DIABETES FACTS!

Diabetes is a chronic condition associated with abnormally high levels of sugar (glucose) in the blood. Insulin produced by the pancreas lowers blood glucose. Absence or insufficient production of insulin causes diabetes. The two types of diabetes are referred to as type 1 and type 2. Former names for these conditions were insulin-dependent and non-insulin-dependent diabetes, or juvenile onset and adult onset diabetes. Symptoms of diabetes include increased urine output, thirst, hunger, and fatigue. Diabetes is diagnosed by blood sugar (glucose) testing. The major complications of diabetes are both acute and chronic.

Acute complications: dangerously elevated blood sugar (hyperglycemia), abnormally low blood sugar (hypoglycemia) due to diabetes medications may occur Chronic complications: disease of the blood vessels (both small and large) which can damage the feet, eyes, kidneys, nerves, and heart may occur

Diabetes treatment depends on the type and severity of the diabetes. Type 1 diabetes is treated with insulin, exercise, and a diabetic diet. Type 2 diabetes is first treated with weight reduction, a diabetic diet, and exercise. When these measures fail to control the elevated blood sugars, oral medications are used. If oral medications are still insufficient, insulin medications and other injectable medications are considered. DEFINITION Diabetes mellitus is a group of metabolic diseases characterized by high blood sugar (glucose) levels that result from defects in insulin secretion, or its action, or both. Diabetes mellitus, commonly referred to as diabetes (as it will be in this article) was first identified as a disease associated with "sweet urine," and excessive muscle loss in the ancient world. Elevated levels of blood glucose (hyperglycemia) lead to spillage of glucose into the urine, hence the term sweet Normally, blood glucose levels are tightly controlled by insulin, a hormone produced by the pancreas. Insulin lowers the blood glucose level. When the blood glucose elevates (for example, after eating food), insulin is released from the pancreas to normalize the glucose level. In patients with diabetes, the absence or insufficient production of insulin causes hyperglycemia. Diabetes is a chronic medical condition, meaning that although it can be controlled, it lasts a lifetime.

PATHOPHYSIOLOGY Environment, Infection or Emotional Stressor

Lack of Insulin

Little breakdown of fat in cells

Breakdown of glycogen to glucose

Decrease use of Glucose

Protein Breakdown

Some free fatty acids to Liver

Hyperglycemia

Formation of new Glucose

Increased BUN

Osmotic diuresis Formation of ketone boies. Extracellular dehydration

Renal insuffeciency

Hypokalemia

Severe hyperosmolality

Shock

Intracellular dehydration

Tissue Hypoxia

COMA

TYPES OF DIABETES MELLITUS There are two major types of diabetes, called type 1 and type 2. A. Type 1 diabetes was also formerly called insulin dependent diabetes mellitus (IDDM), or juvenile onset diabetes mellitus. In type 1 diabetes, the pancreas undergoes an autoimmune attack by the body itself, and is rendered incapable of making insulin. Abnormal antibodies have been found in the majority of patients with type 1 diabetes. Antibodies are proteins in the blood that are part of the body's immune system. The patient with type 1 diabetes must rely on insulin medication for survival. B. Type 2 diabetes was also previously referred to as non-insulin dependent diabetes mellitus (NIDDM), or adult onset diabetes mellitus (AODM). In type 2 diabetes, patients can still produce insulin, but do so relatively inadequately for their body's needs. In many cases this actually means the pancreas produces larger than normal quantities of insulin. A major feature of type 2 diabetes is a lack of sensitivity to insulin by the cells of the body (particularly fat and muscle cells). CAUSES Diabetes mellitus occurs when the pancreas doesn't make enough or any of the hormone insulin, or when the insulin produced doesn't work effectively. In diabetes, this causes the level of glucose in the blood to be too high. In Type 1 diabetes the cells in the pancreas that make insulin are destroyed, causing a severe lack of insulin. This is thought to be the result of the body attacking and destroying its own cells in the pancreas - known as an autoimmune reaction. It's not clear why this happens, but a number of explanations and possible triggers of this reaction have been proposed. These include:

infection with a specific virus or bacteria; Exposure to food-borne chemical toxins; and Exposure as a very young infant to cow's milk, where an as yet unidentified component of this triggers the autoimmune reaction in the body.

