By: STEPHANIE KAYE GABITGARY RUZ

Case PresentationCase PresentationCase PresentationCase Presentation

Name: Mr. Mel DyAge: 65 years oldGender: Male

He was diagnosed of having Type II Diabetes Mellitus a year ago.The client was admitted in the hospital and he verbalized that he experienced loss of appetite, frequent urination, tiredness, weight loss, body weakness. His wife noticed that he is always thirsty.

The client don’t have regular medications for Diabetes Mellitus but the client and his family are conscious about the food that they eat. The client admitted that before he is diagnosed with Diabetes Mellitus he is more prone of having sickness.

Diabetes MellitusDiabetes Mellitus

Global StatisticsGlobal Statistics

Local StatisticsLocal Statistics

Anatomy and PhysiologyAnatomy and Physiology

Anatomy and Physiology

CLASSIFICATIONCLASSIFICATION• In 1979 the National Diabetes Data Group (NDDG)

developed criteria for the classification and diagnosis of diabetes mellitus.

• By 1997, and again in 2003, the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus proposed changes to the original NDDG classification.

• Changes were supported by the American Diabetes Association (ADA) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) .

The four classifications of Diabetes Mellitus :• Type 1 diabetes• Type 2 diabetes• Gestational diabetes mellitus• Other specific types of diabetes

• In 1979 the National Diabetes Data Group (NDDG) developed criteria for the classification and diagnosis of diabetes mellitus.

• By 1997, and again in 2003, the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus proposed changes to the original NDDG classification.

• Changes were supported by the American Diabetes Association (ADA) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) .

The four classifications of Diabetes Mellitus :• Type 1 diabetes• Type 2 diabetes• Gestational diabetes mellitus• Other specific types of diabetes

Type 1 DiabetesType 1 Diabetes

Type 2 Diabetes Type 2 Diabetes

Gestational Diabetes MellitusGestational Diabetes MellitusGestational Diabetes MellitusGestational Diabetes Mellitus

Other specific types of diabetesOther specific types of diabetes

Distinguish Features of DM type 1 and type 2Distinguish Features of DM type 1 and type 2Feature Type 1 Type 2

SynonymsInsulin-dependent diabetes mellitus, juvenile diabetes,

labile or brittle diabetes

Non-insulin-dependent diabetes mellitus, adult or maturity-onset

diabetes, mild diabetes

Age at onset Usually occurs before age 30, but may occur at any age

Usually occurs after age 30, but can occur in children

Incidence ~10% ~90%

Type of onset Usually abrupt, with rapid onset of hyperglycemia

Insidious, may be asymptomatic or mildly asymptomatic; body

adapts to slow onset of hyperglycemia

Endogenous insulin production Little or none Below normal, normal, or above

normal

Body weight at onset Ideal body weight or thin 85% of clients are obese, may be of ideal body weight

ketosisProne to ketosis, usually present

at onset, often present during poor control

Resistant to ketosis, can occur with infections or stress

manifestations Polyuria, polydipsia, polyphagia, fatigue

Often none, may be mild manifestation of hyperglycemia

Etiology Genetic factors, auto immune Genetic factors, Obesity,

Disease ProcessDisease Process

Absolute Insulin DeficiencyAbsolute Insulin Deficiency

Insulin ResistanceInsulin Resistance

Clinical ManifestationClinical ManifestationClinical ManifestationClinical Manifestation

Clinical Manifestation Type 1 Pathophysiologic Basis Type 2

Polyuria (frequent urination)

++

Water not reabsorbed from renal tubules secondary to osmotic activity of glucose;

leads to loss of water, glucose, and electrolytes

+

Polydipsia (excessive thirst) ++ Dehydration secondary to polyuria causes

thirst +

Polyphagia (excessive

hunger)++ Starvation secondary to tissue breakdown

( catabolism) causes hunger +

Weight loss ++

Initial loss secondary to depletion of water, glycogen, and triglyceride stores; chronic

loss secondary to decreased mnuscle mass as amino acides are diverted to form

glucose and ketone bodies.

