1. Adult Medical-Surgical Nursing Endocrine Module: Longterm Complications of Diabetes Mellitus

2. Long-term Complications of DM  Uncontrolled hyperglycaemia gives rise to longterm complications within 5 -10 years usually

3. Long-term Complications of DM  Macrovascular disease  Microvascular disease  Neuropathy

4. Long-term Complications of DM  Macrovascular Disease

5. DM: Macrovascular Disease  Accelerated atherosclerosis of large vessels →  Coronary artery disease: may include “ silent myocardial infarction ” (on ECG)  Cerebrovascular disease: TIA, stroke  Peripheral vascular disease: gradual occlusion of lower arteries, ↓ pulses, intermittent claudication, ↓ blood flow to extremities → gangrene

6. Macrovascular Disease: Management  Close control of blood glucose (diet and exercise; oral hypoglycaemics or insulin)  Control of obesity  ↓ hyperlipidaemia ( ↓ LDL, ↑ HDL)  Control of hypertension  ↓ smoking; promote foot care/ hygiene  Close monitoring of disease progress and intervention as necessary

7. Long-term Complications of DM  Microvascular Disease

8. DM: Microvascular Disease  Microvascular complications are unique to DM, especially type 1  Hyperglycaemia thickens the capillary basement membrane, base for the single layer of endothelial cells (the intima) where exchange of gases and nutrients occurs  Affects microvascular circulation of:  The retina (retinopathy)  The kidneys (nephropathy)

9.  Diabetic Retinopathy

10. Diabetic Retinopathy: Pathophysiology  Hyperglycaemia → micro-aneurysms, small haemorrhages, capillary closure, macula oedema and loss of nerve fibres leading to blurred vision and gradual loss of central vision  Proliferation of new capillaries across retina in vitreous humour, which are prone to bleed  Vitreous haemorrhage, fibrous scars, retinal detachment and blindness

11. Diabetic Retinopathy: Clinical Manifestations  Blurring of vision  Loss of central vision  Spots before the eyes  No pain  Gradually leads to blindness

12. Diabetic Retinopathy: Diagnosis  Patient history and clinical manifestations  Examination with Ophthalmoscope  Fluroscein angiography (dye outlines the capillaries)

13. Diabetic Retinopathy: Prevention  Control blood glucose  Regular eye examinations

14. Diabetic Retinopathy: Management  Treatment:  Intensive regular insulin therapy (6- hourly) reduces disease progression  Laser (LA) destroys new and leaking blood vessels  Vitrectomy (advanced): removes vitreous humour replacing with saline; improves vision but not completely

15.  Diabetic Nephropathy

16. Diabetic Nephropathy: Pathophysiology  Thickened basement membrane in the glomerulus of the Bowman’s Capsule →  Elevated pressure affecting glomerular filtration → microalbuminuria/ proteinuria

17. Diabetic Nephropathy: Clinical Manifestations  Usual symptoms of renal disease: oliguria, oedema and weight gain, hypertension, fatigue, anaemia  Usually other systems failing: poor vision, impotence, neuropathy and maybe “diabetic foot” ulcers, dyspnoea (CHF), nocturnal diarrhoea (autonomic neuropathy)

18. Diabetic Nephropathy: Diagnosis  Lab test for albumen in urine (albumen in urine indicates nephropathy in 85% diabetics)  24 hour urine save for albumen  KFT  Creatinine clearance test

19. Diabetic Nephropathy: Management  Control blood glucose  ACE inhibitors to control BP (These will reduce proteinuria also)  Low salt diet  Treat infection early (UTI)  Adjust medications with kidney function  Dialysis  Renal Transplant

20. DM: Longterm Complications  Diabetic Neuropathy

21. Diabetic Neuropathy  Hyperglycaemia leads to demyelination of the nerves and reduced conduction of impulses  Classification:  Peripheral neuropathy (sensory or motor) is most common. Usually affects lower extremities symmetrically  Autonomic  Spinal nerve

22. Peripheral Diabetic Neuropathy: Clinical Manifestations  Paraesthesia: heightened sensation with tingling, burning at night → numbness with disease progression  ↓ proprioception; deep tendon reflex  Unsteady gait: ↓ sensation to touch; ↑ risk of injury and infection  Joint deformities (weight distribution effect)  Painful lower extremities (lactic acid)

23. Diabetic Peripheral Neuropathy: Diagnosis  Patient history and clinical picture  Neurological examination and tendon reflexes  Nerve conduction studies  Corresponding assessment of blood supply to extremities

24. Diabetic Peripheral Neuropathy: Management  Control blood glucose; frequent monitoring  Control pain  Careful regular foot care/ hygiene  Splints to prevent/ correct deformity  Exercises to improve circulation  Vitamin B complex and B12

25.  Diabetic Neuropathy: Autonomic Nervous System and Spinal Nerves

26. Autonomic Diabetic Neuropathy: Clinical Manifestations  Silent MI; orthostatic hypotension ( ↓ sympathetic activity)  Delayed gastric emptying, nausea, constipation, nocturnal diarrhoea, swings in blood glucose as inconsistent absorption  Neurogenic bladder (retention)  Adrenal disorder: inability to sense and respond to hypoglycaemia (dangerous)

27. Diabetic Spinal Neuropathy: Clinical Manifestations  Neurogenic bladder (flaccid bladder: retention overflow incontinence); chronic infection risk  Sexual impotence  Problems with mobility

28. Diabetic Autonomic and Spinal Neuropathy: Diagnosis  Patient history and clinical picture  ECG  Bladder function studies (micturating cystogram)  Reflexes and nerve conduction tests

29. Diabetic Neuropathy (Autonomic and Spinal): Management  Control blood glucose  Avoid strenuous exercise  Monitor BP, ECG  Elastic stockings ( ↑ venous return)  Small frequent meals; ↓ salt, ↓ fat  Ensure bladder emptying/ hygiene  Prevention/ prompt treatment of UTI  Skin care (pressure); counselling