Diabetes Mellitus

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					Diabetes Mellitus



           Dr. Belle Erickson
With thanks to
       Karen McKenna, MSN, RN

                                1
PANCREAS - An Endocrine Gland

   Islets of Langerhans
    – Beta Cells
            » INSULIN

    – Alpha Cells
            » GLUCAGON




                                2
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                              3
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)
                                                     4
Hormones affecting CHO
metabolism
   ACTH (Adrenocorticotropic hormone)
    and Glucocorticoids
    – enhances gluconeogenesis


   Epinephrine
    – enhances glycogenolysis


                                         5
Vocabulary
   Glucose
   Glucagon
   Glycogen
   Glycogenesis
   Gluconeogenesis
   Glycogenolysis
   Lipogenesis
   Glycolysis
                      6
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


                                           7
CHO (not enough)

   Decreased blood sugar & depleted
    glycogen stores

   Unable to use available glucose




                                       8
Body needs energy source

   Catabolism of fats and proteins
       • Where?


   Ketones




                                      9
Diabetes Mellitus

   Chronic disorder characterized by
    hyperglycemia
    – Imbalance between Insulin supply &
      demand
   Abnormal metabolism of fat,
    carbohydrate, & protein


                                           10
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



                                           11
                       Type l
                      (Type I)
      IDDM = Insulin Dependent Diabetes Mellitus
                  Juvenile Diabetes
              Body produces NO INSULIN
              Must take at least one injection of
Know This Stuff insulin per day to control blood

                sugar
              Usually occurs before 30 years old
              Body weight thin or ideal
              Onset abrupt
     Know This Stuff   TYPE 2
                   Type II
           Adult/Maturity Onset
NIDDM = Non Insulin Dependent Diabetes Mellitus

        Body does not produce enough insulin

                         and/or

        Body cannot use the insulin it has made
   Know This Stuff   TYPE 2
                   Type II
           Adult/Maturity Onset
NIDDM = 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
    RISK FACTORS
                    _____Type______
   Heredity             1        2
                                   African,Hispanic,
    – Race          1 caucasions 2 Asian, Native Americans
   Increased Age                 2
   Obesity                       2
   Stress               ?        2
   Viruses               1
   Diet                           2
   Auto-immune           1        2
   Environment           1

                                                     16
DM - Pathophysiology
   Lack of Insulin
    Glucose
       • Where?
       • ECF
   Fat & Protein breakdown

   Ketosis & Negative Nitrogen balance

   Hyperglycemia - - - WHY?
                                          17
Pathophysiology (cont’d)

   Intracellular fluid deficit

   Glycosuria

   ECF deficit

   Signs of DM
                                  18
Four Cardinal Symptoms

   Polyuria

   Polydypsia

   Polyphagia

   Weight Loss
                         19
     WARNING SIGNS -TYPE 1
            usually occur suddenly

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




                                     20
      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

                                                     21
      Assessment - Lab Studies

FBS
Postprandial glucose
Glycosylated Hgb (Hb A1c)
  normal value is 3-8%
(Oral Glucose Tolerance Test =OGTT)
(Fractionals)



                                      23
Control

   Normal FBS

   B.S.  180mg 2hrs. after a meal

   Glycosylated Hgb 10% or less

   Normal weight and general good health
                                        24
Diabetes Management

   Diet management

   Physical Activity

   Medications



                        25
          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
Medications

                  Type 1
 – Insulin
    • Administered SQ or IV   NOT ORALLY
                         NOT IN TUBE FEEDINGS


                 Type 2
 – Oral Hypoglycemic Agents
 – Insulin
                                            28
Insulin

   Types of insulin

   Duration of action
       • Short - Intermediate - Long


   Action
       • Onset - Peak - Duration

                                       29
Insulin - (cont’d)

   Concentration
    – Expressed in Units
       • U100


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


                                                  30
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          2-4
                      lispro 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




                                                                                                   31
Sliding Scale Insulin
Measure 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     32
Insulin

   Dosage
    – Individual requirements

    – Individual response




                                33
Insulin Administration

   Check Order

   Gather equipment

   Insulin - Precipitate



                            34
Administration - cont’d

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


   Drawing up

   Injecting
    – NO aspiration - 900 angle not 450
                                          35
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)
Teaching
   Pathophysiology
   Diet
   Exercise
   Diabetes Mellitus ID
   Sexuality
   Community Resources
   Stress Management
   Health Care

                           38
Teaching

   Home management
    – Insulin
       •   administration
       •   storage
       •   travel
       •   exercise
       •   sick days



                            39
Insulin pumps
   Mimic release of pancreas
    – electro - mechanical with computer chip


   Basal rate (++)

   Sub-Q

   Complications
                                                40
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
                                              41
Physical Activity

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



                                              42

				
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posted:4/20/2011
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