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Description

Diabetes is a chronic disease, which occurs when the pancreas does not produce enough

insulin, or when the body cannot effectively use the insulin it produces. This leads to an

increased concentration of glucose in the blood (hyperglycaemia).

Type 1 diabetes(previously known as insulin-dependent or childhood-onset diabetes) ischaracterized by a lack of insulin production.

Type 2 diabetes(formerly called non-insulin-dependent or adult-onset diabetes) iscaused by the bodys ineffective use ofinsulin. It often results from excess body weight

and physical inactivity.

Gestational diabetes is hyperglycaemia that is first recognized during pregnancy.

Causes

The cause of diabetes depends on the type.

Type 1 diabetes

Is partly inherited, and then triggered by certain infections, with some evidence pointingat Coxsackie B4 virus. A genetic element in individual susceptibility to some of thesetriggers has been traced to particular HLA genotypes (i.e., the genetic "self" identifiers

relied upon by the immune system). However, even in those who have inherited the

susceptibility, type 1 DM seems to require an environmental trigger. The onset of type 1

diabetes is unrelated to lifestyle.

Type 2 diabetes

is due primarily to lifestyle factors and genetics.

The following is a comprehensive list of other causes of diabetes:

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Genetic defects of -cell function

o Maturity onset diabetes of the young

o Mitochondrial DNA mutations

Genetic defects in insulin processing or insulin actiono Defects in proinsulin conversion

o Insulin gene mutations

o Insulin receptor mutations

Exocrine pancreatic defects

o Chronic pancreatitiso Pancreatectomy

o Pancreatic neoplasia

o Cystic fibrosis

o Hemochromatosis

o Fibrocalculous pancreatopathy

Endocrinopathieso Growth hormone excess (acromegaly)

o Cushing syndrome

o Hyperthyroidism

o Pheochromocytoma

o Glucagonoma

Infections

o Cytomegalovirus infection

o Coxsackievirus B

Drugs

o Glucocorticoids

o Thyroid hormoneo -adrenergic agonists

o Statins

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TYPE I VERSUS TYPE 2 DIABETES

PE I (IDDM) TYPE 2 (NIDDM)

Age of onset Usually younger than 40 Usually older than 40

Body weight Thin Usually overweightSymptoms Sudden onset Insidious onset

Insulin produced None Too little, or not effectiveInsulin requirements Exogenous insulin required May require insulin

Pathophysiology

DM Type I

DM Type II

Signs and symptoms

The classic symptoms of untreated diabetes are loss of weight, polyuria (frequent

urination),polydipsia (increased thirst) and polyphagia (increased hunger).Symptoms may

develop rapidly (weeks or months) in type 1 diabetes, while they usually develop muchmore slowly and may be subtle or absent in type 2 diabetes.

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Prolonged high blood glucose can cause glucose absorption in the lens of the eye, which

leads to changes in its shape, resulting in vision changes. Blurred vision is a commoncomplaint leading to a diabetes diagnosis; type 1 should always be suspected in cases of

rapid vision change, whereas with type 2 change is generally more gradual, but should

still be suspected. A number of skin rashes that can occur in diabetes are collectively

known as diabetic dermadromes.

Diabetic emergencies

People (usually with type 1 diabetes) may also present with diabetic ketoacidosis, a state

of metabolic dysregulation characterized by the smell of acetone, a rapid, deep breathingknown as Kussmaul breathing, nausea, vomiting and abdominal pain, and altered states

of consciousness.

A rare but equally severe possibility is hyperosmolar nonketotic state, which is more

common in type 2 diabetes and is mainly the result of dehydration.

