Diabetes

• A chronic multi-system disease related to abnormal insulin production or impaired insulin
• utilization.

•Autoimmune

•Viral

•Environmental

•Medication Induced; removal of pancreas

Absent or insufficient insulin

–Family Hx. of diabetes

–Obesity esp. abdominal and visceral adiposity.

–BMI>27%

• –Race/Ethnicity
•    •Hispanics more prone to having diabetes

–GDM or babies > 9 lbs.

• –HTN > 140/90 mm Hg
•    •73% of adults will have

–Triglycerides > 200mg/dL

–Prev. impaired glucose tolerance

27%

140/90

Glycolysis

Glycogenolysis

Gluconeogenesis

Glycolysis: the process through which glucose is broken down into water and carbon dioxide with the release of energy

They are important in ensuring a supply of glucose for body fuel.

the breakdown of stored glycogen (from the liver or skeletal muscles)

epinephrine and glucagon

Epinephrine breaks down glycogen in the muscle

breaks down glycogen in the liver

• The building of glucose from new sources like amino acids, lactate and glycerol can
• be converted into glucose.

Glucagon, Glucocorticoids, Thyroid

the liver

They work to oppose the effects of insulin. These hormones work to increase blood glucose levels by stimulating glucose production and output by the liver and decreasing the movt of glucose into the cells.

–Glucagons

–Epinephrine

–Growth hormone

–Cortisol

• Controls blood glucose levels by regulating glucose production and storage in the liver
• and muscle

produce insulin in the islets of langerhans

normally released in small increments when food is ingested

The amt of insulin a person is secreting can be tested by checking the levels of C peptide

high blood glucose

• Depends on what blood sugars are on
• how much the body is going to be making insulin

amylin

• •Amylin and insulin work together to
• suppress the secretion of glucagon by the liver

• •Amylin slows the transfer of nutrients to
• the intestine

insulin

glucagon

Stimulates the break-down of glycogen and  fats to glucose and promotes gluconeogensis from fats and proteins.

epinephrine and norepinephrine

Inhibiting insulin release and decreasing movement of glucose into the cells

Type 1, type 2, gestational

injury to the pancreas

**From corticoids

–Form estrogen containing preparations

–Once you stop the medication or correct the problem then the blood sugar should go back to normal

100-126

Destruction of their pancreatic cells, genetic, immunologic, and possibly environment

no insulin= rapid onset=life-threatening condition called DKA

•Used to be called juvenile diabetes

•Ketosis-prone diabetes

•Brittle diabetes

•Insulin dependent diabetes mellitus (IDDM)

•Now known as Type 1

Type 1 Diabetes

–1.Osmotic diuresis

–2. Loss of fluids from vomiting

• –3. Loss of body tissue because body has to use fat stores and cellular protein as
• fuel source because of lack of insulin.

rapid onset

–Polydipsia- extreme thirst caused by dehydration

–Polyuria produced by osmotic effect of glucose, glycosuria >excessive loss of F & E > dehydration

• –Polyphagia-cellular malnutrition  body starving for energy turns fat to fat
• stores and protein

type 1 diabetes

type 1 diabetes

uncontrolled type 1 diabetes

• •At
• time of diagnosis of type 1 with symptomatic hyperglycemia

–Remaining functioning beta cells heavily stressed.

• –Once insulin is started cells recover reducing insulin injections but is only
• temporary

–Honeymoon lasts only a short time weeks to months before needing insulin again.

• (Up to 48 hours) due to depletion of glycogen stores is a contributing factor of
• hypoglycemia

15 grams

• •Need to monitor BS before, during and after exercise to determine alterations in
• food or insulin

•Food amount varies from person to person.

• –Check blood sugar before, during and after exercise period and snack on carbohydrate
• snacks as needed to maintain blood glucose level.

Type 2 diabetes

gradual onset

obesity!

–Insulin resistance

–Impaired insulin secretion

• *Also:
• –Inappropriate glucose production by liver

–Alteration in the production of hormones and cytokines by adipose tissue.

