Diabetes Mellitus

Diabetic Ketoacidosis (DKA) 1. Results from breakdown of fat and overproduction of ketones by the liver and loss of bicarbonate 2. Occurs when Diabetes Type 1 is undiagnosed or known diabetic has increased energy needs, when under physical or emotional stress or fails to take insulin
1. Mortality as high as 14%

3.

Pathophysiology a. Hypersomolarity (hyperglycemia, dehydration) b. Metabolic acidosis (accumulation of ketones) c. Fluid and electrolyte imbalance (from osmotic diuresis)

Diabetes Mellitus
Diagnostic tests a. Blood glucose greater than 250 mg/dL b. Blood pH less than 7.3 c. Blood bicarbonate less than 15 mEq/L d. Ketones present in blood e. Ketones and glucose present in urine f. Electrolyte abnormalities (Na, K, Cl) G. serum osmolality < 350 mosm/kg (normal 280-300)

Diabetes Mellitus
DKA
Signs and symptoms
Kussmals respirations
Blow off carbon dioxide to reverse acidosis

Fruity breath Nausea/ abdominal pain Dehydration Lethargy Coma Polydipsia, polyuria, polyphagia

Diabetes Mellitus
Treatment a. Requires immediate medical attention and usually admission to hospital B .Frequent measurement of blood glucose and treat according to glucose levels with regular insulin (mild ketosis, subcutaneous route; severe ketosis with intravenous insulin administration) c. Restore fluid balance: initially 0.9% saline at 500 1000 mL/hr.; regulate fluids according to client status; when blood glucose is 250 mg/dL add dextrose to intravenous solutions

Diabetes Mellitus
DKA
d.Correct electrolyte imbalance: client often is initially hyperkalemic
As patient is rehydrated and potassium in pushed back into the cell they become hypokalemic Monitor K levels

e. Monitor cardiac rhythm since hypokalemia puts client at risk for dysrrhythmias f. Treat underlying condition precipitating DKA G. Acidosis is corrected with fluid and insulin therapy and rarely needs bicarb

Diabetes Mellitus
Syndrome X or Metabolic Syndrome
Chronic, low grade inflammatory process Gives rise to diabetes type 2, ischemic heart disease, left ventricular hypertrophy Group of disorders with insulin resistance as the main feature Includes
Obesity especially around the waist and abdomen Low levels of physical activity High blood pressure Increased blood cholesterol (high LDL, low HDL, high triglycerides

Diabetes Mellitus
Manifestations 1. Client usually unaware of diabetes a. Discovers diabetes when seeking health care for another concern b. Most cases arent diagnosed for 5-6 years after the development of the disease c. Usually does not experience weight loss

Diabetes Mellitus
2. Possible symptoms or concerns a. Hyperglycemia (not as severe as with Type 1) b. Polyuria c. Polydipsia d. Blurred vision e. Fatigue f. Paresthesias (numbness in extremities) g. Skin Infections

Diabetes Mellitus
Hypersomolar Hyperglycemic Nonketotic Syndrome (HHNS) 1. Potential complication of Diabetes Type 2 2. Life threatening medical emergency, high mortality rate, as high as 50% 3. Enough insulin is secreted to prevent ketosis, but not enough to prevent hyperglycemia 4. High blood sugar causes an extreme diuresis with severe electrolyte and fluid loss

 Characterized by
Plasma osmolarity 340 mOsm/l or greaternormal 280-300 Blood glucose severely elevated, 800-1000 Altered level of consciousness

Diabetes Mellitus
4. Precipitating factors a. Infection (most common)
pneumonia

b. Therapeutic agent or procedure c. Acute or chronic illness

MI Stroke Pancreatitis pregnancy

5.

Slow onset 1 14 days

Diabetes Mellitus
Pathophysiology a. Hyperglycemia leads to increased urine output and dehydration b. Kidneys retain glucose; glucose and sodium rise c. Severe hyperosmolar state develops leading to brain cell shrinkage Manifestations a. Altered level of consciousness (lethargy to coma) b. Neurological deficits: hyperthermia, motor and sensory impairment, seizures c. Dehydration: dry skin and mucous membranes, extreme thirst, tachycardia, polyuria, hypotension

Diabetes Mellitus
Treatment a. Usually admitted to intensive care unit of hospital for care since client is in life-threatening condition: unresponsive, may be on ventilator, has nasogastric suction b. Correct fluid and electrolyte imbalances giving isotonic or colloid solutions and correct potassium deficits c. Lower glucose with regular insulin until glucose level drops to 250 mg/dL Monitor for renal failure d. Treat underlying condition

Diabetes Mellitus
Complications of Diabetes A. Alterations in blood sugars: hyperglycemia and hypoglycemia B. Macrocirculation (large blood vessels) 1. Atherosclerosis occurs more frequently, earlier in diabetics 2. Involves coronary, peripheral, and cerebral arteries C. Microcirculation (small blood vessels) 1. Affects basement membrane of small blood vessels and capillaries 2. Involves tissues affecting eyes and kidneys D. Prevention of complications 1. Managing diabetes 2. Lowering risk factors for conditions 3. Routine screening for complications 4. Implementing early treatment

