHO Thiazolidinediones: Pioglitazone (Actos) 13/04/2011

47 Diabetes Mellitus Drug Therapy: Oral Agents
Other drugs affecting blood glucose levels: -Adrenergic blockers Thiazide Loop diuretics 13/04/2011

48 Diabetes Mellitus Nutritional Therapy
American Diabetes Association (ADA) Guidelines indicate that within the context of an overall healthy eating plan, a person with diabetes can eat the same foods as a person who does not have diabetes 13/04/2011

49 Diabetes Mellitus Nutritional Therapy
American Diabetes Association (ADA) Overall goal: Assist people in making changes in nutrition and exercise habits that will lead to improved metabolic control 13/04/2011

50 Diabetes Mellitus Nutritional Therapy
Type 1 DM Meal plan based on the individual’s usual food intake and is balanced with insulin and exercise patterns 13/04/2011

51 Diabetes Mellitus Nutritional Therapy
Type 2 DM Emphasis placed on achieving glucose, lipid, and blood pressure goals Calorie reduction 13/04/2011

52 Diabetes Mellitus Nutritional Therapy
Food composition Individual meal plan developed with a dietitian Nutritionally balanced Does not prohibit the consumption of any one type of food 13/04/2011

53 Diabetes Mellitus Nutritional Therapy
Food composition Alcohol High in calories Promotes hypertriglyceridemia Can cause severe hypoglycemia 13/04/2011

54 Diabetes Mellitus Nutritional Therapy
Diet teaching Dietitian initially provides instruction Should include the patient’s family and significant others 13/04/2011

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56 Diabetes Mellitus Nutritional Therapy
Exercise Essential part of diabetes management Increases insulin sensitivity Lowers blood glucose levels Decreases insulin resistance 13/04/2011

57 Diabetes Mellitus Nutritional Therapy
Exercise Several small carbohydrate snacks can be taken every 30 minutes during exercise to prevent hypoglycemia 13/04/2011

58 Diabetes Mellitus Nutritional Therapy
Exercise Best done after meals Exercise plans should be individualized Monitor blood glucose levels before, during, and after exercise 13/04/2011

59 Diabetes Mellitus Monitoring Blood Glucose
Self-monitoring of blood glucose (SMBG) Enables patient to make self-management decisions regarding diet, exercise, and medication 13/04/2011

60 Diabetes Mellitus Monitoring Blood Glucose
Self-monitoring of blood glucose (SMBG) Important for detecting episodic hyperglycemia and hypoglycemia Patient training is crucial 13/04/2011

61 Diabetes Mellitus Pancreas Transplantation
Used for patients with type 1 diabetes who have end-stage renal disease and who have had or plan to have a kidney transplant 13/04/2011

62 Diabetes Mellitus Pancreas Transplantation
Eliminates the need for exogenous insulin Can also eliminate hypoglycemia and hyperglycemia 13/04/2011

63 Diabetes Mellitus New Developments in Diabetic Therapy
New insulin delivery systems not yet approved by the FDA: Inhaled insulin Skin patch Oral spray Insulin pills 13/04/2011

64 Diabetes Mellitus Nursing Management Nursing Assessment
Viral infections Medications Recent surgery Positive health history Obesity 13/04/2011

65 Diabetes Mellitus Nursing Management Nursing Assessment
Weight loss Thirst Hunger Poor healing Kussmaul respirations: Deep, rapid respiration characteristic of diabetic acidosis or other conditions causing acidosis. 13/04/2011

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67 Diabetes Mellitus Nursing Management Nursing Diagnoses
Ineffective therapeutic regimen management Fatigue Risk for infection Powerlessness 13/04/2011

68 Diabetes Mellitus Nursing Management Planning
Overall goals: Active patient participation No episodes of acute hyperglycemic emergencies or hypoglycemia 13/04/2011

69 Diabetes Mellitus Nursing Management Planning
Overall goals: Maintain normal blood glucose levels Prevent chronic complications Lifestyle adjustment with minimal stress 13/04/2011

70 Diabetes Mellitus Nursing Management Nursing Implementation
Health Promotion Identify those at risk Routine screening for overweight adults over age 45 13/04/2011

71 Diabetes Mellitus Nursing Management Nursing Implementation
Acute Intervention Hypoglycemia Diabetic ketoacidosis Hyperosmolar hyperglycemic nonketotic syndrome 13/04/2011

72 Diabetes Mellitus Nursing Management Nursing Implementation
Acute Intervention Stress of illness and surgery:  Blood glucose level  Hyperglycemia Continue regular meal plan 13/04/2011

73 Diabetes Mellitus Nursing Management Nursing Implementation
Acute Intervention Stress of illness and surgery: Increase intake of noncaloric fluids Continue taking oral agents and insulin Frequent monitoring of blood glucose 13/04/2011

74 Diabetes Mellitus Nursing Management Nursing Implementation
Ambulatory and Home Care Overall goal: Enable the patient or caregiver to reach an optimal level of independence 13/04/2011

75 Diabetes Mellitus Nursing Management Nursing Implementation
Ambulatory and Home Care Insulin therapy and oral agents Personal hygiene Medical identification and travel Patient and family teaching 13/04/2011