•Fatigue

•Recurrent infections

•Recurrent vaginal yeast infections

•Prolonged wound healing

•Visual changes

greater than or equal to 6.5%

test done to test for type 2 diabetes, fast 8 hrs prior to being testing and if you have 2 tests that are greater than or equal to 126 mg/dL you have diabetes

Test for being a diabetic. You admin glucose and then test every hour to see what it is doing to your levels

Greater than 200 mg/dL using a 75 g glucose

Greater than or equal too

•History

–Signs related to Dx. Of DM

• –Signs- hyperglycemia
•    •How often are they having these symptoms and do they know s/s

• –Signs-hypoglycemia
•    •How often are they having these symptoms and do they know s/s

–Monitor frequency, timing, severity and resolution

–BS monitoring

–Status of symptoms

• –Adherence to Tx. Regimen
•    •Are they taking their meds and what kind

• –Lifestyle.Culture, psychosocial and economic factors
•    •What do they do for a living

–Effects of complications

–B/P sitting and lying-(orthostatic chg.)

–BMI

–Dilated eye exam

–Foot exam

–Skin exam

–Neuro. exam

• –Oral exam
•    •Recommend they see a dentist q 6 months, brush teeth 2x a day, floss

glucose testing from blood cell over the last 120 days (3-4 months)

• •Labs
• –Hgb A1C
•    –Average over the past 120 days of blood glucose

• –Fasting lipid profile
•   –Why?
•     –Cholesterol elevated, triglycerides, low 
•       HDL, high LDL

• –Microalbuminuria
•   –Why?
•     –Check for proteins bc protein damage in
•       the kidneys
•      –Damage filtration site of the kidney

• –Serum Creatine
•    –Checking kidney fxn

• –UA
•    –Making sure they don’t have a UTI

• –EKG
•   –Why?
•     –Bc they have a higher risk of  
•       cardiovascular problems

• –Referrals-Opthal., Podiatry, Dietician
•    –Ophthalmologist- seeing if they have   
•     retinopathy, need to have dilated
•     eye exam to look at back of  the eye and
•     look at blood vessels and see that they  
•     are not bleeding
•    –Podiatrist- take care of feet, cut nails
•    –Dietician: they need to have an  
•    individualized meal plan that works for
•    them
•         –Need to reduce 500 calories a week  
•           to lose a pound a week
•     Baking, grilling, boiling, steaming is 
•     good. Frying is bad

•Be an active participant

• •To experience few or no episodes of acute
• hyper/hypoglycemia emergencies

•Maintain BS levels as close to normal

•Prevent, minimize or delay complications

•Adjust lifestyle to decrease stress

• DPP showed a modest wt. loss of 5-10% of body wt. with regular exercise-30 min
• 5X/wk

•Central obesity

•Insulin resistance

•Elevated insulin levels

•High triglycerides

•Decreased HDL levels

•Increased LDL levels

•HTN

• •Total Cholesterol < or equal to 200mg/dl
• –HDL  < or equal to 50 mg/dl
• –LDL < 100mg/dl  (<70mg/dl ideal)
• –Triglycerides < or equal to 150

• –Damage/injury/interference or destruction
• of pancreas

• –Conditions
• •Cushing's
• •Hyperthyroidism
• •Recurrent pancreatitis
• •Use of parenteral nutrition (TPN)
•     –Has a lot of calories, a lot od sugar

• •Asthma
• –Pt taking steroids

–Corticosteroids

–Thiazides

–Dilantin

–Atypical antipsychotics

• –Resolves when treatment of underlying
• condition is  treated

•Nutritional Management

• •Exercise
•    –Any kind of movement is better
•       than no movement
•           •Walk
•           •March in place

•Monitoring

• •Pharmacologic Management
•     –They have to take the medication that  
•        is working for them. If it isn’t       
•         working, they need to go back and
•         see Dr.

•Education

human insulin

One or more injections of short and intermediate insulin

–Three injections of rapid acting insulin

–Plus a long acting insulin

–Rapid Acting

–Short Acting

–Intermediate Acting

–Long Acting

Rapid, acting insulin

Onset 10 – 30 min.

Peak 60-120 min

Duration 3-6 hrs

• –Rapidly
• reduce glucose level

• –Treat postprandial hyperglycemia
•    –Happens 2hrs after eating

–Prevent nocturnal hypoglycemia

Humulin R, Novolin R, ReliOn R, Aprida

Onset: 30 minutes- 1hr

peak 2-4 hrs

Duration: 4-6 hrs

20-30 mins before eating

you draw up the Regular short-acting insulin before NPH

Clear to Cloudy

NPH, Novolin N, Humulin N, ReliOn N

cloudy, roll the vial between hands to mix

Onset 1-2 hrs

Peak 4-12 hrs

Duration: 16-24 hrs

30-45 minutes before they eat

•Glargine (Lantus) clear

•Detemir (levemir) clear

Onset 1-2 hours

NO PEAK!!

