DIABETES MELLITUS DIABETES MELLITUS

Rachel S. Natividad RN, MSN, NPRachel S. Natividad RN, MSN, NP

Review A&PReview A&P

Role of Insulin

Insulin:– Counters metabolic

activity that would increase blood glucose levels

– Enhances transport of glucose into body cells

– Lowers blood glucose levels

Physiology Cont: InsulinPhysiology Cont: Insulin Basal (continuous)Basal (continuous) Prandial (Bolus)Prandial (Bolus)

*Blood glucose increases within 10 minutes of the beginning of a meal*

Diabetes MellitusDiabetes Mellitus

A disorder of carbohydrate, protein, A disorder of carbohydrate, protein, and fat and fat metabolismmetabolism resulting from an resulting from an imbalance between insulin imbalance between insulin availability and insulin need. (Porth, availability and insulin need. (Porth, 2002)2002)

End Result : End Result : HYPERGLYCEMIAHYPERGLYCEMIA

Physiology Cont.:Glucose Control

Patho: DM Type 1

Patho Cont.: DM Type 2

Normal PhysiologyNormal Physiology

Pathophysiology-Cont.:DM Type 2 Pathophysiology-Cont.:DM Type 2

DM 1&2: The big difference…DM 1&2: The big difference…DM TYPE 1DM TYPE 1 DM TYPE 2DM TYPE 2

No endogenous insulinNo endogenous insulin Some endogenous Some endogenous insulininsulin

Tx requires insulin Tx requires insulin injectionsinjections

Tx diet and exercise 1st, Tx diet and exercise 1st, then pills and /or insulinthen pills and /or insulin

Usually < age 30 yrs.Usually < age 30 yrs. Usually over 30 yrs. (peaks Usually over 30 yrs. (peaks at 50)at 50)

Ketosis prone (DKA)Ketosis prone (DKA) no ketosisno ketosis

Former names: IDDM Former names: IDDM (Juvenile)(Juvenile)

Diabetes Type IDiabetes Type I

NIDDM (maturity/adult- NIDDM (maturity/adult- onset)onset)

Diabetes Type IIDiabetes Type II

ThinThin to normal body to normal body weightweight

Usually OverweightUsually Overweight

Acute metabolic Acute metabolic complicationscomplications

(DKA)(DKA)

Chronic vascular Chronic vascular complicationscomplications

Case StudyCase Study

THE 3 POLYs

POLYURIA POLYPHAGIA

POLYDYPSIA

14

Diabetes: Clinical Manifestations

Diabetes Clinical ManifestationsCont: Signs and SymptomsSigns and Symptoms

Early signsEarly signs 3 Polys 3 Polys Weight lossWeight loss Fatigue/Always tiredFatigue/Always tired Visual BlurringVisual Blurring

Late signsLate signs Any of the 3 PolysAny of the 3 Polys Infections Infections Numbness/ tingling of Numbness/ tingling of

feet or leg painfeet or leg pain Slow healing woundsSlow healing wounds Chronic ComplicationsChronic Complications

Diabetes: Dx TestsDiabetes: Dx Tests

Fasting Blood Glucose Fasting Blood Glucose (FBG): <100 mg/dL(FBG): <100 mg/dL– Iggy: 70-110 mg/dLIggy: 70-110 mg/dL

**Random/Casual Blood Random/Casual Blood Glucose*:<200 mg/dLGlucose*:<200 mg/dL

Oral Glucose Tolerance Test Oral Glucose Tolerance Test (OGTT): < 140 mg/dL(OGTT): < 140 mg/dL

Glycosylated Hemoglobin Glycosylated Hemoglobin (HgbA1C): 4-6%(HgbA1C): 4-6%

Check MD orders or agency protocol for frequency of BS MonitoringIn General:AC&HS if pt able to eat;Q4-6 hours if NPO or tube feedings

Diabetes: Diagnostic Tests Cont.Diabetes: Diagnostic Tests Cont. Glycosylated hemoglobin test –

Hemoglobin A1C (HbA1c) – measures the amount of glycosylated

hemoglobin (hemoglobin that is chemically linked to glucose) in blood.

– Normal -4-6%Normal -4-6%– Target range DM patient <7%Target range DM patient <7%

HbA1C Control

Criteria for the Diagnosis of Diabetes MellitusCriteria for the Diagnosis of Diabetes Mellitus

Normal Normal – FPG <110 mg per dL FPG <110 mg per dL – 2hr OGTT <140 mg per dL 2hr OGTT <140 mg per dL

Diabetes-Diabetes- positive findings from any two of the following positive findings from any two of the following tests on different days: tests on different days:

– Symptoms of diabetes mellitus* plus casual Symptoms of diabetes mellitus* plus casual (random) plasma glucose concentration >=200 (random) plasma glucose concentration >=200 mg / dL mg / dL

oror – FPG >=126 mg per dLFPG >=126 mg per dLoror – 2hr OGTT >=200 mg per dL after a 75-g glucose 2hr OGTT >=200 mg per dL after a 75-g glucose

load load

Diagnostic Tests – Cont.Diagnostic Tests – Cont.Is it Diabetes Yet?Is it Diabetes Yet?

