Advanced Theoretical concepts in Nursing

Diabetes Mellitus Type-II

By Talat Rashid

December 12, 2007

Objectives

• Define the disease in the case study• Discuss the prevalence, significance of Diabetes

Mellitus type II.(DM II) • Describe the etiology, normal and altered

pathology, and s/s of DM II• Explain the prevention/complications of DM II • Review the pharmacological manag. of DM II• Discuss nursing management of DM II by

incorporating the appropriate theory.

Case study 47 yrs old, father. Appeared in Diabetes consultant clinic on 29-11-07 Presenting features (from last 04 months) - Sense of heaviness over lower abdomen - Retention of urine - Excessive urination (Polyuria) - Excessive thirst (Polydipsia) - Excessive eating (Polyphagia) - Becomes angry on minor issues

cont……

Family Hx:

DM (-), HTN (+), Cardiac dis (+)

Personal/social Hx:

Businessman, normal sleep, Appetite,

feels has lost wt from 01 yr., smoking

from last 10 yrs

Vitals • B.P 125/80 mmHg

• Pulse: 80/min (regular)

• RR: 22/min (unlabored)

• Wt 85 kg

• Ht: 180 cm

• Pain score: 1(on pain scale of 1-10)

• Allergies: Not known

General appearance

• An adult man with average built walked in comfortably into the CC (accompanied by his wife) and sit on the chair with ease. Oriented to time, place and person, has clear speech & relevant talk but seems to have attention & eye contact during history taking and gives incomplete answers occasionally, looks depressed. Is well groomed and hydrated.

Physical Examination

• Ht 180cm• Wt 85kgs• Body Mass Index (BMI)

BMI = Wt (kgs) / Ht (mxm)

= 85 kgs /1.8m x1.8m

= 85 / 3.24

= 26.23kgs/m2 (n.range= 19-24kgs/m2)

Overweight

Review of systems Skin: inspection for breakdown, non healing pustules, diabetic ulcer or wound, Diabetic foot.

Neurological system: Sensory & motor system. Paralysis, Balance, response to pain & sensitization of hot or cold application over limbs for parasthesia to rule out Diabetic Neuropathy,

Cognition status: orientation, alertness, memory status.

Eyes: vision, pain, cataracts, fundoscopy to rule out Diabetic Retinopathy

Mouth: inspection of gums & teeth for infection, buccal mucosa for sores,

Cont…. CVS: pain, palpitation, heart sounds, dysnea, murmurs,, HTN

PVS: varicose veins, thrombophlebitis, leg cramps

Genito-urinary : frequency of micturation, pressure symtoms, burning

micturation, incontinence of urine, Diabetic Nephropathy

Musculoskeletal system : ROMs, strength, gait & balance

Endocrine : Goiter, change in weight, polyphagia, polidypsia, polyuria, glycosuria

Differential Diagnosis

• Diabetes Mellitus Type II

• Diabetes Mellitus Type I

• Hyperlipidemia

• UTI

• BPH

• Anxiety

Investigations• FBS 134 mg/dl • RBS 213 mg/dl• Lipid Profile

T. Cholesterol 201 mg/dl (Nor < 250) Triglycerides 104 mg/dl (Nor < 150)

HDL 40 mg/dl (Nor > 40) LDL 143 mg/dl (Nor > 100)

• DIABETES MELLITUS TYPE II

(Non Insulin Dependant Diabetes Mellitus)

Definition

• Type II diabetes is a chronic, common, complex metabolic disorder characterized by hyperglycemias, a disease of growing public health concern

SignificanceINCIDENCE

PREVENTABLE COMPLICATIONS

COMORBIDS

HOSPITAL / TERTIARY CARE

HOSPITAL WORKLOAD / NOSOCOMIAL INFECTIONS

NATIONAL ECONOMY

HEALTHY AND PRODUCTIVE COMMUNITY

Prevalence

• 2.9 million people globally died of diabetes in 2000, about three times its previous estimate.

