Diabetes Mellitus Type 2

Symptoms and Diagnosis
1. Symptoms and Presentation
  1. Acute
    1. Nausea
    2. Vomiting
    3. Abdominal Pain
    4. Dehydration
    5. Hyperosmolar Nonketotic State
    6. Infection
    7. Prolonged Wound Healing
  2. Subacute
    1. Fatigue
    2. Polydipsia
    3. Polyuria
    4. Weight Loss
    5. Polyphagia
  3. Asymptomatic
    1. Can eventually lead to presentation of symptoms
2. Diagnostic Tests
  1. Hemoglobin A1C Test
    1. Normal: <5.7% Pre-diabetes: 5.7%-6.4% Diabetes: >6.5%
  2. Fasting Plasma Glucose Level
    1. Normal: <100mg/dl Pre-diabetes: 100-125mg/dl Diabetes: >126mg/dl
  3. Random/Casual Plasma Glucose Measurement
    1. Normal: <115mg/dl Pre-diabetes: N/A Diabetes: >200mg/dl
  4. Two-hour OGTT Level
    1. Normal: <140mg/dl Pre-diabetes: 140-199mg/dl Diabetes: >200mg/dl
Treatment
1. Mild Presentation
  1. Lifestyle modifications
    1. Diet
      1. Carbohydrates (Less than 10% of calorie intake)
      2. Fats (Less than 7% of calorie intake)
      3. Proteins (Limited to 15% of calorie intake)
    2. Exercise
      1. 30 minutes a day, 5 days a week
        Increases insulin receptor sites, lowers blood sugar
2. Moderate to Severe Presentation
  1. Medication in conjunction with lifestyle modifications
    1. Drugs
      1. First-line Medication
        Biguanides
        Increases insulin sensitivity, therefore increasing glucose transport into tissues
        Decreases glucagon, therefore reducing glucose production
        Can decrease A1C levels by 1%
        If blood glucose hasn't improved, add another medication
        Thiazolidinediones
        Increases insulin transport and sensitivity on cell receptors
        Improves insulin use at tissues
        Sulfonylureas
        Inhibits potassium channels on beta cells
        Influx of calcium in beta cells
        Releases insulin
        If blood glucose still hasn't improved, add insulin to treatment
        Insulin
        Issues with insulin therapy
        Hypoglycemia
        Could be caused by overdose of insulin
        Allergic Reaction
        Lipodystrophy
        Can result in areas of insulin if injection site is unchanged
        Somogyi Effect
        Rebound effect from too much insulin causing hypohlycemia
        Dawn Phenomenon
        Hyperglycemia when waking in the morning due to hormones that counter insulin during this time
        Meglitinides
        Increases insulin production from beta cells in pancreas
        Alpha-Glucosidase Inhibitors
        Slows carbohydrate absorption
Nursing Care
1. Assessment
  1. Patient's ability to perform ADL/iADL
    1. Community Dwelling Patients
    2. Assisted Living Facilities
    3. Hospitalized Inpatients
    4. Nursing Facility (Long-term)
  2. Mentally incompetent patients
    1. Confused, cognitively dysfunctional, or delirious
    2. Depression
  3. Past health history
    1. Viral infections
      1. Respiratory Syncytial Virus (RSV) causes a change in the pathways that regulate insulin levels
    2. Hypertension in diabetic patients
      1. Beta-blockers are not ideal medications for diabetic patients with HTN
        Beta-blockers not ideal because they have been shown to ↑ TG, ↓ HDL cholesterol, heighten insulin resistance, induce systemic weight gain, and mask hypoglycemia.
    3. Recent surgery
      1. eg. CABG surgery alters body glucose homeostasis and increases stress causing HHS
  4. Identify daily basal rate and bolus doses
  5. Obese individuals are more likely to develop T2D than overweight or normal BMI individuals
  6. Check for family history of diabetes
2. Planning
  1. Actively engage patient to participate in lowering blood glucose levels
  2. Prevent or delay T2D complications
  3. Prevent or eliminate acute hyperglycemic emergencies or hypoglycemia
  4. Maintain appropriate blood glucose levels according to patient profile
  5. Adjust lifestyle management with minimal stress
3. Implementation
  1. Patient Education
    1. Travelling with diabetes
      1. Must continue medications as regular
    2. Self-Management
      1. Consider mentally incompetent individuals. May require self-management assistance
        Offer regular diet and preferred food items
        Offer food substitutions if meal intake is <75%
        Increase blood glucose monitoring during acute mental status or behaviour changes
        Depression
        Assess and treat depression
        Encourage physical activity as possible
        Encourage socialization, especially during meals
      2. Consider physically incompetent individuals ranging from the ability to perform ADLs independently to ADL-dependent individuals, to successfully apply self-management skills
        For hospitalized patients who require temporary self-management assistance
        Monitor BG levels as required based on patient complexity and avoid relying on A1C levels due to recent acute illness
        For rehab patients who require partial self-management assistance
        Nursing staff monitor BG levels based on the patient complexity of T2D and risks of hypoglycemia. Use caution when interpreting A1C levels as many conditions interfere with A1C levels.
        After discharge, patients need to be able to perform self-care skills and informed about self-adminstration skills for home management
        For chronically ill patients who require full or partial self-management assistance
        Continuous nursing staff education to provide T2D management
        For community-dwelling patients who require no self-management assistance (are fully independent)
        Educate the patient in preventing Type 2 diabetes complications and maintaining BG levels within normal ranges
    3. Plate Method
  2. Prevent or delay T2D and its complications
