2_Diabetes Mellitus Type II

2_Diabetes Mellitus Type II

1. Pathophysiology

   • 1. Insulin Resistance
     • Insulin receptors are unresponsive and limited in number
   • 2. Decreased insulin production by the pancreas
     • Insufficient insulin secreted into the blood stream
     • Islet dysfunction
       • Beta cell: produces less insulin
       • Alpa cell: produces excess glucagon
   • 3. Altered production of adipokines
     • Lower adiponectin
     • Increase leptin
   • 4. Over production of glucose by the liver
     • Increased glucose in the blood stream
       • Muscle unable to use glucose due to insulin resistance

2. Risk Factors

   • Pre-diabetes
     • Impaired glucose tolerance (IGT)
       • 2h OGTT: 7.8-11.1 mmol/L (ADA, 2004)
     • Impaired fasting glucose (IFG)
       • FPG 5.6-6.9 mmol/L (ADA, 2004)
   • Genetics
   • Obesity
   • Aging
   • Metabolic Syndrome (Grundy et al., 2004)
     • Dyslipidemia
     • Abdominal obesity

3. Diagnosis

   • Methods (use 1 of 4)
     • Hemoglobin A1C > 6.5%
       • Must be confirmed on a subsequent day
     • FPG > 7 mmol/L
     • Random plasma glucose > 11.1 mmol/L plus classic symptoms
     • 2h OGTT > 11.1 mmol/L with glucose load 75g
   • symptoms
     • weight loss
     • vision changes
     • recurrent infection
     • prolonged wound healing
     • fatigue
     • polyuria, polydipsia, polyphagia

4. CLINICAL MANIFESTATIONS

5. MANAGEMENT

   • PHARMACOLOGICAL
     • Insulin
       • Preparations
         • rapid-acting: peak 1.5-2.5h
         • short-acting (regular): peak 2-4h
         • Intermediate (NPH - cloudy): peak 6-8h
         • Long-acting: no peak
       • Admin
         • self-admin
         • subcutaneous
           • abdomen, buttocks, thigh, deltoid
             • rotate injection sites
         • intravenous
     • Oral Anti-hyperglycemic Agents
       • α-glucosidase inhibitors
         • mech: slow carb digestion
       • DPP-4 inhibitors
         • mech: slow incretin hormone inactivation
       • Biguinides (i.e. metformin)
         • FIRST-LINE OHA TREATMENT! (Nathan et al., 2009; Inzucchi et al., 2012)
       • Thiazolidinediones
         • mech: decrease insulin resistance
       • sulphonylureas
       • metglitinides
         • mech: increase insulin production by β cells
   • STRESS MANAGEMENT (Surwit et al., 2002)
     • Muscle Relaxation
     • Cognitive Behavioural
       • Recognizing stressors
       • Guided imagery
   • EXERCISE
     • 150 min/week moderate intensity
     • Mechs
       • ↓ blood glucose
       • ↑ insulin sensitivity
       • weight loss
   • NUTRITION
     • Diet Teaching
       • Personalized diet planning (Inzucchi et al., 2012)
       • Fat <7% of daily intake
       • Carbs < 10% of daily intake from sucrose
       • Protein: 15-20% of daily intake

6. Nursing Considerations

   • Nursing Process
     • 1. Assessment
       • Learning needs, motivation and the ability to learn
       • Physical history
         • BMI, height, weight, vital signs
         • Current medication
         • Past surgical procedure
         • History of infection
       • Lifestyle
         • Stress
         • Exercise
     • 2. Plan
       • Determine goals and expected outcome with the patient
         • Setting priorities
         • Learning objectives
         • Selecting teaching methods
     • 3. Implementation
       • Home care
         • Importance of medication adherence
         • Travel
           • Adequate medication
           • Diabetic medical bracelet
       • Health promotion
         • Patient education
           • Diet
           • Define the disease
           • Purposeful factiities that can control the disease
           • Self monitoring blood glucose
           • Important resources
     • 4. Evaluation
       • Patient understanding
         • Up-to-date immunizations

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