76 Diabetes Mellitus Nursing Management Evaluation
Knowledge Endurance Immune status Health beliefs 13/04/2011

77 Diabetes Mellitus Acute Complications
Diabetic ketoacidosis (DKK) Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) Hypoglycemia 13/04/2011

78 Diabetes Ketoacidosis (DKA)
Life-threatening illness in type 1 Hyperglycemia, dehydration, coma Excess glucose leads to dehydration, sodium and potassium loss Burning of fat leads to ketosis Kidneys unable to excrete ketones, leads to ketoacidosis 13/04/2011

79 DKA Treatment Hospital admission
Treatment: fluids, insulin, electrolytes 13/04/2011

80 Hyperosmolar hyperglycemic nonketotic syndrome (HHNS)
Hyperosmolar Hyperglycemic Nonketotic Syndrome, or HHNS, is a serious condition most frequently seen in older persons. HHNS can happen to people with either type 1 or type 2 diabetes, but it occurs more often in people with type 2. HHNS is usually brought on by something else, such as an illness or infection. In HHNS, blood sugar levels rise, and your body tries to get rid of the excess sugar by passing it into your urine. You make lots of urine at first, and you have to go to the bathroom more often. Later you may not have to go to the bathroom as often, and your urine becomes very dark. Also, you may be very thirsty. Even if you are not thirsty, you need to drink liquids. If you don't drink enough liquids at this point, you can get dehydrated. If HHNS continues, the severe dehydration will lead to seizures, coma and eventually death. HHNS may take days or even weeks to develop. Know the warning signs of HHNS. 13/04/2011

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82 Hypoglycemia Type 1 or type 2 diabetes Causes
Too much insulin Overdose of oral antidiabetic agents Too little food Excess physical activity Sudden onset; blood glucose < 50 mg/dL 13/04/2011

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84 Hypoglycemia Unawareness
May develop in some people with long-standing type 1 diabetes No symptoms of hypoglycemia in the presence of a low blood glucose level 13/04/2011

85 Hypoglycemia Treatment Mild Severe Immediate treatment
15 g rapid-acting sugar Severe Hospitalized Intravenous glucose 13/04/2011

86 Diabetes Mellitus Chronic Complications
Macrovascular (atherosclerotic plaque) Coronary arteries → (MI’s) Cerebral arteries → (strokes) Peripheral vessels → (ulcers, amputations, infection) Microvascular (capillary damage) Retinopathy Neuropathy Nephropathy Whether it is type 1 or type 2 if hyperglycemia remains uncontrolled, serious long term adverse effects can result both macrovascular (large Vessels) and microvascular (small vessel damage). Large vessel damage is relate to deposition of atherosclerotic plaque in the vessels Macrovascular (atherosclerotic plaque) Coronary arteries MI Cerebral arteries strokes Peripheral vessels foot ulcers, amputations Microvascular (capillary damage) Retinopathy partial or complete blindness Neuropathy autonomic nerve damage: for example diabetic gastroparesis, bladder dysfunction, unawareness of hypoglycemia, (somatic nerve damage, foot ulcers, due to loss of sensations.) Nephropathy proteinuria (microalbuminuria) chronic renal failure requires dialysis. 13/04/2011 86

87 Macrovascular Complications
Macrocirculation Large blood vessels undergo changes due to atherosclerosis Complications Coronary artery disease Stroke Peripheral vascular disease 13/04/2011

88 Complication: CAD Risk factor for an MI
High cholesterol and high triglycerides 13/04/2011

89 Complication: Stroke Two to six times more likely to occur in type 2
Hypertension plays a role 13/04/2011

90 Complication: Peripheral Vascular Disease
Greater in type 2 Diabetes-induced arteriosclerosis Can lead to leg ulcers and gangrene 13/04/2011

91 Microvascular Complications
Microcirculation Eyes Kidneys Nerves 13/04/2011

92 Complication: Diabetic Retinopathy
Changes in the retinal capillaries; lead to retinal ischemia, retinal hemorrhage, or detachment Retinopathy stages: nonproliferative and proliferative Leading cause of blindness in people ages 20 to 74 Yearly eye exams are recommended 13/04/2011

93 Complication: Diabetic Nephropathy
Disease of the kidneys Characterized by albumin in the urine, hypertension, edema, renal insufficiency Most common cause of renal failure First indication: microalbuminuria Treatment: ACE inhibitors 13/04/2011

94 Complication: Diabetic Neuropathy
Disorder of the peripheral nerves and autonomic nervous system Results: sensory and motor impairments, postural hypotension, delayed gastric emptying, diarrhea, impaired genitourinary function Result from the thickening of the capillary membrane and destruction of myelin sheath 13/04/2011

95 Complication: Diabetic Neuropathy
Bilateral sensory disorders Appear first in toes, feet, and progress upward to fingers and hands Treatment None specific Focus on controlling neuropathic pain with tricyclic antidepressants or topical cream capsaicin (Zostrix) 13/04/2011

96 Ulceration after trauma to the foot of a person with diabetes
Ulceration after trauma to the foot of a person with diabetes. (Source: Courtesy of Harry Przekop/Medichrome/The Stock Shop, Inc.) 13/04/2011

97 Complication: Autonomic Neuropathy
Involves numerous body systems such as cardiovascular, gastrointestinal, genitourinary 13/04/2011

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