Diabetes

• It is estimated that more than 25.8 million people in the US have diabetes
• Diabetes Mellitus (DM) is the leading cause of nontraumatic amputations, blindness in working-age adults, and end-stage kidney disease
• Diabetes is a leading cause of death from disease, primarily because of the high rate of cardiovascular disease
• Hospitalization rates for people with diabetes are 2.4 times greater for adults
• Type 1 Diabetes


  Common in younger adults, characterized by destruction of the pancreatic beta cells resulting in decreased insulin production, fasting and postprandial hyperglycemia
• Type 2 Diabetes


  Common in older than 30 years adults and obese, characterized by insulin resistance and impaired insulin secretion, may lead to metabolic syndrome
• Other types of Diabetes


  • Diabetes associated with other conditions
  • Gestational diabetes
  • Prediabetes
• Risk Factors for Diabetes

  • Family history of diabetes
  • Obesity (≥20% over desired body weight)
  • Race/ethnicity
  • Age ≥45 years
  • Previously identified impaired fasting glucose or impaired glucose tolerance
  • Hypertension (HTN) (≥140/90 mm Hg)
  • HDL level ≤35 mg/dL (0.90 mmol/L) and/or triglyceride level ≥250 mg/dL (2.8 mmol/L)
  • History of gestational diabetes or delivery of a baby over 9 lb
• 3 "Ps"


  Polyuria, Polydipsia, Polyphagia (manifestations of hyperglycemia)
• Other symptoms of Diabetes

  • Fatigue and weakness
  • Sudden vision changes
  • Tingling or numbness in hands and feet
  • Dry skin or slow healing wounds
  • Recurrent infections
  • Sudden weight loss, nausea, vomiting, abdominal pain
• Criteria for Diagnosis of Diabetes

  • HbA1C ≥6.5%
  • Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L) (fasting for 8hr)
  • 2-hour plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT
  • A random plasma glucose ≥200 mg/dL (11.1 mmol/L), in patients with classic symptoms of hyperglycemia or hyperglycemic crisis
• Goals of Medical Management of Diabetes

  • Normalize insulin activity and blood glucose levels
  • Reduce development of vascular and neuropathic complications
  • Maintaining high quality of life
• Components of Diabetes Treatment

  • Nutritional therapy
  • Physical activity and exercise
  • Monitoring
  • Pharmacologic therapy
  • Patient and family education
• Goals of Nutritional Therapy

  • Blood glucose levels in the normal range
  • Lipid and lipoprotein profile that reduces the risk for vascular disease
  • Blood pressure levels in the normal range
  • Weight management
  • Meal planning and calorie control
• ADA and the Academy of Nutrition and Dietetics recommend that for all levels of caloric intake: 50% to 60% of calories should be derived from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein
• Low fat does not automatically mean low sugar
• Dietary animal fat does not need to be eliminated from the diet
• Goals of Exercise


  • Slow and gradual increase in the exercise period is encouraged
  • Exercise 3 times each week with no more than 2 consecutive days without exercise
  • Perform resistance training twice a week
  • Exercise at the same time of day (preferably when blood glucose levels are at their peak) and for the same duration each session
  • Use proper footwear
  • Avoid trauma to the lower extremities
  • Inspect feet daily after exercise
  • Avoid exercise in extreme heat or cold
  • Avoid exercise during periods of poor metabolic control
• Monitoring


  • Monitoring of glucose levels and ketones
  • Self-monitoring of blood glucose
  • Continuous glucose monitoring system
  • Testing for HgbA1C
  • Testing for Ketones in blood and urine
• Insulin Therapy


  • Administered mainly for DM1
  • Different preparations with different onset, peak, and duration of action
  • Regimens include one or a combination of insulin types with different administration methods, insulin pump may be considered
  • Complications of insulin and morning hyperglycemia
• Oral Antidiabetic Agents


  • Effective with DM2 patients
• Nursing Care of Client with Diabetes

  • Provide patient and family education
  • Manage glucose control in the hospital setting
• Hypoglycemia


  • Blood glucose < 70mg/ dL
  • Severe hypoglycemia: blood glucose < 40mg/dL
  • Caused by too much insulin or oral hypoglycemic, too little food, excessive physical activity
  • Symptoms: sweating, tremor, tachycardia, palpitation, nervousness, hunger, inability to concentrate, confusion, lightheadedness, numbness of lips and tongue, drowsiness, slurred speech, irritability, LOC
  • Treatment: glucagon 1 mg IM/SC or D50W IV, fast acting carbohydrate, patient education
• Hyperglycemia


  • Signs: high blood glucose, high levels of sugar in the urine, frequent urination, increased thirst
  • Can lead to DKA (diabetic ketoacidosis) or diabetic coma (DM1)
  • Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS) mainly with DM2 and triggered by another illness such as infections and is characterized by hyperglycemia, hyperosmolarity, and dehydration without significant ketoacidosis
• Diabetic Ketoacidosis (DKA)


