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DIABETES MELLITUS Rachel S. Natividad RN, MSN, NP
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Review A&P
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Role of Insulin Insulin:
Counters metabolic activity that would increase blood glucose levels Enhances transport of glucose into body cells Lowers blood glucose levels
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Physiology Cont: Insulin
Basal (continuous) Prandial (Bolus) *Blood glucose increases within 10 minutes of the beginning of a meal*
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Diabetes Mellitus A disorder of carbohydrate, protein, and fat metabolism resulting from an imbalance between insulin availability and insulin need. (Porth, 2002) End Result : HYPERGLYCEMIA
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Physiology Cont.:Glucose Control
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Patho: DM Type 1
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Patho Cont.: DM Type 2
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Normal Physiology 10
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Pathophysiology-Cont.:DM Type 2
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DM 1&2: The big difference…
DM TYPE 1 DM TYPE 2 No endogenous insulin Some endogenous insulin Tx requires insulin injections Tx diet and exercise 1st, then pills and /or insulin Usually < age 30 yrs. Usually over 30 yrs. (peaks at 50) Ketosis prone (DKA) no ketosis Former names: IDDM (Juvenile) Diabetes Type I NIDDM (maturity/adult- onset) Diabetes Type II Thin to normal body weight Usually Overweight Acute metabolic complications (DKA) Chronic vascular complications
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Case Study
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Diabetes: Clinical Manifestations
THE 3 POLYs POLYDYPSIA POLYURIA POLYPHAGIA 14
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Diabetes Clinical Manifestations Cont: Signs and Symptoms
Early signs 3 Polys Weight loss Fatigue/Always tired Visual Blurring Late signs Any of the 3 Polys Infections Numbness/ tingling of feet or leg pain Slow healing wounds Chronic Complications
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Diabetes: Dx Tests Fasting Blood Glucose (FBG): <100 mg/dL
Check MD orders or agency protocol for frequency of BS Monitoring In General: AC&HS if pt able to eat; Q4-6 hours if NPO or tube feedings Fasting Blood Glucose (FBG): <100 mg/dL Iggy: mg/dL *Random/Casual Blood Glucose*:<200 mg/dL Oral Glucose Tolerance Test (OGTT): < 140 mg/dL Glycosylated Hemoglobin (HgbA1C): 4-6%
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Diabetes: Diagnostic Tests Cont.
Glycosylated hemoglobin test – Hemoglobin A1C (HbA1c) measures the amount of glycosylated hemoglobin (hemoglobin that is chemically linked to glucose) in blood. Normal -4-6% Target range DM patient <7%
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HbA1C Control
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Criteria for the Diagnosis of Diabetes Mellitus
Normal FPG <100 mg per dL 2hr OGTT <140 mg per dL Diabetes- positive findings from any two of the following tests on different days: Symptoms of diabetes mellitus* plus casual (random) plasma glucose concentration >=200 mg / dL or FPG >=126 mg per dL 2hr OGTT >=200 mg per dL after a 75-g glucose load
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Diagnostic Tests – Cont. Is it Diabetes Yet?
