Diabetes
Type 1 Diabetes
characterized by a total deficit of circulating insulin
Type 2 Diabetes
characterized by insulin resistance
90% have type 2
What does DM cause?
End stage renal Dz
Adult blindness
nontraumatic lower limb amputation
Contributing factor for: Stroke & Heart Dz
DM Care plans to be based on:
types of diabetes
length since diagnosis
prior knowledge
the patients individual health & socio economic circumstances
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
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
Causes of DM 1
Genetic predisposition
- Related to human leukocyte antigens (HLAs)
Exposure to a virus
S/S of hyperglycemia
Polyuria
Polydipsia
Polyphagia.
Weight loss
Malaise
Fatigue
Blurred vision
Blood glucose above 180mg.dL (above renal threshold)
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%.
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
Secondary Diabetes
Results from another medical condition, such as:
Cushing syndrome
Hyperthyroidism
Pancreatitis
Parenteral nutrition
Cystic fibrosis
Hemochromatosis
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
Clinical manifestations of DM 1
Classic symptoms
Polyuria (frequent urination)
Polydipsia (excessive thirst)
Polyphagia (excessive hunger)
Weight loss
Weakness
Fatigue
Blurred vision
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
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
Goals of DM mgmt
Decrease symptoms.
Promote well-being.
Prevent acute complications.
Delay onset and progression of
long-term complications.
Problems with insulin therapy
Hypoglycemia
Allergic reaction
Lipodystrophy
Somogyi effect
Dawn phenomenon
Sulfonylureas
Increase insulin production from pancrease
decreases chance of prolonged hypoglycemia
(Glipizide, Glimepiride)
Meglitinides
increased insulin production from pancrease
(repaglinidie)
Biguanides
Reduce glucose production by liver
enhance insulin sensitivity at tissues
improve glucose transport into cells
do not promote weight gain
(Metformin- Glucophage)
a-glucosidase inhibitors
slows down absorption of carbohydrates in small intestine
(acarbose)
Thiazolidinediones
most effective in those with insulin resistance
improves sensitibity, transport, utilization at target tissues.
(Pioglitzazone)
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
Variables for Exercising DM
Type of DM
Intensity of exercise
duration
& time of day
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
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.
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
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
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
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
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
Neuropathy Sensory Treament
Tight blood glucose control
Drug therapy
- Topical creams
- Tricyclic antidepressants
- Selective serotonin and norepinephrine reuptake inhibitors
- Antiseizure medications
Autonomic Neuropathy
Can affect nearly all body systems
Complications
- Gastroparesis
- Delayed gastric emptying
- Cardiovascular abnormalities
Complications
- Sexual function
- Neurogenic bladder