DIABETES MELLITUS

Review of the Anatomy and Physiology of the Pancreas located in the upper abdomen behind the stomach has exocrine (secretion of pancreatic enzymes into the gastrointestinal tract through the pancreatic duct) as well as endocrine functions (secretion of insulin, glucagon, and somatostatin directly into the bloodstream)

Factors necessary for synthesis and release of Insulin and Glucose

Healthy pancreas with functioning alpha and beta cells Adequate diet and increase in protein Normal K+ levels

 Alpha Cells secrete GLUCAGON The effect of glucagon (opposite to that of insulin) is chiefly to raise the blood glucose by converting glycogen to glucose in the liver. Glucagon is secreted by the pancreas in response to a decrease in the level of blood glucose. Glycogen is a principal storage form of carbohydrates in mammals Promotes rose of blood glucose when glucose levels are low

 Beta Cells produce INSULIN major action of insulin is to lower blood glucose by permitting entry of the glucose into the cells of the liver, muscle, and other tissues, where it is either stored as glycogen or used for energy; also promotes the storage of fat in adipose tissue and the synthesis of proteins in various body tissues.

Functions
Stimulate active transport of glucose into tissue and adipose tissue To cross the cell membrane, glucose must be bound to insulin and hook up on the receptor site on a cell Normal insulin actively promotes processes that lower blood glucose Inhibit processes that raise the blood glucose level Amount of glucose in the blood regulates the rate of insulin secretion of the beta cells Regulates rate at which CHO are used by the cell Promotes conversion of glucose to glycogen for storage but inhibits the conversion of glycogen to glucose Promotes the conversion of fatty acids into fat which can be stored as adipose tissue and inhibits the breakdown ao adipose tissue, the mobilization of fats and conversion of fat to ketone bodies Stimulate protein synthesis: breakdown of proteins to amino acids

 Delta Cells secrete SOMATOSTATIN Which exerts a hypoglycemic effect by interfering with release of growth hormone from the pituitary and glucagon from the pancreas, both of which tend to raise blood glucose levels.

GLYCOGENOLYSIS
Conversion of glycogen to glucose in the liver Glycogen Synthesis -conversion of glucose, fructose, galactose into glycogen b. Gluconeogenesis - Transformation of amino acids pyruvate and lactate into glucose/glycogen c. Glycolysis - Initial process of glucose catabolism - Breakdown of glucose into smaller compounds d. Kreb s Cycle - completes glucose metabolism - breakdown of glucose molecules into CO2, H2o and energy

Diagnostic Tests for Pancreatic Function

Fasting Blood Sugar: measures serum glucose levels: client fasts from midnight before the test Two-Hour Postprandial Blood sugar: measurement of blood glucose 2 hours after a meal is ingested Fast midnight before the test Client etas a meal consisting of at least 75 g carbohydrates or ingests 100 g of glucose Blood drawn 2 hours after the meal.

 Oral Glucose Tolerance Test: most specific and sensitive test for diabetes mellitus Fast from midnight before the test Fasting blood sugar and urine glucose specimens obtained Client ingests 100 g of glucose; blood sugars are drawn at 30 to 60 minutes and then hourly for 3-5 hours; urine specimen may also be collected Diet for 3 days before the test should include 200 g of carbohydrate and at least 1500 kcal/day During test, assess the client for reactions such as dizziness, sweating and weakness

 Glycosylated Hemoglobin (Hemoglobin A1c ) reflects the average blood sugar level for the previous 100-200 days. Glucose attaches to a minor hemoglobin (A1c ). This attachment is irreversible. Fasting is not necessary. Excellent method to evaluate long term control of blood sugar

DIABETES MELLITUS
Is a complex multisystem disease characterized by the absence of or a severe decrease in the secretion or utilization of insulin A CHRONIC DISORDER OF IMPAIRED GLUCOSE INTOLERANCE AND CARBOHYDRATE, PROTEIN & LIPID METABOLISM; CAUSED BY A DEFIECIENCY OF INSULIN

Pathophysiology:
The primary function of insulin is to decrease the blood glucose level Necessary for the transport of glucose into the ells of the liver, muscles, and other tissues. Insulin is secreted by the beta cells in the islets of langerhans in the pancreas. Insulin allows the body to use carbohydrates more effectively for the conversion of glucose for energy. If carbohydrates are not available to be utilized for energy, cells will begin to oxidize the fats and protein stores. Breakdown of fat results in the production of ketone bodies. Protein is broken down and converted to glucose by the liver. When circulating glucose cannot be utilized for energy, the level of serum glucose will increase.

Classification:
Type 1: Insulin-Dependent DM (IDDM) Absence of insulin. Childhood onset, before the age of 18, from 10 to 15 y/o. Juvenile diabetes. Lifelong disease.

 Type 2: Noninsulin-Dependent DM (NIDDM) Insulin deficiency caused by defects in insulin production or by severe or by excessive demands for insulin. Adult onset, generally after the age of 40 years. AODM Associated with obesity or overweight.

Gestational DM Develops during pregnancy, second trimester. Returns to normal after delivery. Risk for having type 2 DM. Infant may be large for gestational age.