>126 >200 >6 Impaired Fasting Glucose Impaired Glucose Tolerance <100 <140 <6
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Acute Complications Hyperglycemic-Hyperosmolar Nonketotic Syndrome (HHNS) BS > 800 mg/dL Similar symptoms No Ketosis Diabetic Ketoacidosis (DKA) BS > 300 mg/dL Classic symptoms Ketosis Check urine for ketones
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(ADA)
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Chronic Complications of DM
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Effects on Blood Vessels
Lumen
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Chronic Complications - Macrovascular
Cardiovascular heart disease Cerebrovascular Stroke Peripheral vascular disease DM pts have heart disease and stroke risks 2 to 4 X higher than non-DM pts
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Chronic Complications-Microvascular :
Diabetic Retinopathy The leading cause of new cases of blindness in adults ages
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Chronic Complications-Microvascular
Nephropathy The leading cause of end-stage renal disease (ESRD), occurs in about % of patients with diabetes
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Chronic Complications-Microvascular
Diabetic Neuropathy - the poor blood supply will cause the nervous system to malfunction In the case of feet, the first complication is that the circulation of blood is impeded. It is thought that high sugar levels in the blood affect the lining of blood vessels making them rough. This allows fatty deposits to stick to the lining and leads to arteriosclerosis. It is harder to push blood round the body and it is generally the outermos parts of the body that suffer the most. This means the feet are liable to pick up cuts and bruises and take longer to heal from these problems. Over time, continued poor circulation begins to affect the capillaries or small blood vessels that are responsible for providing blood to the nervous system and extremities of the body. Eventually the poor blood supply will cause the nervous system to malfunction. This is another complication of diabetes and is called diabetic neuropathy. Common Diabetes Foot Problems And How To Prevent Them Circulation Foot problems in diabetes can be caused by damage to both large and small blood vessels, which is much more common in diabetes. Foot problems, including nerve damage or peripheral neuropathy, usually begin with vascular disease. Damage to small blood vessels, in particular, appears to be the major cause of nerve damage that results in loss of feeling, or worse pain and burning sensations that bother the feel and legs. Once nerve damage progresses, it triggers loss of motor control and the abnormal gait that results in ulcers and amputations. Preventing foot problems in diabetes begins by preventing the loss of circulation that will result in serious nerve damage. This is relatively easy today if the risks for circulatory problems is recognized early. Keeping the blood pressure below 130/80 is essential for reducing damage to blood vessel walls. Preventing placque formation is also critical. This is done with medications the lower triglycerides and raise HDL, such as gemfibrozil and niacin, and those that lower LDL and make it lighter, such as the statins. Blood vessels walls can also be protected with certain blood pressure meds called ACE inhibitors. Blood flow may be improved with high dose vitamin E, although 1200 mg to 1500 mg a day are usually required for this effect. Signs Of Blood Vessel Problems In The Feet: absence of foot pulses a pale color of the foot when it is raised feet that feel cold pain at rest pain pain at night relieved by hanging the feet over the side of the bed thin appearing skin loss hair from the toes and feet shiny skin a blue color of the toes reddish color of the feet ulcers that don't heal a foot infection that is hard to heal Although amputations are 15 times as common with diabetes, about half can be prevented with simple steps that protect the feet: Nerve Damage Unfortunately, about 60 to 70 percent of people with diabetes already have at least a mild form of nerve damage. Damage appears to be largely caused by damaged circulation, but can also be worsened by direct damage to the nerves caused by high blood sugars. There are three types of nerve damage in diabetes: sensory, motor, and autonomic. Ways in which nerve damage may appear: loss of sweating which can causes dry skin, cracks in the skin, and callus buildup pain, tingling , burning, and numbness that start in the feet and slowly progress up the calves loss of tendon reflex and sense of vibration to a tuning fork inability to detect excessive heat such as in a bath or heating pad inability to detect objects in shoes, like rocks, paper clips, safety pins, tacks, or coins, leading to injury, infection, and an ulcer weakness in small muscles of the foot that cause the toes to claw, and in later stages causes foot drop ulcers occur after feeling is lost, combined with an abnormal gait and foot deformities (once you can't feel the ground, you can't walk right) How to care for feet in trouble Preventing trauma is the best way to prevent amputation. Properly fitted shoes are essential, with tennis shoes being ideal whenever possible. Plastisote shoe inserts are ideal for many shoes. If foot deformities such as hammar toes are present, orthodic shoes should be obtained immediately to reduce callus