zeenat ayaz diabetes mellitus. diabetes mellitus is a group of metabolic diseases characterized by...
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ZEENAT AYAZ
Diabetes mellitus
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Diabetes mellitus
Diabetes mellitus is a group of metabolic diseases characterized by elevated levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both
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Insulin, a hormone produced by the pancreas, controls the level of glucose in the blood by regulating the production and storage of glucose.
• Transports and metabolizes glucose for energy
• Stimulates storage of glucose in the liver and muscle (in the form of glycogen)
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Signals the liver to stop the release of glucose
Enhances storage of dietary fat in adipose tissue
Accelerates transport of amino acids (derived from dietary protein) into cells
Also inhibits the breakdown of stored glucose, protein, and fat.
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InsulinInsulin and glucagon are hormones secreted by islet cells within thepancreas
Insulin is normally secreted by the beta cells (a type of islet cells) of the pancreas
Stimulus for insulin is high blood glucose levels
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Classification
Type 1 diabetes (insulin-dependent diabetes mellitus)
Type 2 diabetes (non-insulindependent diabetes mellitus)
Gestational diabetes mellitus
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Type 1 Diabetes Mellitus
Most often occurs in people under 30 years of age
Peak onset between ages 11 and 13Formerly known as “juvenile onset” or
“insulin dependent” diabetes
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Type 1 Diabetes MellitusEtiology and Pathophysiology
Progressive destruction of pancreatic cells Autoantibodies cause a reduction of 80% to
90% of normal cell function before manifestations occur
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Type 1 Diabetes MellitusEtiology and Pathophysiology
Causes: Genetic predisposition
Related to human leukocyte antigens (HLAs) Exposure to a virus
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Type 1 Diabetes MellitusOnset of Disease
Manifestations develop when the pancreas can no longer produce insulin Rapid onset of symptoms Present at ER with ketoacidosis
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Type 1 Diabetes MellitusOnset of Disease
Weight lossPolydipsiaPolyuriaPolyphagia
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Type 1 Diabetes MellitusOnset of Disease
Diabetic ketoacidosis (DKA) Occurs in the absence of exogenous insulin Life-threatening condition Results in metabolic acidosis
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Type 2 Diabetes Mellitus
Accounts for 90% of patients with diabetes
Usually occurs in people over 40 years of age
80-90% of patients are overweight
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Type 2 Diabetes MellitusEtiology and Pathophysiology
Pancreas continues to produce some insulin
Insulin produced is either insufficient or poorly utilized by the tissues
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Type 2 Diabetes MellitusEtiology and Pathophysiology
Insulin resistance Body tissues do not respond to insulin Results in hyperglycemia
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Type 2 Diabetes MellitusEtiology and Pathophysiology
Inappropriate glucose production by the liver Not considered a primary factor in the
development of type 2 diabetes
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Type 2 Diabetes MellitusEtiology and Pathophysiology
Type 2 Diabetes MellitusEtiology and Pathophysiology
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Type 2 Diabetes MellitusOnset of Disease
Gradual onsetPerson may go many years with
undetected hyperglycemia 75% of type 2 diabetes is detected incidentally
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Gestational Diabetes
Develops during pregnancy Detected at 24 to 28 weeks of gestation Risk for cesarean delivery, perinatal
death, and neonatal complications
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Secondary Diabetes
Results from another medical condition or due to the treatment of a medical condition that causes abnormal blood glucose levels Cushing syndrome Hyperthyroidism Parenteral nutrition
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Clinical ManifestationsDiabetes Mellitus
PolyuriaPolydipsia (excessive thirst)PolyphagiaIn Type I
Weight loss Ketoacidosis
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Clinical ManifestationsNon-specific symptoms
Fatigue and weakness Sudden vision changes Tingling or numbness in hands or feet Skin lesions or recurrent infections Prolonged wound healing Visual changes
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Clinical Manifestations23
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Risk Factors for Diabetes Mellitus
Family history of diabetes (i.e., parents or siblings with diabetes)
Obesity (i.e., ≥20% over desired body weight or BMI ≥27 kg/m2)
Race/ethnicity (e.g., African Americans, Hispanic Americans, Native Americans, Asian Americans, Pacific Islanders)
Age ≥45 years Previously identified impaired fasting
glucose or impaired glucose tolerance
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Risk factors (cont.)