12-24 hrs +

Long-acting insulin bc it has NO PEAK and is around for a long time

long-acting

long-acting insulin

effectiveness depends on the clients absorption of the drug

30 days

in the refrigerator until expiration date

30 days in the refrigerator

30 days

–In and out of refrigerator

–Don’t leave in hot car

REMEMBER: don't keep insulin in glove box and have pens handy at all times

Return to pharmacy

Discard it

Freeze or keep out in direct sunlight

more than once in 2-3 weeks

a limb that will be used to exercise

use same anatomic area at the same time of the day

•Abdomen- more stable and rapid absorption

•Arms- posterior surface

•Thighs anterior surface

•Hips        

–1 ml-holds 100 units

–0.5ml-holds 50u

–0.3 ml-holds 30u

insulin concentration

•Hypoglycemia

•Local allergic reaction(itching, erythema, and burning around inject site

•Systemic allergic reactions-hives (urticaria and antiphylactic shock)

•Insulin lipodystrophy(atrophy of tissue)

6 months, do not use that are during that time

lipodystrophy

• •Dawn Phenomenon-hyperglycemia that
• is present when awakening from release of counterregulatory hormones in the predawn hours. (growth hormone)

•More severe when growth hormone is peaking (Adolescence and young adulthood)

•Treatment- adjustment in timing of insulin or an increase in insulin

more insulin!!

Phenomenon-hyperglycemia that is present when awakening from release of counterregulatory hormones in the predawn hours. (growth hormone)

–Nocturnal

–Rebound effect –overdose of insulin produces hypoglycemia

–During the hours of sleep

• –Counterreglatory hormones released, stimulate lipolysis, gluconeogensis, and
• glycogenolysis  and in turn produce rebound hyperglycemia and ketosis.

Relatively normal blood glucose until about3 AM, when the level begins to rise

•Insulin Waning- progressive rise in glucose from bedtime until morning

–Can occur if evening NPH dose is taken before dinner

–So...Move evening dose of NPH or basal acting insulin to bedtime

• –Actos (pioglitazone)
•     •Improve muscle receptor sensitivity to
•       insulin with 2nd effects in the liver
•     •May slow progression of disease

• –Avandia (rosiglitazone)
•     •Restricted  distribution program (MI   
•      risk)A
•        –Ristricted but still can be used with  
•          monitoring

Volume expansion, heart failure, anemia, weight gain (peripheral not central)

Bigger Problem?? Can exacerbate CHF

• Sulfonylureas
• –Glipizide ( Glucotrol), glimipride ( Amaryl)
• •Increase secretion of insulin by pancreas
• •Increase receptor sensitivity

• Weight gain, hypoglycemia
• --Be careful with the elderly who don't eat and aren't as active

Metformin (Glucophage) Biquanide

–Decreased hepatic glucose production

–Increases glucose uptake by muscle

–Increase insulin sensitivity

–Lowers B/P; Increase HDL; Lowers LDL

•GI Blues bloating

•Need functioning organs, especially kidneys and heart

• –Avoid in patients with S/S CHF, heavy alcohol use
• –Hold 48 hrs. before IV contrast dye and 48 hrs. after
• –COMPLICATION- lactic acidosis- DEADLY

Byetta–Exenatide

–Synthetic peptide stimulates release of insulin from pancreatic B cells.

–Suppression of glucagon, decrease glucose from liver

–Slowing of gastric emptying

• –Not indicated with insulin use
• –Administer SubQ
• –Come form the saliva of gila monster
• –People who take this tend to lose weight
• –Not an insulin

Victoza

Indicated as an adjunct to diet, and exercise to improve glycemic control in adults with Type 2 DM

Sub-Q

Victoza

Pre-filled multiple dose pen

•Doses- 0.6mg;1.2mg; or 1.8mg

•Lowers blood glucose

•Decrease Cardiovascular risk factors.

•Psychological well being.

•Improvement in insulin secretions.

their healthcare provider

–Increases uptake of glucose by body muscles

–Improves insulin sensitivity

–Improves circulation and muscle tone

–Improved functioning of the cardiovascular system.

