Diabetes Mellitus

when a person has a chronic problem with hyperglycemia due to an abnormal production of insulin and/or impaired utilization of insulin

because the pancreas doesn't produce enough insulin or the cells are insulin resistant.

• adult blindness
• end stage renal disease
• non traumatic lower limb amputations

• heart disease
• stroke

• Native Americans
• African Americans
• Hispanics

Under 40.....used to be called juvenile or insulin dependent diabetes

• polydipsia
• polyuria
• polyphagia
• ketoacidosis (not in type 2 typically)

excessive thirst

frequent urination

excessive hunger

exogenous insulin

over 40....however it is now changing to much younger.  Seeing it now more in children and people overweight

Type I it is from a dysfunction of the Beta cells causing hyperglycemia

Type II is from the pancreas producing an insufficient amount of insulin, or the tissues inability to use the insulin

Type II

Type I

• insulin resistance
• decreased production of insulin by the pancreas
• inappropriate production of glucose by the liver

it is an alteration in glucose and lipid metabolism in which insulin receptors on skeletal muscle, fat, and liver cells are unresponsive.   Therefore glucose does not get in to the cells to adequately, so glucose stays in the blood causing hyperglycemia

it is a cluster of abnormalities that act together to greatly increase a persons risk for cardiovascular disease and diabetes.

• the person will have:
• high triglycerides
• increased LDL
• decreased HDL
• Hypertension

the person will be insulin resistant and have elevated insulin levels

a person who has an increased risk for developing diabetes because their blood glucose levels are higher than normal, but not high enough to be called diabetic

Fasting Glucose Test 100-125mg/dL

Oral Glucose Test 140-199mg/dL

HgbA1C  5.7-6.4%

Fasting Glucose....

• Waist size +40 (m) +35 (f)
• Overweight-BMI +25
• Family History
• Decreased HDL and Increased Triglycerides
• HTN
• History of Gestational Diabetes
• Ethnic Background

10 years

change your diet, exercise regularly and lose weight.

If you lose 10% of your weight you will decrease your changes by 58%

the stomach changes food in to glucose, the glucose enters the bloodstream.  The pancreas makes insulin and it enters the bloodstream.   Glucose cant get in to the cells of the body so it builds up in the blood vessels causing hyperglycemia.

• Tachy
• Irritable
• Restless
• Excessive Hunger
• Diaphoresis/Depression

Full bounding rapid pulse

• Dry skin
• Drowsy
• Deep Rapid Labored Breathing
• Dehydrated

Weak rapid pulse

• acetone breath-sweet
• fruity odor
• Hyperventilation-rapid and shallow initially but turns in to deep, labored and gasping

you draw blood and see how much sugar is attached to Hgb, if the level is high then there has been a problem for a while.

RBC's last 120 days....so you cant fool this test

You have them drink a disgusting sugar loaded drink, then 2 hours later you check their blood glucose level.

75g of sugar in this awful orange drink!!

200mg/dL

• lispro-Humalog
• aspart-Novolog

• Onset 15 min
• Peak 1-1.5 hrs
• Duration 3-4 hrs.

• Humulin R
• Novolin R

• Onset 30-60 min
• Peak 2-3 hrs.
• Duration 3-6

NPH

• Onset 2-4 hrs.
• Peak 4-10
• Duration 10-16 hrs.

Lantus

• Onset 1-2 hrs.
• Peak....doesn't peak
• Duration 24+ hrs.

• Provide, assist and teach the client about drug therapy (oral and insulin)
• nutritional therapy
• exercise
• glucose monitoring
• prevention/delay of long term complications

ID, monitor and educate at risk populations

Teach them about weight loss, increasing their exercise

• help them balance their drug therapy
• diet
• exercise
• monitor blood sugar
• minimize complications

Food Pyramid

carb counting.....

an appropriate serving size is 15g with a total of 45-60 g/meal.

total carb intake amount is dependent on age, weight, activity and medications

• increased calories to maintain a good body weight
• diet + insulin for glucose control
• must plan carbs in each meal and make adjustments for insulin
• consistent timing of meals with insulin is important
• Snacks btwn meals and at bedtime are normal
• eat more carbs for moderate physical activity

NPH

• for overweight/obese pt reduce calories to lose weight
• diet alone may be sufficient for glucose control
• low fat diet
• consistent with carbs at meals
• NO SNACKS....(usually overweight)

nutritional supplements

screening of everyone when they turn 45

tells you how quickly different foods will increase a persons blood sugar levels.

Carbs with a high glycemic index will sharply raise blood glucose levels and consequently the pt will crash (potatoes, white/bread/rice).

Carbs with a low glycemic index will raise blood glucose more slowly and will sustain the patient longer without a severe crash (brown rice, multigrain breads)

to be able to balance carbs, fats and proteins without sharp increases/decreases of blood glucose levels

• appetite decreases
• may not realize they haven't eaten
• may not recognize signs of hypoglycemia

make a schedule for meals

• it decreases insulin resistance by increasing insulin receptor sensitivity
• contributes to weight loss that also decreases insulin resistance.  It also:

• Decreases blood glucose, triglycerides and LDL cholesterol levels
• Decrease BP
• Improves circulation

• if increased physical activity occurs at peak time of insulin, sulfonylureas or meglitinides
• if insufficient calories have been consumed to maintain glucose levels
• if don't take supplemental carbs during or after exercise.

