Case PresentationName: Mr. Mel DyAge: 65 years oldGender: MaleHe was diagnosed of having Type II Diabetes Mellitus a year ago.The client was admitted in the hospital and he verbalized that heexperienced loss of appetite, frequent urination, tiredness, weightloss, body weakness. His wife noticed that he is always thirsty.The client don’t have regular medications for Diabetes Mellitus butthe client and his family are conscious about the food that they eat.The client admitted that before he is diagnosed with DiabetesMellitus he is more prone of having sickness.
CLASSIFICATION• 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
Distinguish Features of DM type 1 and type 2 Feature Type 1 Type 2 Insulin-dependent diabetes Non-insulin-dependent diabetes Synonyms mellitus, juvenile diabetes, mellitus, adult or maturity-onset labile or brittle diabetes diabetes, mild diabetes Usually occurs before age 30, Usually occurs after age 30, but Age at onset but may occur at any age can occur in children Incidence ~10% ~90% Insidious, may be asymptomatic Usually abrupt, with rapid onset or mildly asymptomatic; body Type of onset of hyperglycemia adapts to slow onset of hyperglycemiaEndogenous insulin Below normal, normal, or above Little or none production normal 85% of clients are obese, may beBody weight at onset Ideal body weight or thin of ideal body weight Prone to ketosis, usually present Resistant to ketosis, can occur ketosis at onset, often present during with infections or stress poor control Polyuria, polydipsia, polyphagia, Often none, may be mild manifestations fatigue manifestation of hyperglycemia Etiology Genetic factors, auto immune Genetic factors, Obesity,
The following are the distinguish features of diabetes mellitus: The following are the distinguish features of diabetes mellitus: Clinical Type 1 Pathophysiologic Basis Type 2 Manifestation Water not reabsorbed from renal tubules Polyuria secondary to osmotic activity of glucose; (frequent ++ + leads to loss of water, glucose, and urination) electrolytes Polydipsia Dehydration secondary to polyuria causes ++ + (excessive thirst) thirst Polyphagia Starvation secondary to tissue breakdown (excessive ++ + ( catabolism) causes hunger hunger) Initial loss secondary to depletion of water, glycogen, and triglyceride stores; chronic Weight loss ++ loss secondary to decreased mnuscle mass - as amino acides are diverted to form glucose and ketone bodies. Recurrent blurred Secondary to chronic exposure of ocular + ++ vision lens and retina to hyperosmolar fluids Black, J. (2008). Medical-Surgical Nursing 8th Edition. Singapore: Elsevier Pte. Ltd
Clinical Type 1 Pathophysiologic Basis Type 2 ManifestationPruritus, skin Bacterial and fungal infections of skin seem infections, + ++ to be more common; research conflicting vaginitis 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 Ketonuria ++ - type 2 diabetes mellitus, sufficient insulin is present to depress excessive use of fatty acids but not enough to permit use of glucoseWeakness and Decreased plasma volume leads to postural fatigue, ++ hypotension; potassium loss and protein + dizziness catabolism contribute to weakness Body can “adapt” to a slow rise in blood Often - glucose level to a greater extent than it can ++asymptomatic to a rapid riseBlack, J. (2008). Medical-Surgical Nursing 8th Edition. Singapore: Elsevier Pte. Ltd
Complications of Diabetes MellitusDKA ( Diabetic Ketoacidosis ) – Dehydration – Fruity odor of ketones on breath – Hyperpnea or kussmauul’s respirations – Impaired level of consciousness or coma – Tachycardia – Weakness
Laboratory Tests 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
Laboratory Tests Related to DM ( Protein ) •• Micro albuminuria Micro albuminuria measures microscopic measures microscopic amounts of protein in the amounts of protein in the urine (proteinuria). urine (proteinuria). •• Presence of protein (micro Presence of protein (micro albuminuria) in urine is an albuminuria) in urine is an EARLY sign of kidney EARLY sign of kidney disease. disease. •• Testing the urine for micro Testing the urine for micro albuminuria shows early albuminuria shows early nephropathy, long before it nephropathy, long before it would be evident on would be evident on routine urinalysis. routine urinalysis.
