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Diabetes Mellitus Type 2

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Diabetic Pre-screen
- Risk for DIabetes? Let's find out!
  - Have the following risk factors?
    - High LDL
    - Diet of high Glycemic Index foods
    - Family history
    - Over 45 years old
    - Lack of physical activity
    - Sleep disorders
    - Obesity (abdominal/visceral)
    - Genetic mutations
      - ↑ obesity risk
      - Lead to insulin resistance
    - Hypertension
  - Pre-Diabetes Lab Values?
    - Impaired fasting glucose 6.1-6.9 mmol/L
    - 2 hour plasma glucose levels between 7.1-11 mmol/L
    - Hemoglobin A1C level of 5.7%-6.4%
  - Symptoms?
    - Usually none!
    - Sometimes polyphagia, polydipsia, and polyuria!
Treatment
- DIET
  - Balance of Diet Required!
    - Carbohydrates <10% of daily Intake
      - Check GI after eating!
    - Proteins 15-20% of daily intake
    - Combined Trans and Saturated Fat <7%
      - Have plant oils and polyunsaturated omega-3 fatty acids
    - Alcohol is detrimental!
      - High caloric value
      - Can impair liver functioning (i.e. liver cirrhosis)
      - Promotes hypertriglyceridemia and hypoglycemia
  - Diet teaching by Diabetic Nurse Educators and Dieticians
    - Count carbohydrates to reduce calorie intake
    - Use Canada's Food Guide as a guideline
    - Plate Method
      - Use 9 inch plate to portion protein, vegatables, and carbohydrates
- EXERCISE
  - Many Benefits
    - Lowers blood glucose
    - Increases insulin receptor sites
    - Weight loss
  - Start after speaking to a health care professional
    - Start small and increase activity slowly
      - Have a carbohydrate snack every 30 minutes while exercising
        Before - During - After BLOOD GLUCOSE CHECK!
  - If cannot do high intensity exercise...
    - Studies show walking and/or simple resistance exercises are beneficial
      - Decreases
        Diabetic complications
        Cardiovascular complications
      - Found similar glucose reduction in walking intermittently vs continuous 30 min vigorous walking
- DRUG THERAPY
  - Oral Hypoglycemic Agents
    - Helps with:
      - Decreased insulin production
        Insulin resistance
        Increased hepatic glucose production
    - 5 types:
      - Sulphonylureas
        Meglitinides
        Increases insulin production in pancreas AND only take if going to have a meal (take 30 minutes prior) i.e. Repaglinide (GlucoNorm)
        Improves tissue insulin sensitivity and cellular glucose transport and decreases liver glucose production and no weight gain i.e. Metformin (Glucophage)
        Decreases absorption of carbohydrates in small intestine i.e. Acarbose (Glucobay)
        Enhances target tissue insulin transport, sensitivity and utilization i.e. Pioglitazone (Actos)
        Biguanides
        a-Glucosidase Inhibitors
        Thiazolidinediones
        Increases insulin production in pancreas i.e. Gliclazide (i.e. Diamicron, Diamicron MR)
  - Insulin
    - First try oral hypoglycemic agents!, diet and exercise changes! If unsuccessful, then insulin!
      - Insulin Storage is Important!
        DO NOT HEAT OR FREEZE!
        If vial is opened, can leave it in room temperature for 4 weeks
        If unopened, refridgerate!
        Ensure no direct sunlight
      - Administration
        Sub-cutaneous, SC, injection (especially for self-administration) OR intra-venous!
        Sites for injection:
        1. Abdomen (preferred!)
        2. Arm
        3. Thigh
        4. Buttocks
        Don't forget to rotate within the site when injecting!
        DO NOT inject the site that will be exercised!
      - Types
        Rapid Acting
        Short Acting
        Intermediate Acting
        Long Acting
        Extended Zinc Insulin Suspension, SC/IM, cloudy
        Onset: 4-8 hours
        Peak: 14-24 hours
        Duration: 36 hours
        Isophane Insulin Suspension, NPH, SC/IM, cloudy
        Onset: 1-4 hours
        Peak: 8-12 hours
        Duration: 18-24 hours
        Regular, SC, Clear
        Onset: 60 minutes
        Peak: 2-3 hours
        Duration: 5-7 hours
        Insulin Lispro, SC
        Onset: 1 hour
        Peak: 30-60 minutes
        Duration: <5 hours
        Insulin Pump
        A device that has an ongoing subcutaneous plastic tube and catheter inserted into the abdomen. Can strictly control glucose BUT can cause DKA and skin infections!
      - Any issues with insulin?
        Allergies, lipodystrophy, hypoglycemia AND
        Somoygi Effect
        Occurs when take too much insulin before bed. In early hours of night, hypoglycemia due to hormones released from circardian rhythm. Hyperglycemia and ketosis can also happen.
        Dawn Phenomenon
        Hyperglycemia occurs when wake in morning due to counterregulatory hormones from circadian rhythm. Can also be caused by cortisol factors and growth factors.
- SELF MONITOR BLOOD GLUCOSE
  - Must teach client how to do this effectively
    - Especially safe glucose ranges and how to use blood glucose meter
  - Helps client analylze exercise, diet, and medication needs
  - Able to detect hyper/hypoglycemia
  - Continuous glucose monitoring
    - Displays immediate blood glucose every 1-5 minutes
Complications
- Chronic
  - Macrovascular Angiopathy
    - Disease of large blood vessels including the aorta and cornary arteries
      - Due to changes in lipid metabolism
        Can lead to atheroscelorosis, coronary artery disease, and stroke
        So...strictly monitor
        Blood pressure
        Blood glucose
        Be physically active!
