Ch. 51 Diabetes

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Consequences of Diabetes
in the US diabetes is the leading cause of non traumatic amputation blindness in working age adults and end stage kidney disease
it is a leading cause at death from disease primarily because of the high rate of cardiovascular disease
hospitalization Wright for people with diabetes are higher than the general population
classifications
type 1 diabetes, type 2 diabetes, gestational diabetes, and diabetes associated with other conditions or syndromes
type 1 diabetes
5 to 10 percent of all diabetes
onset any age but usually under age 30
usually thin at diagnosis recent weight loss
often have antibodies to insulin even before insulin treatment
little or no insulin
need exogenous insulin to live
diabetic ketoacidosis
an acute complication of hyperglycemia
type 2 diabetes
90 to 95 percent
onset any age usually over mage 30
causes include obesity, heredity, environmental factors
most patient can control blood glucose through weight loss if obese
may need insulin on a short or long term basis to prevent hyperglycemia
hyperglycemic hyperosmolar syndrome
an acute complication of type 2 diabetes
ketosis uncommon except in stress or infection
gestational diabetes
onset during pregnancy usually in the second or third trimester
due to hormones secreted by the placenta which inhibit the action of insulin
occurs in about 2-5% of all pregnancies
treated with diet and if needed insulin to strictly maintain normal blood glucose levels
may recur in subsequent pregnancies 30 to 40 percent will develop diabetes usually type to within 10 years expecially if obese
risk factors include obesity over age 30 family history and previous large babies over nine pounds
screening tests should be performed on all pregnant women between 24 and 28 weeks of gestation should be screened for diabetes periodically
prediabetes
previous history of hyperglycemia such as during pregnancy or illness
current normal glucose metabolism
impaired glucose tolerance or impaired fasting glucose screening after age 40 years if there is a family history of diabetes or if symptomatic
encourage ideal body weight because loss of 10 to 15 pounds may improve glycemic control
clinical manifestations
polyuria
polydipsia
polyphagia
fatigue and weakness, sudden vision changes, tingling or numbness in hands or feet, dry skin, skin lesions or wounds that are slow to heal, and reaccurent infections
clinical manifestations type 1 diabetes
onset may be associated also with sudden weight loss or not see a vomiting or abdominal pain if DKA has developed
criteria for the diagnosis of diabetes
symptoms of diabetes plus casual plasma glucose concentration equal to or greater than 200 mg/dl
(casual is defined as any time of day without regard to time since last meal).
Or
fasting plasma glucose greater than or equal to 126 mg/dl. fasting is defined as no calorie intake for at least 8 hours
Or
to our post load gluclose equal to or greater than 200 mg/dl during an oral glucose tolerance test.
Gerontologic considerations
type 2 diabetes is the seventh leading cause of death in affects approximately 20% of older adults
there is a high prevalence among African Americans and those who are 65 to 74 years of age
glucose tolerance test is more effective in diagnosis than urine testing for glucose in older patients due to the higher renal threshold for glucose
medical management of diabetes
the main goal of diabetes treatment is to normalize insulin activity and blood glucose levels to reduce the development of vascular and nephropathic complications
intensive treatment
three or four insulin injections per day or continuous subq insulin infusion, insulin pump therapy plus frequent blood glucose monitoring and weekly contacts with diabetes educators.
must be initiated with caution and must be accompanied by through education of the patient and family in and by responsible behavior of the patients
assessing the patient with diabetes includes
history, physical examination, lab examination and need for referrals
history assessment
symptoms related to the diagnosis of diabetes, results of blood glucose monitoring, status symptoms and management of chronic complications of diabetes, adherence to and ability to follow prescribed dietary management plan, use of tobacco alcohol and prescribed OTC meds/drugs ,lifestyle cultural psycho social and economic factors that may affect diabetes treatment, effects of diabetes or its complications on functional status (i.e. mobility, function)
physical examination
BP, BMI, funduscopic exam and visual acuity, foot exam, skin exam, neurologic exam, oral exam
lab exam
Hgb, fasting lipid profile, test for microalbuminuria, serum creatinine level, urinalysis, electrocardiogram
need for referrals
Ophthalmologist, podiatrist, dietitian, diabetes educator, others if indicated
complications of diabetes include
retinopathy small blood vessels that nourish the retina in the eyes are damaged
nephropathy the kidney cells are damaged
neuropathy nerve cells are damaged
nutritional therapy
Nutrition, meal planning, weight control, and increase activity are the foundations of diabetes management.
