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Definition
• Diabetes is a chronic disorder of altered carbohydrate, fat and protein metabolism caused
either by a relative or absolute lack of insulin
• Greek verb diabetes meaning "to run through" Latin Mellitus meaning "honey"
• persistent hyperglycemia
• Impaired leukocyte activity
• long term vascular and neurologic degeneration
Islets of Langerhans
• Consist of three types of cells (little islands) in the pancreas which secrete hormones
• Alpha cells secrete Glucogon which is released in response to low levels of glucose,
protein ingestion and exercise
• Delta cells secrete gastrin & somatostatin which inhibit release of insulin
Insulin
• Hormone secreted by the beta cells in the islets of Langerhans in the pancreas
• Primary function is to transport glucose into cells to be used for energy (brain, nerve,
hepaticytes, intestinal mucosa cells & kidney tubule cells don’t need insulin)
• Insulin affects carbohydrate, fat, & protein metabolism & lowers blood glucose levels
Carbohydrate Metabolism
• Insulin attaches to the receptors on the cell wall causing glucose to be transported into
the cell
• Insulin also causes the liver to convert glucose into glycogen for storage (glucogenesis)
• When glucose blood levels get low the liver reconverts the glycogen back into glucose
(glucogenolysis) resulting in raising blood sugar levels
Fat Metabolism
• Glucose that is not needed by the body is converted into fat & triglyceride with the help of
insulin ( lipogenesis)
Protein Metabolism
• Insulin also promotes the entry of amino acids into cells and decreases the rate at which
amino acids are released from cells
• Protein is not stored by the body - If you eat it and it’s not needed the nitrogen is stripped
and thrown away by the kidneys and the rest is stored as fat
• Cortisol (from the adrenal cortex) causes the conversion of protein & fat into glycogen &
then into glucose
• Somatotropin and Somatastatin also affect blood glucose levels
Absence of Insulin
• Without insulin the glucose cannot get into cells which results in hyperglycemia & cell
starvation. Protein cannot be manufactured because the cells have no amino acids from
which to manufacture it. The liver begins to convert glycogen into glucose and dump it
into the blood stream which causes even higher glucose levels
Absence of Insulin
• Since the cells are starving the body begins to convert fat into usable glycerol and this
conversion releases ketone bodies into the blood stream -
Ketones
• Ketones are eliminated by the kidneys and can be measured in the urine. High ketone
levels are an indication of high blood sugar levels. (Acitest) The ketones combine with
sodium & the sodium is replaced with H+ which in turn causes acidosis
• The body tries to correct the acidosis by increasing the respiratory rate and depth
(Kussmals respirations)
Absence of Insulin
• The kidneys also try to throw away the extra glucose, but to do so they must throw away
some water with it (& some electrolytes) - so the patient gets dehydrated because of the
large urine output
• The kidneys usually will not spill glucose until the blood levels get to about 180 (normals
70 -110) the level at which a person spills sugar varies and is called the renal threshold
• Because of the dehydration the patient gets thirsty
Diabetes Mellitus
Diabetes Mellitus
• People at risk
• Strong Family history of diabetes
• African-American, Hispanic or Native American descent
• Obese
• History of delivering infants weighing > 9# (or gestational diabetes)
• Identical twins have 50% chance of both getting the disease (type 2) when one twin has it
- but fraternal twins have 90% chance - strange!
• Studies are underway to test the Drug Imuran (an immunosuppressant) for diabetes
prevention
• If the oral hypoglycemic meds don’t work they must get insulin
• Many type 2 diabetics require insulin during stress but return to oral hypoglycemics when
the stress is relieved (they are not insulin dependent)
Gestational Diabetes
Clinical Manifestations
• Type 1
• Sudden onset of polyuria, polydipsia, and polyphagia. Weight loss despite increased food
intake, extreme fatigus and pruitus and vaginal itching
• Thin under 40 YOA. Prone to developing ketosis
• Must take insulin
Clinical Manifestations
• Type 2
• Rarely develop polyuria, polydipsia or polyphagia & if they do the symptoms are less
severe than type 1 patients (women do have vaginitis leading to vaginal itching)
• Usually over 30 YOA and obese - can control disease with diet & exercise and can take
oral hypoglycemics
Diagnosis
• Symptoms of diabetes plus a casual blood sugar > 200 (casual = any time of day without
regard to when they ate last)
• OR
• Fasting blood sugar of 126 mg/dl or higher (fasting = NPO >8hrs)
• OR
• 2 hour blood sugar level of >200 during a GTT (WHO guidlines)
• AND confirmed on the following day
Diagnosis
• For gestational diabetes the figures are different but you will not be tested over
pregnancy in this class (wait till next year!)