        Stop smoking
  - Microvascular Angiopathy
    - Disease of small blood vessels: capillary and arteriole membranes thicken
      - Leads to
        Diabetic Retinopathy
        Retinal tissue is damaged
        If treat early, vision unaffected
        Treatment
        Laser photocoagulation
        Laser therapy that removes ischemia in retina
        Stops vision loss
        Common therapy
        Vitrectomy
        Removes vitrous gel in eye
        Does not always stop vision loss
        Diabetic Nephropathy
        Small blood vessels linked to glomeruli are damaged
        Prevention is key to delay progression
        Strictly monitor blood glucose
        Strictly monitor blood pressure
        Angiotensin-converting enzyme/ACE inhibitors (i.e. Enalaprin)
        Angiotensin II receptor antagonists (i.e. Azilsartan)
        Annual Screening
        Serum creatine (blood)
        Microalbuminuria (urine)
  - Diabetic Neuropathy
    - Nerve damage in autonomic nervous system
      - Affects multiple body/organ systems
    - Several complications
      - Gastroparesis
      - Sexual dysfunction
      - UTIs and urinary incontinence
      - Cardiovascular issues
    - No cure
  - Lower Extremity Complications
    - Loss of sensation in feet
      - Unaware when an injury has occurred
        Foot ulcer
        Prevention
        Proper footwear
        Carefully avoid injuries
        Inspect feet daily + skin and nail care
        Gangrene
        Treatment
        Amputation (in severe cases)
        Antibiotics
        Hyperbaric oxygen therapy
    - Peripheral vascular disease
      - Decreased blood flow to lower extremities
        Wounds take longer to heal
    - Hyperglycaemia
      - Damages blood vessels
  - Integumentary Complications
    - Bacterial Infections
      - Nail and hair follicle infections, boils, styes
    - Fungal infections
      - Most are caused by Candida albicans
      - Athletes foot, vaginal infections, ringworm
    - Caused by changes in blood vessels supplying skin
    - Caused by uncontrolled blood sugar levels
    - Diabetic blisters
    - Diabetic dermopathy
    - Prevention
      - Good skin care!
        Keep skin clean & dry
        Moisturize
        But not between toes!
        Creates environment for fungus growth
        Treat cuts immediately
  - Infection
    - Due to impaired inflammatory response
      - Bacteria and yeast thrive in a high-blood glucose environment
        High glucose in urine
        Bladder/kidney infection
      - Greater risk of developing
        Respiratory infection (e.g. TB, influenza)
        GI and liver infections (e.g. hepatitis B and C)
        Skin and soft tissue infections
    - Prevention
      - Immunization!
- Acute
  - Extremely high glucose blood levels and insufficient insulin levels--> polyuria --> dehydration --> coma --> death
    - Hyperosmolar Hyperglycemic Nonketotic Syndrome
    - Treatment: IV fluids, insulin, and potassium
  - Blood glucose <4 mmol/L. Client can become irritated, confused, hungry, anxious, have heart palpations, become tired.
    - Hypoglycemia
    - If alert: have 15-20g of simple carbohydrate and check blood glucose after 15 mins. Keep doing until blood sugar >4 mmol/L. Check blood sugar 45 minutes after.
      - If not alert and cannot swallow: need 1 mg of glucagon (IM/SC) . Client should have complex carbohydrate after.
  - Body unable to produce sufficient levels of insulin and blood ketone levels rise.
    - Diabetic Ketoacidosis
    - Treatment: Electrolyte and fluid replacement and insulin therapy
Diagnosis
- Diagnostic tests
  - Fasting plasma glucose test ≥ 7mmol/L
  - Random plasma glucose measurement ≥ 11mmol/L + classic symptoms
  - 2 hour OGTT ≥ 11.1mmol/L after taking a 75g glucose load
  - Hemoglobin A1C test ≥6.5%
    - Shows amount of glucose attached to Hg over RBC lifespan of 120 days
- 4 metabolic abnormalities
  - Insulin resistance
    - Insulin receptors are unresponsive or insufficient in numbers
      - Result → hyperglycemia
    - Metabolic Syndrome
      - Abdominal obesity
      - Hypertension
      - Dyslipidemia
      - Dysglycemia
      - Greater risk of developing T2D
  - ↓ ability of pancreas to produce insulin
    - β cells work harder to compensate
      - β cell mass lost
        Impaired fasting glucose + impaired glucose tolerance
  - Inappropriate glucose production by the liver
    - Release does not correspond to body's needs at the time
    - Increased glucagon secretion by α cells of pancreas
      - Stimulates glucose release from pancreas
  - Alterations in the production of hormones & adipokines
    - 2 main adipokines: adiponectin & leptin
      - Affect insulin sensitivity
    - Involved in glucose and fat metabolism
- B-panreatic cells can produce some endogenous insulin, but it is insufficient or poorly utilized by the cells
Assessment
- Objective
  - Rapid and deep breathing
  - Weak and rapid pulse
  - Dry mouth, fruity breath
  - Altered reflexes, confusion, restlessness
  - Muscle wasting
  - Diminished peripheral pulses
  - Soft sunken eyeballs, cataracts
  - Feet pale and cool to touch, foot ulcers, reduced sensation in feet
  - Dry, warm, inelastic skin
  - Pigmented lesions (on legs)
- Subjective
  - Signs and Symptom
    - Muscle weakness
    - Painful peripheral neuropathy in feet
    - Prolonged wound healing
    - Fatigue
    - Visual acuity changes
    - Recurrent infections
    - Polyuria (frequent urination)
    - Polyphagia (excessive hunger)
    - Polydispia (frequent thirst)
BY SONIA DHUGA & NAV DHAMRAIT
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  - References