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  2. 2.  Diabetes mellitus is a group of metabolic diseases in which defects in insulin secretion or action result in high blood sugar level (hyperglycemia). The incidence of diabetes mellitus varies by race and ethnicity. In the United States, Hispanic, black, Native American, Alaska Native, and Asian American populations have a higher rate of diabetes than non-Hispanic white ethnic groups. Songoma JM .MUHAS Friday, April 13, 2012 2
  3. 3.  Diabetes is a serious disease that can cause complications such as blindness, kidney failure, heart attacks, and strokes. It is a leading cause of lower limb amputation. With good education and self-care, patients with diabetes can prevent or delay these complications and lead full, productive lives . A major role of the nurse is helping the patient learn self care Songoma JM .MUHAS Friday, April 13, 2012 3
  4. 4. Diabetes results from faulty production ofinsulin by the beta cells in the pancreas,or from inability of the body’s cells to useinsulin. When glucose is unable to enterbody cells, it stays in the bloodstream;hyperglycemia results, and the cells aredenied their energy source.Abnormal glucagon secretion may alsoplay a role in type 2 diabetes. Songoma JM .MUHAS Friday, April 13, 2012 4
  5. 5. Type 1 Diabetes Mellitus Type 1 diabetes (formerly called juvenile diabetes mellitus, insulin-dependent diabetes mellitus, or IDDM) is the type of diabetes which caused by destruction of the beta cells in the islets of Langerhans of the pancreas hence unable to produce insulin. Insulin must then be injected for the body to use food for energy. Only 5% to 10% of people with diabetes have type 1 diabetes Songoma JM .MUHAS Friday, April 13, 2012 5
  6. 6. ð . Genetic predisposition for increased susceptibility.s Environmental triggers stimulate an autoimmune responsen Viral infections (mumps, rubella coxsackievirus B4)4 Chemical toxins Songoma JM .MUHAS Friday, April 13, 2012 6
  7. 7.  LADA- This is a new type of type 1 diabetes that has recently been identified. Some patients who were initially diagnosed with type 2 diabetes were later found to have islet cell and insulin antibodies (which are usually associated with type 1), and their blood glucose levels were not controlled with oral medications. However, beta cell destruction tended to occur more slowly than with type 1 diabetes. Patients with LADA can be distinguished as either thin or obese because the disorder has slightly different characteristics depending on the patient’s body fat. Songoma JM .MUHAS Friday, April 13, 2012 7
  8. 8. (formerly called adult-onset diabetes mellitus, non–insuline -dépendent diabetes mellitus, or NIDDM). This is a type of diabetes mellitus where by tissues are resistant to insulin. . Insulin is still made by the pancreas, but in inadequate amounts. Sometimes the amount of insulin is normal or even high, but because the tissues are resistant to it, hyperglycemia results. Songoma JM .MUHAS Friday, April 13, 2012 8
  9. 9.  Gestational diabetes mellitus (GDM) –This is a diabetics which develop during pregnancy, especially in women with risk factors for type 2 diabetes. The extra metabolic demands of pregnancy trigger the onset of diabetes. Blood glucose usually returns to normal after delivery, but the mother has an increased risk for type 2 diabetes in the future. If the mother with GDM is overweight, she should be counseled that weight loss and exercise will decrease her risk of later developing diabetes. Mothers with GDM require specialized care and should be referred to an expert in this area Songoma JM .MUHAS Friday, April 13, 2012 9
  10. 10.  Prediabetes refers to blood glucose levels that are above normal but do not meet the criteria for diagnosing diabetes. Prediabetes usually occurs prior to the onset of type 2 diabetes. It is diagnosed by evaluating glucose tolerance or fast-ing glucose level. Individuals with prediabetes may be able to prevent the onset of diabetes with weight loss and exercise. Songoma JM .MUHAS Friday, April 13, 2012 10
  11. 11.  Secondary diabetes may develop as a result of another chronic illness that damages the islet cells, such as pancreatitis or cystic fibrosis. Prolonged use of some drugs, such as steroid hormones, phenytoin (Dilantin), thiazide diuretics, and thyroid hormone, may also impair insulin action and raise blood glucose. Maturity-onset diabetes of the young (MODY) is an inherited defect in insulin secretion that usually occurs in individuals under the age of 25. Less common causes include pancreatic trauma and other endocrine Songoma JM .MUHAS Friday, April 13, 2012 11