-

Recurrent blurred vision + Secondary to chronic exposure of ocular

lens and retina to hyperosmolar fluids ++

The following are the distinguish features of diabetes mellitus:The following are the distinguish features of diabetes mellitus:

Black, J. (2008). Medical-Surgical Nursing 8th Edition. Singapore: Elsevier Pte. Ltd

Clinical Manifestation Type 1 Pathophysiologic Basis Type 2

Pruritus, skin infections, vaginitis

+Bacterial and fungal infections of skin seem

to be more common; research conflicting++

Ketonuria ++

When glucose cannot be used for energy in insulin-dependent cells, fatty acids are used for energy; fatty acids are broken down into ketones in blood and excreted by kidneys; in type 2 diabetes mellitus, sufficient insulin is present to depress excessive use of fatty

acids but not enough to permit use of glucose

-

Weakness and fatigue,

dizziness++

Decreased plasma volume leads to postural hypotension; potassium loss and protein

catabolism contribute to weakness+

Often asymptomatic

-Body can “adapt” to a slow rise in blood

glucose level to a greater extent than it can to a rapid rise

++

Black, J. (2008). Medical-Surgical Nursing 8th Edition. Singapore: Elsevier Pte. Ltd

Complications of Diabetes MellitusComplications of Diabetes MellitusComplications of Diabetes MellitusComplications of Diabetes Mellitus

DKA ( Diabetic Ketoacidosis )– Dehydration – Fruity odor of ketones on

breath– Hyperpnea or

kussmauul’s respirations– Impaired level of

consciousness or coma– Tachycardia– Weakness

DKA ( Diabetic Ketoacidosis )– Dehydration – Fruity odor of ketones on

breath– Hyperpnea or

kussmauul’s respirations– Impaired level of

consciousness or coma– Tachycardia– Weakness

• Hypoglycemia– Shakiness– Irritability– Nervousness– Tachycardia– Tremor, pallor– Hunger– Headache– Mental illness– Slurred

speech– Confusion;

Lethargy– Seizure

• Hypoglycemia– Shakiness– Irritability– Nervousness– Tachycardia– Tremor, pallor– Hunger– Headache– Mental illness– Slurred

speech– Confusion;

Lethargy– Seizure

Macrovascular– Coronary artery

disease– Cerebrovascular

disease– Hypertension– Peripheral vascular

disease– Infection

Microvascular – Retinopathy– Nephropathy– Leg and foot ulcer– Sensorimotor

neuropathy– Autonomic

neuropathy

DiagnosticsDiagnostics

Oral Glucose Tolerance Test

Values InterpretationOral Glucose

Tolerance test, 2 hours after eating

< 140 mg/dl Normal fasting glucose140-199 mg/dl Impaired fasting glucose

>200 mg/dl Diagnosis of diabetes mellitus

Laboratory Tests Related to DM ( ketones )Laboratory Tests Related to DM ( ketones )Laboratory Tests Related to DM ( ketones )Laboratory Tests Related to DM ( ketones )

Laboratory Tests Laboratory Tests Related to DM (ketones)Related to DM (ketones)Laboratory Tests Laboratory Tests Related to DM (ketones)Related to DM (ketones)

• Urine levels of ketones can be tested by clients use of dip strips or tablets.

• The presence of ketones in the urine (a condition called ketonuria) indicates that the body is using fat as a major source of energy ,which may result in ketoacidosis.

• Test results are indicated by the presence of color changes, indicating the presence of ketone.

• All clients with diabetes mellitus should test their urine for ketones during acute illness or stress

• Urine levels of ketones can be tested by clients use of dip strips or tablets.

• The presence of ketones in the urine (a condition called ketonuria) indicates that the body is using fat as a major source of energy ,which may result in ketoacidosis.

• Test results are indicated by the presence of color changes, indicating the presence of ketone.

• All clients with diabetes mellitus should test their urine for ketones during acute illness or stress

Laboratory Tests Related to DM ( Protein )Laboratory Tests Related to DM ( Protein )

• Micro albuminuria measures microscopic amounts of protein in the urine (proteinuria).

• Presence of protein (micro albuminuria) in urine is an EARLY sign of kidney disease.

• Testing the urine for micro albuminuria shows early nephropathy, long before it would be evident on routine urinalysis.

• Micro albuminuria measures microscopic amounts of protein in the urine (proteinuria).

• Presence of protein (micro albuminuria) in urine is an EARLY sign of kidney disease.

• Testing the urine for micro albuminuria shows early nephropathy, long before it would be evident on routine urinalysis.

Medical ManagementMedical ManagementMedical ManagementMedical ManagementRestoring and maintaining blood glucose levels to as near normal as possible by:

Balanced dietExercise Use of oral hypoglycemic agents or insulin.

Initial as well as ongoing client education is vital in helping the client manage this chronic condition

Promote Proper NutritionPromote Proper NutritionIt can help clients improve metabolic control by making changes in nutrition habits. The specific goals include:

Improving blood glucose and lipid levels,Providing consistency in day-to-day food intake ( in

type 1 diabetes mellitus),Facilitating weight management ( in type 2 diabetes

mellitus ), and Providing adequate nutrition for all stages of life.