–Improved strength and physical activity capacity

–Reduced risk factors of coronary artery disease

lean muscle mass

metabolic rate

Also helps to decrease weight, decrease stress, and maintains well being.

lipid

–Increases levels of high density lipo-protein (HDL)

–Decreases total cholesterol and triglyceride levels

• Important to patients with diabetes with
• an increase risk of cardiovascular disease.

greater than 250 mg/dL

proper fitting shoes

ketones

•Should not exercise until urine test negative for ketones

1-2 hrs after a meal

Exercising increases blood glucose when it is elevated prior to exercising

Exercising increases the secretion of glucagon, growth hormone and catecholamines

• Liver releases more glucose resulting in
• an increase in blood glucose level.

True

–Exercise and dietary management improves glucose metabolism and enhances loss of body fat

–Improves insulin sensitivity and may decrease the need for insulin or oral agents.

•Exercise at the same time each day.

•Exercise the same amount of time each day.

•If patient has diabetes complications, alter the exercise type and amount as necessary. Increased B/P assoc. with exercise may aggravate diabetic retinopathy

30 mins a day and yes you can break this time up

eyes, so make sure you know your pts risk

True

The ADA recommends to advise people with  to perform at least 150 min/wk of moderate-intensity aerobic physical activity (50-70% of max. heart rate), spread over at least 3 days a week with no more than 2 consecutive days w/o exercise

In absence of contraindications, people with type 2 DM should be encouraged to perform resistance training at least 2 times per week

Yes, Blood glucose monitoring is a cornerstone in diabetes management

Glucometers-Pick the one that best suits the patient. Consider ease of use, skill level,cost of strips, visual numbers etc….

•Improper application of blood-most common

•Improper meter cleaning

•Damage to reagent strips

•Coding of meter

cleaning or coding

Nurses should evaluate the technique of patient’s while they use the SMBG for the first time

•Uncontrolled diabetes

•A tendency for hypoglycemia

•Hypoglycemia unawareness

•Patients on insulin

• •During illness
•    –Illness leads to higher blood glucose

–To identify and treat hypoglycemia

–To make decisions regarding food intake and med adjustment when exercising

–Determine the effect of food/glucose

–Pattern management

–To manage intermittent  illness

•Referred to as HgbA1c or A1C

•Reflects average blood glucose levels over a period of approximately 2 to 3 months, (ADA, 2004)

BS >110

BS 120-150

BS 150-200

BS 200-250

BS 250-300

BS > 300

Hypoglycemia-Abnormally low blood glucose level 50-70mg/dL)

–Too much insulin or oral hypoglycemic agents

–Too little food or excessive exercise

• –Delayed or skipped meals
•    •Should eat at same time and amount
•       –Only way they will know if what they   
•         are doing is working

Bc of their decreased appetite

•Hypoglycemia

•Diabetic Ketoacidosis (DKA)

•Hyperglycemia Hyperosmolar Nonketotic Syndrome (HHNS)

Mild hypoglycemia- sympathetic nervous system is stimulated- surge of epinephrine and norepinephrine

S/S- sweating, tremor, tachycardia, palpitations, nervousness, and hunger.

Central nervous system

Moderate hypoglycemia- deprives the brain cells of needed fuel for functioning

•Frequent insulin adjustment

•Irregular timing of insulin dosage

•Failure to lower dose when eating less

•Skipping meals

•Irregular timing of meals

•Delaying of meal after taking insulin

Rule of 15?

–Teach patients to carry some form of simple sugar with them at all times.

–Avoid over treating hypoglycemia

–Consistent pattern of eating and administering of insulin

Glucagon 1 mg injection can be given sub q

Remember: pt is given complex carbohydrate after to help restore liver glycogen and prevent continued hypoglycemia

–No warning signs and symptoms of hypoglycemia

Increase risk of dangerously low BS

• Beta Blockers (olol) propranolol (Inderal)
•     –Mask S/S of low blood glucose

• Autonomic neuropathy:
•     Gastroparesis can present itself with  
•      bloating after eating.
•         •Unexplained swings of  
•            hypo/hyperglycemia

•Fluid Overload- Administering fluids rapidly to treat DKA or HHNS

• •Hypokalemia-due to treatment of DKA-loss of potassium- may need K+ replacement
•  -- May result form dehydration and excess urine output

•Cerebral Edema-cause unknown, may be by rapid correction of hyperglycemia- resulting in fluid shift- assess mental status.