However, these are only hypotheses and are by no means proven causes. Type 2 diabetes is believed to develop when:

The receptors on cells in the body that normally respond to the action of insulin fail to be stimulated by it - this is known as insulin resistance. In response to this more insulin

may be produced, and this over-production exhausts the insulin-manufacturing cells in the pancreas; There is simply insufficient insulin available; and The insulin that is available may be abnormal and therefore doesn't work properly.

The following risk factors increase the chances of someone developing Type 2 diabetes:

Increasing age; Obesity; and Physical inactivity.

Rarer causes of diabetes include:

Certain medicines; Pregnancy (gestational diabetes); and Any illness or disease that damages the pancreas and affects its ability to produce insulin e.g. pancreatitis.

SIGNS AND SYMPTOMS

The early symptoms of untreated diabetes are related to elevated blood sugar levels, and loss of glucose in the urine. High amounts of glucose in the urine can cause increased urine output and lead to dehydration. Dehydration causes increased thirst and water consumption. The inability of insulin to perform normally has effects on protein, fat and carbohydrate metabolism. Insulin is an anabolic hormone, that is, one that encourages storage of fat and protein. Frequent urination, particularly at night, can also be a symptom of diabetes, but this symptom alone would not necessarily suggest the disease either. This symptom would also have to become pretty annoying and recurrent before it would prompt most people to consult a doctor. Unexplained weight loss is another possible sign of diabetes but again, not a significant indication that the individual necessarily has diabetes. In many cases, people who want to lose weight would consider this an unexpected blessing and might not consult their doctor unless they had lost a considerable amount of weight over a period of time. Fatigue is a classic symptom of the disease. However, fatigue also accompanies many, many other conditions, some of which are serious and others of which may be just simple virus bugs. So fatigue alone, unless it become debilitating, is unlikely to send someone to the doctor for a blood test.

Difficulty with erections in men may be a sign - although this difficulty certainly doesn't conclusively indicate diabetes - but since it is an often-embarrassing subject for some men to talk about, this symptom may not lead to a prompt diagnosis and treatment. In fact, many men will avoid drawing attention to this problem at all. Skin infections, wounds that are slow to heal, particularly sores on the feet and ankles, and recurrent vaginal infections (in women), are signs of possible diabetes that are somewhat more likely to draw attention and result in a diagnosis. Blurred vision and tingling or numbness in the hands or feet are also possible indicators of diabetes, and since these symptoms can be troublesome, are more likely to result in medical attention and diagnosis. Individuals who experience several of the above-mentioned symptoms may have good reason to suspect diabetes, particularly if they are in any of the higher risk categories, and should contact their physician to request a simple blood glucose test which can either confirm or rule out diabetes. According to the ADA, 15.7 million people in the United States currently have diabetes. That's nearly 6% of the population. Unfortunately, the ADA estimates more than one third of those individuals are not aware they have the disease and may go untreated. Untreated or uncontrolled, diabetes can cause comas, blindness, kidney disease and kidney failure, nerve disease and amputations, heart disease, and/or stroke

ASSESSMENT AND DIAGNOSTIC FINDINGS The fasting blood glucose (sugar) test is the preferred way to diagnose diabetes. It is easy to perform and convenient. After the person has fasted overnight (at least 8 hours), a single sample of blood is drawn and sent to the laboratory for analysis. This can also be done accurately in a doctor's office using a glucose meter.

Normal fasting plasma glucose levels are less than 100 milligrams per deciliter (mg/dl). Fasting plasma glucose levels of more than 126 mg/dl on two or more tests on different days indicate diabetes. A random blood glucose test can also be used to diagnose diabetes. A blood glucose level of 200 mg/dl or higher indicates diabetes.

When fasting blood glucose stays above 100mg/dl, but in the range of 100-126mg/dl, this is known as impaired fasting glucose (IFG). While patients with IFG do not have the diagnosis of diabetes, this condition carries with it its own risks and concerns, and is addressed elsewhere.