WARNING SIGNS OF DIABETES

SIGNS AND SYMPTOMSS LABORATORY FINDINGS

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Sudden onset Polyurea

Polydipsia

Polyphagia

20 pound weight loss

Irritability Weakness and fatigue

Nausea, vomiting

Insidious onset Fatigue

Blurred vision

Tingling or numbness in hands and feet

Itching

Any symptoms of IDDM or hard to healwounds

Frequent bladder infections

Signs, Symptoms, and Treatment of Hypoglycemia and

Hyperglycemia

HYPOGLYCEMIA

Cause:Usually secondary to excess insulin, exercise, or not enough food

Signs and Symptoms

Nervousness

Irritability

Diaphoresis (heavy sweating)

Hunger

Weakness

Tachycardia

Fatigue Hypotension

Palpitations

Tachypnea

Tremors or shaking Pallor

Blurred or double vision

Incoherent speech

Headache Numbness of tongue and lips

Confusion Coma

Seizures

Treatment

Provide rapidly absorbed source of glucose:

Fruit juice or cola

Graham crackers

Sugar cubes, sugar packets

Hard candy

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As symptoms improve:

Provide a meal or source of complex protein or carbohydrates

HYPERGLYCEMIA

Cause:Usually secondary to insufficient insulin, illness, or excess food

Signs and Symptoms

Confusion

Nausea

Irritability

Vomiting

Fatigue

Anorexia

Weakness Abdominal cramping

Numbness

Thirst

Tachycardia

Lethargy

Hypotension

Kssmall breathing

Decreased level of consciousness

Increased temperature

Coma

Flushed or dry skin

Fruity breath

Poor skin turgor

Dry mucous membranes

Treatment(Requires Hospitalization)

Restore fluid balance

Replace electrolytes

Lower blood glucose with regular insulin

Monitor: Level of consciousness, vital signs, intake and output, and electrolytes

Provide emotional support

Diagnostic ProcedureSeveral blood tests are used to measure blood glucose levels, the primary test for diagnosing

diabetes. Additional tests can determine the type of diabetes and its severity.

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Random blood glucose testfor a random blood glucose test, blood can be drawn at

any time throughout the day, regardless of when the person last ate. A random blood

glucose level of 200 mg/dL (11.1 mmol/L) or higher in persons who have symptoms ofhigh blood glucose suggests a diagnosis of diabetes.

Fasting blood glucose testfasting blood glucose testing involves measuring blood

glucose after not eating or drinking for 8 to 12 hours (usually overnight). A normalfasting blood glucose level is less than 100 mg/dL. A fasting blood glucose of 126 mg/dL(7.0 mmol/L) or higher indicates diabetes. The test is done by taking a small sample of

blood from a vein or fingertip. It must be repeated on another day to confirm that it

remains abnormally high .

Hemoglobin A1C test (A1C)The A1C blood test measures the average blood

glucose level during the past two to three months. It is used to monitor blood glucose

control in people with known diabetes, but is not normally used to diagnose diabetes.

Normal values for A1C are 4 to 6 percent . The test is done by taking a small sample ofblood from a vein or fingertip.

Oral glucose tolerance testOral glucose tolerance testing (OGTT) is the most

sensitive test for diagnosing diabetes and pre-diabetes. However, the OGTT is notroutinely recommended because it is inconvenient compared to a fasting blood glucose

test.

The standard OGTT includes a fasting blood glucose test. The person then drinks a 75 gram

liquid glucose solution (which tastes very sweet, and is usually cola or orange-flavored). Two

hours later, a second blood glucose level is measured.

Oral glucose tolerance testing is routinely performed at 24 to 28 weeks of pregnancy to screen

for gestational diabetes; this requires drinking a 50 gram glucose solution with a blood glucose

level drawn one hour later. For women who have an abnormally elevated blood glucose level, asecond OGTT is performed on another day after drinking a 100 gram glucose solution. The

blood glucose level is measured before, and at one, two, and three hours after drinking the

solution.

Medical Management

There is no known cure for DM. Management of the disease focuses on control of the

serum glucose level to prevent or delay the development of complications. Individuals with type1 DM require subcutaneous insulin administration. Insulin may be rapid, intermediate, or

slow acting.

Patients with mild DM or those with type 2 DM or GDM may be able to control the disease by

diet management alone. A diabetic diet attempts to distribute nutrition and calories throughoutthe 24-hour period. Daily calories consist of approximately 50% carbohydrates and 30% fat, with

the remaining calories consisting of protein. The total calories allowed for an individual withinthe 24-hour period are based on age, weight, activity level, and medications.