formation. Reduce your risk of amputation with these simple steps: use your eyes and hands daily to sense existing or potential damage to your feet keep a mirror on the floor near your bed to conveniently look at the bottom of your feet for redness, sores and cracks in the skin bacteria love cracks and crevices in the skin --- keep lanolin or other moisturizing lotion handy and use it regularly never walk barefooted even to the bathroom avoid open shoes like the plague thick socks are great tennis shoes and suede shoes are least likely to create foot problems never wear new shoes more than an hour before checking for red pressure spots and early blisters --- new shoes need to be fitted before purchase --- great looking shoes will later look stupid if they cause an amputation. always feel inside your shoes before putting your feet into them corns and calluses need to be treated early --- these deformities present the same danger as having a rock in your shoe that causes repeated trauma to one area of the foot wash and dry your feet thoroughly each day --- keeps bacteria counts down keep a close eye and nose out for athlete's foot, especially between the 4th and 5th toes --- if present, use Tinactin or other powder insid all socks and shoes, and Micotin spray between the toes till gone, and repeat treatment as soon as it reappears (athlete's foot can crack the skin between the toes and this offer triggers the infection that leads to the later amputation) don't reduce your blood flow by crossing your legs trim your toenails straight across --- ingrown toenails are another frequent trigger for infections and ulcers if you have any existing foot problems or deformities, be sure you see your podiatrist regularly
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Chronic Complications-Microvascular
Amputation of Toes
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Chronic Complications-Microvascular
Sexual problems for men erectile dysfunction retrograde ejaculation Sexual problems for women decreased vaginal lubrication decreased sexual response Urologic problems for men and women urinary tract infections neurogenic bladder
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Chronic Complications-Microvascular
Gastroparesis Nerve damage to the digestive system most commonly causes constipation. Damage can also cause the stomach to empty too slowly
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MANAGEMENT OF DM Regular Blood Glucose Monitoring Drug Therapy Diet
Exercise 32
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Management: Diet & Exercise
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Diet : Diabetes Food Pyramid
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Diet Cont: What to do???
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Diet Cont. Carb-Counting
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Diet Cont: Glycemic Index
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Diet Cont.: Getting the balance right
Get your portions right!!
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Management: Exercise Helps regulate blood glucose
Increases insulin effectiveness and sensitivity in the body. Must monitor insulin and food intake to match exercise regimen.
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Insulin & Oral Antidiabetic Agents
Drug Therapy Insulin & Oral Antidiabetic Agents
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Drug Therapy: Insulin Types
Fast-acting insulin Rapid Acting Insulin Analogs Regular Human Insulin Intermediate-acting insulin NPH Human Insulin Pre-Mixed Insulin Long-acting insulin Insulin Glargine, Insulin Detemir BOLUS Used to lower blood sugar after eating a meal BASAL Used to lower blood sugar throughout the day and night
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Drug Therapy Cont.: Insulin
Onset - how soon it starts to work in the blood Peak - when the insulin has the greatest effect on blood sugar levels Duration – how long it keeps working
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Drug Therapy Cont: Goal of Insulin Therapy
Basal and Bolus Insulin Coverage
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Drug Therapy Cont.: Insulin Regimen: Type 1
Multiple insulin doses per day Sample Regimen BOLUS: a rapid-acting (aspart or lispro) or short-acting regular insulin before breakfast, another before dinner, + BASAL: an intermediate-acting insulin (such as NPH) at bedtime. A patient may learn to base doses on her meals and activities that day – this simulates a more physiologic process. May include taking aspart or lispro with meals and NPH or glargine at bedtime.
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Drug Therapy Cont. Insulin Regimen: Type 2
Once-daily insulin in combination with oral agents is appropriate for some patients Combination of either rapid-acting or short-acting insulin with intermediate-acting insulin are commonly used NPH or glargine in the HS or 70/30 NPH + regular insulin before the pm meal Rapid- or short-acting insulin before the first meal of the day + NPH before bedtime
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Drug Therapy Cont: Sample Insulin Regimen (NPH & Regular insulin)
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Drug Therapy-Insulin Cont: Rapid Acting “Logs”
Humalog (insulin lispro) Novolog (insulin aspart) Bolus insulin Onset 15 min; peaks 1-2 hrs; lasts 4-6 hours Ideal for meal coverage “Give the shot while the plate is hot!”
