CHAPTER 46: • Affects 5% to 10% of adults with diabetes

DIABETES Type 2 Diabetes - most common

• Insulin resistance and impaired insulin
DIABETES: secretion
• A group of diseases characterized by • Affects 90% to 95% of adults with diabetes,
hyperglycemia caused by defects in insulin onset at or over age 30 years, increasing in
secretion, insulin action or both children r/t obesity
• Affects nearly 34.1 million people in the • Slow, progressive glucose intolerance
United States; one third of the cases are • no. 1 cause: Obesity usually present at
undiagnosed diagnosis
• Prevalence is increasing
• Ethnic and racial minority populations are Latent Autoimmune Diabetes of Adults
disproportionately affected
(LADA)
• Subtype of diabetes in which progression of
Classifications of Diabetes
autoimmune beta cell destruction in the
• Type 1 diabetes
pancreas is slower than in types 1 and 2
• Type 2 diabetes
diabetes
• Gestational diabetes
• Not insulin dependent in the initial 6
• Prediabetes
months of disease onset.
Latent autoimmune diabetes of adults
• Clinical manifestation of LADA shares the
(LADA)
features of types 1 and 2 diabetes
• Diabetes associated with other conditions
• Emerging subtype has led some to propose
or syndromes
the diabetes classification scheme should
• Refer to Table 46-1
be revised to reflect changes in the beta
cells in the pancreas
Functions of Insulin
Onset: 6 yrs old
• Transports and metabolizes glucose for
BMI: less than 25 pero mataas blood sugar
energy
• Stimulates storage of glucose in the liver
and muscle as glycogen Risk Factors
• Signals the liver to stop the release of
Type 1
glucose • early-onset (age < 30 years), familial,
Enhances storage of dietary fat in adipose genetic predisposition, race/ethnicity
tissue Type 2
• Accelerates transport of amino acids into
• obesity, age >30 years, previous identified
cells impaired fasting glucose or impaired
• Inhibits the breakdown of stored glucose,
glucose tolerance, hypertension, HDL ≤35
protein, and fat mg/dL or triglycerides ≥250 mg/dL, history
of gestational diabetes or babies over 9
Type 1 Diabetes pounds
• Insulin-producing beta cells in the pancreas • TYPE 2 DM IS REVERSIBLE FOR NEWLY
are destroyed by a combination of genetic, DIAGNOSED PATIENTS
immunologic, (insulin as foreign body) and
environmental factors
• Results in decreased insulin production, Clinical Manifestations
unchecked glucose production by the liver • Depends, on the level of hyperglycemia
and fasting hyperglycemia "Three Ps"
 • Polyuria (urine, glucose, electrolytes) Nurse's role:
• Polydipsia • Be knowledgeable about dietary
• Polyphagia management
• Fatigue, weakness, vision changes, tingling • Communicate with dietician or other
or numbness in hands or feet (neuropathy), management specialists
dry skin, skin lesions or wounds that are • Reinforce patient understanding
slow to heal, recurrent infections Support dietary and lifestyle changes
• Type 1 may have sudden weight loss,
nausea, vomiting or abdominal pain Meal Planning
• Consider food preferences, lifestyle, usual
Diagnostic Findings eating times, and cultural and ethnic
• Fasting blood glucose 126 mg/dL or more background
• Casual glucose (random blood sugar) • Review diet history and need for weight
exceeding 200 mg/dL loss, gain, or maintenance
• Two-hour postload (glucose tolerance test, • Caloric requirements and calorie
for pregnant) glucose equal to or greater distribution throughout the day; exchange
than 200mg/dL - most effective lists
• Hemoglobin A1C more than or equal to - Carbohydrates: 50% to 60%
6.5% - most accurate (for 6 mos?) carbohydrates; emphasize whole grains
- Fat: 20% to 30%
False - Nonanimal sources of protein (e.g.,
Rationale: A glucose tolerance test is more legumes, whole grains) and increase
effective in diagnosis of diabetes than urine testing fiber
for glucose in older adults due to the higher renal • Refer to Table 46-2 for exchange list
threshold for glucose.
Glycemic Index
Medical Management of Diabetes • Combining starchy foods with protein and
• Main goal is to normalize insulin activity and fat slows absorption and glycemic response
blood glucose levels to reduce the • Raw or whole foods tend to have lower
development of complications responses than cooked, chopped, or pureed
• The ADA now recommends HgbA1c less foods
than 6.5% • Eat whole fruits rather than juices; this
• Diabetes management has five decreases glycemic response because of
components: fiber (slowing absorption)
- Nutritional therapy • Adding food with sugars may produce lower
- Exercise response if eaten with foods that are more
- Monitoring slowly absorbed
- Pharmacologic therapy
- Education Other Dietary Concerns
3 major complications of DM • Alcohol (in moderation) - suppressant
- Neuropathy, retinopathy, nephropathy Female: 1 bottle
Male: 2 bottles
Dietary Management • Nutritive and nonnutritive sweeteners
Management goals: • Misleading food labels
• Control of total caloric intake to attain or
maintain a reasonable body weight
• Control of blood glucose levels
• Normalization of lipids and blood pressure
to prevent heart disease
Exercise insulins per day
• Lowers blood glucose - Intensive – aggressive, more complex
• Aids in weight loss, easing stress, and (check everytime)
maintaining a feeling of well-being
• Lowers cardiovascular risk
• Refer to Chart 46-4 Complications of Insulin Therapy
• Local allergic reactions
Exercise precautions • Systemic allergic reactions (urticaria)
• Insulin normally decreases with exercise; • Insulin lipodystrophy (laging natutusok na
patients on exogenous insulin should eat a parts)