It can help clients improve metabolic control by making changes in nutrition habits. The specific goals include:

Improving blood glucose and lipid levels,Providing consistency in day-to-day food intake ( in

type 1 diabetes mellitus),Facilitating weight management ( in type 2 diabetes

mellitus ), and Providing adequate nutrition for all stages of life.

Dietary management is an essential component of diabetic care and management

Promote Regular Physical ActivityPromote Regular Physical Activity

Physical activity:Lowers blood glucose level by increasing carbohydrate metabolism, fosters weight reduction and maintenance.Increase insulin sensitivity,increased high-density lipoprotein levels,Decreases triglyceride levels, lowers blood pressure, and reduces stress and tension.

Physical activity:Lowers blood glucose level by increasing carbohydrate metabolism, fosters weight reduction and maintenance.Increase insulin sensitivity,increased high-density lipoprotein levels,Decreases triglyceride levels, lowers blood pressure, and reduces stress and tension.

Administer Oral MedicationsAdminister Oral MedicationsA. Sulfonylureas

Stimulate beta cells of the pancreas to secrete insulin

Second generation also increase tissue response to insulin and decrease glucose production by the liver.

1) Chlorpropamide (diabinese ) It works by stimulating the release of your body's natural insulin, thereby lowering your blood sugar. Take this medication by mouth usually once daily with breakfast.

A. SulfonylureasStimulate beta cells of the pancreas

to secrete insulinSecond generation also increase

tissue response to insulin and decrease glucose production by the liver.

1) Chlorpropamide (diabinese ) It works by stimulating the release of your body's natural insulin, thereby lowering your blood sugar. Take this medication by mouth usually once daily with breakfast.

Glipizide It works by stimulating the release of your body's natural insulin.Take this medication by mouth 30 minutes before a meal, usually once daily before breakfast.

Glipizide It works by stimulating the release of your body's natural insulin.Take this medication by mouth 30 minutes before a meal, usually once daily before breakfast.

B. BiguanidesIncrease tissue response to insulinDecrease hepatic production of glucoseDecrease absorption of glucose from the small intestineDecrease triglyceride and low-density lipoprotein level.

1) MetforminWorks by helping to restore your body's proper response to the insulin you naturally produce. Decreases the amount of sugar that your liver makes and that your stomach/intestines absorb.Take metformin with a meal.

C. ThiazolidinedionesIncrease insulin action at receptors and post receptors

in hepatic and peripheral tissue to decrease insulin resistance

Often decrease triglyceride level.

1) RosiglitazoneTake this medication by mouth, with or without food, usually once or twice daily. It may take up to 2 to 3 months before the full benefit of this drug takes effect.

D. Alpha-glucosidase inhibitiorsDelay the digestion of complex carbohydrates

and certain sugars to blunt the peak of blood glucose and insulin levels after meals.

1) AcarboseCan be use with other medications (e.g., insulin, metformin, sulfonylureas such as glipizide) to control diabetes because they work in different ways.Take this medication by mouth, usually 3 times a day at the start (with the first bite) of each main meal.

D. Alpha-glucosidase inhibitiorsDelay the digestion of complex carbohydrates

and certain sugars to blunt the peak of blood glucose and insulin levels after meals.

1) AcarboseCan be use with other medications (e.g., insulin, metformin, sulfonylureas such as glipizide) to control diabetes because they work in different ways.Take this medication by mouth, usually 3 times a day at the start (with the first bite) of each main meal.

E. InsulinDrug of choice for patients who have type 1 DM.Patients with DM 2 may take this to have adequate insulin control during times of illness and stress.Two thirds of the dose is commonly given in the morning, and one third is given in the evening. Insulin is made chemically by recombinant DNA technology (human insulin) with different durations of action, there are four types:

– Rapid acting– Short acting– Intermediate acting– Long acting

Site of Injection

Foot CareFoot Care

Latest ModalitiesLatest ModalitiesMiniMed insulin pump

Continuous subcutaneous insulin infusing involves the use of small, externally worn devices that closely mimic the functioning of the normal pancreas. Insulin pumps contain a 3-mL syringe attached to a long (24-42in), thin, narrow-lumen tube with a needle or Teflon catheter attached to the end.

Advantages:Increased flexibility in

lifestyle (in terms of timing and amount of meals, exercise and travel).

Improved blood glucose control

Disadvantages:Unexpected

disruptions in the flow of insulin from the pump

Infection

Alternative TreatmentAlternative TreatmentAlternative TreatmentAlternative Treatment

Bitter melon

natural remedy for type 2 diabetes among

traditional medicine practitioners.

Bitter melon

natural remedy for type 2 diabetes among

traditional medicine practitioners.

Green tea

can improve glucose tolerance, and upping the sensitivity to

insulin.