Medical ManagementRestoring and maintaining blood glucose levelsto as near normal as possible by: Balanced diet Exercise Use of oral hypoglycemic agents or insulin.Initial as well as ongoing client education is vitalin helping the client manage this chroniccondition
Promote Proper NutritionIt can help clients improve metabolic control bymaking changes in nutrition habits. The specificgoals 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 Activity Physical activity: Physical activity: Lowers blood glucose Lowers blood glucose level by increasing level by increasing carbohydrate metabolism, carbohydrate metabolism, fosters weight reduction fosters weight reduction and maintenance. and maintenance. Increase insulin Increase insulin sensitivity, sensitivity, increased high-density increased high-density lipoprotein levels, lipoprotein levels, Decreases triglyceride Decreases triglyceride levels, lowers blood levels, lowers blood pressure, and reduces stress pressure, and reduces stress and tension. and tension.
Administer 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 ofyour bodys natural insulin, therebylowering your blood sugar. Take this medication by mouth usuallyonce daily with breakfast.
Glipizide It works by stimulatingthe release of your bodysnatural insulin.Take this medication bymouth 30 minutes beforea meal, usually once dailybefore breakfast.
B. Biguanides Increase tissue response to insulin Decrease hepatic production of glucose Decrease absorption of glucose from the small intestine Decrease triglyceride and low-density lipoprotein level.1) MetforminWorks by helping to restore your bodys proper responseto the insulin you naturally produce.Decreases the amount of sugar that your liver makes andthat your stomach/intestines absorb.Take metformin with a meal.
C. Thiazolidinediones Increase 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 ofthis drug takes effect.
D. Alpha-glucosidase inhibitiors Delay 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 controldiabetes because they work in different ways.Take this medication by mouth, usually 3 times a dayat 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 adequateinsulin 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 DNAtechnology (human insulin) with different durations ofaction, there are four types: – Rapid acting – Short acting – Intermediate acting – Long acting
Latest ModalitiesMiniMed insulin pump Continuous subcutaneous insulin infusing involvesthe use of small, externally worn devices that closelymimic the functioning of the normal pancreas. Insulinpumps contain a 3-mL syringe attached to a long (24-42in), thin, narrow-lumen tube with a needle or Tefloncatheter attached to the end.
Advantages: Disadvantages:Increased flexibility in Unexpected lifestyle (in terms of disruptions in the timing and amount of flow of insulin from meals, exercise and the pump travel). InfectionImproved blood glucose control
Alternative Treatment Bitter melonnatural remedy for type 2 diabetes among traditional medicine practitioners. Green tea Green teacan improve glucose tolerance, can improve glucose tolerance, and upping the sensitivity to and upping the sensitivity to insulin. insulin.
Chinese Wolfberries Chinese Wolfberries way to help lessen vision way to help lessen vision problems associated problems associated with type-2 diabetes. with type-2 diabetes. Root of the Zingibera medicinal plant in Asian, Indian,and Arabic herbal traditions since ancient times as a digestive aidand an anti-inflammatory helpingto treat arthritis and the common cold. Researchers from the University of Sydney have also found that extracts may helpimprove long-term diabetic blood sugar control
RESEARCH FOCUSSugar-Sweetened Beverages Increase Risk of Type 2 Diabetes and Metabolic Syndrome An analysis conducted by an American DiabetesAssociation-funded researcher,Frank Hu, MD, PhD, MPH., shows that regularconsumption of sugar-sweetened beverages is stronglyassociated with developing type 2 diabetes andmetabolic syndrome. Providing the first quantitativeconfirmation of this link, Dr. Hu and fellow researchersat the Harvard School of Public Health analyzed datafrom eleven different studies with 310,819 individualsevaluated for diabetes and 19,431 for metabolicsyndrome. Results showed that participants who drankone to two 12 ounce servings per day increased theirrisk of developing type 2 diabetes by 26% and ofdeveloping metabolic syndrome increased by 20%,compared to those who drank less than one serving permonth.
"The association that we observed between sodaconsumption and risk of diabetes is likely a cause-and-effectrelationship because other studies have documented thatsugary beverages cause weight gain, and weight gain isclosely linked to the development of type 2 diabetes," said Dr.Hu, senior author of the study published in theNovember 2010 edition of Diabetes Care. Apart from overall weight gain, the authors alsoconsider that since these liquid carbohydrates are usuallyconsumed in fairly high quantities and can quickly raiseblood-sugar levels, the drinks may lead to insulin resistanceand glucose intolerance—both of which are linked to type 2diabetes. The researchers recommend that consumers "limitconsumption of these beverages in place of healthyalternatives such as water to reduce obesity-related chronicdisease risk."(Malik VS, Popkin BM, Bray GA, Despres JP, Willet WC, Hu, FB. Sugar-sweetenedbeverages 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