A metabolic derangement in type 1 diabetes that results from deficiency of insulin, highly acidic ketone bodies are formed, resulting in acidosis, requiring hospitalization for treatment. IV fluids and insulin drip.

Seen mostly in adolestants, a lot of young girls don’t want to gain weight from insulin so they stop taking insulin and go into DKA.

Insulin deficit promotes metabolism of fat stores which produce large amounts of acidic ketones leading to metabolic acidosis

–DKA caused by an absence or markedly inadequate amounts of insulin.

–Disorders in the metabolism of fats, CHO, and proteins.

–Illness or infection

Insulin resistance→Increase hormones (glucagon, epinephrine cortisol)→increase glucose production by liver→ interfere with glucose usage by muscle & fat tissue.

• Undiagnosed and untreated DKA may be initial manifestation of
• diabetes.

carbohydrate juices to prevent DKA

–Due to Na and K+ loss in urine clients experience

•Muscle weakness

•Extreme fatigue

•Malaise

•Cardiac arrhythmias can lead to cardiac arrest

•Acidosis-fruity breath, tachycardia and hypotension

If acidosis is not corrected it can lead to a coma of severe acidosis

–Decreased or missed dose of insulin

–Not drawing adequate dose

–Illness or infection

–Undiagnosed or untreated diabetes

• –Treatment
•    •IV fluid and electrolyte replacement

•Correct fluid and electrolytes

•Correct acidosis

• •Provide adequate insulin
•    –When giving insulin drip monitor for  
•      hyper/hypoglycemia
•     –Do not infuse fluids too rapidly to
•      prevent cerebral edema 1-2 L in 1-2
•       hrs

Treat K but the main thing is to hydrate!

•Provide adequate fluid to dehydrate Correct dehydration first

•Provide adequate insulin to restore and maintain normal glucose metabolism

•Correct electrolyte deficits and acidosis

•Prevent complications

•Provide source of glucose when needed

•Provide patient education

All pts with DKA will need insulin (use insulin drip more often)

When glucose reaches 250, then they will go to 5-10% dextrose added to normal saline

•Fluid Overload

• •Hypokalemia-due to treatment of DKA- loss of potassium
•     –If potassium is low need to correct this   first.

• •Cerebral Edema
•     –Cause unknown, may be by rapid correction of hyperglycemia- resulting in fluid shift-assess mental status

Monitor blood glucose 1-2 hrs in order to have successful treatment

•Serious condition – Blood  glucose 800-1000 mg/dl

•Ketosis usually minimal or absent

• •Defect or lack of  effective insulin (insulin resistance)
•    –Persistent hyperglycemia→ osmotic   diuresis →  glycosuria →and
• dehydration→hypernatremia
• & increased osmolarity

•Usually occurs in older adults

•Acute illness

•Medications that exacerbate hyperglycemia (thiazides)

•Elderly

**No ketosis

•Hypotension

•Profound dehydration

•Tachycardia

•Variable neurological signs

•Morality rate- 10% to 40%

•Treatment-fluid replacement and correct electrolytes

•Monitor V/S closely

•Fluid Status

• •Labs
•    –Esp. K

•Maintain safety and prevent injury

•I/O –high risk of renal failure due to dehydration

•Assess cardiovascular, pulmonary and renal function

• •Recommended
•    –Rapid fluid resuscitation to maintain cardiovascular integrity
•     •Need to administer 6 L of fluid over 24  hrs

• 1.  Provide adequate fluids to rehydrate
• •Guideline: infuse half of the fluid deficit over the first 12 hours and the remaining during the following 12-24 hours.

2.  Correct Electrolyte Deficits

3.  Provide adequate insulin to restore and maintain normal glucose metabolism

4.  Provide complications

Glucose can drop as much as 80-200 mg/dL per hour from rehydration.

Hydration is essential to lower glucose levels.