  12. 12.  Polyuria (hyperglycemia acts as osmotic diuretic) Glycosuria (renal threshold for glucose: 180 mg/ dL) Polydipsia (thirst from dehydration from polyuria) Polyphagia (hunger and eats more since cell cannot utilize glucose) Weight loss (body breaking down fat and protein to restore energy source Malaise and fatigue (from decrease in energy) Blurred vision (swelling of lenses from osmotic effects) Headache Abdominal pain Songoma JM .MUHAS Friday, April 13, 2012 12
  13. 13.  FASTING PLASMA GLUCOSE. Diagnosis of diabetes mellitus is based on plasma glucose levels measured by a laboratory. A normal plasma glucose level is less than 100 mg/ dL, although different laboratories may have slightly different normal values. When the fasting plasma glucose (drawn after at least 8 hours without eating) is 126 mg/dL, diabetes is diagnosed. A second test may be required if the first test is not clearly diagnostic. If the fasting plasma glucose is between 100 and 125 mg/dL, the patient has impaired fasting glucose (IFG) Songoma JM .MUHAS Friday, April 13, 2012 13
  14. 14.  CASUAL PLASMA GLUCOSE. Sometimes it is not feasible to check a fasting plasma glucose. A casual plasma glucose (CPG) is checked without regard to the last meal. Diabetes is diagnosed if the CPG is 200 mg/dL, with symptoms of diabetes. Songoma JM .MUHAS Friday, April 13, 2012 14
  15. 15.  ORAL GLUCOSE TOLERANCE TEST. Another test to diagnose diabetes is the oral glucose tolerance test (OGTT). An OGTT measures blood glucose at intervals after the patient drinks a concentrated carbohydrate drink. Diabetes is diagnosed when the blood glucose level is 200 mg/Dl after 2 hours. A result between 140 and 199 mg/dL at 2 hours diagnoses impaired glucose tolerance (IGT). Songoma JM .MUHAS Friday, April 13, 2012 15
  16. 16. • GLYCOHEMOGLOBIN.• The glycohemoglobin test (also called glycosylated hemoglobin, or HbA1c) is used to gather baseline data and to monitor progress of diabetes control (not to diagnose diabetes).• Glucose in the blood attaches to hemoglobin in the red blood cells.• When the glucose that is attached to the hemoglobin is measured, it reflects the average blood glucose level for the previous 2 to 3 months.• A normal HbA1c is 4% to 6%• . This is a helpful measurement when blood glucose levels fluctuate and a single Songoma JM .MUHAS Friday, April 13, 2012 16
  17. 17.  ADDITIONAL TESTS. Because diabetes affects so many body systems, additional tests recommended for baseline data include a lipid profile, serum creatinine and urine microalbumin levels to monitor kidney function, urinalysis , and electrocardiogram Songoma JM .MUHAS Friday, April 13, 2012 17
  18. 18.  The only cure for diabetes is a pancreas (or islet cell) transplant. However, diabetes can be controlled. Treatment begins with diet and exercise. Insulin is added in patients with type 1 diabetes and insulin or oral hypoglycemic medication as needed in those with type 2 diabetes. Blood glucose monitoring and education are also important to good diabetes control. To monitor the effectiveness of treatment, patients should have regular health care follow-up visits. Songoma JM .MUHAS Friday, April 13, 2012 18
  19. 19.  INJECTED INSULIN. The individual with type 1 diabetes has no endogenous insulin and therefore must administer insulin daily. Insulin is generally given subcutaneously, although fast-acting insulin may be ordered via the intramuscular or intravenous route in urgent situations, or sometimes inhaled. There are several types of insulin and schedules by which it may be given. In general, the more frequent the injections, the better the glucose control. Songoma JM .MUHAS Friday, April 13, 2012 19
  20. 20.  Insulin injections should be given in a different subcutaneous site each time to avoid injury to the tissues. Because each area absorbs insulin at a slightly different rate, it is advisable to use one area for a week, then move on to the next Within that area, each injection should be spaced at least 1 inch from the previous injection. Most experts recommend using primarily the torso (abdomen and buttocks) to provide more uniform absorption Songoma JM .MUHAS Friday, April 13, 2012 20
