Type 2 Diabetes Mellitus

PATHOGENESIS
1. Type 2 diabetes is a consequence of pathophysiologic changes that make diabetics vulnerable to subsequent disruption of normal glucose homeostasis.
  1. Insulin resistance is often the primary metabolic abnormality in Type II Diabetes
    1. Etiological Factors
      1. Increased Food Consumption
      2. Sedentary Lifestyle
      3. Genetics
        OBESITY
        Less glucose utilization in liver
        Fat and muscles do not utilize glucose as well
        Decreased sensitivity to insulin
        INSULIN RESISTANCE
        Increased insulin demand and release
        HYPERGLYCEMIA
        Due to the lack of glucose absorption by cells, the liver releases glucose into the bloodstream in attempt to supply organs that need glucose (cell starvation).
        Excess glucose is not absorbed by cells of organs even when there is resistance; receptors do not work properly. Thus, increasing blood sugar in the blood stream
        ABNORMAL
        <-- Glucose is unable to enter cells despite the presence of insulin
        CELL STARVATION
        Increased Gluconeogenesis
        Increased Glycogenolysis
        a or death if left untreated.
        KIDNEYS
        HEART
        EYES
        BRAIN
        Increased build-up of plaque in arteries keep blood from flowing to the brain
        STROKE
        High blood pressure is a leading risk factor for stroke
        Brief loss of consciousness
        Dizziness
        Sudden, inability to move part of the body
        HEADACHE
        HEADACHES
        COMA
        If cells are unable to get energy from glucose, the body will try to convert fats and proteins into sugar. The liver forms ketone bodies for energy, but in high enough levels, ketoacidosis will occur. This can lead to coma or death if left untreated.
        High blood glucose and high blood pressure damages blood vessels in eyes
        RETINOPATHY
        Blurred Vision
        Studies report a positive correlation between hypertension and insulin resistance
        HYPERTENSION
        Chest Pain
        Myocardial infarction
        PANCREAS
        Abnormalities in insulin secretion
        Increased Urination
        Loss of Electrolytes
        Frequent Urination
        Hyponatremia (Low Na+)
        Hypokalemia (Low K+)
        Hypochloremia (Low Cl-)
        KIDNEYS
        DEHYDRATION
        Hyperosmolarity
        Cell Shrinkage
        Slow Blood Flow
        Brittle Nails
        BRAIN
        EYES
        HEART
        ANGINA
        KIDNEYS
        BLOOD VESSELS
        FEET
        Blue-tinged skin
        EXTREMITIES
        Burn
        EXTREMITIES
        Stabbing pain
        Burning pain
        NERVE DAMAGE
        Problems with positional awareness
        Fainting
        Weakness
        Excessive sweating
        Trouble digesting food
        Stomach spasm
        Constipation
        Pain on arms, shoulder, back and chest
        Excessive Sweating
        Shortness of breath
        Myocardial Infarction
        STOMACH
        Polyphagia
        Always hungry
        Increased food-intake (if uncontrolled)
        PARADOX: Increased food-intake does not equate to weight gain. In fact, diabetics will experience weight-loss due to the decreased usage of glucose.
        Nausea
        Vomitting
        SMOOTH MUSCLE DISORDERS
        Heartburn
        Acid reflux
        Stomach spasm
        Blurred Vision
        Blurred Vision
        Exhaustion
        Headaches
        Muscle weakness
        INSOMNIA
        Difficulty staying asleep
        Waking up too early
        Daytime tiredness
        Ongoing worries about sleep
        Stress
        Anxiety
        MENTAL
        Irritability
        Anger
        Easily upset
        One of the things the thalamus is responsible for is emotional self-control. .
        The thalamus' emotional control will not be regulated with insufficient insulin.
        Anxiety
        Lack of concentration
        Mood Swings
        Memory loss
        High glucose levels, over many years, can damage nerves, including those of the brain, which can increase the risk of memory loss.
        DEMENTIA
        Depression
        Dry Skin
        Thin Hair
        Poor skin turgour
        Hypovolemia (decreased blood volume)
        Ischemia (inadequate blood supply)
        Hypoxia (decreased Oxygen content)
        Anaerobic Metabolism
        Lactic Acid Build-Up
        MUSCLE SPASM
        Pain
        CELL NECROSIS
        Gangrene
        Impaired Tissue Integrity
        CYANOSIS
        Cold feet
        Numbness
        Deformed feet
        Blisters our wounds without pain
        FOOT ULCERS
        Swelling
        Discolouration
        Callused skin surrounding ulcer
        iNFECTIONS
        Fever
        Chills
        Shaking
        Shock
        LIVER
        BLOOD VESSELS
        FEET
        Nerve damage
        High blood glucose can damage nerves to pain, weakness and numbness in hands and feet
        Plaque build-up damages blood vessels
        Insulin resistance weakens blood vessels as well.
