1. DIABETES MELLITUS
Rachel S. Natividad RN, MSN, NP

2. Review A&P

3. Role of Insulin Insulin:
Counters metabolic activity that would increase blood glucose levels
Enhances transport of glucose into body cells
Lowers blood glucose levels

4. Physiology Cont: Insulin
Basal (continuous)
Prandial (Bolus)
*Blood glucose increases within
10 minutes of the beginning
of a meal*

5. 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

7. Physiology Cont.:Glucose Control

8. Patho: DM Type 1

9. Patho Cont.: DM Type 2

10. Normal Physiology 10

11. Pathophysiology-Cont.:DM Type 211

12. 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

13. Case Study

14. Diabetes: Clinical Manifestations
THE 3
POLYs
POLYDYPSIA
POLYURIA
POLYPHAGIA 14

15. 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

16. 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%

17. 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%

18. HbA1C Control

19. 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

20. Diagnostic Tests – Cont. Is it Diabetes Yet?
>126
>200
>6
Impaired Fasting Glucose
Impaired Glucose Tolerance
<100
<140
<6

21. 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

22. (ADA)

23. Chronic Complications of DM

24. Effects on Blood Vessels
Lumen

25. 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

26. Chronic Complications-Microvascular :
Diabetic Retinopathy
The leading cause of new cases of blindness in adults ages

27. Chronic Complications-Microvascular
Nephropathy
The leading cause of end-stage renal disease (ESRD), occurs in about % of patients with diabetes

28. 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

29. Chronic Complications-Microvascular
Amputation of Toes

30. 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

31. Chronic Complications-Microvascular
Gastroparesis
Nerve damage to the digestive system most commonly causes constipation. Damage can also cause the stomach to empty too slowly

32. MANAGEMENT OF DM Regular Blood Glucose Monitoring Drug Therapy Diet
Exercise 32

33. Management: Diet & Exercise

34. Diet : Diabetes Food Pyramid

35. Diet Cont: What to do???

36. Diet Cont. Carb-Counting

37. Diet Cont: Glycemic Index

38. Diet Cont.: Getting the balance right
Get your portions right!!

39. Management: Exercise Helps regulate blood glucose
Increases insulin effectiveness and sensitivity in the body.
Must monitor insulin and food intake to match exercise regimen.

41. Insulin & Oral Antidiabetic Agents
Drug Therapy
Insulin
&
Oral Antidiabetic Agents

42. 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

43. 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

44. Drug Therapy Cont: Goal of Insulin Therapy
Basal and Bolus Insulin Coverage

45. 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.

46. 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

47. Drug Therapy Cont: Sample Insulin Regimen (NPH & Regular insulin)

48. 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!”

49. 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

50. 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!!!! ♪

51. 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

52. 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

53. 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

54. 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

55. Lantus

56. 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

57. 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

58. 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)

59. Oral Antidiabetic agents (see handout)
Drug Therapy Cont:
Oral Antidiabetic agents
(see handout)

60. 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).

61. 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?

62. 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?)

63. Acute Complication of (some) Oral Meds: Hypoglycemia

64. 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?

65. Hyperglycemia

66. Critical Thinking Exercises
Course Packet pp

67. 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.

68. DIABETES can be controlled!!!
Prevention of Complications….
Tight BS control