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Diabetes Part 1


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Diabetes Part 1

  1. 1. Care of Clients with Diabetes Mellitus <br />1<br />Part 1 - Basics<br />
  2. 2. ADA Guidelines for Diagnosis<br />Normal serum glucose: 70-110<br />Diabetes<br />FBS &gt; 126 on 2 occasions<br />Random glucose &gt; 200 with symptoms<br />Pre-diabetes<br />FBS &gt; 100 <br />Random glucose 140- 200<br />2<br />
  3. 3. Type 1 Diabetes<br />Autoimmune reaction in which beta cells that produce insulin are destroyed<br />Genetic predisposition: HLA linkage<br />Environmental triggers can stimulate an autoimmune response <br />Viral infections: mumps, rubella, coxsackievirus<br />3<br />
  4. 4. Treatment Type 1 Diabetes<br />Diet<br />Exercise<br />Insulin<br />Monitoring <br />4<br />
  5. 5. Type 2 Diabetes- Etiology<br />Insulin resistance<br />Decreased production of insulin by beta cells<br />Liver releases too much glucose<br />Genetics<br /><br />5<br />
  6. 6. Type 2 Diabetes- symptoms<br />Few symptoms initially<br />Fatigue<br />Altered vision<br />Nocturia<br />Skin infections, vaginal infections, poor wound healing<br />6<br />
  7. 7. Type 2 Diabetes Risk Factors<br />Obesity<br />Family history<br />Over age 45<br />High-risk ethnic group: African, Native American, Hispanic<br />Delivery of baby &gt; 9 pounds<br />History of: gestational diabetes, polycystic ovary syndrome<br />Hypertension<br />7<br />
  8. 8. Type 2 diabeteschildren & adolescents<br />Incidence on the rise<br />No symptoms in early stage of disease<br />Symptoms: frequent infections, weight loss with increased appetite, blurry vision, polyuria, bed wetting<br />8<br />
  9. 9. Acanthosis nigricans<br />Area of darkened skin & velvety thickening on the child’s neck, armpits, groin, or other areas of skin folds.<br />Sign of insulin resistance<br />Found in 90% of children with type 2<br />Most often seen in African American & Hispanics <br />9<br />
  10. 10. Acanthosis nigricans<br />10<br />
  11. 11. Type 2 diabetes in children<br />Prevention: Exercise 1 hr/day, healthy diet<br />Test high risk groups age 10 years or more every 2 years<br />Overweight<br />Family history<br />Hispanic, African American, Asian American<br />11<br />
  12. 12. Treatment Type 2 Diabetes<br />Diet<br />Monitoring blood glucose<br />Exercise<br />Oral Medication<br />Insulin <br />12<br />
  13. 13. Gestational diabetes<br />Last half of pregnancy placenta produces insulin antagonist <br />(human placental lactogen) <br />Leads to increased placental destruction of insulin<br />Insulin production needs to increase 2-3 X non- pregnant level<br />13<br />
  14. 14. Gestational Diabetes: Diagnosis<br />1 hour glucose challenge test using a 50 gram oral glucose if results &gt; 140 mg/dl will have to retest with:<br />3 hour glucose tolerance test using 100 gram oral glucose: diagnosis confirmed when any 2 or more glucose values are over 140 mg/dl<br />14<br />
  15. 15. Gestational Diabetes: Treatment<br />Blood glucose self-monitoring<br />Diet<br />Exercise<br />Stress management<br />Pharmacologic therapy: insulin<br />15<br />
  16. 16. Gestational diabetes- effects on infant<br />Macrosomia- 9.9 lbs or &gt;<br />Hypoglycemia- for first 72 hours of life<br />Infant accustomed to increase in glucose which leads to hyperinsulinemia in the infant. At birth the glucose supply from mother is no longer present but infants pancreas continues to produce large amounts of insulin.<br />16<br />
  17. 17. Gestational Diabetes<br />No longer have diabetes after delivery of infant<br />Women with gestational diabetes have up to a 45% risk of recurrence with next pregnancy and up to 63% risk of developing type 2 diabetes later in life<br />17<br />
  18. 18. Diet<br />Food Guide Pyramid<br /><br /> Carbohydrate Counting<br />15 gm CHO= 1 exchange<br /> 45-60 grams per meal <br />Plate Method<br />Exchange List<br />18<br />
  19. 19. Diet education<br />Initially should be done by dietitian<br />Never skip meals if on oral sulfonylureas<br />Learn to recognize food portions<br />Alcohol suppresses liver production of sugar<br />19<br />
  20. 20. Diet Education<br />Remember:<br />No foods are forbidden for people with diabetes<br />It’s not carbs the patient should worry about<br />It’s the amount of carbs consumed<br />Portion control !!!!<br />20<br />
