Nursing Care of Patients with Diabetes

 

DIABETES MELLITUS

Definition:

Diabetes is a group of metabolic diseases characterized by increased levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both.

Types and Causes

1.      Type 1 Diabetes Mellitus

Type 1 diabetes (formerly called juvenile diabetes mellitus, insulin-dependent diabetes mellitus, or IDDM) is caused by destruction of the beta cells in the islets of Langerhans of the pancreas. When the beta cells are destroyed, they are unable to produce insulin.

2.      Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (formerly called adult-onset diabetes mellitus, non–insulin-dependent diabetes mellitus, or NIDDM). In type 2 diabetes mellitus, tissues are resistant to insulin.

3.      Gestational Diabetes

Gestational diabetes mellitus (GDM) occurs in pregnancies, especially in women with risk factors for type 2 diabetes. The extra metabolic demands of pregnancy trigger the onset of diabetes.

4.      Prediabetes

Prediabetes usually occurs before the onset of type 2 diabetes. Those with prediabetes may be able to prevent the onset of diabetes with weight loss and exercise.

5.      Other Types of Diabetes

·       Secondary diabetes can develop as a result of another chronic illness that damages the islet cells, such as pancreatitis or cystic fibrosis.

·       Prolonged use of some drugs, such as steroid hormones, phenytoin, thiazide diuretics, and thyroid hormone, can also impair insulin action and raise blood glucose.

·       Less common causes include pancreatic trauma and other endocrine disorders.

Risk factors:

·       Physical inactive

·   First degree relative with diabetes

·       Hypertension ≥ 140/90 mm Hg.

·       HDL cholesterol < 35 mg/dL and/or triglyceride level >250 mg/dL.

·       Diagnosis of prediabetes

·       Prior history of GDM

·       History of cardiovascular disease

·       History of insulin resistance

Signs and Symptoms:

·       Polydipsia (excessive thirst),

·       Polyuria (excessive urination), and

·       Polyphagia (excessive hunger).

·       Fatigue and weakness,

·       Sudden vision changes,

·       Tingling or numbness in hands or feet,

·       Dry skin, skin lesions

·       Delayed wound healing and

·       Recurrent infections.

Pathophysiology:

                      Diet high in Carbohydrates
                          + Sedantary life Style
                                      + Genetic

                                             ⬇️

              Insulin levels increase in blood stream

                                             ⬇️ 

                      Cell becomes resistant to insulin

                                             ⬇️

                      Blood glucose levels becomes high

                                             ⬇️

                                   Type 2 Diabetes

Diagnostic Criteria:

1.      Fasting Plasma Glucose Level

When the fasting plasma glucose is 126 mg/dL or greater, diabetes is diagnosed.

If the fasting plasma glucose is between 100 and 125 mg/dL, the patient has prediabetes.

2.      Random Plasma Glucose

Diabetes is diagnosed if the Random Plasma Glucose is 200 mg/dL or greater, with symptoms of diabetes.

3.      Oral Glucose Tolerance Test

An OGTT measures blood glucose at intervals after the patient drinks a concentrated carbohydrate drink. Diabetes is diagnosed when the blood glucose level is 200 mg/dL or greater after 2 hours. A result between 140 and 199 mg/dL at 2 hours leads to a diagnosis of impaired glucose tolerance and prediabetes.

4.      Glycohemoglobin

The glycohemoglobin test (also called glycosylated haemoglobin, or HbA1c [haemoglobin A1C]). It reflects the average blood glucose level for the previous 2 to 3 months.

A normal HbA1c is 4% to 6%.

An HbA1c of 6.5% or higher is diagnostic for diabetes.

An HbA1c between 6% and 6.5% indicates prediabetes.

Complications of Diabetes Mellitus.

Complications associated with diabetes are classified as acute and chronic.

1.      Acute complications are:

·       Hypoglycemia

·       Hyperglycemia and Diabetes Keto Acidosis (DKA)

·       Hyperglycemic Hyperosmolar Non-ketotic Syndrome (HHNS)

2.      Chronic complications are:

v  Macrovascular (large vessel) disease:

·       Coronary vascular disease

·       Cerebrovascular disease

·       Hypertension

·       Peripheral vascular disease

v  Microvascular (small vessel) disease:

·       Diabetic Retinopathy

·       Diabetic Nephropathy

·       Neuropathy

·       Diabetic foot ulcer

Management:

Medical management for clients diabetes includes restoring and maintain blood glucose levels as near as possible by

1.      Balanced diet,

2.      Exercise,

3.      Use of oral hypoglycemic agents or insulin,

4.      Health education and

5.      Monitoring by follow-up and check ups.

1.      Balanced diet:

§  A balanced diet low in carbohydrate, low in fat and cholesterol is ideal for diabetes.

§  Advice the patient to avoid junk foods.

§  Instruct to increasing intake of low glycemic food.

§  Advice to eat lot of fibre rich diet and drink adequate amount of water

§  Advice to eat small frequent meals than three large meals.

§  Weight reduction is a primary treatment of type 2 diabetes.

2.      Exercise :

§  Exercise is important factors in controlling blood glucose and lipid level.

§  Regular scheduled, moderate exercise performed for at least 30 minutes per day.

§  An aerobic exercise, strengthening exercise, and stretching exercise can help the diabetic patients

3.      Oral hypoglycemic agents:

§  Alpha-glucosidase inhibitors (AGIs) Blocks the action of enzymes in digestive tract that break down the carbohydrates. Example: Acarbose

§  DPP-4 inhibitor Inhibits DPP-4, an enzyme that breaks incretins. Example: Sitagliptin

§   Biguanides Decreases glucose production by liver; increases glucose uptake by muscle. Example: Metformin

§ Thiazolidinediones Reduce insulin resistance in muscles. Example: Pioglitazone, Rosiglitazone

§  Sulfonylureas Stimulate insulin secretion by pancreas, increase insulin receptor sensitivity. Example : glipizide, glimepiride, glyburide

4.      Insulin:

§  Insulins are available in rapid-acting, short-acting, intermediate-acting, and long-acting preparations.

§  Insulin is administered by sterile, single-use needles and either disposable insulin syringes or a multiple dose insulin pen.

§   Insulin injections should be given in a different subcutaneous site with each dose to avoid tissue injury.

§  Aspirating for blood before injection and rubbing the site after injection are not recommended with insulin injections.

Nursing Diagnoses:

·       Imbalanced Nutrition: less than body requirements  

         related to insulin deficiency

·       Fear related to medication injection.

·       Risk for unstable blood glucose level related to effect of insulin                     

·       Activity Intolerance related to poor glucose control.

·       Deficient Knowledge related to use of oral hypoglycemic agents and injectable agents.

·       Risk for Impaired Skin Integrity related to decreased sensation and circulation to lower extremities.

·       Ineffective Coping related to chronic disease and complex selfcare regimen.