Insulin administration to lower BS

Diseases of large and medium-size vessels

Macrovascular complication:

• •From altered lipid metabolism
•    –Hardening of arteries leads to occlusion of vessel leads to MI
•       •Treatment
•         –Angioplasty
•         –ASA

Macrovascular

2-4 times increased risk of heart and cerebral vascular

at an earlier age

Morality rate is 3 to 5x greater in DM

• –Intermittent dizziness
• –Transient loss of vision
• –Slurring of speech
• –Paresthesia or weakness of one limb
• –Occurrence of a stroke
•     •Mild or TIA sometimes before having full blown stroke
•         –Give ASA, or take to ER

type 2 diabetic mellitus

Macrovascular

• –Pain in the buttock, calf, or thigh that occurs during exercise and relieved with
• rest. (intermittent claudication)

• –Cold foot or limb, shiny skin
•     •Shiny skin esp in lower legs

–Discolored or blue mottled appearance

–Decreased pulses, and absence of hair

• –Treatment:
•     •Tramadol
•        –Lessing s/s by decreasing blood flow  
•        –ASA
•        –If all else fails have a bipass

•Treatable risk factors

–Smoking

–Hypertension

–Hyperlipidemia

–Hyperglycemia

–Hyperinsulinemia

1 hr

LDL

Retina and Kindeys

Every pt should have dilated eye exam q/yr

• Looking for any bulging or aneurysm
• behind the eye

Blurred vision

Floaters

Flashes

Sudden lose of vision

• •The ADA recommends an initial dilated and comprehensive eye examination by an
• ophthalmologist or optometrist
•     –Adults and children aged 10 years or older with type 1 diabetes
•        •Within 5 years after diabetes onset
•     –Patients with type 2 diabetes
•        •Shortly after diagnosis
•            –Bc want to have a baseline

Results from chronic hyperglycemia

Diabetic retinopathy

type 1 and type 2  with prevalence related to the duration of the disease

Longer they have it without the treatment the more severe retinopathy can be

most common form

most severe form

• Partial occlusion of small blood vessels in the retina-develop microanueryms. Vision can be affected if Macula is involved.
•      –Should avoid dramatic physical activity that increase BP

• Retinal capillaries become occluded, hemorrhage. If blood vessels pull retina can cause a tear or partial or complete detachment of retina.
•       –Without treatment more than ½ will go blind

A visual acuity that is <20/200 in the better eye with corrective lenses and or a visual acuity field of < 20 degrees.

Prevention is key



If vision loss occurs, nursing education must address  the patient’s adjustment to vision impairment

•Control of blood glucose

•Control of hypertension

•Cessation of smoking

Glaucoma & cataracts

increased ocular pressure has damaged the optic nerve causing vision loss

• Opacities of the lens.
•    –Ppl with diabetes are more prone to cataract at a younger age

microvascular

Damage to small blood vessels that supply glomeruli of the kidney

end-stage renal disease

•HTN

•Genetic predisposition

•Smoking

• •Chronic hyperglycemia
•     –Some pts you will not be able to control it

•Studies DCCT and UKPDS showed significant reduction when near-normal blood glucose control was achieved and maintained

rapid onset

Acute renal failure (ARF)-rapid onset on symptoms including > in blood urea nitrogen (BUN), creatinine, electrolytes and minimal urinary output.

severity of disease

• Nephrotic syndrome:
• –Changes in glomerular basement membrane that occur secondary to diabetes then glomerular nephritis that lead to profound urine leading to kidney disease

Test for albumin (Protein that leaks into the urine)

--Check annually if microalbumin present and it exceeds >30mg in 24 hours on two consecutive random urine, treatment is needed

• Aggressive B/P management
• –Goal: lower blood pressure to <120/80 mm/Hg

• •Antihypertensive agents
•    –Ace Inhibitors-(pril)
•    –ARB’s-(sartans)
•    –Beta blockers

lifestyle and dietary changes

When ACE inhibitors, ARBs, or diuretics are used, monitor serum creatinine and potassium levels for the development of increased creatinine and hyperkalemia

• Continuing monitoring of urine albumin excretion to assess response to therapy and progression of disease.
•    –If having problems
•      •Might consider sending to nephrologist
•        –The earlier you send them the better

Exercise and CHF

90-130 mg/dL

• A1C <7%
• Endos<6.5%

<180 mg/dL

Endos: <140

There are three primary treatment options for individuals who experience ESRD:

   1. Hemodialysis:changes your lifestyle

   2. Peritoneal Dialysis: can be done at home but have to be careful to watch for infection (use sterile area)

   3. Kidney Transplantation

•Blood pressure control

•Blood glucose control

•Lipid levels for CVD risk

•Hemoglobin,for anemia

•Serum markers of bone and mineral metabolism

About 60-70% of people with diabetes have mild to severe forms of nervous system damage, including:

