Adult Medical-Surgical Adult Medical-Surgical NursingNursing

Endocrine Module: Endocrine Module: Longterm Complications of Longterm Complications of

Diabetes MellitusDiabetes Mellitus

Long-term Complications of DMLong-term Complications of DM

Uncontrolled hyperglycaemia gives Uncontrolled hyperglycaemia gives rise to longterm complications within rise to longterm complications within 5 -10 years usually 5 -10 years usually

Long-term Complications of DMLong-term Complications of DM

Macrovascular diseaseMacrovascular disease

Microvascular diseaseMicrovascular disease

NeuropathyNeuropathy

Long-term Complications of DMLong-term Complications of DM

Macrovascular DiseaseMacrovascular Disease

DM: Macrovascular DiseaseDM: Macrovascular Disease

Accelerated atherosclerosis of large Accelerated atherosclerosis of large vessels →vessels →

Coronary artery disease: may include Coronary artery disease: may include ““silent myocardial infarctionsilent myocardial infarction”” (on ECG) (on ECG)

Cerebrovascular disease: TIA, strokeCerebrovascular disease: TIA, stroke Peripheral vascular disease: gradual Peripheral vascular disease: gradual

occlusion of lower arteries, ↓ pulses, occlusion of lower arteries, ↓ pulses, intermittent claudication, ↓ blood flow intermittent claudication, ↓ blood flow to extremities → gangreneto extremities → gangrene

Macrovascular Disease: Macrovascular Disease: ManagementManagement

Close control of blood glucose (diet and Close control of blood glucose (diet and exercise; oral hypoglycaemics or insulin) exercise; oral hypoglycaemics or insulin)

Control of obesityControl of obesity ↓ ↓ hyperlipidaemia (↓ LDL, ↑ HDL)hyperlipidaemia (↓ LDL, ↑ HDL) Control of hypertensionControl of hypertension ↓ ↓ smoking; promote foot care/ hygienesmoking; promote foot care/ hygiene Close monitoring of disease progress and Close monitoring of disease progress and

intervention as necessaryintervention as necessary

Long-term Complications of DMLong-term Complications of DM

Microvascular DiseaseMicrovascular Disease

DM: Microvascular DiseaseDM: Microvascular Disease

Microvascular complications are Microvascular complications are unique to DM, especially type 1unique to DM, especially type 1

Hyperglycaemia thickens the capillary Hyperglycaemia thickens the capillary basement membrane, base for the basement membrane, base for the single layer of endothelial cells (the single layer of endothelial cells (the intima) where exchange of gases and intima) where exchange of gases and nutrients occurs nutrients occurs

Affects microvascular circulation of:Affects microvascular circulation of: The retina (retinopathy)The retina (retinopathy) The kidneys (nephropathy)The kidneys (nephropathy)

Diabetic RetinopathyDiabetic Retinopathy

Diabetic Retinopathy: Diabetic Retinopathy: PathophysiologyPathophysiology

Hyperglycaemia → micro-aneurysms, Hyperglycaemia → micro-aneurysms, small haemorrhages, capillary small haemorrhages, capillary closure, macula oedema and loss of closure, macula oedema and loss of nerve fibres leading to blurred vision nerve fibres leading to blurred vision and gradual loss of central vision and gradual loss of central vision

Proliferation of new capillaries across Proliferation of new capillaries across retina in vitreous humour, which are retina in vitreous humour, which are prone to bleedprone to bleed

Vitreous haemorrhage, fibrous scars, Vitreous haemorrhage, fibrous scars, retinal detachment and blindnessretinal detachment and blindness

Diabetic Retinopathy:Diabetic Retinopathy: Clinical Manifestations Clinical Manifestations

Blurring of visionBlurring of vision Loss of central visionLoss of central vision Spots before the eyesSpots before the eyes No painNo pain Gradually leads to blindnessGradually leads to blindness

Diabetic Retinopathy: DiagnosisDiabetic Retinopathy: Diagnosis

Patient history and clinical Patient history and clinical manifestationsmanifestations

Examination with OphthalmoscopeExamination with Ophthalmoscope

Fluroscein angiography (dye outlines Fluroscein angiography (dye outlines the capillaries)the capillaries)

Diabetic Retinopathy: PreventionDiabetic Retinopathy: Prevention

Control blood glucoseControl blood glucose

Regular eye examinationsRegular eye examinations

Diabetic Retinopathy: ManagementDiabetic Retinopathy: Management

Treatment:Treatment: Intensive regular insulin therapy (6-Intensive regular insulin therapy (6-

hourly) reduces disease progression hourly) reduces disease progression Laser (LA) destroys new and leaking Laser (LA) destroys new and leaking

blood vesselsblood vessels Vitrectomy (advanced): removes Vitrectomy (advanced): removes

vitreous humour replacing with saline; vitreous humour replacing with saline; improves vision but not completelyimproves vision but not completely

Diabetic NephropathyDiabetic Nephropathy

Diabetic Nephropathy: Diabetic Nephropathy: PathophysiologyPathophysiology

Thickened basement membrane in Thickened basement membrane in the glomerulus of the Bowman’s the glomerulus of the Bowman’s Capsule →Capsule →

Elevated pressure affecting Elevated pressure affecting glomerular filtration → glomerular filtration → microalbuminuria/ proteinuriamicroalbuminuria/ proteinuria

Diabetic Nephropathy: Diabetic Nephropathy: Clinical ManifestationsClinical Manifestations

Usual symptoms of renal disease: Usual symptoms of renal disease: oliguria, oedema and weight gain, oliguria, oedema and weight gain, hypertension, fatigue, anaemiahypertension, fatigue, anaemia

