Diabetes
Chronic multi system disease related to abnormal insulin production, impaired insulin utilization, or both
Pre-diabetes – Glucose is high, but not yet high enough to be diagnosed with DM
Complications
Diabetic complications/comorbidities:
1. HTN and CVD
- Stroke and MI
- Kidney disease (nephropathy)
- Diabetic retinopathy
- Complications of feet and lower extremities, amputations
- Infection
- Psychological considerations – increased risk of disordered eating behaviors
T2DM (90-95%)
Alterations:
1. Pancreas – Defective beta cell secretion of insulin; resistance stimulates increased insulin secretion and exhaustion of beta cells
- Liver – Inappropriate regulation and production of excess glucose
- Adipose tissue – Altered production of adipokines (role in glucose and fat metabolism)
- Muscle – Defective insulin receptors, insulin resistance, and decreased uptake of glucose
Clinical manifestations
CM of T1DM:
- Onset is rapid, acute manifestations
- Polyuria, polydipsia, polyphagia
- Weight loss
- Weakness, fatigue
- DKA
CM of T2DM:
- Nonspecific
- Polyuria, polydipsia, polyphagia
- Fatigue
- Recurrent infections
- Recurrent vaginal yeast infection or candida infections
- Prolonged wound healing
- Visual changes
Diagnostic tests
A1C >6.5%
FBG >126 mg/dl
Glucose tolerance test >200mg/dl (after 2 hrs.)
Classic symptoms of:
- Hyperglycemia – polyuria, polydipsia, unexplained weight loss
- Hyperglycemic crisis – RBG >200 mg/dl
Medical management
T1DM:
- Lifestyle – diet (45-60g carbs./meal) and increasing exercise
- Drug therapy – insulin (IV, insulin pump, basal/bolus)
- Monitor for complications
T2DM – similar to T1DM
Nutrition
Options:
1. Reducing fat intake
- Encourage carbs. with low glycemic index
- Restricting the total amount of dietary carbs. (45-60g/meal)
Pharmacologic management
T1DM (Insulin management) – short, intermediate, rapid, and long-acting
T2DM:
- Insulin – during acute periods of distress
- Other meds.: Sulfonurea (glyburide), Biguanide (metformin), alpha glucosidase inhibitor (acarbose, miglitol), and thiazolinediones (rosiglitazone)
Monitoring symptoms
Hypoglycemia (BG <70 mg/dl):
- Faintness, dizziness
- Rapid heartbeat
- Hunger
- Nervousness, tremor
- Changes in vision
- Unsteady gait, slurred speech
- Seizures, coma
Hyperglycemia:
- Weakness, fatigue
- Increased urination
- Glycosuria
- Abdominal cramps, N/V/
- HA
- Blurred vision
* *Correction: Notify provider, give insulin as ordered and monitor closely
Nursing management
Monitoring pts for S/S of hyper/hypoglycemia
Management of nutrition
Pharmacologic management
Prevent complications
PT EDUCATION:
1. Exercise – moderate intensity aerobic activity (30 min./5 days a week); glucose lowering effects can happen up to 48 hrs. after activity (recommend exercise 1 hr. after meal or 10-15g carb. snack to prevent hypoglycemia)
- Nutrition
- Medications
- Self-monitoring – BG, skin, dental hygiene, wound healing
- Knowing when to call their PCP – impaired wound healing, vision changes, BG too low/high
**Care coordination – nutrition, PCP, pharmacy, family
Basal and bolus insulin
Basal – long-acting (Glargine, Lantus) regardless if they had a meal, going to surgery, or NPO
Correctional (fingerstick prior to meal) and nutritional (must eat 1/2 carbs.) insulin given immediately after meal
Prevention of complications
Treat DM to prevent:
1. ANGIOPATHY – Treat with tight glucose control to prevent damage to BVs due to chronic hyperglycemia (it is the leading cause of diabetes-related death; macro- and microvascular)
- Blindness
- Cataracts
- Charcot joints
- Damage to arterial walls
- Gangrene (wound healing)
- Glaucoma
- Nephropathy
- Osteoporosis
- Peripheral neuropathy
- Alzheimer’s and vascular dementia
- Hearing impairment
- Stroke
Angiopathy: Macrovascular
Disease of large and medium-size vessels – Presents as: CVD, cerebrovascular disease, PVD
Happens in populations with uncontrolled diagnosis in relation to hyperglycemia, excess fatty acids and insulin resistance
Decrease risk factors (yearly screening):
- Obesity
- Smoking
- HTN
- High fat intake
- Sedentary lifestyle
Angiopathy: Microvascular
Thickening of vessel membranes in capillaries and arterioles
Presents as:
1. Retinopathy – annual eye exam
- Nephropathy – BUN, Cr., GFR, creatine clearance; and urine microalbumin
- Peripheral neuropathy – monofilament testing; Report tingling/loss of sensation and monitor extremities closely
- Autonomic neuropathy (affects all body systems) – i.e. Gastroparesis; postural hypotension, resting tachycardia, painless MI; sexual function (erectile dysfunction, decreased libido, increased vaginal infections); neurogenic bladder (urinary incontinence)
Wound healing
Defect in mobilization of inflammatory cells and impaired phagocytosis = Recurrent or persistent infections
Treat quickly and aggressively
Prevent by:
- Hand hygiene
- Flu vaccine
- Early detection
Exercise and caloric output
Caloric output:
1. LIGHT (100-200 kcal/hr) – driving, fishing, teaching, secretarial work, light housework
- MODERATE (200-350 kcal/hr) – active housework, cycling, bowling, dancing, gardening, walking briskly
- HIGH (400-900 kcal/hr) – aerobic exercise, hard labor, ice skating, soccer, running, chopping wood
Nutrition plan
CARBOHYDRATES (130g/day minimum or 45-60g/meal) – fiber 25-30g/day, non-nutritive sweetness, and low glycemic index
PROTEIN – 15-20% total calories
FAT – <7% total calories, limit trans. fat, and >2 servings of fish/week (polyunsaturated fats)
ETOH – 2 drinks/day (men) and 1 drink/day (women)
**15g of carbs. = 1 small piece of fresh fruit (4 oz.), 1 cup of canned/frozen fruit, 1 slice of bread/tortilla, 1 cup of oatmeal, 1/3 cup of pasta/rice, 4-6 crackers, 1/2 English muffin/hamburger bun, 1 cup of black beans/starchy vegetables, or 1/2 serving of medium French fry
Glycemic index
LOW GI (<55):
- 100% stone-ground whole wheat or pumpernickel bread
- Oatmeal, oat bran, muesli
- Pasta, converted rice, barley, bulgar
- Sweet potato, corn, yam, lima/butter beans, peas, legumes, and lentils
- Most fruits, non-starchy vegetables, and carrots
MEDIUM GI (56-69):
- Whole wheat, rye, pita bread
- Quick oats
- Brown, wild, basmati rice, couscous
HIGH GI (>70):
- White bread or bagel
- Corn flakes, puffed rice, bran flakes, instant oatmeal
- Shortgrain white rice, rice pasta, macaroni and cheese mix
- Russet potato, pumpkin
- Pretzels, rice cakes, popcorn, saltine crackers, melons, and pineapples