the most important objectives in the dietary and nutritional management are control of total calorie intake to attain or maintain a reasonable body weight, control of blood glucose levels, and normalization of lipids and BP to prevent heart disease
nutritional management of diabetes includes the following goals
to achieve and maintain blood glucose levels in the normal range or as close to normal as safely possible, elected in lipid-protein profile that reduces the risk of vascular disease, BP levels in the normal range or as close to normal as safely possible;
to prevent or at least slow the rate of development of the chronic complications of diabetes by modifying nutrient intake and lifestyle;
to address individual nutrition needs taking into account personal and cultural preferences and willingness to change;
to maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence
calorie distribution
The caloric distribution currently recommended is higher in carbohydrates than in fats and proteins
50 to 60 percent of calories should be derived from carbs, 20 to 30 percent from fat, and the remaining 10 to 20 percent from protein
increase fiber in the diet may improve blood glucose levels decrease the need for insulin and lower total cholesterol and low density lipoprotein levels in the blood
exercise
extremely important in diabetes management because of its effects in lowering blood glucose and reducing cardiovascular risk factors
lowers blood glucose levels by increasing uptake of glucose by body muscles and by improving insulin utilization
exercise precautions
patients who have blood glucose levels exceeding 250 mg/dl
Aunt you have ketones in their urine should not begin exercising until the urine test results are negative for ketones and the blood glucose level is closer to normal
patients require insulin should be taught to eat a 15 gram carbohydrate snack before exercise to prevent unexpected hypoglycemiathe exact amount of food varies and should be determined by blood glucose monitoring
another potential concern for patients to take insulin is hypoglycemia that occurs many hours after exercise to avoid post-exercise hypoglycemia the patient may need to eat a snack at the end of exercise amd at bedtime and monitor the blood glucose level more frequently
patients taking insulin in participating in extended periods of exercise should test your blood glucose levels before during and after the exercise and they should snack on carbs as needed to maintain blood glucose levels
continuous glucose monitoring system
can be used to continuously monitor blood glucose levels. A sensor attached to an infusion set which is similar to an insulin pump infusion set is inserted in the abdomen subq and connected to the device worn on the patient's clothing or place in a pocket. after 72 hours the data from the device are downloaded and blood glucose readings are analyzed
testing for ketones
kittens are byproducts of that breaks down and they accumulate in the blood and urine. Ketones in the urine signal that there is a deficiency of insulin and control of type 1 diabetes is deteriorating. when there is almost no effective insulin available the body starts to break down stored fat for energy. most commonly the patient uses a urine dipstick to detect ketonuria.
urine ketone testing should be performed when patients with type 1 diabetes have glycosuria or persistently elevated blood glucose levels(more than 240 mg/dl) for 2 testing periods in a row
pharmacologic therapy
insulin is secreted by the beta cells of the islets of Langerhans and lower the blood glucose level after meals by facilitating the uptake and utilization of glucoseby muscle ,fat and liver cells.
rapid acting insulins
produced a more rapid effect that is of shorter duration than regular insulin
because of their rapid onset the patient should be instructed to eat no more than 5 to 15 minutes after injection
because of the short duration patients may also require a long acting insulin to maintain glucose control
used for rapid reduction of glucose level
short acting insulin / regular insulin
regular insulin is a clear solution and is usually administered 20 to 30 minutes before a meal either alone or in combination with a longer acting insulin it is the only insulin approved for IV use
intermediate acting insulins are called NPH insulin
usually taken after food
appear white and cloudy
is taken alone it is not crucial that it needs taken 30 minutes before the meal. however patients should eat some food around the time of the onset and peak of these insulins
insulin regimens
vary from one to four injections per day. Usually there is a combo as a short acting in a longer acting insulin
very long acting
used for basal dose
insulin waning
progressive rise in blood glucose from bedtime to morning
dawn phenomenon
relatively normal blood glucose until about 3 a.m. when the levels begin to rise
Somogyi effect
normal or elevated blood glucose at bedtime a decrease at 2 to 3 a.m. to hypoglycemic levels and a subsequent increase caused by the production of counter-regulatory hormones
the methods of insulin delivery
insulin pen, insulin pump, jet injectors