WHO (2005)

• 200 million cases worldwide

(Report of a WHO Meeting, 2004 )

Prevalence in United States 20.8 million (7 % population) had diabetes in 2005, 6.2 million of them undiagnosed. 90 to 95 % (18.7 million - 19.8

million people) of Diabetics had type 2 diabetes. (U.S. National Institutes of Health-2006)

Prevalence in Pakistan The prevalence rate of diabetes 16.2% (9% known and 7.2% newly

diagnosed) in men and 11.7% (6.3% known and 5.3% newly diagnosed) in women. The prevalence increased to almost 30% and 21% in 65-74 years old men and women respectively. 79% of Diabetic men & 96% of Diabetic womenin Pakistan are obese.

(Javed, 2003)

Incidence

• Age

Traditionally thought to affect > 40 years

However, Incidence increasing in younger persons, in prepubertal children, teenagers, and young adults.

Type 2 diabetes mellitus is observed even in some obese children.

• Sex; more common in women

Background

• Unlike type 1 diabetes mellitus, patients are not absolutely dependent upon insulin for life, even though many of these patients are ultimately treated with insulin.

• Many people do not realize that they are suffering from type 2 diabetes as they experience symptoms of fatigue, lethargy, extreme thirst, frequent urination, susceptibility to infections and vision changes over a prolonged period of time.

• Being overweight can keep your body from making and using insulin properly. It can also cause high blood pressure

Endocrine system

• Endocrine glands release hormones (chemical messengers) into the bloodstream to be transported to various organs and tissues throughout the body.The pancreas secretes insulin, which allows the body to regulate levels of sugar in the blood.

www.medline.medicine

Pancreas

• The pancreas is located behind the liver and is where the hormone insulin is produced. Insulin is used by the body to store and utilize glucose.

www.medline.medicine

Islets of Langerhans

• Islets of Langerhans contain beta cells and are located within the pancreas. Beta cells produce insulin which is needed to metabolize glucose within the body.

www.medline.medicine

Role of InsulinFood intakeFood intake

containing CHOcontaining CHO

End product of CHO End product of CHO metabolism GLUCOSEmetabolism GLUCOSE

Insulin is releasedGlucose in the blood

Movement of glucose to body’s muscle, fat & liver cells

Glucose used by the body as FUEL for ENERGY

Path physiology Production of Insulin (Auto immune) Insulin resistanceProduction of Insulin (Auto immune) Insulin resistance

by liver, fat & muscle by liver, fat & muscle cellscells

Ineffective movement of Glucose to the cellIneffective movement of Glucose to the cell

no energy available to cellsno energy available to cells Blood Levels of GlucoseBlood Levels of Glucose

HyperglycemiaHyperglycemia

Etiology

• Presumably, the defects of type 2 diabetes mellitus occur when a diabetogenic lifestyle (ie, excessive calories a high-fat diet, inadequate caloric expenditure, obesity) is superimposed upon a susceptible genotype appears to cause type 2 diabetes mellitus.

• Diabetes mellitus may be caused by other conditions. Secondary diabetes may occur in patients taking glucocorticoids or when patients have conditions that antagonize the actions of insulin (eg, Cushing syndrome, acromegaly, pheochromocytoma).

Risk factors of DM

• A parent, brother, or sister with diabetes • Obesity ( fat cells become insulin resistant)• Age greater than 45 years • Gestational diabetes or delivering a baby

weighing more than 9 pounds • High blood pressure • High blood levels of triglycerides (a type of fat

molecule) • High blood cholesterol level • Not getting enough exercise

Cardinal characteristics of DM

• Hyperglycemia. Abnormally high glucose. Left untreated to coma or death.

• Hypoglycemia. Abnormally low glucose. Left untreated convulsions, unconsciousness or brain damage.

COMPLICATIONS•

. Microvascular Diabetic Neuropathy eg; parasthesias and foot problems

limb amputations Diabetic retinopathy eg; glaucoma, cataracts, macular

degeneration and blindness).