The oral glucose tolerance test Though not routinely used anymore, the oral glucose tolerance test (OGTT)is a gold standard for making the diagnosis of type 2 diabetes. It is still commonly used for diagnosing gestational diabetes and in conditions of pre-diabetes, such as polycystic ovary syndrome. With an oral glucose tolerance test, the person fasts overnight (at least eight but not more than 16 hours). Then first, the fasting plasma glucose is tested. After this test, the person receives 75 grams of glucose. There are several methods employed by obstetricians to do this test, but the one described here is standard. Usually, the glucose is in a sweet-tasting liquid that the person drinks. Blood samples are taken at specific intervals to measure the blood glucose. For the test to give reliable results:

The person must be in good health (not have any other illnesses, not even a cold). The person should be normally active (not lying down, for example, as an inpatient in a hospital), and The person should not be taking medicines that could affect the blood glucose. The morning of the test, the person should not smoke or drink coffee.

The classic oral glucose tolerance test measures blood glucose levels five times over a period of three hours. Some physicians simply get a baseline blood sample followed by a sample two hours after drinking the glucose solution. In a person without diabetes, the glucose levels rise and then fall quickly. In someone with diabetes, glucose levels rise higher than normal and fail to come back down as fast. People with glucose levels between normal and diabetic have impaired glucose tolerance (IGT). People with impaired glucose tolerance do not have diabetes, but are at high risk for progressing to diabetes. Each year, 1% to 5% of people whose test results show impaired glucose tolerance actually eventually develop diabetes. Weight loss and exercise may help people with impaired glucose tolerance return their glucose levels to normal. In addition, some physicians advocate the use of medications, such asmetformin (Glucophage), to help prevent/delay the onset of overt diabetes. Research has shown that impaired glucose tolerance itself may be a risk factor for the development of heart disease. In the medical community, most physicians are now understanding that impaired glucose tolerance is nor simply a precursor of diabetes, but is its own clinical disease entity that requires treatment and monitoring. Evaluating the results of the oral glucose tolerance test Glucose tolerance tests may lead to one of the following diagnoses:

Normal response: A person is said to have a normal response when the 2-hour glucose level is less than 140 mg/dl, and all values between 0 and 2 hours are less than 200 mg/dl. Impaired glucose tolerance: A person is said to have impaired glucose tolerance when the fasting plasma glucose is less than 126 mg/dl and the 2-hour glucose level is between 140 and 199 mg/dl. Diabetes: A person has diabetes when two diagnostic tests done on different days show that the blood glucose level is high. Gestational diabetes: A pregnant woman has gestational diabetes when she has any two of the following:, a fasting plasma glucose of 92 mg/dl or more, a 1-hour glucose level of 180 mg/dl or more, or a 2-hour glucose level of 153 mg/dl, or more.

COMPLICATIONS: The damage to small blood vessels leads to a microangiopathy, which can cause one or more of the following:

Diabetic cardiomyopathy, damage to the heart, leading to diastolic dysfunction and eventually heart failure. Diabetic nephropathy, damage to the kidney which can lead to chronic renal failure, eventually requiring dialysis. Diabetes mellitus is the most common cause of adult kidney failure worldwide in the developed world. Diabetic neuropathy, abnormal and decreased sensation, usually in a 'glove and stocking' distribution starting with the feet but potentially in other nerves, later often fingers and hands. When combined with damaged blood vessels this can lead to diabetic foot (see below). Other forms of diabetic neuropathy may present as mononeuritis or autonomic neuropathy. Diabetic amyotrophy is muscle weakness due to neuropathy. Diabetic retinopathy, growth of friable and poor-quality new blood vessels in the retina as well as macular edema (swelling of the macula), which can lead to severe vision loss or blindness. Retinal damage (from microangiopathy) makes it the most common cause of blindness among non-elderly adults;

Macrovascular diseases lead to cardiovascular disease, to which accelerated atherosclerosis is a contributor: Coronary artery disease, leading to angina or myocardial infarction ("heart attack") Diabetic myonecrosis ('muscle wasting') Peripheral vascular disease, which contributes to intermittent claudication (exertionrelated leg and foot pain) as well as diabetic foot. Stroke (mainly the ischemic type)

