Definition: metabolic disorder characterized by hyperglycemia due to an absolute or relative lack of insulin or to a cellular resistance to insulin

Major classificationsType 1 DiabetesType 2 Diabetes

Diabetes Type 1 Definition Metabolic condition in which the beta cells

of pancreas no longer produce insulin; characterized by hyperglycemia, breakdown of body fats and protein and development of ketosis

Accounts for 5 – 10 % of cases of diabetes; most often occurs in childhood or adolescence

Formerly called Juvenile-onset diabetes or insulin-dependent diabetes (IDDM)

Pathophysiology Autoimmune reaction in which the beta

cells that produce insulin are destroyed Alpha cells produce excess glucagons

causing hyperglycemia

Risk Factors Genetic predisposition for increased

susceptibility; HLA linkage Environmental triggers stimulate an

autoimmune response Viral infections (mumps, rubella,

coxsackievirus B4) Chemical toxins

Diabetic Ketoacidosis (DKA) Results from breakdown of fat and

overproduction of ketones by the liver and loss of bicarbonate

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

Pathophysiology a. Hypersomolarity (hyperglycemia,

dehydration)b. Metabolic acidosis (accumulation of

ketones)c. Fluid and electrolyte imbalance (from

osmotic diuresis)

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

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

Treatment Requires immediate medical attention and

usually admission to hospital Frequent measurement of blood glucose

and treat according to glucose levels with regular insulin (mild ketosis, subcutaneous route; severe ketosis with intravenous insulin administration)

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

DKA 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

Monitor cardiac rhythm since hypokalemia puts client at risk for dysrrhythmias

Treat underlying condition precipitating DKA

Acidosis is corrected with fluid and insulin therapy and rarely needs bicarb

Diabetes Type 2Definition: condition of fasting

hyperglycemia occurring despite availability of body’s own insulin

Was known as non-insulin dependent diabetes or adult onset diabetes Both are misnomers, it can be found

in children and type II DM may require insulin

Pathophysiology Sufficient insulin production to

prevent DKA; but insufficient to lower blood glucose through uptake of glucose by muscle and fat cells

Cellular resistance to insulin increased by obesity, inactivity, illness, age, some medications

Risk Factors History of diabetes in parents or siblings;

no HLA Obesity (especially of upper body) Physical inactivity Race/ethnicity: African American, Hispanic,

or American Indian origin Women: history of gestational diabetes,

polycystic ovary syndrome, delivered baby with birth weight > 9 pounds

Clients with hypertension; HDL cholesterol < 35 mg/dL, and/or triglyceride level > 250 mg/dl.

2. Possible symptoms or concerns Hyperglycemia (not as severe as with

Type 1) Polyuria Polydipsia Blurred vision Fatigue Paresthesias (numbness in

extremities) Skin Infections

Pathophysiology Hyperglycemia leads to increased urine

output and dehydration Kidneys retain glucose; glucose and sodium

rise Severe hyperosmolar state develops leading

to brain cell shrinkage

Manifestations Altered level of consciousness (lethargy to

coma) Neurological deficits: hyperthermia, motor

and sensory impairment, seizures Dehydration: dry skin and mucous

membranes, extreme thirst, tachycardia, polyuria, hypotension

Treatment 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

Correct fluid and electrolyte imbalances giving isotonic or colloid solutions and correct potassium deficits

Lower glucose with regular insulin until glucose level drops to 250 mg/dL

Monitor for renal failure Treat underlying condition

Complications of Diabetes Alterations in blood sugars: hyperglycemia and

hypoglycemiaMacrocirculation (large blood vessels) Atherosclerosis occurs more frequently, earlier

in diabetics Involves coronary, peripheral, and cerebral

arteriesMicrocirculation (small blood vessels) Affects basement membrane of small blood

vessels and capillaries Involves tissues affecting eyes and kidneysPrevention of complications Managing diabetes Lowering risk factors for conditions Routine screening for complications Implementing early treatment

Complications of Diabetes: Alterations in blood sugarsA.Hyperglycemia: high blood sugar DKA (mainly associated with Diabetes Type 1) HHS (mainly associated with Diabetes Type 2) 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

B. Hypoglycemia (insulin reaction, insulin shock, “the lows”): low blood sugar

Mismatch between insulin dose, carbohydrate availability and exercise

May be affected by intake of alcohol, certain medications

Specific manifestations Cool, clammy skin Rapid heartbeat Hunger Nervousness, tremor Faintness, dizziness Unsteady gait, slurred and/or incoherent speech Vision changes Seizures, coma Severe hypoglycemia can result in death Clients taking medications, such as beta-

adrenergic blockers may not experience manifestations associated with autonomic nervous system

Hypoglycemia unawareness: clients with Diabetes Type 1 for 4 or 5 years or more may develop severe hypoglycemia without symptoms which can delay treatment

Treatment for mild hypoglycemia 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

