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Description

Diabetes is a chronic disease, which occurs when the pancreas does not produce enough
insulin, or when the body cannot effectively use the insulin it produces. This leads to an
increased concentration of glucose in the blood (hyperglycaemia).
Type 1 diabetes (previously known as insulin-dependent or childhood-onset diabetes) is
characterized by a lack of insulin production.
Type 2 diabetes (formerly called non-insulin-dependent or adult-onset diabetes) is
caused by the bodys ineffective use of insulin. It often results from excess body weight
and physical inactivity.
Gestational diabetes is hyperglycaemia that is first recognized during pregnancy.

Causes
The cause of diabetes depends on the type.



Type 1 diabetes
Is partly inherited, and then triggered by certain infections, with some evidence pointing
at Coxsackie B4 virus. A genetic element in individual susceptibility to some of these
triggers has been traced to particular HLA genotypes (i.e., the genetic "self" identifiers
relied upon by the immune system). However, even in those who have inherited the
susceptibility, type 1 DM seems to require an environmental trigger. The onset of type 1
diabetes is unrelated to lifestyle.

Type 2 diabetes
is due primarily to lifestyle factors and genetics.
The following is a comprehensive list of other causes of diabetes:
Genetic defects of -cell function
o Maturity onset diabetes of the young

o Mitochondrial DNA mutations
Genetic defects in insulin processing or insulin action
o Defects in proinsulin conversion
o Insulin gene mutations
o Insulin receptor mutations
Exocrine pancreatic defects
o Chronic pancreatitis
o Pancreatectomy
o Pancreatic neoplasia
o Cystic fibrosis
o Hemochromatosis
o Fibrocalculous pancreatopathy
Endocrinopathies
o Growth hormone excess (acromegaly)
o Cushing syndrome
o Hyperthyroidism
o Pheochromocytoma
o Glucagonoma
Infections
o Cytomegalovirus infection
o Coxsackievirus B
Drugs
o Glucocorticoids
o Thyroid hormone
o -adrenergic agonists
o Statins




TYPE I VERSUS TYPE 2 DIABETES
PE I (IDDM)
TYPE 2 (NIDDM)
Age of onset
Usually younger than 40 Usually older than 40
Body weight Thin Usually overweight
Symptoms Sudden onset Insidious onset
Insulin produced None Too little, or not effective
Insulin requirements Exogenous insulin required May require insulin

Pathophysiology

DM Type I
DM Type II


Signs and symptoms
The classic symptoms of untreated diabetes are loss of weight, polyuria (frequent
urination),polydipsia (increased thirst) and polyphagia (increased hunger).Symptoms may
develop rapidly (weeks or months) in type 1 diabetes, while they usually develop much
more slowly and may be subtle or absent in type 2 diabetes.

Prolonged high blood glucose can cause glucose absorption in the lens of the eye, which
leads to changes in its shape, resulting in vision changes. Blurred vision is a common
complaint leading to a diabetes diagnosis; type 1 should always be suspected in cases of
rapid vision change, whereas with type 2 change is generally more gradual, but should
still be suspected. A number of skin rashes that can occur in diabetes are collectively
known as diabetic dermadromes.
Diabetic emergencies
People (usually with type 1 diabetes) may also present with diabetic ketoacidosis, a state
of metabolic dysregulation characterized by the smell of acetone, a rapid, deep breathing
known as Kussmaul breathing, nausea, vomiting and abdominal pain, and altered states
of consciousness.
A rare but equally severe possibility is hyperosmolar nonketotic state, which is more
common in type 2 diabetes and is mainly the result of dehydration.
WARNING SIGNS OF DIABETES

SIGNS AND SYMPTOMSS LABORATORY FINDINGS
Sudden onset
Polyurea
Polydipsia
Polyphagia
20 pound weight loss
Irritability
Weakness and fatigue
Nausea, vomiting
Insidious onset
Fatigue
Blurred vision
Tingling or numbness in hands and feet
Itching
Any symptoms of IDDM or hard to heal
wounds
Frequent bladder infections