Green tea

can improve glucose tolerance, and upping the sensitivity to

insulin.

Root of the Zingibera medicinal plant in Asian, Indian, and Arabic herbal traditions since

ancient times as a digestive aid and an anti-inflammatory helping to treat arthritis and the common

cold. Researchers from the University of Sydney have also found that extracts may help

improve long-term diabetic blood sugar control

Root of the Zingibera medicinal plant in Asian, Indian, and Arabic herbal traditions since

ancient times as a digestive aid and an anti-inflammatory helping to treat arthritis and the common

cold. Researchers from the University of Sydney have also found that extracts may help

improve long-term diabetic blood sugar control

Chinese Wolfberries way to help lessen vision

problems associated with type-2 diabetes.

Chinese Wolfberries way to help lessen vision

problems associated with type-2 diabetes.

RESEARCH FOCUSRESEARCH FOCUSSugar-Sweetened Beverages Increase Risk of

Type 2 Diabetes and Metabolic SyndromeAn analysis conducted by an American Diabetes

Association-funded researcher, Frank Hu, MD, PhD, MPH., shows that regular consumption of sugar-sweetened beverages is strongly associated with developing type 2 diabetes and metabolic syndrome. Providing the first quantitative confirmation of this link, Dr. Hu and fellow researchers at the Harvard School of Public Health analyzed data from eleven different studies with 310,819 individuals evaluated for diabetes and 19,431 for metabolic syndrome. Results showed that participants who drank one to two 12 ounce servings per day increased their risk of developing type 2 diabetes by 26% and of developing metabolic syndrome increased by 20%, compared to those who drank less than one serving per month.

Sugar-Sweetened Beverages Increase Risk of Type 2 Diabetes and Metabolic Syndrome

An analysis conducted by an American Diabetes Association-funded researcher, Frank Hu, MD, PhD, MPH., shows that regular consumption of sugar-sweetened beverages is strongly associated with developing type 2 diabetes and metabolic syndrome. Providing the first quantitative confirmation of this link, Dr. Hu and fellow researchers at the Harvard School of Public Health analyzed data from eleven different studies with 310,819 individuals evaluated for diabetes and 19,431 for metabolic syndrome. Results showed that participants who drank one to two 12 ounce servings per day increased their risk of developing type 2 diabetes by 26% and of developing metabolic syndrome increased by 20%, compared to those who drank less than one serving per month.

"The association that we observed between soda consumption and risk of diabetes is likely a cause-and-effect relationship because other studies have documented that sugary beverages cause weight gain, and weight gain is closely linked to the development of type 2 diabetes," said Dr. Hu, senior author of the study published in the November 2010 edition of Diabetes Care. 

Apart from overall weight gain, the authors also consider that since these liquid carbohydrates are usually consumed in fairly high quantities and can quickly raise blood-sugar levels, the drinks may lead to insulin resistance and glucose intolerance—both of which are linked to type 2 diabetes. The researchers recommend that consumers "limit consumption of these beverages in place of healthy alternatives such as water to reduce obesity-related chronic disease risk."  (Malik VS, Popkin BM, Bray GA, Despres JP, Willet WC, Hu, FB. Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis. Diabetes Care. 2010 Nov; 33(11): 2477-2483.)

"The association that we observed between soda consumption and risk of diabetes is likely a cause-and-effect relationship because other studies have documented that sugary beverages cause weight gain, and weight gain is closely linked to the development of type 2 diabetes," said Dr. Hu, senior author of the study published in the November 2010 edition of Diabetes Care. 

Apart from overall weight gain, the authors also consider that since these liquid carbohydrates are usually consumed in fairly high quantities and can quickly raise blood-sugar levels, the drinks may lead to insulin resistance and glucose intolerance—both of which are linked to type 2 diabetes. The researchers recommend that consumers "limit consumption of these beverages in place of healthy alternatives such as water to reduce obesity-related chronic disease risk."  (Malik VS, Popkin BM, Bray GA, Despres JP, Willet WC, Hu, FB. Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis. Diabetes Care. 2010 Nov; 33(11): 2477-2483.)

REFERENCES• http://www.diabetes.org.uk• Black, J. (2008). Medical-Surgical Nursing 8th Edition.

Singapore: Elsevier Pte. Ltd• Morrison A., Lykestos C. (2005). The Pathophysiology of

Alzheimer’s Disease and Directions in Treatment. Galen Publishing LLC.

• http://care.diabetesjournals.org/content/33/11/2477.full• Patrick M., Woods S., Craven R., Rokosky J., Medical-

Surgical Nursing Pathophysiological Concenpts, 2nd edition. Lippincott

• Corwin E. Handbook of Pathophysiology. 3rd edition, Lippincott. 2008