• Impaired glucose tolerance is more than normal limite (70 - 110) but not as high as the
criteria for full blown diabetes. It is a warning sign that the patient could become diabetic,
but with careful management can avoid it. GTT 2 hr FBS of >140 but<200
Management
• Diet - cornerstone of diabetic treatment - lack of adherence to the diet is the one area of
self-management most responsible for poor control of diabetes
• most widespread & currently accepted diet is the exchange diet created by the American
Diabetes Association
Diabetic Diets
• some foods are free foods because they have fewer than 20 calories per serving (sugar
free carbonated drinks, coffee, tea, lettuce, sugar free geletin and 1 tbsp catsup -
seasonings)
• All diabetic patients require diet education and many behavior modification
Diet Education
• A specific # of calories is prescribed for each patient depending upon patient’s body
weight, occupation, age, activities, and type of diabetes
• responses to the diet should be monitored & adjustments made as necessary
Diet Education
Exercise
Exercise
• should be avoided if blood sugar is > 250 (increases secretion of glucagon and growth
hormone, causing the liver to release more glucose)
• If blood glucose is low, the patient may need to eat a fruit exchange
• Diabetics on medication should always carry a simple carbohydrate when exercising
(lemon drops)
• Sulfonylureas are used for type II diabetics who have some functioning beta cells
• It stimulates the beta cells to produce more insulin, reduces the accelerated rate of
hepatic glucose production in type 2 diabetics, partially reduces the number of cellular
insulin receptors
Metformin (Glucophage)
• Not a sulfonylurea
• Not bound to plasma proteins, is not metabolized in the liver and is eliminated rapidly by
the kidneys
• It lowers blood sugar but does not cause hypoglycemia
Insulin
• Beta Cells stop producing insulin in Type 1 diabetics so they must have insulin to survive.
• Type 2 diabetics also must have insulin if their blood sugar is not controlled by diet and
exercise or diet & exercise & OHA or in stress producing situations as a temporary
measure
Types of Insulin
• Beef (made from cow pancreas) was most commonly used kind until about 10 years ago)
• Pork was used by some people who did not respond well to the beef insulin -patients
could have insulin allergies or reactions to proteins left in the insulin during the extracting
process
Humulin Insulin
• Humulin insulin is a biosynthetic insulin made by altering common bacteria (E-Coli) using
recombinant deoxyriboneucleic acid (DNA) technology. It is identical to human insulin
• By adding chemicals, the length of time the insulin is active can be altered
Catagories of Insulin
Examples of Insulins
Regular
Injections
• Rotate injection sites to avoid lipodystrophy. Do not inject within 1 inch of the previous
injection site. Best to use the abdomen for consistent absorption. Do not inject into a part
which will be exercised that day
• Insulin pumps are available but they are expensive $4100 to $10,000
• Blood Glucose Monitoring
• Many machines are available
• Patient should be matched to a machine (cognitive functioning and physical coordination)
• Many patients test their own blood sugar 4 times/day - but most only do it once while at
home.