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Drug Therapy-Insulin Cont: Short Acting: Regular Insulin
Bolus insulin Onset ½-1 hr; peaks 2-4 hrs; lasts 6-8 hrs Give 30 minutes to 1 hour before a meal
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Drug Therapy-Insulin Cont: Short Acting: Regular Insulin
♪ It’s time give you your regular insulin ♪ ♪ It’s time to give it 30 minutes before your plate is in ♪ ♪ Come back to check you in 2 (hours) ♪ ♪ Watch out for shakes and sweats too ♪ ♪ If your lucky you’ll have no clue!!!! ♪
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Drug Therapy-Insulin Cont: Rapid Acting (Humalog/Novolog) VS
Drug Therapy-Insulin Cont: Rapid Acting (Humalog/Novolog) VS. Short Acting (Regular Insulin) Delayed onset Peaks in 2-4 hr Lasts 4-6 hours Rapid onset 1 hour peak Limited duration
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Drug Therapy-Insulin Cont: Hypoglycemia
BS < mg/dL An acute complication of insulin administration Tx: (15/15 or 20/20 Rule) Give 15/20 g simple carb and recheck BG in 15/20 minutes
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Drug Therapy-Insulin Cont: Intermediate acting: NPH Insulin
Basal insulin: covers blood sugar between meals Satisfies overnight insulin requirement Onset 1-2 hrs, peaks 6-10 hrs, lasts 12+ hrs Need snack if NPH given at 5 pm (only) Ideal to be given at 9 pm (HS) to address Dawn Phenomenon
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Drug Therapy-Insulin Cont: L ong-Acting: Peakless Insulins!!!
Lantus (insulin glargine) Levimir (insulin detimir) Basal Insulin Onset 1.5 hrs; no peak (max effect in 5 hrs); lasts 24 hours No risk for hypoglycemia Do not mix with other insulins – becomes inactivated when mixed with other insulins
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Lantus
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Synthetic injectables
Byetta: Synthetic incretin mimetic hormone Indicated for patients with type 2 diabetes who don’t use insulin Symlin: Synthetic analogue of human amylin Approved for use with insulin in adults with type 1 and type 2 diabetes
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Drug Therapy Cont: Other Methods of Administration
Used to manage type 1 and type 2 diabetes Often considered if patient’s diabetes isn’t controlled despite appropriate use of insulin, oral agents, and lifestyle changes A rapid-acting insulin such as insulin aspart is commonly used
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Continuous IV insulin infusion
Used to maintain glycemic control in hospitalized patients with high blood glucose levels; in DKA and HHNS May also be given preoperatively or postoperatively More frequent BS monitoring ( q1-2 hours per agency protocol)
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Oral Antidiabetic agents (see handout)
Drug Therapy Cont: Oral Antidiabetic agents (see handout)
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New Oral Med Januvia (Sitagliptin)
An oral drug that reduces blood sugar levels in patients with type 2 diabetes. Sitagliptin is the first approved member of a class of drugs that inhibit the enzyme, dipeptidyl peptidase-4 (DPP-4).
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Administer meds (see Simon’s MAR)
Things to Ponder Look at MAR and decide which meds you’ll administer at what time. What are your concerns with Simon’s schedule of meds? Hint: look at onset/peak of Diabetes meds It is now 0730 and the BS at 0700 = 150 mg/dL, what would you do? What do you need to monitor for and when? Why is Simon on insulin and oral diabetes meds?
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Discussion (see Simon’s MAR)
WHAT IF’s: Nurse decided to administer 2 units of Reg insulin at 0730 and Glyburide and Metformin at 1000 as scheduled. Simon calls at 11:30 c/o shaking, sweating. (What would you do?) BS at 11:30 = 62 mg/dL (What would you do?)
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Acute Complication of (some) Oral Meds: Hypoglycemia
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Discussion (see Simon’s MAR)
Nurse decided to give the insulin but held the PO meds. What is going to happen? At 11:30 BS=325; What would you do?
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Hyperglycemia
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Critical Thinking Exercises
Course Packet pp
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Diabetic Teaching Needs
Disease process S/S of hyperglycemia and hypoglycemia Blood sugar monitoring Diet Exercise Drug therapy Sick Day Rules Complications (acute and chronic) Prevention: Foot care, eye exam etc.
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DIABETES can be controlled!!!
Prevention of Complications…. Tight BS control
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