Signs, Symptoms, and Treatment of Hypoglycemia and
Hyperglycemia

HYPOGLYCEMIA
Cause: Usually secondary to excess insulin, exercise, or not enough food
Signs and Symptoms
Nervousness
Irritability
Diaphoresis (heavy sweating)
Hunger
Weakness
Tachycardia
Fatigue
Hypotension
Palpitations
Tachypnea
Tremors or shaking Pallor
Blurred or double vision
Incoherent speech
Headache Numbness of tongue and lips
Confusion Coma
Seizures
Treatment

Provide rapidly absorbed source of glucose:
Fruit juice or cola
Graham crackers
Sugar cubes, sugar packets
Hard candy
As symptoms improve:
Provide a meal or source of complex protein or carbohydrates
HYPERGLYCEMIA

Cause: Usually secondary to insufficient insulin, illness, or excess food

Signs and Symptoms
Confusion
Nausea
Irritability
Vomiting
Fatigue
Anorexia
Weakness
Abdominal cramping
Numbness
Thirst
Tachycardia
Lethargy
Hypotension
Kssmall breathing
Decreased level of consciousness
Increased temperature
Coma
Flushed or dry skin
Fruity breath
Poor skin turgor
Dry mucous membranes
Treatment (Requires Hospitalization)
Restore fluid balance
Replace electrolytes
Lower blood glucose with regular insulin
Monitor: Level of consciousness, vital signs, intake and output, and electrolytes
Provide emotional support

Diagnostic Procedure
Several blood tests are used to measure blood glucose levels, the primary test for diagnosing
diabetes. Additional tests can determine the type of diabetes and its severity.
Random blood glucose test for a random blood glucose test, blood can be drawn at
any time throughout the day, regardless of when the person last ate. A random blood
glucose level of 200 mg/dL (11.1 mmol/L) or higher in persons who have symptoms of
high blood glucose suggests a diagnosis of diabetes.
Fasting blood glucose test fasting blood glucose testing involves measuring blood
glucose after not eating or drinking for 8 to 12 hours (usually overnight). A normal
fasting blood glucose level is less than 100 mg/dL. A fasting blood glucose of 126 mg/dL
(7.0 mmol/L) or higher indicates diabetes. The test is done by taking a small sample of
blood from a vein or fingertip. It must be repeated on another day to confirm that it
remains abnormally high .
Hemoglobin A1C test (A1C) The A1C blood test measures the average blood
glucose level during the past two to three months. It is used to monitor blood glucose
control in people with known diabetes, but is not normally used to diagnose diabetes.
Normal values for A1C are 4 to 6 percent . The test is done by taking a small sample of
blood from a vein or fingertip.
Oral glucose tolerance test Oral glucose tolerance testing (OGTT) is the most
sensitive test for diagnosing diabetes and pre-diabetes. However, the OGTT is not
routinely recommended because it is inconvenient compared to a fasting blood glucose
test.
The standard OGTT includes a fasting blood glucose test. The person then drinks a 75 gram
liquid glucose solution (which tastes very sweet, and is usually cola or orange-flavored). Two
hours later, a second blood glucose level is measured.

Oral glucose tolerance testing is routinely performed at 24 to 28 weeks of pregnancy to screen
for gestational diabetes; this requires drinking a 50 gram glucose solution with a blood glucose
level drawn one hour later. For women who have an abnormally elevated blood glucose level, a
second OGTT is performed on another day after drinking a 100 gram glucose solution. The
blood glucose level is measured before, and at one, two, and three hours after drinking the
solution.

Medical Management
There is no known cure for DM. Management of the disease focuses on control of the
serum glucose level to prevent or delay the development of complications. Individuals with type
1 DM require subcutaneous insulin administration. Insulin may be rapid, intermediate, or
slow acting.

Patients with mild DM or those with type 2 DM or GDM may be able to control the disease by
diet management alone. A diabetic diet attempts to distribute nutrition and calories throughout
the 24-hour period. Daily calories consist of approximately 50% carbohydrates and 30% fat, with
the remaining calories consisting of protein. The total calories allowed for an individual within
the 24-hour period are based on age, weight, activity level, and medications.