Hypertension (≥140/90 mm Hg) HDL cholesterol level ≤35 mg/dL (0.90
mmol/L) and/or tri- glyceride level ≥250 mg/dL (2.8 mmol/L)
History of gestational diabetes or delivery of babies over 9 lbs
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ASSESSMENT AND DIAGNOSTIC FINDINGS
high blood glucose levelFasting plasma glucose (FPG) levels of 126
mg/dL (7.0 mmol/L) or more random plasma glucose levels exceeding 200
mg/dL (11.1 mmol/L) on more than one occasion
Plasma glucose values may be 10% to 15% higher than whole
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goal
The main goal of diabetes treatment is to normalize insulin activity and blood glucose levels to reduce the development of vascular and neuropathic complications.
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management
There are five components of diabetes management
• Nutritional management• Exercise• Monitoring• Pharmacologic therapy• Education
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Treatment varies because of changes in lifestyle and physical and emotional status as well as advances in treatment methods.
Therefore, diabetes management involves constant assessment and modification of the treatment plan by health professionals and daily adjustments in therapy by the patient.
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Diabetes MellitusAcute Complications
HypoglycemiaDiabetic ketoacidosis (DKK)Hyperosmolar hyperglycemic nonketotic
syndrome (HHNS)
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hypoglycemia
Type 1 or type 2 diabetesBlood glucose < 50-60 mg/dLCauses
Too much insulin Overdose of oral antidiabetic agents Too little food Excess physical activity
May experience S & S of hypoglycemia if there is sudden decrease in BS
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hypoglycemia
Treatment Mild
Immediate treatment 15 g rapid-acting sugar
Severe Hospitalized Intravenous glucose
Teach patients to carry simple sugar with them
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Life-threatening illness in type 1 Hyperglycemia Dehydration and electrolyte loss Acidosis
Causes of DKA Decreased or missed dose of insulin, Illness or infection, Undiagnosed and untreated diabetes
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Without insulin, the amount of glucose entering the cells is reduced, and production and release of glucose by the liver is increased (lead to hyperglycemia).
Excess glucose leads to polyuria (6.5 L/day) dehydration, sodium and potassium loss
Burning of fat leads to ketosisKidneys unable to excrete ketones, leads to
ketoacidosis
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Diagnosis: Blood glucose (300 and 800 mg/dL)
Treatment Rehydration (0.9-0.45% saline) Restoring Electrolytes (K+)
loss of potassium from body stores and an intracellular-to-extracellular shift of potassium
Reversing Acidosis (reversed with insulin) Regular insulin infusion (5 units/hr) Hourly blood glucose monitoring
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Hyperosmolar hyperglycemic nonketotic syndrome (HHNS)39
Is a serious condition most frequently seen in older persons.
HHNS is usually brought on by something else, such as an illness or infection, dialysis, drugs that increase BS.
Blood sugar levels rise resulting into glycosuria, polyuria, thirst.
Severe dehydration will lead to seizures, coma and eventually death.
HHNS may take days or even weeks to develop. Know the warning signs of HHNS.
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HHNS/ clinical manifestations 40
Hypotension, profound dehydration (dry mucous membranes, poor skin turgor), tachycardia, and variable neurologic signs (eg, alteration of sensorium, seizures, hemiparesis).
Blood glucose level (600 to 1200 mg/dL)Treatment: fluid replacement, correction of
electrolyte imbalances, and insulin.
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Diabetes MellitusChronic Complications
Macrovascular (atherosclerotic plaque) Coronary arteries → (MI’s) Cerebral arteries → (strokes) Peripheral vessels → (ulcers, amputations, infection)
Microvascular (capillary damage) Retinopathy Neuropathy Nephropathy
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Macrovascular Complications43
Macrocirculation Blood vessel walls thicken, sclerose, and
become occluded by plaque that adheres to the vessel walls. finally, blood flow is blocked.
Complications Coronary artery disease Stroke Peripheral vascular disease
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Complication: CAD44
CAD account for 50% to 60% of all deaths among patients with diabetes.
High cholesterol and high triglyceridesMI is twice as common in men and three
times in women with diabetes, compared to people without diabetes.
Silent MIHigher risk for a second infarction
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Complication: Stroke45
People with diabetes have twice the risk of developing cerebrovascular disease.