        Together, these can raise blood pressure to dangerous levels
        VS,
        NORMAL
        Insulin escorts and allows glucose into your cells, where it is needed for energy. Without insulin, glucose will remain floating in your bloodstream.
        HEART DISEASE
    2. Due to an increase in blood sugar, beta cells release insulin. But with prolonged release, beta cells become exhausted and eventually atrophy, which later decreases insulin production
SIGNS AND SYMPTOMS
1. There are many signs and symptoms that indicate diabetes. However, symptoms for Type 2 Diabetes are mild and unnoticeable until it's too late.
NURSING INTERVENTION
1. Nurses, along with the health care team, ensure that patients are educated about type 2 diabetes and all about anti-diabetic medication. Diabetics need to know how to have proper nutrition and have a physically active lifestyle. Additionally, monitoring blood glucose level is vital for each diabetic individual.
  1. NUTRITION
    1. REDUCTION IN CALORIES
      1. It is important to reduce foods that are high in fat and sugar. The following are examples...
        Carbonated drinks and sugary juices
        Highly processed carbohydrates and foods
        Foods with trans fat and high-fat animal
        Artificial sweeteners and high fructose corn syrup
    2. BALANCE OF NUTRITION
      1. Energy input should not be more than energy output
        Try to make.... Energy Input = Energy Output
      2. Carbohydrates
        Fats
        Proteins
        Protein helps keep blood glucose levels stable, promotes satiety, and beats cravings
        Eggs and Soy foods
        Lean meats (ex. chicken, or turkey breast)
        Legumes and beans
        Fish (ex. salmon, cod)
        Plant based protein (ex. chia seeds, lentils)
        Try to incorporate plant-based fats in your diet as it helps lowers risk for heart disease
        Avocado
        Nuts and Seeds (ex. almonds, walnuts, sunflower seeds)
        Healthy oils (ex. olive oil, flaxseed oil, sesame oil)
        Reduce the amount of fats from animal meat
        Have foods that have a low glycemic load and high fibre content, such as complex carbohydrates.
        Whole wheat
        Vegetables
        Fruits
        Quinoa
        Avoid simple carbohydrates because they raise blood glucose levels
        White bread, potatoes, & pasta
        Sweets: cookies, pastries, cake
  2. BLOOD GLUCOSE MONITORING
    1. Check blood glucose levels before and after meals and when you are doing physical activity
    2. Self-Monitoring of Blood Glucose (SMBG)
      1. Self-monitoring can give patients the confidence and freedom to live their life without being too worried about their diagnosis
      2. Diabetics can make their own decisions about what to eat and how to maintain a healthy active lifestyle
      3. Requires training from a health care professional
    3. Glucometer to Check Blood Glucose Levels
      1. Use a lancet to obtain blood sample from the side of a fingertip and add it on channel of the glucose meter strip
        Make sure enough blood is inputted and wait for results
        Target level of blood glucose BEFORE meals = 4 -7 mmol/L
        Target level of blood glucose AFTER meals = under 8.5 mmol/L
  3. PHYSICAL ACTIVITY
    1. Exercise has numerous benefits for diabetic patients
      1. Physical activity decreases blood glucose levels thus reducing hyperglycemia
      2. It can increase insulin receptor sites so that cells can store more glucose
      3. Weight loss
    2. Aim to have at last 150 minutes of moderate to vigorous physical activity a week
      1. Moderate to vigorous activity includes an increase in heart rate and respiratory rate, and involves perspiration
        Brisk walking
        Biking
        Dancing
        Sports: Badminton, tennis
        Swimming
    3. To prevent hypoglycemia from occurring during exercise, have a snack every 20-30 minutes. Examples of snacks: fruit, granola bars, yogurt.
    4. Monitor blood glucose levels before, during, and after physical activity
  4. ANTI-DIABETIC MEDICATION
    1. INSULIN
      1. Administration Sites
        Abdomen (most preferable site)
        Arm
        Thigh
        Buttocks
        It is important to rotate injection sites for a particular area
        Insulin should not be given orally
        Injections are to be given subcutaneously
        Pinch 2 inches of skin and inject straight at 90 degrees OR grasp 1 inch of skin and inject at a 45 degree angle
        Contact a health care provider if you have any questions about administering injections
      2. Types of Insulin
        Rapid Acting
        Onset: 15 minutes
        Peak: 30 - 60 minutes
        Duration: < 5 hours
        Administer: 0 - 15 minutes before meal
        Example: lispro
        Short Acting
        Onset: 60 minutes
        Peak: 2 - 3 hours
        Duration: 5 - 7 hours
        Administer: 30 - 45 minutes before meal
        Example: regular insulin
        Intermediate Acting
        Onset: 1 - 4 hours
        Peak: 8 - 12 hours
        Duration: 18 - 24 hours
        Administer: 30 - 60 minutes before meal
        Example: Isophane insulin suspension (NPH)
        Long Acting
        Onset: 4 - 8 hours
        Peak: 12 - 24 hours
        Duration: 36 hours
        Administer: once a day; morning or before bedtime
        Example: Extended insulin zinc suspension
      3. Side Effects of Insulin
        Dawn Phenomenon
        Hyperglycemia occurs when patient wakes up. Growth factor hormones are released, therefore increasing blood sugar levels.