Macrovascular Coronary, peripheral- vascular, diabetic nephropathy

associated with BP & albumin in the urine (detected by urinalysis) kidney failure

Others Skin disorders and infections. The stomach disorder  Sexual dysfunction.. Urinary incontinence Gum disease

Arteriosclerosis of extremities• Arteriosclerosis of the

extremities is a disease of the blood vessels characterized by narrowing and hardening of the arteries that supply the legs and feet. This causes a decrease in blood flow that can injure nerves and other tissues.

•www.medline.medicine

www.medline.medicine

Diabetic retinopathy

• Excessive amount of glucose in the blood stream may cause damage to the blood vessels. Within the eye the damaged vessels may leak blood and fluid into the surrounding tissues and cause vision problems. www.medline.medicine

Diabetic nephropathy• Uncontrolled diabetes

causes thickening and hardening of the internal kidney structures. A kidney biopsy clearly shows diabetic nephropathy.

www.medline.medicine

Symptoms of DM II

• 3 Ps Polydypsia (Increased thirst) Polyuria (Increased urination) Polyphagia (Increased appetite) • Fatigue • Blurred vision • Slow-healing infections • Impotence in men• Mood changes• Sudden reduction in wt

Diagnostic criteria of DM II

• The criteria adopted for the diagnosis of diabetes & most commonly used is ‘The American Diabetes Association (1997)’ :

1. Fasting plasma glucose (FPG) >126 mg/dL on 2 occasions or random plasma glucose (RPG) > 200 m g/dl

2. Classic symptoms of diabetes mellitus (ie, polyuria, polydipsia, polyphagia, weight loss).

Cont…..

• Oral glucose tolerance test is +ive if glucose level is >/= 200 mg/dL a/f 2 hrs of intake.

• Hemoglobin A1c (HbA1c) level >7% is a measure of average blood glucose during the previous 2 to 3 months. It is a very helpful way to determine how well treatment is working.

• High triglycerides (>250 mg/dL) or low HDL (<35 mg/dL).

Treatment of DM II

• Oral antidiabetics *Tab Amaryl Img Bid *Tab Glucobay 50mg BD Tab Diabenese 100mg, 250mg Tab Metformin 500mg OD Tab Glucophage 500mg OD

Prophylactic drugs *Tab Esso 40 mg OD *Tab Ascard 70 mg OD

Tab Amaryl (Glymeperide)1,2&4mg

• Action unknown, glucose possibly by stimulating release of insulin from functioning pancreatic beta cells. May sensitivity of peripheral tissue to insulin.

• Nsg considerations:

-Watch for hypoglycemia (cautiously used in elderly & malnourished)

-Drug should be taken with first meal of the day

Tab Glucobay (Acarbose) 25,50 &100mg

• Alpha glycosidase inhibitor that delays digestion of CHO, resulting in a smaller rise in glucose level a/f meal

• Nsg considerations:

-Watch for hypoglycemia

-Contraindicated in inflammatory bowel disease, colonic ulceration, predispositon to intestinal obstruction.

Tab Ascard( Aspirin)70mg ODSalicylate

• Reduces risk of recurrent transient Ischemic attacks & stroke in patients at risk, by impeding clotting by blocking prostaglandin synthesis, which prevent formation of platelet aggregation substance Thromboxone A2.

• Nsg considerations - Use cautiously in pts with GI lesions, impaired renal

function, Vit k deficiency, bleeding disorders. -Should be discontinued , if bleeding from any sight

occurs & 7 days prior surgery - Pt taught to take drug with food

Cont…

Research in the proposed treatment of type II diabetes :

Replacement hormones, such as glucagon-like peptide-1 (GLP-1).

Pancreatic cell transplant, (the insulin producing cells will be transferred to a diabetic person to achieve a cure)

Bariatric surgery (Christine 2005)

Complications

• Heart attack

• Stroke

• Renal failure

• Limb amputation

Prevention

• Exercise

• Normal weight control.

