LEGISLATIVE DEPARTMENT

• Pancreas


  Endocrine part: Islets of Langerhans
• Islets of Langerhans


  • Alpha cells
  • Beta cells
  • Delta cells
• Alpha cells


  Secrete glucagon - increases glucose levels (gluconeogenesis)
• Beta cells


  Secrete insulin - decreases glucose levels by: transcellular membrane transport of glucose, inhibits breakdown of fats & carbohydrates, requires Na+ for transport of carbohydrates, requires K+ for production
• Delta cells


  Secrete somatostatin - inhibits action of growth hormone
• Diabetes Mellitus


  A chronic metabolic disease characterized by hyperglycemia due to disorder of carbohydrate, fat and protein metabolism
• Predisposing Factors for Diabetes Mellitus

  • Heredity
  • Obesity (adipose tissues are resistant to insulin, therefore glucose uptake by the cells is poor)
  • Stress (stimulates secretion of epinephrine, nor-epinephrine, glucocorticoids - increased serum carbohydrates)
  • Viral infection (increase risk to autoimmune disorders)
  • Autoimmune Disorders (more associated with Type I DM)
  • Multigravida Women with large babies
• Types of Diabetes Mellitus

  • Type I (IDDM)
  • Type II (NIDDM)
  • Gestational Diabetes
  • Diabetes associated with other conditions or syndromes (Pancreatic disease, Cushing's syndrome, use of certain drugs - steroids, thiazide diuretics, oral contraceptives)
• Type I (IDDM)


  Juvenile-onset, Brittle DM, Unstable DM, Onset is less than 30 years, Common in children or in non-obese adults, NO insulin production, Prone for DKA, Management: Diet, Exercise, Insulin
• Type II (NIDDM)


  Maturity-onset, Stable DM, Ketosis-resistant DM, Onset is 40 years, Common in obese adults, Inadequate insulin production or cells do not respond to insulin, Prone for HHNKS, Management: Diet, Exercise, OHA, Insulin in STRESSFUL situation (surgery, infections, pregnancy, etc.)
• Type II DM during STRESS


  1. Stress response: E, NE, Glucocorticoids release

  2. Hyperglycemia

  3. Give insulin

  4. Normal
• Diabetes Mellitus: Pathophysiology


  INSULIN deficiency leads to HYPERGLYCEMIA
• Symptoms of HYPERGLYCEMIA


  • Polyuria
  • Polydipsia
  • Polyphagia
• How HYPERGLYCEMIA leads to Polyuria

  1. Large amount of glucose pass through the kidney

  2. It will exert high osmotic pressure within the renal tubules

  3. OSMOTIC DIURESIS

  4. POLYURIA
• How HYPERGLYCEMIA leads to Polydipsia and other complications

  1. Due to increased blood osmolarity, water moves from inside to outside the cell (ICF dehydration)

  2. There will be hypovolemia (ECF dehydration)

  3. Glycosuria will occur if glucose in the blood is >180 mg/dl (renal threshold)

  4. Hyperglycemia leads to Polyuria, Loss of Fluids & electrolytes

  5. Hypovolemia leads to Hypotension, Renal failure, Coma & Death (decrease blood flow to the brain)
• How HYPERGLYCEMIA leads to Polyphagia

  1. Cellular starvation leads to Hunger & appetite

  2. Polyphagia
• How HYPERGLYCEMIA leads to Ketoacidosis

  1. Cellular starvation leads to increased breakdown of Protein, Fats, Ketones

  2. Lipolysis, ketonuria, hyperlipidemia, Metabolic acidosis (Ketones are acid bodies - Acetone, acetoacetic acid, β-hydroxybutyric acid)

  3. Osmotic diuresis, ketonemia, atherosclerosis, Acetone breath

  4. Ketones act as CNS depressants and may decrease brain pH leading to coma
• How HYPERGLYCEMIA leads to Weight loss

  1. Cellular starvation leads to increased breakdown of Protein

  2. Protein breakdown leads to increased BUN and serum creatinine, Negative nitrogen balance, Debilitation, Tissue wasting
• How HYPERGLYCEMIA leads to Infections

  1. Due to increased blood viscosity, Sluggish circulation, Proliferation of microorganisms

  2. Infections, Periodontal, UTI, Vasculitis, Cellulitis, Vaginitis, Furuncles, Carbuncles, Retarded Wound Healing
• Complications of Diabetes Mellitus

  • Macroangiopathy (Brain - Cerebrovascular accident, Heart - Myocardial infarction, Peripheral arteries - Peripheral vascular disease)
  • Microangiopathy (Kidneys - Renal failure due to nephropathy, Eyes - Cataract due to retinopathy)
  • Neuropathy (Spinal Cord/ANS - Peripheral neuropathy involving damage to the PNS affecting movement, sensation and bodily functions, Paralysis, Gastroparesis, Neurogenic bladder, Decreased Libido, impotence)
• Diagnostic Tests for Diabetes Mellitus

  • Random Blood Sugar (RBS)
  • Fasting Blood Sugar (FBS)
  • Postprandial Blood Sugar
  • Oral Glucose Tolerance Test (OGTT)
  • Glycosylated hemoglobin (HbA1c)
• Random Blood Sugar (RBS)