Diabetic foot, often due to a combination of sensory neuropathy (numbness or insensitivity) and vascular damage, increases rates of skin ulcers (diabetic foot ulcers) and infection and, in serious cases, necrosis and gangrene. It is why diabetics are prone to leg and foot infections and

why it takes longer for them to heal from leg and foot wounds. It is the most common cause of non-traumatic adult amputation, usually of toes and or feet, in the developed world. Carotid artery stenosis does not occur more often in diabetes, and there appears to be a lower prevalence of abdominal aortic aneurysm. However, diabetes does cause higher morbidity, mortality and operative risks with these conditions. Diabetic encephalopathy is the increased cognitive decline and risk of dementia- including (but not limited to) the Alzheimer's type- observed in diabetes. Various mechanisms are proposed, including alterations to the vascular supply of the brain and the interaction of insulin with the brain itself. MEDICAL MANAGEMENT Oral medications Medications Meglitinides Repaglinide (Prandin) Nateglinide (Starlix) Sulfonylureas

Action Stimulate the release of insulin

Advantages Work quickly

Possible side effects Severely low blood sugar (hypoglycemia); weight gain; nausea; back pain; headache Hypoglycemia; weight gain; nausea; skin rash

Stimulate the release of insulin

Work quickly

Glipizide (Glucotrol) Glimepiride (Amaryl) Glyburide (DiaBeta, Glynase)

Dipeptidy peptidase4 (DPP-4) inhibitors Saxagliptin

Stimulate the release of insulin; inhibit the release of glucose from the liver

Don't cause weight gain

Upper respiratory tract infection; sore throat; headache; inflammation of the pancreas (sitagliptin)

(Onglyza) Sitagliptin (Januvia) Linagliptin (Tradjenta)

Biguanides Metformin

Inhibit the release of glucose from

May promote modest weight loss and

Nausea; diarrhea; rarely, the harmful buildup of

(Fortamet, Glucophage, others)

the liver; improve sensitivity to insulin

modest decline in low-density lipoprotein (LDL), or "bad," cholesterol May slightly increase high-density lipoprotein (HDL), or "good," cholesterol

lactic acid (lactic acidosis)

Thiazolidinediones Rosiglitazone (Avandia) Pioglitazone (Actos)

Improve sensitivity to insulin; inhibit the release of glucose from the liver Slow the breakdown of starches and some sugars

Heart failure; heart attack; stroke; liver disease

Alpha-glucosidase inhibitors Acarbose (Precose) Miglitol (Glyset) Injectable medications Medications Amylin mimetics Pramlintide (Symlin)

Don't cause weight gain

Stomach pain; gas; diarrhea

Action Stimulate the release of insulin; used with insulin injections Stimulate the release of insulin; used with metformin and sulfonylurea

Advantages May suppress hunger; may promote modest weight loss May suppress hunger; may promote modest weight loss

Possible side effects Hypoglycemia; nausea or vomiting; headache; redness and irritation at injection site Nausea or vomiting; headache; dizziness; kidney damage or failure

Incretin mimetics Exenatide (Byetta) Liraglutide (Victoza)

NURSING INTERVENTIONS 1. Administer insulin or an oral antidiabetic drug as prescribed. 2. Have the patient participate in a supervisedexercise program. 3. Treat hypoglycemic reactions promptly by giving carbohydrates in the form of fruit juice, hard candy and honey. 4. Provide meticulous skin care, especially to the feet and legs. 5. Assist the patient to develop coping strategies. 6. Keep accurate records of vital signs, weight, fluid intake, urine output, and caloric intake.

7. Monitor diabetic effects on the cardiovascular, peripheral vascular, and nervous systems. 8. Observe for signs of urinary tract and vaginal infections, and monitor the patients urine for protein, an early sign of nephropathy. 9. Determine the diet and eating patterns of patients and compare it with foods that can be spent on patients. 10. Auscultation bowel sounds, record the existence of abdominal pain / abdominal bloating, nausea, vomit that has not had time to digest food, maintain a state of fasting according to the indication. 11. Give the liquid diet containing foods (nutrients) and the electrolyte immediately if the patient has to tolerate it orally. 12. Involve the patient's family at this meal digestion according to the indication. 13. Observation of the signs of hypoglycemia, such as changes in level of consciousness, skin moist / cold, rapid pulse, hunger, sensitive to stimuli, anxiety, headaches. 14. Collaboration examination of blood sugar. 15. Recommend regular ophthalmologic examinations. 16. Teach the patient how to care for his feet. 17. Teach the patient and the family how to monitor the patients diet 18. Collaboration of insulin treatment. 19. Collaboration with dietitians

CASE STUDY
DIABETES MELLITUS

Maria Cristina O. Regatillo BSN 4C C2A