Impaired Fasting Glucose

Impaired Glucose Tolerance

<6

100-125140-200

<100<140

>126>200>6

Acute ComplicationsAcute Complications Diabetic Diabetic

Ketoacidosis (DKA)Ketoacidosis (DKA) BS > 300 mg/dLBS > 300 mg/dL Classic symptomsClassic symptoms KetosisKetosis

Hyperglycemic-Hyperglycemic-Hyperosmolar Hyperosmolar Nonketotic Syndrome Nonketotic Syndrome (HHNS)(HHNS)

BS > 800 mg/dLBS > 800 mg/dL Similar symptomsSimilar symptoms No KetosisNo Ketosis

Check urine for ketones

(ADA)

Chronic Complications of DM

Effects on Blood Vessels

Blood VesselLumen

Chronic Complications - MacrovascularChronic Complications - Macrovascular CardiovascularCardiovascular

– heart heart diseasedisease CerebrovascularCerebrovascular

– StrokeStroke

Peripheral vascularPeripheral vascular

diseasedisease

DM pts have heart disease and stroke risks 2 to 4 X higher than non-DM pts

Chronic Complications-Chronic Complications-Microvascular :Microvascular :

Diabetic RetinopathyDiabetic Retinopathy

The leading cause of new cases of blindness in adults ages 20 - 74

Chronic Complications-Chronic Complications-MicrovascularMicrovascular

NephropathyNephropathy

The leading cause of end-stage renal disease (ESRD), occurs in about 20 - 40% of patients with diabetes

Chronic Complications-MicrovascularChronic Complications-Microvascular

Diabetic Neuropathy - Diabetic Neuropathy - the poor blood supply will cause the nervous system to malfunction

Chronic Complications-MicrovascularChronic Complications-Microvascular

Amputation of Toes

Chronic Complications-Chronic Complications-MicrovascularMicrovascular

Sexual problems for men erectile dysfunctionretrograde ejaculation

Sexual problems for women

decreased vaginal lubrication decreased sexual response

Urologic problems for men and women

urinary tract infectionsneurogenic bladder

Chronic Complications-Chronic Complications-MicrovascularMicrovascular

Gastroparesis

Nerve damage to the digestive system most commonly causes constipation. Damage can also cause the stomach to empty too slowly

MANAGEMENT OF DM MANAGEMENT OF DM

Regular Blood Glucose Monitoring

Diet

Exercise

Drug Therapy

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Management: Diet & ExerciseManagement: Diet & Exercise

Diet : Diet : Diabetes Food Pyramid

Diet Cont: What to do???Diet Cont: What to do???

Diet Cont.Diet Cont.Carb-CountingCarb-Counting

Diet Cont: Diet Cont: Glycemic Index

Diet Cont.:Getting the balance right

Get your portions right!!Get your portions right!!

Management: ExerciseManagement: Exercise Helps regulate Helps regulate

blood glucoseblood glucose Increases insulin Increases insulin effectiveness and effectiveness and sensitivity in the sensitivity in the body.body.

Must monitor Must monitor insulin and food insulin and food intake to match intake to match exercise regimen. exercise regimen.

Drug TherapyDrug Therapy

InsulinInsulin

&&

Oral Antidiabetic AgentsOral Antidiabetic Agents

Drug Therapy: Insulin Types Fast-acting insulin

– Rapid Acting Insulin Analogs Aspart, Lispro, Glulisine

– Regular Human Insulin

Intermediate-acting insulin – NPH Human Insulin– Pre-Mixed Insulin

Humulin 70/30, Humalog 75/25 Long-acting insulin

– Insulin Glargine, Insulin Detemir

BASALBASALUsed to lower Used to lower blood sugar blood sugar throughout the throughout the day and nightday and night

BOLUSBOLUSUsed to lower Used to lower blood sugar blood sugar after eating a after eating a mealmeal

Drug Therapy Cont.: InsulinDrug Therapy Cont.: InsulinOnset - Onset - how soon it starts to work in the bloodhow soon it starts to work in the blood Peak - Peak - when the insulin has the greatest effect on when the insulin has the greatest effect on

blood sugar levelsblood sugar levels Duration – Duration – how long it keeps workinghow long it keeps working

Drug Therapy Cont:Drug Therapy Cont:

Goal of Insulin TherapyGoal of Insulin Therapy

Basal and Bolus Insulin Coverage

Drug Therapy Cont:Drug Therapy Cont:

SampleSample Insulin Regimen Insulin Regimen (NPH & Regular insulin)(NPH & Regular insulin)

Drug Therapy-Insulin Cont:Drug Therapy-Insulin Cont:

Rapid ActingRapid Acting “ “LogsLogs””HumaHumaloglog (insulin lispro) (insulin lispro)NovoNovologlog (insulin aspart) (insulin aspart)

Bolus insulinBolus insulin Onset 15 min; peaks 1-2 hrs; lasts 4-6 Onset 15 min; peaks 1-2 hrs; lasts 4-6

hourshours Ideal for meal coverageIdeal for meal coverage

““Give the shot while Give the shot while the plate is the plate is hothot!”!”