Diabetes Mellitus
Complications of Diabetes: Alterations in blood sugars A. Hyperglycemia: high blood sugar 1.DKA (mainly associated with Diabetes Type 1) 2.HHS (mainly associated with Diabetes Type 2) 3.Dawn phenomenon: rise in blood sugar between 4 am and 8 am, not associated with hypoglycemia
Glucose released from the liver in the early AM secondary to growth hormones Altering the time and dose of the insulin (NPH or Ultralente) by 2-3 units stabilizes the blood sugar

Diabetes Mellitus
4. Somogyi effect: combination of hypoglycemia during night with a rebound morning hyperglycemia that may lead to insulin resistance for 12 to 48 hours

Diabetes Mellitus
B. Hypoglycemia (insulin reaction, insulin shock, the lows): low blood sugar 1.Mismatch between insulin dose, carbohydrate availability and exercise 2.May be affected by intake of alcohol, certain medications

Diabetes Mellitus
Specific manifestations a. Cool, clammy skin b. Rapid heartbeat c. Hunger d. Nervousness, tremor e. Faintness, dizziness f. Unsteady gait, slurred and/or incoherent speech g. Vision changes h. Seizures, coma 5. Severe hypoglycemia can result in death 6. Clients taking medications, such as beta-adrenergic blockers may not experience manifestations associated with autonomic nervous system 7. Hypoglycemia unawareness: clients with Diabetes Type 1 for 4 or 5 years or more may develop severe hypoglycemia without symptoms which can delay treatment

Diabetes Mellitus
Treatment for mild hypoglycemia a. Immediate treatment: client should take 15 gm of rapid-acting sugar (half cup of fruit juice; 8 oz of skim milk, 3 glucose tablets, 3 life savers b. 15/15 rule: wait 15 minutes and monitor blood glucose; if still low, client should eat another 15 gm of sugar c. Continue until blood glucose level has returned to normal d. Client should contact medical care provider if hypoglycemia occurs more that 2 or 3 times per week

Diabetes Mellitus
Treatment for severe hypoglycemia is often hospitalization a. Client is unresponsive, has seizures, or has altered behavior; blood glucose level is less than 50 mg/dL b. If client is conscious and alert, administer 15 gm of sugar c. If client is not alert, administer 1. 25 % 50% solution of glucose intravenously, followed by infusion of 5% dextrose in water 2. Glucagon 1 mg by subcutaneous, intramuscular, or intravenous route; follow with oral or intravenous carbohydrate d. Monitor client response physically and also blood glucose level

Diabetes Mellitus
Complications Affecting Cardiovascular System, Vision, and Kidney Function A. Coronary Artery Disease 1. Major risk of myocardial infarction in Type 2 diabetics
Increased chance of having a silent MI and delaying medical treatment

2. Most common cause of death for diabetics (40 60%) 3. Diabetics more likely to develop Congestive Heart Failure

Diabetes Mellitus
B. Hypertension 1. Affects 20 60 % of all diabetics 2. Increases risk for retinopathy, nephropathy

Diabetes Mellitus
C. Stroke:
Type 2 diabetics are 2 6 times more likely to have stroke as well as Transient Ischemic Attacks (TIA) or mini stroke

Diabetes Mellitus
D. Peripheral Vascular Disease 1. Increased risk for Types 1 and 2 diabetics 2. Development of arterial occlusion and thrombosis resulting in gangrene 3. Gangrene from diabetes most common cause of non-traumatic lower limb amputation

Diabetic Foot Ulcer

Diabetes Mellitus
Diabetic Retinopathy 1. Definition a. Retinal changes related to diabetes
Hemorrhage, swelling, decreased vision

2. 3.

b. Leads to retinal ischemia and breakdown of blood-retinal barrier Leading cause of blindness ages 25 74 a. Affects almost all Type 1 diabetics after 20 years b. Affects 60 % of Type 2 diabetics Diabetics should be screened for retinopathy and receive treatment (laser photocoagulation surgery) to prevent vision loss
1. Should be sent immediately to ophthalmologist upon diagnosis because may already have damage

4.

Diabetics also have increased risk for cataract development

Diabetes Mellitus
Diabetic Nephropathy 1. Definition: glomerular changes in kidneys of diabetics leading to impaired renal function 2. First indicator: microalbuminuria 3. Diabetics without treatment go on to develop hypertension, edema, progressive renal insufficiency a. In type 1 diabetics, 10 15 years b. May occur soon after diagnosis with type 2 diabetes since many are undiagnosed for years 4. Most common cause of end-stage renal failure in U.S. 5. Kimmelstiel-Wilson syndrome: glomerulosclerosis associated with diabetes

Diabetes Mellitus
Male erectile dysfunction
Half of all diabetic men have erectile dysfunction

Diabetes Mellitus
Other Complications from Diabetes A. Increased susceptibility to infection 1. Predisposition is combined effect of other complications 2. Normal inflammatory response is diminished 3. Slower than normal healing B. Periodontal disease C. Foot ulcers and infections: predisposition is combined effect of other complications