In addition to strict dietary adherence to control blood glucose, obese patients with type 2 DM
also need weight reduction. The dietitian selects an appropriate calorie allotment depending on
the patients age, body size, and activity level. A useful adjunct to the management of DM is
exercise. Physical activity increases the cellular sensitivity to insulin, improves tolerance
to glucose, and encourages weight loss. Exercise also increases the patients sense of well-
being concerning his or her health.

Pharmacological Highlights
When diet, exercise and maintaining a healthy weight arent enough, you may need the help of
medication. Medications used to treat diabetes include insulin. Everyone with type 1 diabetes
and some people with type 2 diabetes must take insulin every day to replace what their pancreas
is unable to produce. Unfortunately, insulin cant be taken in pill form because enzymes in your
stomach break it down so that it becomes ineffective. For that reason, many people inject
themselves with insulin using a syringe or an insulin pen injector,a device that looks like a pen,
except the cartridge is filled with insulin. Others may use an insulin pump, which provides a
continuous supply of insulin, eliminating the need for daily shots.

The most widely used form of insulin is synthetic human insulin, which is chemically identical to
human insulin but manufactured in a laboratory. Unfortunately, synthetic human insulin isnt
perfect. One of its chief failings is that it doesnt mimic the way natural insulin is secreted. But
newer types of insulin, known as insulin analogs, more closely resemble the way natural insulin
acts in your body. Among these are lispro (Humalog), insulin aspart (NovoLog) and glargine
(Lantus).
A number of drug options exist for treating type 2 diabetes, including:
Sulfonylurea drugs. These medications stimulate your pancreas to produce and release
more insulin. For them to be effective, your pancreas must produce some insulin on its
own. Second-generation sulfonylureas such as glipizide (Glucotrol, Glucotrol XL),
glyburide (DiaBeta, Glynase PresTab, Micronase) and glimepiride (Amaryl) are
prescribed most often. The most common side effect of sulfonylureas is low blood sugar,
especially during the first four months of therapy. Youre at much greater risk of low
blood sugar if you have impaired liver or kidney function.
Meglitinides. These medications, such as repaglinide (Prandin), have effects similar to
sulfonylureas, but youre not as likely to develop low blood sugar. Meglitinides work
quickly, and the results fade rapidly.
Biguanides. Metformin (Glucophage, Glucophage XR) is the only drug in this class
available in the United States. It works by inhibiting the production and release of
glucose from your liver, which means you need less insulin to transport blood sugar into
your cells. One advantage of metformin is that is tends to cause less weight gain than do
other diabetes medications. Possible side effects include a metallic taste in your mouth,
loss of appetite, nausea or vomiting, abdominal bloating, or pain, gas and diarrhea. These
effects usually decrease over time and are less likely to occur if you take the medication
with food. A rare but serious side effect is lactic acidosis, which results when lactic acid
builds up in your body. Symptoms include tiredness, weakness, muscle aches, dizziness
and drowsiness. Lactic acidosis is especially likely to occur if you mix this medication
with alcohol or have impaired kidney function.
Alpha-glucosidase inhibitors. These drugs block the action of enzymes in your digestive
tract that break down carbohydrates. That means sugar is absorbed into your bloodstream
more slowly, which helps prevent the rapid rise in blood sugar that usually occurs right
after a meal. Drugs in this class include acarbose (Precose) and miglitol (Glyset).
Although safe and effective, alpha-glucosidase inhibitors can cause abdominal bloating,
gas and diarrhea. If taken in high doses, they may also cause reversible liver damage.
Thiazolidinediones. These drugs make your body tissues more sensitive to insulin and
keep your liver from overproducing glucose. Side effects of thiazolidinediones, such as
rosiglitazone (Avandia) and pioglitazone hydrochloride (Actos), include swelling, weight
gain and fatigue. A far more serious potential side effect is liver damage. The
thiazolidinedione troglitzeone (Rezulin) was taken off the market in March 2000 because
it caused liver failure. If your doctor prescribes these drugs, its important to have your
liver checked every two months during the first year of therapy. Contact your doctor
immediately if you experience any of the signs and symptoms of liver damage, such as
nausea and vomiting, abdominal pain, loss of appetite, dark urine, or yellowing of your
skin and the whites of your eyes (jaundice). These may not always be related to diabetes
medications, but your doctor will need to investigate all possible causes.
Drug combinations. By combining drugs from different classes, you may be able to
control your blood sugar in several different ways. Each class of oral medication can be
combined with drugs from any other class. Most doctors prescribe two drugs in
combination, although sometimes three drugs may be prescribed. Newer medications,
such as Glucovance, which contains both glyburide and metformin, combine different
oral drugs in a single tablet.