Urine Testing
Glycosylated Hemoglobin
Acute Complications of DM
Diabetic Ketoacidosis
• Patient develops severe hyperglycemia, osmotic diuresis, dehydration, hyperlipidemia, &
metabolic acidosis. Ketones are lost in the urine & electrolytes are depleated
Diabetic Ketoacidosis
Diabetic Ketoacidosis
• Treatment - Insulin is given IV in .45% NaCl to treat the hyperglycemia, 1 -2 liters of fluid
in the first 2 -3 hours to treat the hypovolemia, and potassium to correct the electrolyte
depletion
• Similar to Ketoacidosis but this occurs in Type II diabetics and Ketones are not found in
the blood or urine (since the patient’s beta cells produce some insulin the body does not
need to use fats etc and ketones do not develop
• Occurs slowly and almost always in elderly patients who are not getting enough fluids
• Watch for HHNK in patients who are receiving tube feedings (concentrated fluid without
enough water
• Also in patients with diarrhea, vomiting, severe burns, dialysis
• Treatment is rehydrate, replace electrolytes
Hypoglycemia
Hypoglycemia
• Symptoms of mild hypoglycemia (50 -60 blood sugar) - sudden tremors, palpitations,
diaphoresis & hunger - treat with 4 -6 ounces juice or 6 -10 life savers
Hypoglycemia
Somoyi Phenomenon
• Usually occurs at night
• episode of hypoglycemia & oversecretion of counterregulatory hormones which produces
hyperglycemia
Somogyi Phenomenon
• Phenomenon suspected when blood sugar keeps going up despite increasing dosages of
insulin or when patients wake with headache, nightmares or enuresis or unexplained
N&V
• Treatment is decrease evening insulin dose & give bedtime snack
• fever, influenza, vomiting & diarrhea can lead rapidly to hyperglycemia in diabetics
• Stress increases secretion of counter regulatory hormones glucogon, epinephrine and
cortisol thereby raising blood glucose levels
• hyperglycemia leads to osmotic diuresis (fluid, glucose and electrolytes are lost)
Diabetic Retinopathy
Diabetic Neuropathy
Diabetic Neuropathy
• Can have mononeuropathy such as carpal tunnel syndrome, extraocular motor paralysis
& footdrop
• Most patients have numbness, tingling, burning, dull ache & cramping that begins in the
digits & progresses to the foot and hand (worse at night)
Diabetic Neuropathy
• This progresses to muscle weakness & sensory loss, an unbalanced gait, foot ulcers and
lossof fine motor skills.
• Sensory neuropathy leads to loss of pain & pressure sensation & increases the risk of
undetected injury, tissue ischemia or infection
Diabetic Neuropathy
Diabetic Neuropathy
Diabetic Nephropathy
Diabetic Nephropathy
• deterioration of kidney function takes place over many years - first sign is protein in the
urine
• Nephrotic syndrome is diagnosed when protein excreted exceeds 3.5 g/d. When protein
is lost in the urine the serum protein also decreases. Low serum protein causes
decreased oncotic pressure and retention of fluid, weight gain edema, protein tissue
wasting
Diabetic Nephropathy
• Nephrotic syndrome progresses to renal insufficiency when the GFR falls to >25 to 30
mL/min (normal is 125 mL/min) and the patient has elevated serum creatinine and blood
urea nitrogen levels
Diabetic Nephropathy
• Uremia is the next progression (digression) & is diagnosed when the GFR is below 15
mL/min and serum creatinine is greater than 4 to 5 mg/dl (pt will have nausea, vomiting
lethargy, anemia, hypertension & acidosis)
• Patients with nephropathy are at increased risk of renal failure following radiocontrase
procedures such as IVP or CAT scans
• Be sure to assess what the patient knows and whether the information they give is
correct
• How willing are they to learn
• How well have they integrated the many lifestyle changes into their regimen
• Can they see to draw up their insulin? What is their educational level?
• foot care : inspect feet daily for sores, blisters, swelling, redness, & tenderness. Wash
feet daily using mild soap.Pat dry and apply Lanolin type lotion (not between toes). Test
water bfore putting feet in it. Do not soak feet. War shoes with soft linings. Do not walk
barefooted in the house or outside.
• Do not use hot water bottle . Cut toenails straight and even with the toe. If fungus infected
have the podiatrist care for them. Have a podiatrist treat any foot problems like corns or
calluses. Do not cross legs at the knees or ankles
• Anticipatory grieving
• Ineffective individual coping
• Fluid volume deficit
• Altered peripheral tissue perfusion
• Risk for injury
• Risk for altered health maintenance