Clinical manifestations:
Types 1 and 2 3P s: polyphagia, polydipsia, polyuria Fatigue Increased frequency of infection.
Type 1 Weight loss Excessive thirst Bet wetting Onset is rapid Complains of abdominal pain . Type 2 Weight gain Visual disturbance Onset is slow Onset occurs after the age of 40, peaks around 45 to 50 y/o

Diagnostics:
FBS level is above 126 mg/dl GTT: 2 hour glucose values are greater than 200 mg/dl RBS level is greater than 200 mg/dl with symptoms (3 P s, weight loss Glycosylated hemoglobin is above 7%

Nursing and Medical Management:

Exercise Planned exercise; sporadic exercise is discouraged. Reduces insulin needs by reducing the glucose level in the blood. Contributes to weight loss or maintenance of normal weight. Assist the body to metabolize cholesterol more efficiently. Promotes less extreme fluctuations in blood glucose level. Decreased BP.

Nursing and Medical Management:

Diabetic diet Decrease calories for weight loss. Avoid simple sugars. Decrease in cholesterol level. Small frequent meal, regularly scheduled mealtime. High fiber diet

Nursing and Medical Management:

Insulin Administer at the same time each day Administer insulin 30 minutes before a meal. Maintain adequate fluid intake. Route- SC, ideally the abdomen Do not massage the site of injection. Administer insulin at room temperature. Rotate the site of injection. Store vial of insulin in current use at room temperature Roll vial in between palms. Draw up the regular (clear) insulin before the longer-acting (cloudy) insulin. Using alcohol to cleanse the skin before injection is not recommended

Insulin requirement increases when: Client is seriously ill In infection develops. Surgery is performed.

OHA Stimulate islets of langerhans to secrete insulin Example: diabenese, metformin Observe for GI upset.

*Prevent moisture from accumulating between toes *Wear loose socks & well-fitting (not tight) shoes & instruct client not to go barefoot *Change into clean cotton socks daily *Wear socks to keep feet warm *Do not wear the same shoes 2 days in a row *Do not wear open toed shoes or shoes with strap that goes between toes *Check shoes for tears or cracks in lining & for foreign objects before putting them on *Break in new shoes gradually *Cut toenails straight across & smooth nails with an emery board *Do not smoke

*Meticulous skin care & proper foot care *Inspect feet daily & monitor feet for redness, swelling or break in skin integrity *Avoid thermal injuries from hot water, heating pads & baths *Wash feet with warm (not hot) water & dry thoroughly (avoid foot soaks) *Do not soak feet *Do not treat corns, blisters or ingrown nails *Do not cross legs or wear tight garments that may constrict blood flow *Apply moisturizing lotion to feet but not between toes

Diabetic Ketoacidosis
An extreme increase in the hyperglycemic state Metabolism of fats results in the production of fatty acids Occurs predominantly in type 1 DM. May result from: Injury Stress Infection Surgery Lack of effective insulin therapy

Clinical manifestations:
Blood glucose levels of 300-800 mg/dl Metabolic acidosis hyperK, hypoK or normal K level, depending on amount of water loss. Urine ketones and glucosuria Excessive weakness and thirst N/V Fruity acetone breath Kussmaul respirations Decreased LOC Dehydration Increased temperature

Nursing and medical management:

Patent AW O2 therapy Establish IV line Rapid infusion of NSS Regular insulin IV drip Frequent monitoring of V/S Frequent glucose check May use cardiac monitior Monitor K level Hyperkalemia may occur initially in response to the acidosis. Hypokalemia occurs about 4 to 6 hours after treatment Evaluate acid base balance

Hyperosmolar Hyperglycemia Nonketotic Syndrome (HHNS)

General Information Occurs in adult with type 2 DM No acidosis Extreme hyperglycemia from 700 to 1200mg/dl Osmotic dieresis The patient is dehydrated.

Clinical manifestations:
Warm flushed skin Lethargy Decreased level of consciousness Weakness and thirst Increased temperature Tachycardia Decrease in BP No acetone odor in the breath Severe hyperglycemia Serum pH is normal Polyuria Glycosuria

Nursing and medical management:

Establish IV access. NSS Lose dose insulin IV

Hypoglycemia
Decreased serum glucose level. Decreased cerebral functioning. Risk factors: Too little food. Increase in exercise without food intake. Increase in insulin intake.

Clinical manifestations:
Confusion H/A, lightheadedness, seizures, coma Impaired vision Tachycardia, hypotension Nervousness, tremors Diaphoresis

Diagnostics:
serum glucose level is below 50 mg./dl negative urine acetone normal pH

Nursing and medical management:

If conscious: Give carbs by mouth Milk in children Orange juice Honey Candy Glucose tablets If unconscious: Glucagon IV

*3 or 4 commercially prepared glucose tablets

CHILD: 2-3 GLUCOSE TABS

*4-6 ounces of fruit juice or regular soda

CHILD: CUP OR 120 ML OF ORANGE JUICE OR SUGAR-SWEETENED JUICE

*6-10 Life Savers or hard candy

CHILD: 3-4 HARD CANDIES OR 1 CANDY BAR

*2-3 teaspoons of sugar or honey

CHILD: 1 SMALL BOX OF RAISINS

OTHER COMPLICATIONS OF DM Angiopathy PVD HPN Diabetic gastroparesis CVD CAD Ocular complications Nephropathy Neuropathy Infection