  21. 21. • INHALED INSULIN• . A new short-acting human insulin that can be inhaled, Exubera. Exubera is a dry powder insulin that can actually enter the circulation via the lungs faster than a subcutaneous injection.• It can reduce lung function slightly, so patients must have pulmonary function tests before using it.• It cannot be used by patients who smoke or who have quit smoking within the last 6 months. Songoma JM .MUHAS Friday, April 13, 2012 21
  22. 22. • . Two problems that can occur with glucose control are the Somogyi effect and the dawn phenomenon.• The Somogyi effect may be at fault when the patient’s blood glucose seems to be rising in spite of increasing insulin doses.• If insulin levels are too high, the blood glucose may drop too low, stimulating release of counter regulatory hormones (epinephrine, glucagon, corticosteroids, growth hormone) that then elevate the blood glucose. Songoma JM .MUHAS Friday, April 13, 2012 22
  23. 23.  The low glucose levels often occur during the night, and the patient may report night sweats or morning headaches. The high morning glucose is then interpreted as hyperglycemia, and the insulin dose may be further increased, compounding the problem. The dawn phenomenon is thought to occur because of the natural release of growth hormone and cortisol during the early morning hours. This causes hyperglycemia on arising Songoma JM .MUHAS Friday, April 13, 2012 23
  24. 24.  The patient with type 2 diabetes may be able to control blood glucose levels with medical nutrition therapy and exercise alone. Oral hypoglycemic medication or insulin may also be prescribed. Oral hypoglycemics are not insulin pills. Remember that if insulin is ingested, it is digested, because it is a protein. Because most oral hypoglycemic agents depend on at least a partially functioning pancreas, most are not useful for patients with type 1 diabetes Songoma JM .MUHAS Friday, April 13, 2012 24
  25. 25.  Complication of diabetics can be :-2. Acute complicationc) Hyperglycemiad) Hypoglycemiae) Diabetes Ketoacidosisf) Hyperosmolar , hyperglycemic, nonketotic (HHNK)2)Chronic complication or longer term complication Songoma JM .MUHAS Friday, April 13, 2012 25
  26. 26.  When calories eaten exceed insulin available or glucose used, high blood glucose (hyperglycemia) occurs. CAUSES Overeating Stress Illness Too little insulin or medication Songoma JM .MUHAS Friday, April 13, 2012 26
  27. 27. SYMPTOMS Polyuria Polydipsia Polyphagia Blurred vision Headache Lethargy (Weakness characterized by a lack of vitality or energy) Abdominal pain Ketonuria (if type I) Coma Songoma JM .MUHAS Friday, April 13, 2012 27
  28. 28.  TREATMENT Confirm hyperglycemia with glucose meter; if greater than 300 mg/dL, check urine for ketones and increase fluid intake. Assess cause of hyperglycemia, teach prevention. Return to prescribed treatment plan if applicable. Call physician for medication adjustment if indicatedor if blood glucose is 200 mg/dL for 2 days.Call physician if patient is ill or vomiting Songoma JM .MUHAS Friday, April 13, 2012 28
  29. 29.  Hypoglycemia is usually defined as a blood glucose level below 50 mg/dL, although patients may feel symptoms at higher or lower levels. This is sometimes referred to as an insulin reaction . It occurs when there is not enough glucose available in relation to circulating insulin. CAUSES Under eating skipping a meal Too much insulin or medication Exercise Songoma JM .MUHAS Friday, April 13, 2012 29
  30. 30. SYMPTOMS Hunger Sweating Tremor Blurred vision Headache Irritability Confusion Seizures Coma Songoma JM .MUHAS Friday, April 13, 2012 30
  31. 31. TREATMENT Confirm hypoglycemia with glucose meter (if patient is not acutely ill). Administer 15 g fast-acting carbohydrate. Recheck glucose in 15 minutes; if still low, readminister carbohydrate. Continue cycle of checking glucose and administering fast sugar until hypoglycemia subsides; if symptoms worsen, call physician or emergency help .Glucagon subcutaneously or dextrose 50% IV may beadministered if ordered. Assess cause of hypoglycemia, teach prevention. Songoma JM .MUHAS Friday, April 13, 2012 31
  32. 32.  Results from breakdown of fat and overproduction of ketones by the liver and loss of bicarbonate Occurs when Diabetes Type 1 is undiagnosed or known diabetic has increased energy needs, when under physical or emotional stress or fails to take insulin  Mortality as high as 14%Pathophysiology Hypersomolarity (hyperglycemia, dehydration) Metabolic acidosis (accumulation of ketones) Fluid and electrolyte imbalance (from osmotic diuresis) Songoma JM .MUHAS Friday, April 13, 2012 32