    1. Encourage physical activity to minimize the T2D effects of overweight and obese individuals
    2. For overweight adults 45 YO and up, provide routine screening to monitor prognosis
  3. For a Diagnosed T2 Diabetic
    1. Inform patients of the risks of poor blood glucose control
      1. Advise healthy eating habits and nutrition levels and help develop appropriate plate portions and meal plans following Canada's Food Guide
        Continue oral agents and insulin therapy as prescribed
        Track daily basal rates and bolus doses to review progression
        Monitor BG levels according to patient complexity of regimen
  4. Emotional Care
4. Evaluation
  1. Review diet progression and connect with overall health benefits
    1. Follow-up with patient after discharge and evaluate outcomes of patient goals and treatments
      1. A study showed that when nursing staff are actively involved in patient therapy after discharge, including initial individual meeting with an RN, attending a group class meeting for 1 to 2 h (with 4-10 participants) once per week for 4 weeks, and telephone follow-up calls for 1 year, resulted in greater mean change in A1C and total cholesterol and LDL cholesterol
    2. If diet has improved or if physical activity has improved, the risks of CVD would normally decrease
  2. Check if there are any issues with blood glucose control. If it is poorly controlled, then...
  3. Check for the absence of injuries
Collaborative Care
1. Dietitian
  1. Works with the patient, RN and the patient's health care team to develop a meal plan, appropriate plating portion, and guidelines to healthy eating habits - get ready for the yummy fruits and veggies!
2. Chiropodist
  1. Foot care specialist who is trained to trim the toe nails of a diabetic patient's foot - I promise he won't bite!
3. Diabetes Nurse Educator
  1. An RN with specialized training and education in teaching self-management goals, skills, and diabetic complications unique to each individual
  2. Arranges Diabetes Education Programs for patients interested in receiving support for diabetes management
4. Pharmacist
  1. Provides more information on medications and their interactions
5. Optometrist
  1. Uses various vision tests to check for and determine retinal blood vessel damage
6. Cardiologist and Cardiac Rehabilitation
  1. Angioplasty or CABG procedures performed to restore heart function
  2. Cardiac Rehab provides counseling and training on exercise, education for heart-healthy living and stress management therapies
7. Nephrologist
8. Community Organizations
  1. Raises awareness and health promotion strategies to prevent or delay T2D and associating complications such as providing support and services leading to improved self-management goals and skills
Pathophysiology
1. Who could this affect?
  1. Over 35 years of age
    1. Risk increases with age
  2. Family history
  3. 80%-90% of patients are overweight
    1. Due to increase intake of food, insulin is constantly being produced
      1. Insulin receptors on cells become desensitized to insulin
  4. Aboriginal Hispanic South Asian Asian African
    1. Has higher risk
2. What is Diabetes Mellitus Type 2?
  1. The body normally goes through the following cycle to maintain 4 to 6 mmol/L of glucose
    1. When you eat food, glucose begins building up in the blood
      1. Beta cells on Islets of Langerhans on the pancreas secrete insulin
        Insulin "unlocks" receptors on cells
        This step in the cycle is the main problem for patients with type 2 diabetes
        Insulin Resistance
        Insulin receptors on cells do not get "unlocked" by insulin due to receptors being unresponsive or loss of receptors entirely
        Glucose begins to build up in the bloodstream
        Results in hyperglycemia and Type 2 Diabetes
        Analogy: When you put on glasses for the first time, you become very aware that they're on your nose and ears. But over time, those sensations begin to dim until you forget that the glasses are even on your nose!
        Cells receive glucose to use for energy
        Lowers blood glucose levels as the glucose passes out of the bloodstream
        Alpha cells on liver secrete glucagon
        Abnormal glucose production from liver could aid in development of type 2 diabetes
        Promotes conversion of glycogen to glucose
        Pancreas still makes insulin, but could produce less because of fatigue
        Beta-cell mass loss
    2. Analogy: This is just one of the components of the homeostatic elements that our body goes through. It very much works like a thermometer. It detects levels of glucose in the environment, and releases elements to counteract them if they become to rampant.
Complications
1. Hyperosmolar Hyperglycemic Syndrome
  1. BG levels rise immensely and leads to severe dehydration and very dark urine
2. Hypoglycemia
  1. Happens when there's too much glucose compared to insulin
    1. Tremors Hunger Excessive Sweating
3. Macrovascular Angiopathy
  1. increased risk of heart diseases such as CAD and ACS which can lead to increased risk of mortality
4. Microvascular Angiopathy
  1. Diabetic Retinopathy
    1. Retinal blood vessels are damaged and can cause impaired vision and/or blindness
  2. Diabetic Nephropathy
    1. Glomerular arterioles damaged and increases the risk of kidney disease and excretion of proteins in urine
5. Diabetic Neuropathy
  1. Peripheral nerves damaged and increases susceptibility to injuries without being aware of it
6. Foot and lower extremity
  1. Gangrene
7. Skin complications
  1. Decreased blood circulation lead to changes in collagen, changing appearance
8. Infection

Next up

Diabetes Mellitus Type 2

Description

Resource summary

Media attachments

Similar

	Created by Eugene Lee about 7 years ago