• -Impaired sensation or pain in the feet or
• hands

-Slowed digestion of food in the stomach

-Carpal tunnel syndrome

-Other nerve problems

people with diabetes

•Glucose control

•Duration of diabetes

•Damage to blood vessels

•Mechanical injury to nerves

•Autoimmune factors

•Genetic susceptibility

• •Lifestyle factors
•   –Smoking
•   –Diet

•Glucose control

•Duration of diabetes

• •Metabolic factors
•   –High blood glucose
•   –Advanced glycation end products
•   –Sorbitol
•   –Abnormal blood fat levels

•Ischemia

•Nerve fiber repair mechanisms

• Affects the autonomic nerves controlling internal organs
• –Peripheral

–Genitourinary

• –Gastrointestinal
•    •GI tract

• –Cardiovascular
•    •Heart

• absence of sweating of the extremities with a compensatory increase in upper body
• sweating

Women lose the desire to have sex and men become impotent

foot care!

–Annually for all patients

–Patients with neuropathy - visual inspection of feet at every visit with a health care professional

• –Use lotion to prevent dryness and cracking
•    •No lotion between toes

a podiatrist

a pumice stone, never a knife!

Always wear socks and well-fitting shoes


Remember: Notify their health care provider immediately if any foot problems occur

an increased risk of foot infections

•A foot infection is a preventable infection.

50 % of foot care problems could be prevented if pts checked their feet

Foot care measures should be practiced on a daily basis.

Test for loss of sensation: 10 gauge monofilament plus testing any one of

–Vibration using 128HZ tuning fork

–Pinprick sensation

–Ankle reflexes

–Vibration perception threshold

Diabetic foot ulcers

–Begins with soft tissue injury of foot.

–Formation of fissure between toes or in area of dry skin.

• –Formation of callus.
•       •Sometimes take callus off and there is  tunneling underneath

–Ingrown toenails

–Cracks in skin

–Venous insufficiency is a contributing cause of foot ulcers

TRUE! It can damage the skin and the pt not be aware of it

•Chemical

•Traumatic

•Thermal

–Drainage

–Swelling

–Redness (cellulites of leg)

–Gangrene

•Bed rest

•Antibiotics

•Debridement

•Good control of blood glucose (usually increases with infection).

PVD

dark, coarse, thicken skin on the neck

red-brown flat-topped papules

type 1- autoimmune- partial rings of papules, often in dorsal surface of hands and feet

Defect in the mobilization of inflammatory cells and an impairment of phagocytosis.

A chronic, progressive bacterial infection that destroys the supporting tissues of the teeth.

good oral care is a must!

–During stress such as surgery, blood glucose levels rise as a result of an increase level of stress hormones.

–If hyperglycemia is not controlled- osmotic diuresis may lead to excessive loss of fluids and electrolytes.

–Hypoglycemia- withhold SQ insulin morning of surgery

–Changes in treatment regimen

–Medications (eg. Glucocorticoids)

–IV Dextrose

–Overly vigorous treatment of hypoglycemia.

–Overuse of sliding scale

–Lack of dosage changes when dietary intake is changed.

–Overly vigorous treatment of hyperglycemia

• –Delayed meal after lispro or aspart insulin
•       •Which is novolog or humalog

insulin dose may need to be changed

may need to administer insulin

important to administer insulin at regular intervals

•Address any underlying factors affecting diabetes control.

• •Simplify
• the treatment regimen

• •Adjust
• regimen to meet patient’s request.

• •Provide
• positive reinforcement and encouragement.

–Degree of life changes and the complexity of management plan

–Cost of care

–Cultural factors

–Lack of family support

–Other stressors

–Lack of Knowledge

–Fears

•Encourage patient and family to take charge of their health

•Simplify the regimen

•Focus on the normal not the differences

•Teach the tools and help pt. get supplies

•Provide a safe harbor

•Provide adequate education

•Deficient knowledge r/t diabetes self care skills/information.

•Potential self care deficit r/t physical impairments or social factors.

•Anxiety r/t loss of control, fear of inability to manage diabetes, misinformation r/t diabetes, fear of diabetes complications.

•Risk for infection r/t potential sensory loss in feet.

•Imbalanced Nutrition Related to increase in stress hormones

•Risk for impaired skin integrity related to immobility and lack of sensation.

•Improved nutritional status

•Maintenance of skin integrity

•Ability to perform basic diabetes self-management.

•Prevent short and long term diabetes complications

Persons with diabetes mellitus can live a long and healthy life if they control their diabetes instead of letting the diabetes control them!!