Causes HYPERglycemia

it can be perceived as a stressor and can stimulate counter-regulatory hormones which will raise blood sugar levels. 

Should check their blood sugar levels prior to exercise and modify as indicated

• BLOOD GLUCOSE CONTROL (Best)
• Personal hygiene
• Foot Care
• Medical ID bracelet

• diligent skin care
• regular baths and foot care
• good dental hygiene

Cuz have an increased risk for periodontal disease

• wear closed toe shoes that fit properly
• let a podiatrist to nail and skin care of feet
• use a mirror to inspect feet daily
• treat sores right away on the feet
• have a monofilliment test yearly

it is done at home and it detects levels of neuropathy, nerve damage and areas of the feet that a diabetic loses sensation in

• hypoglycemia
• hyperglycemia
• infections

• angiopathy (damage to blood vessels)
• neuropathy (sensory problems)
• autonomic infections
• circulation issues with lower extremities

Lanolin....don't put it btwn the toes

a life threatening syndrome that occurs in the diabetic who can make enough insulin to prevent DKA, but not enough to prevent:

• hyperglycemia
• osmotic diuresis
• extracellular fluid depletion

60+ years old with Type II DM

• UTI infections
• pneumonia
• sepsis
• any acute illness
• newly diagnosed type 2 diabetic

HHS doesn't get DKA

• somnolence (sleepy)
• coma
• seizure
• hemiparesis (weak on one side of the body)
• aphasia

disturbance of the comprehension and formulation of language caused by a dysfunction in specific brain regions

• it is caused by a profound deficiency of insulin and is characterized by
• hyperglycemia
• ketosis
• acidosis
• dehydration

Most likely seen in Type I, but can be seen in Type II

• illness
• infection
• inadequate insulin dosage
• undiagnosed Type 1
• poor self management
• neglect

• BG above 250
• dehydrated
• Urinary frequency
• flushed/dry skin
• restlesness
• anorexia and N/V
• Kussmaul Respirations

• BG higher than 600
• Infection trigger
• osmotic diuresis....dehydration
• neuro changes
• may look like a stroke

• Have their blood glucose levels returned to normal?
• Is the patient asymptomatic for S&S of hyperglycemia?

• Too much insulin/oral meds
• Not enough food in the blood
• Not eating/taking meds on time
• Too much exercise
• ALCOHOL intake without food
• Loss of weight without change in meds

slurred speech

visual disturbances and a headache

• give 4-8 oz of fruit juice or 8 oz of low fat milk
• avoid carbs with fat
• avoid large amounts of quick acting carbs

Eat a 1/2 a turkey sandwich and eat crackers

Recheck glucose within one hour of treatment

• determine blood glucose
• give Glucagon 1mg IM or SQ (IM quicker response)
• D50W 20-50mL (hypertonic-best in central line)
• Give complex carbs as soon as they are conscious to avoid hypoglycemia

Rebound Hypoglycemia

Is their blood glucose normal? 

Are they without S&S of hypoglycemia?

• Coronary Artery Disease
• Cerebral Vascular Disease
• Peripheral Vascular Disease

• Retinopathy
• Nephropathy

• Sensory (Affects PNS)
• Autonomic 9Affects all body systems

• Ulcerations
• Amputations

• Prevent: Stop smoking, control HTN, Low fat and cholesterol diet....weight control
• Interventions: meds and surgical intervention

• memory lapses
• abrupt loss of vision
• abrupt loss of strength "TIA signs"

Prevention:  Control Blood sugar and HTN

Interventions: antiplatelets and anticoagulants

Intermittent claudication (painful and impaired walking-felt in the legs)

Prevention: Stop smoking, regular exercise, daily foot care/inspection

Interventions:  Encourage exercise and teach proper foot care

Prevention:  control blood glucose, eye exams every 6 months

Intervention: Laser Therapy, Vitrectomy (removal of vitreous humor from the eye)

• Proteinuria
• fluid accumulation
• increased incidences of hypoglycemia

Prevention: aggressive treatments of UTI, control HTN and blood glucose levels

Interventions:  low protein diet, dialysis, renal transplant

Ace Inhibitor (Lisinopril...."pril")

numbness, tingling or pain in the extremities

Prevent:  Control Blood Sugar

• Interventions:  Drug Therapy....tricyclic anti depressants, antiseizure meds, topical creams
• Neurontin

Neurontin

• Complications:
• Hypoglycemia
• unawareness
• Bowel Incontinence
• Gastroparesis
• Postural Hypotension
• Sexual dysfunction
• Urinary Retention

Prevention:  Control Blood Glucose

urinary retention

• Stop smoking
• Prevent PVD and neuropathies
• Proper foot wear
• Dilligent skin and foot care

• Reduced beta cell function
• Reduced insulin sensitivity
• Altered Carb metabolism

• Corticosteroids
• Antihypertensives
• Phenothiazines

• Low energy levels
• falls
• dizzy
• confused
• chronic GU infections

• Diabetic Acidosis
• Diabetic Coma

Metabolic Acidosis

Stroke

• Lg and medium blood vessels
• CAD
• CVD
• PVD

Thickening of vessel membranes in the capillaries and arterioles

Diabetics

• Retinopathy
• Nephropathy
• Neuropathy

Recurrent infections

Kussmaul's

initially rapid and shallow, but as acidosis worsens it will go to deep, labored and gasping