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Diabetes Mellitus

Dr. Belle EricksonWith thanks to

Karen McKenna, MSN, RN

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PANCREAS - An Endocrine Gland

Islets of Langerhans– Beta Cells

» INSULIN

– Alpha Cells» GLUCAGON

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INSULIN Lowers blood sugar by:

– Transporting glucose into cell• Receptor sites

– Converting glucose to glycogen for storage in muscle and liver tissue(glycogenesis)

– Converting excess glucose into fat cells, forming lipids from fatty acids (lipogenesis) and promoting storage in adipose tissue

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GLUCAGON

Known as Hyperglycemic agent

Promotes activities that raise blood sugar- - -

• Converting of stored glycogen to glucose (Glycogenolysis)

• Formation of glucose from protein and fat sources (Gluconeogenesis)

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Hormones affecting CHO metabolism ACTH (Adrenocorticotropic hormone)

and Glucocorticoids– enhances gluconeogenesis

Epinephrine – enhances glycogenolysis

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Vocabulary Glucose Glucagon Glycogen Glycogenesis Gluconeogenesis Glycogenolysis Lipogenesis Glycolysis

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Carbohydrate Metabolism

Active transport of glucose into cells & metabolism of glucose with release of energy

Storage of glucose Conversion of glycogen back to glucose Conversion of proteins to glucose

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CHO (not enough)

Decreased blood sugar & depleted glycogen stores

Unable to use available glucose

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Body needs energy source

Catabolism of fats and proteins• Where?

Ketones

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Diabetes Mellitus

Chronic disorder characterized by hyperglycemia– Imbalance between Insulin supply &

demand Abnormal metabolism of fat,

carbohydrate, & protein

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Types of DM

*Type 1 (IDDM) 10 - 15 % of all Diabetics

*Type 2 85 - 90-% of all cases

Secondary Gestational (High Risk) Impaired Glucose Tolerance

Type l (Type I)

IDDM = Insulin Dependent Diabetes MellitusJuvenile Diabetes

Body produces NO INSULIN

Must take at least one injection of insulin per day to control blood sugar

Usually occurs before 30 years old

Body weight thin or ideal

Onset abrupt

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TYPE 2Type II

Adult/Maturity OnsetNIDDM = Non Insulin Dependent Diabetes Mellitus

Body does not produce enough insulin

and/or

Body cannot use the insulin it has made

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TYPE 2 Type II

Adult/Maturity OnsetNIDDM = Non Insulin Dependent Diabetes Mellitus

May control blood sugar with diet and exercise alone (but may take oral meds. or insulin)

Clients usually > 35/40 years old Clients usually overweight/obese 1/2 go undiagnosed for years & by then

complications can be underway

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RISK FACTORS

Heredity– Race

Increased Age Obesity Stress Viruses Diet Auto-immune Environment

_____Type______

1 2

1 caucasions 2

2

2

? 2

1

2

1 2

1

African,Hispanic,Asian, Native Americans

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DM - Pathophysiology

Lack of Insulin Glucose

• Where?• ECF

Fat & Protein breakdown

Ketosis & Negative Nitrogen balance

Hyperglycemia - - - WHY?

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Pathophysiology (cont’d)

Intracellular fluid deficit

Glycosuria

ECF deficit

Signs of DM

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Four Cardinal Symptoms

Polyuria

Polydypsia

Polyphagia

Weight Loss

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WARNING SIGNS -TYPE 1usually occur suddenly

3 “poly’s” & weight loss irritability weakness and fatigue nausea and vomiting

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WARNING SIGNS -TYPE 2 usually occur less suddenly & may be very mild

any of the Type 1 signs recurring or hard-to-heal skin, gum or

bladder infections drowsiness blurred vision tingling or numbness in hands or feet itching

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Assessment - Lab Studies

FBS

Postprandial glucose

Glycosylated Hgb (Hb A1c) normal value is 3-8%

(Oral Glucose Tolerance Test =OGTT)(Fractionals)

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Control

Normal FBS

B.S. 180mg 2hrs. after a meal

Glycosylated Hgb 10% or less

Normal weight and general good health

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Diabetes Management

Diet management

Physical Activity

Medications

Recommended Nutrient Intake

PROTEIN 10 -20% of total energy intake

FAT < 30% (Depends on lipid & glucose levels)

CARBOHYDRATE 40-60% of total intake (Based on glucose & lipid levels and client’s habits)

NCS

***FIBER*** 20-35 grams

Fiber slows/moderates blood absorption of carb/glucose

6 MAJOR EXCHANGE LISTS

MILK Non-Fat, Low Fat

VEGETABLE All Non-Starchy Vegetables

FRUIT All Fruits & Fruit Juices

BRE AD Bread, Cereal, Pasta,

Starchy Vegetables

& Prepared Foods

MEAT Lean Meat, Medium &

High Fat & Other

Protein Rich Food

FATS Polyunsaturated, Saturated and Non Saturated

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Medications

Type 1– Insulin

• Administered SQ or IV NOTNOT ORALLY ORALLY

NOTNOT IN TUBE IN TUBE FEEDINGSFEEDINGS

Type 2– Oral Hypoglycemic Agents– Insulin

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Insulin

Types of insulin

Duration of action• Short - Intermediate - Long

Action• Onset - Peak - Duration

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Insulin - (cont’d)

Concentration– Expressed in Units

• U100

Insulin Order• NPH Humulin (U100) 32U SQ daily before

dinner

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Types of Humulin Insulin and Comparative Actions

Action, hr*Action Preparation Appearance Onset Peak Duration

Short-acting Humalog (insulin Clear Immediate 0.5-1.5 2-4lispro injection)

Regular Clear 0.5-1 2-3 3-6

Intermediate-acting NPH Cloudy 2-4 4-10 10-16

Lente Cloudy 3-4 4-12 12-18

Premixed Cloudy 0.5-1 2 peaks: 16-24 (70% NPH, 3-4 and 8-12 30% regular)

Long-acting Ultralente Cloudy 6-10 None 18-20

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Sliding Scale InsulinMeasure BG at -7am -11am - 4pm - 9pm

Give Humulin Regular Insulin

BG Value Dosage

150-200 0 units

201-250 2 units

251-300 4 units

301-350 6 units

351-400 8 units

over 400 call MD

under 50 give 6oz OJ

repeat BS

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Insulin

Dosage– Individual requirements

– Individual response

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Insulin Administration

Check Order

Gather equipment

Insulin - Precipitate

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Administration - cont’d

Combining Insulins– 30U of NPH & 6U of Regular

Drawing up

Injecting– NO aspiration - 900 angle not 450

Special Things About Regular Insulin

Only one to give IV Only one to give in Emergencies Only one to give for coverage Given via Insulin Pump (or Humalog)

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Teaching Pathophysiology Diet Exercise Diabetes Mellitus ID Sexuality Community Resources Stress Management Health Care

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Teaching

Home management– Insulin

• administration • storage• travel• exercise• sick days

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Insulin pumps Mimic release of pancreas

– electro - mechanical with computer chip

Basal rate (++)

Sub-Q

Complications

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Oral Hypoglycemic Agents Sulfonylureas Insulin ? Functioning Beta Cells OOC on diet and exercise Action

– release insulin from beta cells– enhance sensitivity of receptor sites

*Metformin - (Glucophage) guanidine derivative not a sulfonylureas

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Physical Activity

Exercise– Lowers BS levels uptake of free fatty acids– lower cholesterol & triglycerides– promote cardiac stabillity– reduce stress & sense of well-being