Drug Therapy-Insulin Cont:Drug Therapy-Insulin Cont:

Short Acting: Regular Insulin Short Acting: Regular Insulin RegsRegs

Bolus insulin Onset ½-1 hr; peaks

2-4 hrs; lasts 6-8 hrs

Give 30 minutes to 1 hour before a meal

Drug Therapy-Insulin Cont:Drug Therapy-Insulin Cont:

Short Acting: Regular InsulinShort Acting: Regular Insulin♪ ♪ It’s time give you yourIt’s time give you your regular insulinregular insulin ♪♪

♪♪ It’s time to give itIt’s time to give it 30 minutes before your 30 minutes before your plate is inplate is in ♪♪

♪♪ Come back to check you Come back to check you in 2 (hours)in 2 (hours) ♪♪

♪♪ Watch out for Watch out for shakesshakes and and sweatssweats too too ♪♪

♪♪ If your lucky you’ll have no clue!!!!If your lucky you’ll have no clue!!!! ♪♪

Drug Therapy-Insulin Cont:Drug Therapy-Insulin Cont:Rapid Acting (Humalog/Novolog) VS. Short Acting (Regular

Insulin)

Rapid onset1-2 hour peakLimited duration

Delayed onsetPeaks in 2-4 hrLasts 6-8 hours

Drug Therapy-Insulin Cont:Drug Therapy-Insulin Cont:

Intermediate acting: NPH InsulinIntermediate acting: NPH Insulin

Basal insulin: covers blood sugar between meals

Satisfies overnight insulin requirement

Onset 1-2 hrs, peaks 6-10 hrs, lasts 12+ hrs

Need snack if NPH given at 5 pm (only)

Ideal to be given at 9 pm (HS) to address Dawn Phenomenon

Drug Therapy-Insulin Cont:Drug Therapy-Insulin Cont:

LL ong-Acting: ong-Acting: Peakless InsulinsPeakless Insulins!!!!!!

LLantusantus (insulin glargine) (insulin glargine)

LLevimirevimir (insulin detimir) (insulin detimir)

Basal InsulinBasal Insulin Onset 1.5 hrs; no peak (max effect in 5 Onset 1.5 hrs; no peak (max effect in 5

hrs); lasts 24 hourshrs); lasts 24 hours No risk for hypoglycemiaNo risk for hypoglycemia Do not mix with other insulins – Do not mix with other insulins – becomes becomes

inactivated when mixed with other insulinsinactivated when mixed with other insulins

Lantus

Drug Therapy-Drug Therapy-Insulin Cont:Insulin Cont:HypoglycemiaHypoglycemia

BS < 60-70 mg/dLBS < 60-70 mg/dL

An acute An acute

complication complication

of insulin administrationof insulin administration

Tx: (15/15 or Tx: (15/15 or

20/20 Rule)20/20 Rule)

– Give 15/20 g simple Give 15/20 g simple

carb and recheck carb and recheck

BG in 15/20 minutesBG in 15/20 minutes

Synthetic injectables

Byetta: Synthetic incretin mimetic hormone– Indicated for patients with type 2

diabetes who don’t use insulin

Symlin: Synthetic analogue of human amylin– Approved for use with insulin in adults

with type 1 and type 2 diabetes

Drug Therapy Cont:Drug Therapy Cont:Other Methods of AdministrationOther Methods of Administration

For Uncontrolled DM 1 0r 2

Rapid-acting insulin

Continuous IV insulin infusion Used to maintain glycemic control

in hospitalized patients with high blood glucose levels; in DKA and HHNS

Regular insulin may be used IV

May also be given preoperatively or postoperatively

More frequent BS monitoring ( q1-2 hours per agency protocol)

Drug Therapy Cont:Drug Therapy Cont:

Oral Antidiabetic agents Oral Antidiabetic agents

(see handout)(see handout)

New Oral Med

Januvia (Sitagliptin)

– An oral drug that reduces blood sugar levels in patients with type 2 diabetes.

– Sitagliptin is the first approved member of a class of drugs that inhibit the enzyme, dipeptidyl peptidase-4 (DPP-4).

Oral Agents: How do they work?

Acute ComplicationAcute Complicationof Insulin and (some) Oral Meds of Insulin and (some) Oral Meds

HypoglycemiaHypoglycemia

Hyperglycemia

Critical Thinking Exercises

Course Packet pp. 81-84

Diabetic TeachingDiabetic TeachingNeedsNeeds

Disease processDisease processS/S of hyperglycemia and hypoglycemiaS/S of hyperglycemia and hypoglycemiaBlood sugar monitoringBlood sugar monitoringDiet Diet ExerciseExerciseDrug therapyDrug therapySick Day RulesSick Day RulesComplications (acute and chronic)Complications (acute and chronic)Prevention: Foot care, eye exam etc.Prevention: Foot care, eye exam etc.

DIABETES can be controlled!!!DIABETES can be controlled!!!