Nursing Intervention
Advice patient about the importance of an individualized meal plan in meeting weekly
weight loss goals and assist with compliance.
Assess patients for cognitive or sensory impairments, which may interfere with the ability
to accurately administer insulin.
Demonstrate and explain thoroughly the procedure for insulin self-injection. Help patient
to achieve mastery of technique by taking step by step approach.
Review dosage and time of injections in relation to meals, activity, and bedtime based on
patients individualized insulin regimen.
Instruct patient in the importance of accuracy of insulin preparation and meal timing to
avoid hypoglycemia.
Explain the importance of exercise in maintaining or reducing weight.
Advise patient to assess blood glucose level before strenuous activity and to eat
carbohydrate snack before exercising to avoid hypoglycemia.
Assess feet and legs for skin temperature, sensation, soft tissues injuries, corns, calluses,
dryness, hair distribution, pulses and deep tendon reflexes.
Maintain skin integrity by protecting feet from breakdown.
Advice patient who smokes to stop smoking or reduce if possible, to reduce
vasoconstriction and enhance peripheral flow.

DOCUMENTATION GUIDELINES
Results of urine and blood tests for glucose
Physical findings: Visual problems, skin problems or lesions, changes in sensation or
circulation to the extremities
Patient teaching, return demonstrations, patients understanding of teaching
Response to insulin
DISCHARGE AND HOME HEALTHCARE GUIDELINES

MEDICATIONS. Patients need to understand the purpose, dosage, route, and possible
side effects of all prescribed medications. If the patient is to self-administer insulin, have the
patient demonstrate the appropriate preparation and administration techniques.

PREVENTION. The patient and family require instruction in the following areas to minimize or
prevent complications of DM.
Diet. Explain how to calculate the American Diabetic Association exchange list to
develop a satisfactory diet within the prescribed calories. Emphasize the importance
of adjusting diet during illness, growth periods, stress, and pregnancy. Encourage
patients to avoid alcohol and refined sugars and to distribute nutrients to maintain a
balanced blood sugar throughout the 24-hour period.
Insulin. Patients need to understand the type of insulin prescribed. Instructions
should include onset, peak, and duration of action. Stress proper timing of meals and
planning snacks for the time when insulin is at its peak, and recommend an evening
snack for those on long-acting insulins. Reinforce that patients cannot miss a dosage
and there may be a need for increasing dosages during times of stress or illness.
Teaching regarding the proper preparation of insulin, how to administer, and the
importance of rotating sites is necessary.
Urine and Blood Testing. Teach patients the appropriate technique for testing blood
and urine and how to interpret the results. Patients need to know when to notify the
physician and increase testing during times of illness.
Skin Care. Stress the importance of close attention to even minor skin injuries.
Emphasize foot care, including the importance of properly fitting shoes with clean,
nonconstricting socks; daily washing and thorough drying of the feet; and inspection
of the toes, with special attention paid to the areas between the toes. Encourage the
patient to contact a podiatrist as needed. Because of sensory loss in the lower
extremities, teach the patient to test the bath water to prevent skin trauma from
water that is too hot and to avoid using heating pads.
Circulation. Because of the atherosclerotic changes that occur with DM, encourage
patients to stop smoking. In addition, teach patients to avoid crossing their legs
when sitting and to begin a regular exercise program.

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