15-g carbohydrate snack before moderate - lipoatrophy (loss of subcutaneous fats)
exercise to prevent hypoglycemia or lipohypertrophy (matigas na fats,
• Patients with type 2 diabetes not taking swelling) *tiyan, thighs
insulin or an oral agent may not need extra • Resistance to injected insulin
food before exercise • Morning hyperglycemia (Chart 46-5)
• Potential postexercise hypoglycemia - Dawn phenomenon – approximately 3
• Need to monitor blood glucose levels AM, when blood glucose levels begin to
• Gerontologic considerations rise.
- Insulin waning – frequently seen if the
Insulin Therapy evening NPH dose is given before
• Blood glucose monitoring: dinner; it is prevented by moving the
- Individualize treatment regimen to evening dose of NPH insulin to bedtime.
obtain optimal blood glucose control - Somogyi effect - nocturnal
- Self-monitoring of blood glucose hypoglycemia followed by rebound
(SMBG) levels has dramatically altered hyperglycemia
diabetes care
• Categories of insulin: Methods of Insulin Delivery
- Rapid acting - less than 15 mins; Aspart • Traditional subcutaneous injections
- Short acting: regular insulin (clear) • Insulin pens - long acting
(through IV only) • Jet injectors - similar, but with more
- Intermediate acting: NPH insulin pressure
(cloudy) • Insulin pumps - IV
- Long acting: No peak (cloudy), Glargine • Future: Implantable insulin pumps
- Rapid-acting inhalation powder:
Afrezza (immediately before meals) Educating patients in insulin self-management
• Use and action of insulin
Insulin regimen • Symptoms of hypoglycemia and
• Insulin preparations vary according to time hyperglycemia
course of action, source, and manufacturer - Required actions
• Table 46-4 describes several insulin • Blood glucose monitoring
regimens and the advantages and • Self-injection of insulin
disadvantages of each • Insulin pump use
• Two general approaches to insulin therapy:
- Conventional - constant dose everyday Oral Antidiabetic Agents
(for terminally ill) • Used for patients with type 2 diabetes who
* simplified regimen (e.g., one or more require more than diet and exercise alone
injections of a mixture of short- and • Combinations of oral drugs may be used
intermediate-acting • Major side effect: hypoglycemia
 • Nursing interventions: monitor blood - Acidosis
glucose for hypoglycemia and other • Physiology/Pathophysiology: Refer to Figure
potential side effects 46-6
• Patient education
• Table 46-5 Assessment of DKA
• Blood glucose levels between 250 and 800
Acute Complications of Diabetes mg/dL
• Hypoglycemia • Severity of DKA not only due to blood
• DKA glucose level
• Hyperglycemic hyperosmolar syndrome • Ketoacidosis is reflected in low serum
(HHS) bicarbonate, low pH; low PCO2 reflects
• Comparison of DKA and HHS: refer to Table respiratory compensation (Kussmaul
46-6 respirations)
• Ketone bodies in blood and urine
Hypoglycemia • Electrolytes vary according to degree of
• Abnormally low blood glucose level below dehydration; increase in creatinine, Hct,
70 mg/dL; too much insulin or oral BUN
hypoglycemic agents, excessive physical
activity, and not enough food Management of DKA
• Adrenergic symptoms: sweating, tremors, • Rehydration with IV fluid
tachycardia, palpitations, nervousness, • IV continuous infusion of regular insulin
• Reverse acidosis and restore electrolyte
hunger
• Central nervous system symptoms: inability balance
to concentrate, headache, confusion, • Note: rehydration leads to increased plasma
memory lapses, slurred speech, drowsiness volume and decreased K; insulin enhances
• Severe hypoglycemia: disorientation, the movement of K+ from extracellular fluid
seizures, loss of consciousness, death into the cells
• Monitor blood glucose, renal function and
Management of Hypoglycemia urinary output, ECG, electrolyte levels, VS,
• Give 15 to 20 g of fast-acting, concentrated lung assessments for signs of fluid overload
carbohydrate
- Three or four glucose tablets Hyperglycemic Hyperosmolar Syndrome
- 4 to 6 ounces of juice or regular soda • Hyperosmolar hyperglycemia is caused by a
(not diet soda) lack of sufficient insulin; ketosis is minimal
• Emergency measures; if the patient cannot or absent
swallow or is unconscious: • Hyperglycemia causes osmotic diuresis, loss
- Subcutaneous or intramuscular of water and electrolytes, hypernatremia,
glucagon (1 mg) and increased osmolality
- 25 to 50 mL of 50% dextrose solution IV • Manifestations include hypotension,
profound dehydration, tachycardia, and
Diabetic Ketoacidosis (DKA) variable neurologic signs caused by cerebral
• Absence or inadequate amount of insulin dehydration
• High mortality rate
resulting in abnormal metabolism of
carbohydrate, protein, and fat Management of HHS
• Clinical features • Rehydration
• Insulin Administration
- Hyperglycemia
• Monitor fluid volume and electrolyte status
- Dehydration (osmotic diuresis -
excretion of f&e) • Prevention
 - Diagnosis and management of diabetes
- Assess and promote self-care
management skills

Long-Term Complications of Diabetes

• Macrovascular: accelerated atherosclerotic
changes; coronary artery disease,
cerebrovascular disease, peripheral vascular
disease
• Microvascular: microangiopathy; diabetic
retinopathy (refer to Table 46-7),
nephropathy
• Neuropathic: peripheral neuropathy
(tingling fingers), autonomic neuropathies
(CARDIO: tachycardia, orthostatic
hypotension
GASTRO: bloated, diarrhea and constipation
RENAL: urinary retention)
hypoglycemic unawareness, sudomotor
neuropathy (abnormal/decreased sweating,
compensatory sa upper body), sexual
dysfunction