  21. 21. Carbohydrate<br />Healthy carbs come from fruit, veggies, whole grains, legumes and low-fat milk<br />Need to monitor intake and divide throughout the day<br />Sugar is allowed within reason<br />Fiber is recommended<br />21<br />
  22. 22. Food Labels<br />Locate serving size<br />Locate total grams of carbohydrate<br />15 g = 1 carb choice<br />Ignore sugar grams<br />22<br />X<br />
  23. 23. Exercise<br />Regular<br />Consistent<br /> Aerobic: 30 min/day most days<br /> Resistance training: 2-3 times/week<br /> Type 1- increases insulin sensitivity<br /> Type 2- wt loss, decrease insulin resistance <br />23<br />
  24. 24. Self-Monitoring of Blood Glucose(SMBG)<br />Modern meters<br />Small blood volume (0.3 to 4 L)<br />Ability to use alternate sites <br />Shorter results time: 5 to 10 seconds<br />Very accurate if maintained properly<br />24<br />
  25. 25. Monitoring Glycemic Control<br />A1C formerly know as Hgb A1C<br />Blood test measuring glycosylated Hgb A<br />Glycosylation: glucose binds irreversibly to Hgb<br />A1C reflects mean glucose level past 2-3 months <br />Check every 3-6 months <br />Normal &lt; 6%<br />Goal for diabetic &lt; 7%<br />25<br />
  26. 26. Targets for Glucose ControlType 1 and Type 2 Diabetes<br />70-130 mg/dL<br />&lt;180 mg/dL<br />100-140 mg/dL<br /> 7%<br />Fasting/Pre-meal glucose <br />Post-meal glucose<br />2 hr. after start of meal<br />Bedtime glucose<br />A1C<br />26<br />
  27. 27. A1C and blood sugar results<br />27<br />
  28. 28. Insulin Therapy<br />Type 1- always required<br />Type 2- during periods of stress, illness, surgery and when all other treatments fail<br />28<br />
  29. 29. Insulin <br />36% with type 2 diabetes use insulin<br />within 5 years of diagnosis 50% require<br />Weight gain can be significant: 5-10 kg 1st yr<br />Insulin dose needed varies<br />Most serious side effect is hypoglycemia<br />29<br />
  30. 30. Terms describing time & effect of insulin<br />Onset: time span after administration when insulin will begin to effect the blood glucose level<br />Peak: time span after administration when the insulin will have the greatest effect on the blood glucose level<br />Duration: time span after administration when insulin will continue to effect the blood glucose level<br />30<br />
  31. 31. Basal & Bolus<br />Basal Insulin: insulin required to suppress hepatic glucose production between meals<br />Bolus Insulin: insulin required to maintain normal glucose disposal after meals<br />Normal process of pancreas in healthy person<br />31<br />
  32. 32. Storage of Insulin<br />Open vial at room temperature 30 days<br />No direct sunlight<br />Do not store in freezer<br />Keep out of glove compartment <br />Extra vial in door of refrigerator <br />32<br />
  33. 33. Mixing Insulin<br />Always draw up clear first to prevent contamination of fast acting insulin<br />Can be pre-drawn and stored in refrigerator for 1 week<br />Store needle upright & agitate syringe before administering<br />33<br />
  34. 34. 34<br />Box 18.3 Mixing insulin (Figures only)<br />
  35. 35. Sliding Scale<br />Used with intensive insulin therapy and during hospitalization to maintain euglycemia<br />Accu-check should be no more than ½ hour prior to the administration of the corrective insulin dose<br />35<br />
  36. 36. Sites for injection<br />Abdomen<br />Back of arm<br />Middle anterior thigh<br />Upper buttocks<br />36<br />
  37. 37. Rotation of sites<br />Insulin injections should be given in the same region at a specific time of day & rotated within that region<br />Due to difference in absorption rates of sites<br />37<br />
  38. 38. Insulin devises<br />Insulin pump- receives rapid acting insulin continuously per subcutaneous route<br />Insulin pen- good for visually impaired and people with problems with dexterity<br />38<br />
  39. 39. Insulin Pumps<br />39<br />
  40. 40. Insulin Pump site<br />
  41. 41. Insulin Pump: During hospitalization<br />Have physician write orders to leave the pump in place<br />Don’t discontinue the pump unless insulin therapy is given IV or subcutaneously <br />41<br />
  42. 42. Insulin Pump: During hospitalization<br />Patient should change their site every 2-3 days <br /> and<br />Whenever blood glucose is over <br />240 mg/dl for 2 tests in a row<br />42<br />
  43. 43. Oral Antihyperglycemic Agentsfor Type 2 Diabetes<br />43<br />Class <br />Sulfonylureas<br />Biguanides<br />Thiazolidinediones<br />Meglitinides<br />α-Glucosidase inhibitors <br />DPP-4 Inhibitors<br />