        Somogyi Phenomenon
        Occurs when a patient takes too much insulin before bed, thus causing hypoglycemia when asleep. But then, later in the morning as glucocorticoid concentrations from circadian rhythms are released, it causes hyperglycemia.
        Lipodystrophy
        abnormal distribution of fat in the body
        Allergic reaction
        Hypoglycemia
      4. Monitor blood sugar levels
    2. BiGUANIDE
      1. Reduces gluconeogenesis by the liver
        Slows gastrointestinal absorption of glucose
        Increases insulin receptor sensitivity
        Example: metformin
      2. Side Effects: gastrointestinal problems
        Contraindications: renal dysfunction, unstable or acute congestive heart failure, liver disease, surgery, iodinated dyes
    3. SULFONYLUREAS
      1. Acts as a secretagogue to promote insulin production
        Example: Glipizide
      2. Side Effects: hypoglycemia, weight gain, hyperinsulinemia
        Contraindications: renal insufficiency, hepatic insufficiency
    4. MEGLITINIDES
      1. Stimulates insulin to be released from pancreatic beta cells
        Requires frequent administration, and good for patients with an irregular lifestyle.
        Example: Prandin
      2. Side Effects: hypoglycemia
        Contraindications: diabetic ketoacidosis
    5. THIAZOLIDINEDIONES
      1. Improves insulin sensitivity and reduce glucose production
      2. Side Effects: fluid retention, heart failure, anaemia, weight gain, bladder cancer, bone fractures in women
        Contraindications: history of heart failure, hepatic disease
      3. Example: Troglitazone
    6. ALPHA GLUCOSIDASE INHIBITORS
      1. Prevents digestion rate of carbohydrates to reduce absorption of glucose in blood.
        Example: acarbose
      2. Side Effects: hypoglycemia, gastrointestinal problems
      3. Contraindication: chronic intestinal disease
DIAGNOSIS
1. Diagnostic Tests
  1. Glycated haemoglobin (HbA1c)
    1. A blood test that measures the amount of glucose bound to red blood cells. The higher the amount of glucose, the higher the HbA1c reading.
      1. Takes the average number based of 2 or more blood tests within the last 3 months.
        Diabetes = HbA1c result higher than 48 mmol/mol
  2. Fasting blood sugar test
    1. A blood test taken after an overnight fast.
      1. Diabetes = result of 7.0 mmol/L
        Prediabetes = result between 5.6 - 6.9 mmol/L
  3. Random Sugar Test
    1. A random blood sugar test taken regardless if an individual has eaten recently
      1. Diabetes = a result higher than 11.1 mmol/L or higher
  4. Oral Glucose Tolerance Test
    1. A blood test is taken after an overnight fast
      1. A sugary drink is given to drink afterwards, and then blood sugar levels are tested periodically for two hours.
        Diabetes = a result higher than 11.1 mmol/L after two hours
  5. Prevention
    1. Maintain weight by exercising and eating healthy
    2. Reduce alcohol intake, and stop smoking
    3. Visit your doctor regularly to prevent risk for cardiovascular disease and risk for diabetes
    4. Risk Factors
      1. Family History
        An individual is has a higher chance getting type 2 diabetes if their parent or sibling has the disease
      2. Sedentary Lifestyle
        Aim to be physically active so that your weight is controlled and glucose is used as energy instead of being stored as becoming fat deposits
      3. Age
        An aging individual is at a higher risk for developing type 2 diabetes due to weight gain and less physically active
      4. Poor personal health
        High blood pressure
        High levels of low density lipoprotein
      5. Ethnic background
        Several races are more susceptible to having type 2 diabetes (ex. African Americans, Pacific Islanders, Asian Americans)
2. With the increasing in incidence of type 2 diabetes, testing for diabetes is very important. Individuals that are over the age of 45, and persons with a body mass index of 25 or higher should be tested for diabetes to rule out this disease.
3. Coping with Diabetes
  1. Have a strong social support network with family and friends or those that also have the same diagnosis
  2. Seek support for your doctor and support for your mental health. You should never go through this alone
  3. Practice mindfulness and relaxation. Attend meditation or yoga classes.
  4. Exercise regularly so that you body releases endorphins which makes you happier, and reduces stresses and worries

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Type 2 Diabetes Mellitus

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	Created by Marizzy Aliabilon about 6 years ago