  • Caused by inadequate amount of insulin, decreased or missed dose of insulin, illness or infection, undiagnosed or untreated DM1
  • Clinical features: hyperglycemia, acidosis, dehydration & electrolyte loss (Na, K)
  • Prevention: "sick day rules"– never eliminate insulin, drink fluids, assess blood glucose and urine ketones
  • Clinical manifestation: blood glucose: 300-800 mg/dL or even higher, low serum bicarbonate, low pH, low PCO2, kussmaul respirations, high blood and urine ketones, dehydration
  • Management: hydration (IV), restoring electrolytes (K), reversing acidosis (insulin IV), bicarb, monitor blood glucose, ECG, U/O
• Hyperglycemic Hyperosmolar Syndrome (HHS)

  • Result of relative insulin deficiency (DM2), increased demand of insulin resulting in hyperosmolarity and hyperglycemia, no ketosis and no acidosis (unlike DKA)
  • Caused by: infection or acute illness, medications that cause hyperglycemia, some treatments such as dialysis
  • Clinical manifestations: polyuria for weeks, polydipsia, neurologic changes, hypotension, severe dehydration, tachycardia, altered LOC, seizures
  • Assessment: blood glucose, electrolytes, BUN, osmolality, mental status, postural hypotension
  • Management: fluid replacement, correction of electrolytes, and insulin
• Macrovascular Complications


  • Changes to medium to large blood vessels: atherosclerotic changes, coronary artery disease, cerebrovascular disease, peripheral vascular disease
  • Direct relationship between hyperglycemia and atherosclerosis
  • Management: lifestyle modification, weight management, exercise, patient and family education, compliance with DM treatment regimen, manage HTN, hyperlipidemia, reduce triglycerides, smoking cessation
• Microvascular Complications


  • Capillary basement membrane thickening, diabetic retinopathy, diabetic nephropathy, diabetic neuropathies
  • Management: control HTN (ACE inhibitors), prevent UTI, manage blood glucose levels, low Na, low protein diet, avoid nephrotoxic medications, contrast dye, insulin therapy and glucose control, pain management
• Peripheral Neuropathy


  Affects nerves of lower extremities, symptoms: paresthesias (prickling, tingling, or heightened sensation) and burning sensations (especially at night), decreased deep tendon reflexes and vibration sensation
• Autonomic Neuropathies


  Affects all body organs: cardiac, GI, renal, sexual dysfunction, decreased sweating, dryness of skin (foot ulcers), hypoglycemia unawareness
• Causes of Hyperglycemia during Hospitalization


  Physiologic stress such as illness, surgery, changes in the usual treatment regimen, medications (e.g., corticosteroids such as prednisone), IV dextrose, overly vigorous treatment of hypoglycemia, inappropriate withholding of insulin or inappropriate use of "sliding scales", mismatched timing of meals and insulin, lack of change of insulin dosage when dietary intake is changed
• Nursing Assessment of DM Client

  • Age, characteristics of diabetes onset, family history and risk factors, eating patterns, physical activity habits, nutritional status, and weight history, history of diabetes education, review of previous treatment regimens and response to therapy, current treatment of diabetes, results of glucose monitoring and patient's use of data, history of DM complications
• Nursing Physical Assessment of DM Client

  • Height, weight, and body mass index (BMI), blood pressure, palpation of the thyroid, examination of the skin, fasting blood glucose, A1C, fasting lipid profile, liver function tests, urine albumin excretion, serum creatinine, BUN, glomerular filtration rate (GFR), thyroid-stimulating hormone (TSH)
• Nursing Referrals for DM Client

  • Eye care professional for annual dilated eye examination
  • Family planning counseling for women of reproductive age
  • Registered dietitian for medical nutrition therapy (MNT)
  • Diabetes self-management education (DSME) tools
  • Dentist for comprehensive periodontal examination
  • Mental health professional
• Cardiovascular Recommendations


  • Assessment, management, & control for CAD and HTN
  • HTN: people with DM and HTN should be treated to a systolic blood pressure (SBP) goal of <140 mmHg and a diastolic blood pressure (DBP) <80 mmHg
• Dyslipidemia Recommendations


  • LDL cholesterol <100 mg/dL, HDL cholesterol >50 mg/dL, and triglycerides <150 mg/dL
  • Lifestyle modification focusing on the reduction of saturated fat, trans fat, and cholesterol intake
  • Statin therapy
• Aspirin Therapy Recommendation


  Aspirin therapy is considered as a primary prevention strategy in patients with type 1 or type 2 diabetes at increased cardiovascular risk
• Smoking cessation is recommended for diabetic patients
• Nephropathy Recommendations


  • To reduce the risk or slow the progression of nephropathy, optimize glucose and BP control
  • Diabetic nephropathy occurs in 20-40% of patients with diabetes and is the single leading cause of end-stage renal disease
  • Perform an annual test to quantitate urine albumin (normal <30) excretion in type 1 diabetic patients with diabetes duration of ≥5 years and in all type 2 diabetic patients starting at diagnosis
• Retinopathy Recommendations


  • Adults with diabetes should have an initial dilated and comprehensive eye examination by an within 5 years for DM1 and shortly after for DM2 after the onset of diabetes
  • To reduce the risk or slow the progression of retinopathy, optimize glucose and BP control