  33. 33. Diagnostic tests Blood glucose greater than 250 mg/dL Blood pH less than 7.3 Blood bicarbonate less than 15 mEq/L Ketones present in blood Ketones and glucose present in urine Electrolyte abnormalities (Na, K, Cl) serum osmolality < 350 mosm/kg (normal 280-300) Songoma JM .MUHAS Friday, April 13, 2012 33
  34. 34. Signs and symptoms  Kussmals respirations  Blow off carbon dioxide to reverse acidosis  Fruity breath  Nausea/ abdominal pain  Dehydration  Lethargy  Coma  Polydipsia, polyuria, polyphagia Songoma JM .MUHAS Friday, April 13, 2012 34
  35. 35. Treatment Requires immediate medical attention and usually admission to hospital Frequent measurement of blood glucose and treat according to glucose levels with regular insulin (mild ketosis, subcutaneous route; severe ketosis with intravenous insulin administration) Restore fluid balance: initially 0.9% saline at 500 – 1000 mL/hr.; regulate fluids according to client status; when blood glucose is 250 mg/dL add dextrose to intravenous solutions Songoma JM .MUHAS Friday, April 13, 2012 35
  36. 36. • Correct electrolyte imbalance: client often is initially hyperkalemic  As patient is rehydrated and potassium in pushed back into the cell they become hypokalemic  Monitor K levels  Monitor cardiac rhythm since hypokalemia puts client at risk for dysrrhythmias• Treat underlying condition precipitating DKA• Acidosis is corrected with fluid and insulin therapy and rarely needs bicarbonate Songoma JM .MUHAS Friday, April 13, 2012 36
  37. 37.  PATHOPHYSIOLOGY. Hyperosmolar, hyperglycemic, nonketotic (HHNK) syndrome occurs primarily in type 2 diabetes, when blood glucose levels are high as a result of stress or illness. Because the person with type 2 diabetes has some insulin production, cells do not starve and DK usually does not occur Songoma JM .MUHAS Friday, April 13, 2012 37
  38. 38. . HHNK occurs more often in the elderly. As the blood glucose rises (hyperglycemic), polyuria causes profound dehydration, producing the hyperosmolar (concentrated) state. Blood glucose may rise as high as 1500 mg/dL, and electrolyte imbalances occur Because ketoacidosis is not present, the patient may not feel as physically ill as the patient with DKA and may delay seeking treatment. Songoma JM .MUHAS Friday, April 13, 2012 38
  39. 39.  Symptoms of HHNK include: extreme thirst, lethargy, and mental confusion. Shock, coma, and death occur if HHNK is left untreated . The mortality rate for HHNK is between 10% and 20%. Songoma JM .MUHAS Friday, April 13, 2012 39
  40. 40.  THERAPEUTIC INTERVENTION. Treatment includes IV fluids and insulin, and glucose monitoring. Electrolytes are closely monitored. The cause of HHNK should be identified and treated. HHNK syndrome can be prevented with careful monitoring of glucose levels at home. Patients should be instructed to drink plenty of fluids if blood glucose levels are beginning to rise, especially in times of stress and illness. Songoma JM .MUHAS Friday, April 13, 2012 40
  41. 41.  Small blood vessels can become diseased, eventually leading to retinopathy in most patients with diabetes. Retinopathy involves damage to the tiny blood vessels that supply the eye. Small hemorrhages occur, which can cause blindness if not corrected. Diabetes is also associated with a high incidence of cataracts. Patients with diabetes should have a yearly dilated eye examination Songoma JM .MUHAS Friday, April 13, 2012 41
  42. 42. . Nephropathy is caused by damage to the tiny blood vessels within the kidneys. Up to 40% of patients with diabetes develop some degree of nephropathy. A primary risk factor for diabetic nephropathy is poor control of blood glucose . Patients should be taught the importance of blood glucose control to prevent or delay kidney disease. Songoma JM .MUHAS Friday, April 13, 2012 42
  43. 43.  Neuropathy can cause numbness and pain in the extremities, erectile dysfunction (impotence) in males, sexual dysfunction in women, gastroparesis (delayed stomach emptying), and other problems. Unfortunately, pain caused by neuropathy is difficult to treat with traditional analgesics Some antidepressant and anticonvulsant drugs may be helpful, and in some cases local injections of anesthetics may be used. A new drug, pregabalin (Lyrica), that reduces painful nerve impulses Songoma JM .MUHAS Friday, April 13, 2012 43