15/15 rule: wait 15 minutes and monitor blood glucose; if still low, client should eat another 15 gm of sugar

Continue until blood glucose level has returned to normal

Client should contact medical care provider if hypoglycemia occurs more that 2 or 3 times per week

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 25 %– 50% solution of glucose

intravenously, followed by infusion of 5% dextrose in water

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

Complications Affecting Cardiovascular System, Vision, and Kidney Function

A. Coronary Artery Disease Major risk of myocardial infarction in Type 2

diabetics Increased chance of having a silent MI and

delaying medical treatment Most common cause of death for diabetics

(40 – 60%) Diabetics more likely to develop Congestive

Heart Failure

B. Hypertension1. Affects 20 – 60 % of all

diabetics2. Increases risk for

retinopathy, nephropathy

C. Stroke: Type 2 diabetics are 2 – 6 times

more likely to have stroke as well as Transient Ischemic Attacks (TIA) or mini stroke

D. Peripheral Vascular Disease1. 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

Male erectile dysfunction Half of all diabetic men have

erectile dysfunction

Collaborative CareA. Based on research from 10-year study of

Type 1 diabetics conducted by NIH focus is on keeping blood glucose levels as close to normal by active management interventions; complications were reduced by 60%

B. Treatment interventions are maintained through

Medications Dietary management ExerciseC. Management of diabetes with pancreatic

transplant, pancreatic cell or Beta cell transplant is in investigative stage

Other Complications from DiabetesA. Increased susceptibility to infection Predisposition is combined effect of

other complications Normal inflammatory response is

diminished Slower than normal healingB. Periodontal diseaseC. Foot ulcers and infections:

predisposition is combined effect of other complications

Diagnostic tests to monitor diabetes management

1. Fasting Blood Glucose (normal: 70 – 110 mg/dL)

2. Glycosylated hemoglobin (c) (Hemoglobin A1C)

Considered elevated if values above 7% Blood test analyzes excess glucose

attached to hemoglobin. Since rbc lives about 120 days gives an average of the blood glucose over previous 2 to 3 months Not a fasting test, can be drawn any time of the

day % of glycated (glucose attached) hemoglobin

measures how much glucose has been in the bloodstream for the past 3 months

3. Urine glucose and ketone levels (part of routine urinalysis) a. Glucose in urine indicates

hyperglycemia (renal threshold is usually 180 mg/dL)

b. Presence of ketones indicates fat breakdown, indicator of DKA; ketones may be present if person not eating

4. Urine albumin (part of routine urinalysis)

If albumin present, indicates need for workup for nephropathy

Typical order is creatinine clearance testing

MedicationsA.Insulin Sources: standard practice is use of human insulin

prepared by alteration of pork insulin or recombinant DNA therapy

2. Clients who need insulin as therapy: All type 1 diabetics since their bodies essentially no

longer produce insulin Some Type 2 diabetics, if oral medications are not

adequate for control (both oral medications and insulin may be needed)

Diabetics enduring stressor situations such as surgery, corticosteroid therapy, infections, treatment for DKA, HHNS

Women with gestational diabetes who are not adequately controlled with diet

Some clients receiving high caloric feedings including tube feedings or parenteral nutrition

Role of Diet in Diabetic ManagementA. Goals for diabetic therapy includeMaintain as near-normal blood

glucose levels as possible with balance of food with medications

Obtain optimal serum lipid levelsProvide adequate calories to attain

or maintain reasonable weight

Care of diabetic older clients 40% of all clients with diabetes are over

age of 65 Need to include spouse, members of family

in teaching who may assist with client meeting medical needs

Diet changes may be difficult to implement since client has established eating habits

Exercise programs may need adjustment to meet individual’s abilities (such as physical limitations from other chronic illnesses) Obesity worsens diabetes Minimum of 30 minutes of moderate exercise like

walking or swimming most days of the week

Care of diabetic older clients Individual reluctance to accept

assistance to deal with chronic illness, assist with hygiene

Limited assets for medications, supplies, dietary

Visual deficits or learning challenges to learn insulin administration, blood glucose monitoring

A.Risk for impaired skin integrity: Proper foot care Daily inspection of feet Checking temperature of any water before washing

feet Need for lubricating cream after drying but not

between toes Patients should be followed by a podiatrist Early reporting of any wounds or blistersB.Risk for infection Frequent hand washing Early recognition of signs of infection and seeking

treatment Meticulous skin care Regular dental examinations and consistent oral

hygiene care

C. Risk for injury: Prevention of accidents, falls and burns

D. Sexual dysfunction Effects of high blood sugar on sexual

functioning, Resources for treatment of

impotence, sexual dysfunctionE. Ineffective coping Assisting clients with problem-

solving strategies for specific concerns

Providing information about diabetic resources, community education programs, and support groups

Utilizing any client contact as opportunity to review coping status and reinforce proper diabetes management and complication prevention