In addition to strict dietary adherence to control blood glucose, obese patients with type 2 DMalso need weight reduction. The dietitian selects an appropriate calorie allotment depending on

the patients age, body size, and activity level. A useful adjunct to the management of DM is

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exercise. Physical activity increases the cellular sensitivity to insulin, improves tolerance

to glucose, and encourages weight loss. Exercise also increases the patients sense of well-

being concerning his or her health.

Pharmacological HighlightsWhen diet, exercise and maintaining a healthy weight arent enough, you may need the help of

medication. Medications used to treat diabetes include insulin. Everyone with type 1 diabetesand some people with type 2 diabetes must take insulin every day to replace what their pancreas

is unable to produce. Unfortunately, insulin cant be taken in pill form because enzymes in your

stomach break it down so that it becomes ineffective. For that reason, many people injectthemselves with insulin using a syringe or an insulin pen injector,a device that looks like a pen,

except the cartridge is filled with insulin. Others may use an insulin pump, which provides a

continuous supply of insulin, eliminating the need for daily shots.

The most widely used form of insulin is synthetic human insulin, which is chemically identical to

human insulin but manufactured in a laboratory. Unfortunately, synthetic human insulin isnt

perfect. One of its chief failings is that it doesnt mimic the way natural insulin is secreted. But

newer types of insulin, known as insulin analogs, more closely resemble the way natural insulinacts in your body. Among these are lispro (Humalog), insulin aspart (NovoLog) and glargine

(Lantus).

A number of drug options exist for treating type 2 diabetes, including:

Sulfonylurea drugs. These medications stimulate your pancreas to produce and release

more insulin. For them to be effective, your pancreas must produce some insulin on its

own. Second-generation sulfonylureas such as glipizide (Glucotrol, Glucotrol XL),glyburide (DiaBeta, Glynase PresTab, Micronase) and glimepiride (Amaryl) are

prescribed most often. The most common side effect of sulfonylureas is low blood sugar,especially during the first four months of therapy. Youre at much greater risk of low

blood sugar if you have impaired liver or kidney function.

Meglitinides. These medications, such as repaglinide (Prandin), have effects similar to

sulfonylureas, but youre not as likely to develop low blood sugar. Meglitinides work

quickly, and the results fade rapidly.

Biguanides. Metformin (Glucophage, Glucophage XR) is the only drug in this class

available in the United States. It works by inhibiting the production and release of

glucose from your liver, which means you need less insulin to transport blood sugar into

your cells. One advantage of metformin is that is tends to cause less weight gain than doother diabetes medications. Possible side effects include a metallic taste in your mouth,

loss of appetite, nausea or vomiting, abdominal bloating, or pain, gas and diarrhea. Theseeffects usually decrease over time and are less likely to occur if you take the medicationwith food. A rare but serious side effect is lactic acidosis, which results when lactic acid

builds up in your body. Symptoms include tiredness, weakness, muscle aches, dizziness

and drowsiness. Lactic acidosis is especially likely to occur if you mix this medication

with alcohol or have impaired kidney function.

Alpha-glucosidase inhibitors. These drugs block the action of enzymes in your digestive

tract that break down carbohydrates. That means sugar is absorbed into your bloodstream

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more slowly, which helps prevent the rapid rise in blood sugar that usually occurs right

after a meal. Drugs in this class include acarbose (Precose) and miglitol (Glyset).

Although safe and effective, alpha-glucosidase inhibitors can cause abdominal bloating,gas and diarrhea. If taken in high doses, they may also cause reversible liver damage.