• Physical activity

• Healthy diet

• Strict blood glucose control

Integration of Theory in patient with DM

“Bandura’s Self-Efficacy Theory”

Model of triade resiprocality

Background of theory

• Self-Efficacy theory is an important component of Bandura’s social cognitive theory (1986), which suggests high inter-relation b/w individual’s Behavior, Environment and Personal ( cognitive, affective, & biological events) factors.

(Graham & Winner, 1996)

Assumptions • The reciprocal nature of the determinants of

human functioning in social cognitive theory makes it possible for therapeutic & counseling efforts to be directed at personal, environmental or Behavioral factors.

• Hence strategies for well-being can be aimed at improving emotional, cognitive, or motivational processes, increasing behavioral competencies, or altering the social conditions under which people live & work.

Cont…..• Self-efficacy beliefs provide the foundation for

human motivation, well-being and personal accomplishment.

• People who regard themselves as highly efficacious act, think & feel differently from those who perceive themselves as inefficacious.

• Because individual’s operate collectively as well as individually, self- efficacy is both a personal & social construct.

Self-Efficacy

• Self-efficacy is the belief in one’s effectiveness in performing specific tasks.

(Bandura, 1986)

Self – efficacy in DM type IISelf- monitoring of

Blood glucose, Compliance with Rx

Follow Dietary restriction.Control weight

Regular exercise.Regular follow ups in cc.

Health outcome (improved health)

Develop habits of positive thinking, willingness to do

Actions andself-reflection

TreatmentNurse

Health Educator.PersuaderCounselor

FamilyHEALH CARE PROGRAMS

Nursing diagnosis

• Fear r/t diagnosis of chronic illness

• Knowledge deficit r/t control of disease/ prevention of complications.

• Risk of ineffective coping r/t chronic disease

• Risk of noncompliance r/t the complexity of the prescribed regime and follow up.

Nsg interventions• Explain to the patient that the disease is controllable and

the symptoms can be reduced by improving behaviors like:

-Control on weight through a weight reduction program and exercise. Use of stairs instead of elevators, and a regular program of walk, starting from small distance to gradually increasing the distance.

-Reduction of calories in diet. Limit fat intake to about 25 percent of total calories. For example, if the food choices add up to about 2,000 calories a day, should eat no more than 56 grams of fat.

-Diet can be planed with the dietition. The patient can be asked to check food labels for fat content too.

Cont…..• Avoid taking saturated fats coming from

animals meats & dairy products like milk, cheese and ice cream; and in some kinds of cooking oils.

• Reduce serving sizes of foods (such as meat, desserts, and foods high in fat). Increase the amount of fruits and vegetables in the diet.

• Controlling carbohydrates in diet, such as: pasta, bread, rice, potatoes

Cont….

• The patient is allowed to choose activities he/she enjoys. Some ways to work extra activity into daily routine:

• Take the stairs rather than an elevator or escalator.

• Park at the far end of the plot and walk. • Get off the bus a few steps early and walk the

rest of the way. • Walk or ride bicycle instead of drive whenever

he/she can.

Cont….

• Compliance with Rx. The medicine must be taken as prescribed by the physician, at the right time in the right dose.

• Regular follow ups in cc, once in three months, with raflo checks and lipid profile and review of risk of appearance of 3 cardinal pathies.

Acknowledgements

• Miss Salma Jaffer

• Ms Saleema Moiz

• Ms Zubaida ( Diabetic cc nurse)

• All Collegues

References

– Anne.J., ‘Diabetes Causes and Prevention, retrieved from http://www.a1articles.com on 9/12/2007– Author: Bandura.A. (1986), ‘Social foundation of thought and action’: a social cognitive theory, England cliffs NJ, Prentice Hall

- ‘Diabetic diet information, what should you eat’,retr. From http://www.a1articles.com on 7/12/2007 - Pajares F., ‘Overview of Social Cognitive Theory And of Self-Efficacy’, retrieved from www.healthology.com on 7/12/2007 - Porth, C. M. (2004). Pathophysiology: Concepts of altered health states (7th ed.). New York: Lippincott.