  Blood specimen is drawn without preplanning, ≥200mg/dl + symptoms is suggestive of DM
• Fasting Blood Sugar (FBS)

  Blood specimen after 8 hours of fasting, Normal (70-100 mg/dl), pre diabetes (101 but <126mg/dl), DM- > 126 mg/dl
• Postprandial Blood Sugar


  Blood sample is taken 2 hrs after a high CHO meal, No DM (70-140mg/dl), prediabetes (≥140 but <200 mg/dl)
• Oral Glucose Tolerance Test (OGTT)

  1. Diet high in CHO is eaten for 3 days

  2. Client then fast for 8 hours. A baseline blood sample is drawn & a urine specimen is collected

  3. An oral glucose solution is given and time of ingestion recorded

  4. Blood is drawn at 30 minutes & 1, 2, and 3 hours after the ingestion of glucose solution. Urine is collected

  5. No DM (glucose returns to normal in 2-3 hours & urine is negative for glucose)

  6. DM (blood glucose returns to normal slowly; urine is positive for glucose)
• Glycosylated hemoglobin (HbA1c)


  Single sample of venous blood is withdrawn, The amount of glucose stored by the hemoglobin is elevated above 7% in the newly diagnosed client with DM, in one who is noncompliant, or in one who is inadequately treated
• Management of Diabetes Mellitus

  • DIET (Low caloric diet specially if obese, Diet should be in proportion - 20% Carbohydrates, 30% Fats, 50% Carbohydrates, Consume complex Carbohydrates and HIGH fiber diet)
  • EXERCISE (Increases Carbohydrate uptake by the cells, Decreases insulin requirements, Maintains ideal body weight, serum carbohydrates & serum lipids)
  • Medications (Insulin for Type I & II, Oral Hypoglycemic Agents (OHA) for Type II - Sulfonylureas, Nonsufonylureas, Biguanides, Alpha-glucosidase inhibitors, Thiazolidinediones, Meglitinides)
• Insulin


  Used for Type I diabetes, used in Type II diabetes (client in stressful situation or hospitalized), Insulin preparations can consist of a mixture of beef and pork insulin, pure beef, pure pork, human insulin - purest insulin and has the lowest incidence of hypersensitivity
• Human insulin


  Recommended for all newly diagnosed Type I diabetics, Type II diabetics who need short-term insulin therapy, pregnant client, diabetic clients with insulin allergy or severe insulin resistance
• Insulin Types


  • Rapid acting (Lispro (Humalog), Aspart (Novalog))
  • Short acting (Regular (Humulin R, Novolin R, Iletin II regular))
  • Intermediate (NPH, Humulin N, Lente, Humulin L)
  • Long acting (Ultralente, Glargine (Lantus))
• Rapid acting insulin


  Onset: 5 minutes, Peak: 30 mins - 1hr, Duration: 2 to 4 hrs
• Short acting insulin


  Onset: 30 min to 1 hr, Peak: 2 t0 4 hrs, Duration: 6 to 8 hrs
• Intermediate insulin


  Onset: 1 to 2 hrs, Peak: 1 to 2 hrs, Duration: 6 to 12 hrs, 8 to 12 hrs, 18 to 24 hrs
• Long acting insulin


  Onset: 5 to 8 hrs, Peak: UK, Duration: 14 to 20 hrs, 30 to 36 hrs, 24 hrs
• Nursing Responsibilities in Insulin Therapy

  • Route: Subcutaneous (slow absorption, less painful, 90° (thin) 45° obese clients, no need to aspirate, do not massage site of injection), IV insulin: given in emergency cases (DKA)
  • Administer insulin at room temperature (Cold insulin can cause lipodystrophy - Lipoatrophy, Lipohypertrophy)
  • Store vial of insulin in current use at RT (Insulin can be stored at RT for 1 month, Other vials should be refrigerated)
  • Rotate the site of injection (To prevent lipodystrophy which inhibits insulin absorption)
  • Gently roll vial in between the palms to redistribute insulin particles
• Ultralente


  Long-acting insulin with onset of 5-8 hrs, peak unknown, and duration of 30-36 hrs
• Glargine (Lantus)


  Long-acting insulin with onset of 14-20 hrs, peak unknown, and duration of 24 hrs
• Insulin types


  • Rapid acting (clear): Lispro (Humalog), Aspart (Novalog)
  • Short acting (clear): Regular (Humulin R, Novolin R, Iletin II regular)
  • Intermediate (cloudy): NPH, Humulin N, Lente, Humulin L
  • Long acting: Ultralente, Glargine (Lantus)
• Diabetes Mellitus: Management


  • Insulin
  • Sulfonylureas (insulin releasers)
  • Biguanides (insulin sensitizers)
  • Alpha-glucosidase inhibitors
  • Thiazolidinediones (insulin sensitizers)
  • Meglitinides (insulin releasers)
• Nursing Responsibilities in Insulin Therapy

  • Route: Subcutaneous
  • Slow absorption, less painful, 90° (thin) 45° (obese) clients, no need to aspirate, do not massage site of injection
  • IV insulin: given in emergency cases (DKA)
  • Administer insulin at room temperature
  • Cold insulin can cause lipodystrophy (lipohypertrophy, lipoatrophy)