  44. 44.  Persons with diabetes are prone to infection for several reasons If injuries occur, healing may be slow because of impaired circulation. There may not be enough blood supply to heal the wound or fight an infection . In the presence of hyperglycemia, white blood cells become sluggish and ineffective, further reducing the body’s ability to fight infection . The incidence of periodontal (gum) disease, caused by bacteria in plaque, is also increased in individuals with diabetes.. Songoma JM .MUHAS Friday, April 13, 2012 44
  45. 45.  Individuals with diabetes develop atherosclerosis and arteriosclerosis faster than the general population. They are more likely to have hypertension and elevated low-density lipoprotein (LDL) cholesterol and triglyceride levels. High blood glucose may also affect platelet function, leading to increased clotting. These problems lead to a higher incidence of strokes, heart attacks, and poor circulation in the feet and legs. The risk of cardiovascular disease and strokes is two to four times more common in persons with diabetes than in the general population. Songoma JM .MUHAS Friday, April 13, 2012 45
  46. 46.  The combination of vascular disease, neuropathy, and risk for infection makes patients with diabetes prone to foot problems . Consider the patient who has no feeling in his or her feet because of neuropathy. Vascular disease will prevent a good blood supply from preventing infection and promoting healing If infection sets in, it is slow to resolve and may progress to necrosis and gangrene. Pressure points on the feet may also break Neuropathy can also lead t o deformities of the feet, further increasing the risk for injuries . For these reasons, diabetes is the leading cause of amputation of the lower extremities. Songoma JM .MUHAS Friday, April 13, 2012 46
  47. 47. • History of current problem• History of stress, illness, virus• Family history of diabetes• Current medications• Other medical or surgical conditions• Knowledge of diabetes self-care• Vital signs• Signs of dehydration Songoma JM .MUHAS Friday, April 13, 2012 47
  48. 48. • Fruity breath• Presence of complications if suspect diabetes was undiagnosed for period of time• History of diabetes:type, onset, duration,degree of blood glucose control• Knowledge of selfcare and degree of compliance• Support systems• History of complications• Labs: blood glucose level, HbA1c, BUN, creatinine, ketones, cholesterol, triglycerides• Condition of legs and feet; pulses, presence of circulatory or sensation impairment Songoma JM .MUHAS Friday, April 13, 2012 48
  49. 49. Risk for ineffective health maintenance related to knowledge deficit in the patient with newly diagnosed diabetes mellitus Songoma JM .MUHAS Friday, April 13, 2012 49
  50. 50.  Assess knowledge of diabetes self-care.Assist patient to collaborate with health care provider to determine appropriate blood glucose levels and action to be taken if glucose levels are too high or too low. Teach patient to assess glucose levels before meals and at bedtime or as ordered by health care provider. Ensure that patient knows how to obtain glucose monitor and instruction for home use. Teach patient how to administer insulin or oral hypoglycemic agent. Songoma JM .MUHAS Friday, April 13, 2012 50
  51. 51.  Ensure that meals are timed appropriately with medications . Replace any uneaten foods to prevent hypoglycemia. Teach technique for administering insulin if indicated. Observe for symptoms of hypoglycemia and hyperglycemia and treat as necessary. Teach causes, prevention, recognition, and treatment of hypoglycemia and hyperglycemia Consult with dietician for nutrition therapy instruction. Consult with social worker or case manager as needed. Songoma JM .MUHAS Friday, April 13, 2012 51
  52. 52.  Does patient exhibit knowledge of diabetes self-care? Are blood glucose levels within parameters negotiated with health care provider? Does patient state appropriate blood glucose levels and action to take if glucose is high or low? Does patient demonstrate correct use of glucose monitor or state how monitor and instruction will be obtained? Does patient state correct meal and medication schedule? Songoma JM .MUHAS Friday, April 13, 2012 52
  53. 53.  Does patient demonstrate correct injection technique? Does patient state causes, prevention, symptoms, and treatment of hypoglycemia? Does patient carry fast sugar at all times? Is patient able to state plan for obtaining appropriate meals? Does patient state availability of adequate resources for selfcare Songoma JM .MUHAS Friday, April 13, 2012 53
  54. 54.  William,JS and Hopper , PD(2007) . Uderstanding Medical –Surgical Nursing 3rd edition FA Davis company Philidea Songoma JM .MUHAS Friday, April 13, 2012 54