Usually other systems failing: poor Usually other systems failing: poor vision, impotence, neuropathy and vision, impotence, neuropathy and maybe “diabetic foot” ulcers, maybe “diabetic foot” ulcers, dyspnoea (CHF), nocturnal diarrhoea dyspnoea (CHF), nocturnal diarrhoea (autonomic neuropathy) (autonomic neuropathy)

Diabetic Nephropathy: DiagnosisDiabetic Nephropathy: Diagnosis

Lab test for albumen in urine Lab test for albumen in urine (albumen in urine indicates (albumen in urine indicates nephropathy in 85% diabetics)nephropathy in 85% diabetics)

24 hour urine save for albumen24 hour urine save for albumen KFT KFT Creatinine clearance test Creatinine clearance test

Diabetic Nephropathy: Diabetic Nephropathy: ManagementManagement

Control blood glucoseControl blood glucose ACE inhibitors to control BP (These ACE inhibitors to control BP (These

will reduce proteinuria also)will reduce proteinuria also) Low salt dietLow salt diet Treat infection early (UTI)Treat infection early (UTI) Adjust medications with kidney Adjust medications with kidney

functionfunction DialysisDialysis Renal TransplantRenal Transplant

DM: Longterm ComplicationsDM: Longterm Complications

Diabetic NeuropathyDiabetic Neuropathy

Diabetic NeuropathyDiabetic Neuropathy

Hyperglycaemia leads to demyelination of Hyperglycaemia leads to demyelination of the nerves and reduced conduction of the nerves and reduced conduction of impulsesimpulses

Classification:Classification: Peripheral neuropathy (sensory or motor) Peripheral neuropathy (sensory or motor)

is most common. Usually affects lower is most common. Usually affects lower extremities symmetricallyextremities symmetrically

AutonomicAutonomic Spinal nerveSpinal nerve

Peripheral Diabetic Neuropathy: Peripheral Diabetic Neuropathy: Clinical ManifestationsClinical Manifestations

Paraesthesia: heightened sensation Paraesthesia: heightened sensation with tingling, burning at night → with tingling, burning at night → numbness with disease progressionnumbness with disease progression

↓ ↓ proprioception; deep tendon reflexproprioception; deep tendon reflex Unsteady gait: ↓ sensation to touch; ↑ Unsteady gait: ↓ sensation to touch; ↑

risk of injury and infection risk of injury and infection Joint deformities (weight distribution Joint deformities (weight distribution

effect)effect) Painful lower extremities (lactic acid)Painful lower extremities (lactic acid)

Diabetic Peripheral Neuropathy: Diabetic Peripheral Neuropathy: DiagnosisDiagnosis

Patient history and clinical picturePatient history and clinical picture Neurological examination and tendon Neurological examination and tendon

reflexesreflexes Nerve conduction studiesNerve conduction studies Corresponding assessment of blood Corresponding assessment of blood

supply to extremitiessupply to extremities

Diabetic Peripheral Neuropathy: Diabetic Peripheral Neuropathy: ManagementManagement

Control blood glucose; frequent Control blood glucose; frequent monitoringmonitoring

Control painControl pain Careful regular foot care/ hygieneCareful regular foot care/ hygiene Splints to prevent/ correct deformitySplints to prevent/ correct deformity Exercises to improve circulationExercises to improve circulation Vitamin B complex and B12Vitamin B complex and B12

Diabetic Neuropathy: Autonomic Diabetic Neuropathy: Autonomic Nervous System and Spinal NervesNervous System and Spinal Nerves

Autonomic Diabetic Neuropathy: Autonomic Diabetic Neuropathy: Clinical Manifestations Clinical Manifestations

Silent MI; orthostatic hypotension Silent MI; orthostatic hypotension (↓ sympathetic activity)(↓ sympathetic activity)

Delayed gastric emptying, nausea, Delayed gastric emptying, nausea, constipation, nocturnal diarrhoea, swings constipation, nocturnal diarrhoea, swings in blood glucose as inconsistent absorptionin blood glucose as inconsistent absorption

Neurogenic bladder (retention)Neurogenic bladder (retention) Adrenal disorder: inability to sense and Adrenal disorder: inability to sense and

respond to hypoglycaemia (dangerous)respond to hypoglycaemia (dangerous)

Diabetic Spinal Neuropathy: Diabetic Spinal Neuropathy: Clinical ManifestationsClinical Manifestations

Neurogenic bladder (flaccid bladder: Neurogenic bladder (flaccid bladder: retention overflow incontinence); retention overflow incontinence); chronic infection riskchronic infection risk

Sexual impotenceSexual impotence Problems with mobilityProblems with mobility

Diabetic Autonomic and Spinal Diabetic Autonomic and Spinal Neuropathy: DiagnosisNeuropathy: Diagnosis

Patient history and clinical picturePatient history and clinical picture ECG ECG Bladder function studies (micturating Bladder function studies (micturating

cystogram)cystogram) Reflexes and nerve conduction testsReflexes and nerve conduction tests

Diabetic Neuropathy (Autonomic Diabetic Neuropathy (Autonomic and Spinal): Managementand Spinal): Management

Control blood glucoseControl blood glucose Avoid strenuous exerciseAvoid strenuous exercise Monitor BP, ECGMonitor BP, ECG Elastic stockings (Elastic stockings (↑ ↑ venous return)venous return) Small frequent meals; Small frequent meals; ↓↓ salt, salt, ↓ ↓ fat fat Ensure bladder emptying/ hygieneEnsure bladder emptying/ hygiene Prevention/ prompt treatment of UTIPrevention/ prompt treatment of UTI Skin care (pressure); counsellingSkin care (pressure); counselling