Diabetes

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1

Type 1 Diabetes

characterized by a total deficit of circulating insulin

2

Type 2 Diabetes

characterized by insulin resistance

90% have type 2

3

What does DM cause?

End stage renal Dz

Adult blindness

nontraumatic lower limb amputation

Contributing factor for: Stroke & Heart Dz

4

DM Care plans to be based on:

types of diabetes

length since diagnosis

prior knowledge

the patients individual health & socio economic circumstances

5

What does insulin do?

Promotes glucose transport from bloodstream across cell membrane to cytoplasm of cell

  • Decreases glucose in the bloodstream

increase of insulin after a meal

  • Stimulates storage of glucose as glycogen in liver and muscle
  • Inhibits gluconeogenesis
  • Enhances fat deposition
  • ↑ protein synthesis
6

Details of DM 1

Autoimmune destruction of the pancreatic islet cells

No insulin produced

Occurs in childhood/adolescence

Genetic predisposition plus environmental factors such as onset following viral illness

Includes 5–10% of all patients with DM

7

Causes of DM 1

Genetic predisposition

  • Related to human leukocyte antigens (HLAs)

Exposure to a virus

8

S/S of hyperglycemia

Polyuria

Polydipsia

Polyphagia.

Weight loss

Malaise

Fatigue

Blurred vision

Blood glucose above 180mg.dL (above renal threshold)

9

Prediabetic Values

IFG: Fasting glucose levels are 100 to 125 mg/dL

IGT: 2-Hour plasma glucose levels are between 140 and 199 mg/dL

AIC is in range of 5.7% to 6.4%.

10

Type 2 DM etiology

1. Insulin resistance

  • Body tissues do not respond to insulin.
  • Insulin receptors are either unresponsive or insufficient in number.
  • Results in hyperglycemia
  • 2. Pancreas ↓ ability to produce insulin

β cells fatigued from compensating

  • β-cell mass lost

3. Inappropriate glucose production from liver

  • Liver’s response of regulating release of glucose is haphazard.
  • Not considered a primary factor in development of type 2

4. Alteration in production of hormones

  • Play a role in glucose and fat metabolism
  • Contribute to pathophysiology of type 2 diabetes
11

Secondary Diabetes

Results from another medical condition, such as:

Cushing syndrome

Hyperthyroidism

Pancreatitis

Parenteral nutrition

Cystic fibrosis

Hemochromatosis

12

For older adults, these conditions indicate a need for diabetic screening

Hypertension

Periodontal disease

Frequent infections

Central arterial disease

Peripheral Artery disease

Slow gastric emptying

13

Clinical manifestations of DM 1

Classic symptoms

Polyuria (frequent urination)

Polydipsia (excessive thirst)

Polyphagia (excessive hunger)

Weight loss

Weakness

Fatigue

Blurred vision

14

Clinical Manifestations of DM 2

Nonspecific symptoms

May have classic symptoms of type 1

Fatigue

Recurrent infection

Recurrent vaginal yeast or monilia infection

Prolonged wound healing

Visual changes

15

Diagnostic testing for DM

AIC ≥ 6.5%- Levels of 5.7% to 6.49% indicate diabetes and cardiovascular disease

Fasting plasma glucose level >126 mg/dL (normal 100mg/dL)

Random or casual plasma glucose measurement ≥200 mg/dL plus symptoms

Two-hour OGTT level ≥200 mg/dL

16

Goals of DM mgmt

Decrease symptoms.

Promote well-being.

Prevent acute complications.

Delay onset and progression of
long-term complications.

17

Problems with insulin therapy

Hypoglycemia

Allergic reaction

Lipodystrophy

Somogyi effect

Dawn phenomenon

18

Sulfonylureas

Increase insulin production from pancrease

decreases chance of prolonged hypoglycemia

(Glipizide, Glimepiride)

19

Meglitinides

increased insulin production from pancrease

(repaglinidie)

20

Biguanides

Reduce glucose production by liver

enhance insulin sensitivity at tissues

improve glucose transport into cells

do not promote weight gain

(Metformin- Glucophage)

21

a-glucosidase inhibitors

slows down absorption of carbohydrates in small intestine

(acarbose)

22

Thiazolidinediones

most effective in those with insulin resistance

improves sensitibity, transport, utilization at target tissues.

(Pioglitzazone)

23

Nutritional therapy

Carbohydrates

  • Sugars, starches, and fiber
  • Carbohydrate allowance is a minimum of 130 g/day.

Fats

  • Less than 200 mg/day of cholesterol and trans fats
    • <7% from saturated fats

Protein

  • Contribute 15% to 20% of total energy consumed
  • Intake should be significantly less than in the general population.

Fiber

  • 14g/1000 per day
24

Variables for Exercising DM

Type of DM

Intensity of exercise

duration

& time of day

25

S/S Hypoglycemia

Too much insulin in proportion to glucose in the blood

Blood glucose level less than 70 mg/dL

Confusion

Irritability

Diaphoresis

Tremors

Hunger

Weakness

Visual disturbances

26

Diabetic Retinopathy- Nonproliferative

Most common form

Partial occlusion of small blood vessels in retina

Causes development of microaneurysms

  • Capillary fluid leaks out.
  • Retinal edema and eventually hard exudates or intraretinal hemorrhages occur.
27

Diabetic Retinopathy- Proliferative

Most severe form

  • Involves retina and vitreous
  • When retinal capillaries become occluded
  • Body forms new blood vessels
  • Vessels are extremely fragile and hemorrhage easily
  • Produce vitreous contraction
  • Retinal detachment can occur
28

Treatment options for Retinopathy

Laser photocoagulation

  • Most common
  • Laser destroys ischemic areas of retina
  • Prevents further visual loss

Vitrectomy

  • Aspiration of blood, membrane, and fibers inside the eye
29

Diabetic Nephropathy

Associated with damage to small blood vessels that supply the glomeruli of the kidney

Leading cause of end-stage renal disease

Critical factors for prevention/delay

Tight glucose control

Blood pressure management

Angiotensin-converting enzyme (ACE) inhibitors

Used even when not hypertensive

Angiotensin II receptor antagonists

Yearly screening

30

Diabetic Neuropathy

60% to 70% of patients with diabetes have some degree of neuropathy

Nerve damage due to metabolic derangements of diabetes

Sensory versus autonomic neuropathy

Sensory neuropathy

Distal symmetric

Most common form

Affects hands and/or feet bilaterally

Characteristics include

Loss of sensation, abnormal sensations, pain, and paresthesias

31

Diabetic Neuropathy: Sensory

Sensory neuropathy

Distal symmetric

Most common form

Affects hands and/or feet bilaterally

Characteristics include

Loss of sensation, abnormal sensations, pain, and paresthesias

Usually worse at night

Foot injury and ulcerations can occur without the patient having pain.

Can cause atrophy of small muscles of hands/feet

32

Neuropathy Sensory Treament

Tight blood glucose control

Drug therapy

  • Topical creams
  • Tricyclic antidepressants
  • Selective serotonin and norepinephrine reuptake inhibitors
  • Antiseizure medications
33

Autonomic Neuropathy

Can affect nearly all body systems

Complications

  • Gastroparesis
  • Delayed gastric emptying
  • Cardiovascular abnormalities

Complications

  • Sexual function
  • Neurogenic bladder