There is a greater likelihood of death from cerebrovascular disease.
Recovery is slower with high BS.Hypertension plays a role
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Complication: Peripheral Vascular Disease46
Diabetes-induced arteriosclerosis2-3 times higher than in nondiabetic
peopleS & S: diminished peripheral pulses and
intermittent claudication (pain in the buttock, thigh, or calf during walking)
Can lead to leg ulcers and gangrene and amputation.
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Management of Macrovascualr changes
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Prevention and treatment of risk factors for atherosclerosis. obesity, hypertension, and hyperlipidemia (exercise,
stop smoking). Control of blood glucose levels may reduce
triglyceride concentrations and can significantly reduce the incidence of complications.
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Microvascular Complications48
Microcirculation Eyes Kidneys Nerves
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Complication: Diabetic Retinopathy49
Leading cause of blindness in people ages 20 to 74 in US
Almost all patients with type 1 diabetes and more than 60% of patients with type 2 diabetes have some degree of retinopathy after 20 years
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Diabetic Retinopathy50
Changes in the retinal capillaries; lead to retinal ischemia.
Changes include microaneurysms, intraretinal hemorrhage, hard exudates, and focal capillary closure.
Yearly eye exams are recommended
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Complication: Diabetic Nephropathy
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Disease of the kidneys (50% of RF due to DM)Characterized by albumin in the urine,
hypertension, edema, renal insufficiencyDM is the most common cause of renal failureFirst indication: microalbuminuriaTreatment: ACE inhibitors, control BP and BS,
prevent & treat UTI, low Na & protein diet.
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Complication: Diabetic Neuropathy52
Disorder of the peripheral nerves, spinal cord, and autonomic nervous system
Results: sensory and motor impairments, postural hypotension, delayed gastric emptying, diarrhea, impaired GU function
Result from the thickening of the capillary membrane and destruction of myelin sheath which disrupt nerve conductions.
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Complication: Diabetic Neuropathy53
Bilateral sensory disorders Appear first in toes, feet, and progress upward to
fingers and hands Tingling, decrease in proprioception , and a
decreased sensation of light touch Treatment
Controlling BS delay the onset. Analgesics to control pain
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Complication: Autonomic Neuropathy54
Involves numerous body systems such as: Cardiovascular (slight tachycardia, orthostatic
hypotension & silent MI). Gastrointestinal (Delayed gastric emptying , N&V,
early satiety, variation of BS absorption) Genitourinary (urinary symptoms of neurogenic
bladder, UTI, erectile dysfunction) Hypoglycemic unawareness (DM diminish function
of adrenal medulla)
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Foot and Leg Problems55
50% -75% of lower extremity amputations are performed on people with diabetes.
More than 50% of these amputations are thought to be preventable.
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Foot and Leg ProblemsContributing factors
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• Neuropathy• Peripheral
vascular disease • Immunocompromi
se• Injuries could be:
Chemical Thermal Traumatic
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Foot Care 57
1. Take care of your diabetes.2. Inspect your feet every day.3. Wash your feet every day (dry between
toes well).4. Keep the skin soft and smooth.5. Smooth corns and calluses gently.6. Trim your toenails each week or when
needed.7. Wear shoes and socks at all times.8. Protect your feet from hot and cold.9. Keep the blood flowing to your feet.10.Check with your health care provider.
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Special Issues in Diabetes Care58
Patients with diabetes who are undergoing surgery Hyperglycemia (due to stress hormones) Hypoglycemia (being NPO)
Hold morning insulin unless it is > 200 mg/dL. Diuresis leads to fluid and electrolytes imbalance
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Nursing Diagnoses59
Risk for fluid volume deficit related to polyuria and dehydration
Imbalanced nutrition related to imbalance of insulin, food, and physical activity
Deficient knowledge about diabetes self-care skills/information
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Nursing Diagnoses60
Deficient knowledge about diabetes self-care skills/information
Potential self-care deficit related to physical impairments or social factors
Anxiety related to loss of control, fear of inability to manage diabetes, misinformation related to diabetes, fear of diabetes complications
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Collaborative Problems/ Potential Complications
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Fluid overload, pulmonary edema, and heart failure
HypokalemiaHyperglycemia and ketoacidosisHypoglycemiaCerebral edema