Thiazolidinediones. These drugs make your body tissues more sensitive to insulin and

keep your liver from overproducing glucose. Side effects of thiazolidinediones, such asrosiglitazone (Avandia) and pioglitazone hydrochloride (Actos), include swelling, weightgain and fatigue. A far more serious potential side effect is liver damage. The

thiazolidinedione troglitzeone (Rezulin) was taken off the market in March 2000 because

it caused liver failure. If your doctor prescribes these drugs, its important to have yourliver checked every two months during the first year of therapy. Contact your doctor

immediately if you experience any of the signs and symptoms of liver damage, such as

nausea and vomiting, abdominal pain, loss of appetite, dark urine, or yellowing of your

skin and the whites of your eyes (jaundice). These may not always be related to diabetesmedications, but your doctor will need to investigate all possible causes.

Drug combinations. By combining drugs from different classes, you may be able to

control your blood sugar in several different ways. Each class of oral medication can becombined with drugs from any other class. Most doctors prescribe two drugs in

combination, although sometimes three drugs may be prescribed. Newer medications,

such as Glucovance, which contains both glyburide and metformin, combine different

oral drugs in a single tablet.

Nursing Intervention

Advice patient about the importance of an individualized meal plan in meeting weeklyweight loss goals and assist with compliance.

Assess patients for cognitive or sensory impairments, which may interfere with the abilityto accurately administer insulin.

Demonstrate and explain thoroughly the procedure for insulin self-injection. Help patient

to achieve mastery of technique by taking step by step approach.

Review dosage and time of injections in relation to meals, activity, and bedtime based onpatients individualized insulin regimen.

Instruct patient in the importance of accuracy of insulin preparation and meal timing to

avoid hypoglycemia.

Explain the importance of exercise in maintaining or reducing weight.

Advise patient to assess blood glucose level before strenuous activity and to eat

carbohydrate snack before exercising to avoid hypoglycemia.

Assess feet and legs for skin temperature, sensation, soft tissues injuries, corns, calluses,dryness, hair distribution, pulses and deep tendon reflexes.

Maintain skin integrity by protecting feet from breakdown.

Advice patient who smokes to stop smoking or reduce if possible, to reduce

vasoconstriction and enhance peripheral flow.

DOCUMENTATION GUIDELINES

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Results of urine and blood tests for glucose

Physical findings: Visual problems, skin problems or lesions, changes in sensation or

circulation to the extremities

Patient teaching, return demonstrations, patients understanding of teaching

Response to insulin

DISCHARGE AND HOME HEALTHCARE GUIDELINES

MEDICATIONS. Patients need to understand the purpose, dosage, route, and possibleside effects of all prescribed medications. If the patient is to self-administer insulin, have the

patient demonstrate the appropriate preparation and administration techniques.

PREVENTION. The patient and family require instruction in the following areas to minimize orprevent complications of DM.

Diet. Explain how to calculate the American Diabetic Association exchange list to

develop a satisfactory diet within the prescribed calories. Emphasize the importance

of adjusting diet during illness, growth periods, stress, and pregnancy. Encourage

patients to avoid alcohol and refined sugars and to distribute nutrients to maintain a

balanced blood sugar throughout the 24-hour period.

Insulin. Patients need to understand the type of insulin prescribed. Instructions

should include onset, peak, and duration of action. Stress proper timing of meals and

planning snacks for the time when insulin is at its peak, and recommend an evening

snack for those on long-acting insulins. Reinforce that patients cannot miss a dosage

and there may be a need for increasing dosages during times of stress or illness.

Teaching regarding the proper preparation of insulin, how to administer, and the

importance of rotating sites is necessary.

Urine and Blood Testing. Teach patients the appropriate technique for testing blood

and urine and how to interpret the results. Patients need to know when to notify the

physician and increase testing during times of illness. Skin Care. Stress the importance of close attention to even minor skin injuries.

Emphasize foot care, including the importance of properly fitting shoes with clean,

nonconstricting socks; daily washing and thorough drying of the feet; and inspection

of the toes, with special attention paid to the areas between the toes. Encourage the

patient to contact a podiatrist as needed. Because of sensory loss in the lower

extremities, teach the patient to test the bath water to prevent skin trauma from

water that is too hot and to avoid using heating pads.

Circulation. Because of the atherosclerotic changes that occur with DM, encourage

patients to stop smoking. In addition, teach patients to avoid crossing their legs

when sitting and to begin a regular exercise program.