Diabetes

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Diabetes Mellitus Type 1

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Cause

• Beta cells of the pancreas DO NOT make insulin.
• Autoimmune.
• Genetic.
• Diagnosed in childhood.
• No insulin to bring glucose into cells.
• Cells use alternative energy: fat and protein ⇒forming ketones and acidosis.
• Abrupt onset

Signs and Symptoms

Abrupt onset of symptoms in younger patients

• The P’s: Polydipsia, Polyphagia, Polyuria
• Also weight loss, fatigue, blurry vision and delayed wound healing.

Treatment

• Insulin and only insulin
• Oral medications will not work. Only life-long insulin
• Remember that pancreas does not produce insulin.

Diabetes Mellitus Type 2

Cause

• Pancreas produces some insulin, but insulin receptors DO NOT WORK properly.
• Insulin resistance.
• Diagnosed in adulthood
• Usually due to poor lifestyle (poor diet, no exercise, and obesity), smoking, family history, and sedentary lifestyle.

Signs and Symptoms

• Gradual onset in adulthood
• Sometimes asymptomatic or same symptoms as Type 1. Most dangerous since patient may not know and not get treatment for years.

Treatment

• Diet and exercise
• Oral hypoglycemic drugs such as glipizide and metformin
• Insulin if unable to control blood sugar with oral hypoglycemics

Diagnosing Diabetes

Random Blood Sugar

Random Blood Sugar > 200 mg/dl. I know table below does not show random blod sugar. But this is a great table to memorize.

Fasting Blood Sugar

126 mg/dl after fasting for 8 hours

Glucose Tolerance Test

Blood sugar > 200mg/dl after ingesting 75 grams of glucose in water. Patient must be NPO. Glucose is taken before ingesting glucose and 2-3 times every 60 minutes.

Hemoglobin A1C

The A1C test measures what percentage of hemoglobin proteins in your blood are coated with sugar (glycated).  Measures how well-controlled blood glucose levels have been over the past 2-3 MONTHS.

Insulin Complications

Dawn Phenomenon

• Reduced sensitivity to insulin or surge of growth hormone at night that causes hyperglycemia before breakfast (5am to 8 am)
• Treatment: Increase bedtime dose of insulin. Dawn Phenomenon = Down insulin.  DD

Somogyi Phenomenon

• Normal blood sugar at bedtime, but hypoglycemia occurs at about 03 am causing glucagon to be released and hyperglycemia occurs at 07 am.
• Treatment:  Decrease bedtime insulin or increase bedtime snack
• Somogyi = 03 am hypoglycemia, need less insulin or more snack
• How to remember Somogyi=Somogyi  So much insulin  that we need to decrease.

Diabetes Complications

Long-Term Complications

Slow wound healing

Pay special attention to feet. With peripheral neuropathy, patients may have a wound and not even feel it until it begins to turn into gangrene. 

Surgical wounds may take longer to heal. Keep blood sugar under control. Even type 2 diabetics may need insulin when hospitalized. 

Peripheral Neuropathy

Hyperglycemia damages nerves

This causes numbness, tingling, and even loss of sensation.

Diabetic Retinopathy

Hyperglycemia damages vessels of retina. Clients may also have glaucoma and cataracts. 

Nephropathy

Hyperglycemia damages glomeruli

Diabetes is the second most common cause of end-stage renal disease. #1 = hypertension. Most clients with renal failure have both.

Cardiovascular Disease

Blockage of the blood vessels supplying the heart.

Cerebral Vascular Accident

Cerebral Vascular Accident = Stroke

Foot Care

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Inspect feet daily

• Use mirror if necessary
• check for cuts, blisters, or sores.

Wash feet daily

• Avoid Soaks
• Use warm water and mild soap
• Gently pat feet completely dry

Apply lotion to feet

BUT DO NOT APPLY BETWEEN TOES

Do not cross legs

Decreases circulation

Buy correct shoe size

• Never buy bigger shoes
• Buy shoes in the afternoon when feet are larger
• Have each foot measured every time you buy new shoes
• Buy leather shoes, not vinyl

Toe nails

Cut straight across

Report Infection to PCP

DKA vs HHNS

How Diabetic Ketoacidosis Develops

Low insulin prevents glucose from entering cells. Serum glucose becomes very high. The body starts to metabolize protein and fat into energy, which leads into ketones and acidosis

Causes of DKA

Signs and Symptoms of DKA
 

• Elevated glucose levels
• Dehydration
• Acidosis/Ketosis
• Kussmaul respirations: fast breathing to blow off acid. Lungs are trying to compensate for the metabolic acidosis
• Acetone/fruity breath

Treatment for DKA

• Regular Insulin drip
• Hydration
• Correct electrolyte imbalances and acidosis
• Insulin drives K+ into the cell, so watch for hypokalemia
• Regular insulin is the ONLY insulin given IV

How HHNS develops

No acidosis and no ketones, but very high blood sugar

Causes of HHNS

• Dehydration
• Infection
• Stress
• Decreased kidney function

Signs and Symptoms

• Dehydration
• Neuro changes (decreased LOC)
• No metabolic acidosis, no Kussmaul respirations
• Blood sugars can be very high (600+)

Treatment

• Rehydration
• Correct electrolytes
• IV insulin with potassium replacement

Hyperglycemia vs. Hypoglycemia

Blood Sugar > 200 mg/dL

• All of the above plus. Ok, some repeat, but I want you to know them.
• Nausea/Vomiting
• Blurred vision/diplopia
• The 3 P’s. You better know them by now!
• Numbness
• Sugar in the urine (glycosuria)

Causes

The S’s again

Treatment

Blood sugar < 70 mg/dL

• Diaphoresis (sweaty)
• Palpitations
• Headache
• Irritability and Shakiness
• Fatigue
• Weakness
• Confusion
• Can lead to a coma and seizures without treatment

Causes

Treatment

Dextrose 50% IV or Glucagon if unconscious. 

The different types of insulin

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