1 DIABETES MELLITUS Rachel S. Natividad RN, MSN, NP

2 Review A&P

3 Physiology: Role of Insulin

4 Physiology Cont: InsulinBasal (continuous) Prandial (Bolus) *Blood glucose increases within 10 minutes the beginning of a meal*

5 Diabetes Mellitus A disorder of carbohydrate, protein, and fat metabolism resulting from an imbalance between insulin availability and insulin need. (Porth, 2002) End Result : HYPERGLYCEMIA

6 Classifications Type 1 (no insulin)Type 2 (some insulin + insulin resistance) Gestational Diabetes (pregnancy-related) Secondary Diabetes (Cushing’s disease, pancreatitis, etc.)

7 Pathophysiology

8 Normal

9 Patho: DM Type 1 No Insulin

10 Patho-Cont.:DM Type 2

11 The big difference… DM TYPE 1 DM TYPE 2 No endogenous insulinSome endogenous insulin Tx requires insulin injections Tx diet and exercise 1st, then pills and later insulin Usually < age 30 yrs. Usually over 30 yrs. (peaks at 50) Ketosis prone (DKA) no ketosis Former names: IDDM (Juvenile) Diabetes Type I NIDDM (maturity/adult- onset) Diabetes Type II Thin to normal body weight Usually Overweight Acute metabolic complications Chronic vascular complications

12 Case Study

13 Clinical ManifestationsTHE 3 POLYs POLYDYPSIA POLYURIA POLYPHAGIA 13

14 Clinical Manifestations Cont: Signs and SymptomsEarly signs 3 Polys Weight loss Fatigue/Always tired Visual Blurring Late signs Any of the 3 Polys Infections Numbness/ tingling of feet or leg pain Slow healing wounds Chronic Complications

15 Diagnostic Tests Fasting Blood Glucose (FBG): 70-110 mg/dL*Random/Casual Blood Glucose*:<200 mg/dL Oral Glucose Tolerance Test (OGTT) Glycosylated Hemoglobin (HgbA1C) Normal -4-6% Target range DM patient 6-8%

16 Criteria for the Diagnosis of Diabetes MellitusNormal FPG <110 mg per dL 2hr OGTT <140 mg per dL Diabetes- positive findings from any two of the following tests on different days: Symptoms of diabetes mellitus* plus casual (random) plasma glucose concentration >=200 mg / dL or FPG >=126 mg per dL 2hr OGTT >=200 mg per dL after a 75-g glucose load

17 Diagnostic Tests – Cont. Is it Diabetes Yet?IFG IGT Impaired Glucose Tolerance Impaired Fasting Glucose

19 Chronic Complications - MacrovascularCardiovascular Cerebrovascular Peripheral vascular

20 Chronic Complications-Microvascular :1. Diabetic Retinopathy

21 Chronic Complications-Microvascular2. Nephropathy

23

25 MANAGEMENT OF DM Exercise Diet Drug Therapy 25Blood Glucose Monitoring Drug Therapy 25

26 Management: Diet & Exercise

27 Diet Cont: Diabetes Food Pyramid

28 Diet Cont: What to do???

29 Diet Cont. Carb-Counting

30 Diet Cont.: Getting the balance rightGet your portions right!!

31 Management: Exercise Helps regulate blood glucoseIncreases insulin effectiveness and sensitivity in the body. Must monitor insulin and food intake to match exercise regimen.

32 The results showed that people in the lifestyle change group reduced their risk of getting type 2 diabetes by 58 percent. In the first year of the study, people lost an average of 15 pounds. Lifestyle change was even more effective in those aged 60 and older. They reduced their risk by 71 percent. People receiving metformin reduced their risk by 31 percent. Exercise is also known as physical activity and includes anything that gets you moving, such as walking, dancing, or working in the yard. You can earn the benefits of being physically active without going to a gym, playing sports, or using fancy equipment. When you're physically fit, you have the strength, flexibility, and endurance needed for your daily activities. Being physically active helps you feel better physically and mentally. How Does Exercise Affect Blood Glucose Levels? Normally, insulin is released from the pancreas when the amount of glucose (sugar) in the blood increases, such as after eating. Insulin stimulates the liver and muscles to take in excess glucose. This results in a lowering of the blood glucose level. When exercising, the body needs extra energy or fuel (in the form of glucose) for the exercising muscles. For short bursts of exercise, such as a quick sprint to catch the bus, the muscles and the liver can release stores of glucose for fuel. With continued moderate exercising, however, your muscles take up glucose at almost 20 times the normal rate. This lowers blood glucose levels. But intense exercise can have the opposite effect and actually increase your blood glucose levels. This is especially true for many people with diabetes. The body recognizes intense exercise as a stress and releases stress hormones that tell your body to increase available blood glucose to fuel your muscles. If this happens to you, you may need a little bit of insulin after intense workouts. For a variety of reasons, after exercise, people with diabetes may have an increase or a decrease in their blood glucose levels. Is Blood Glucose Ever Too High to Exercise? Yes. In some cases, you should hold off on exercising if your blood glucose is very high. What Types of Exercise Are Best for Blood Glucose Control? While most any exercise is healthy for people with diabetes, let’s look at some specific types of exercise and their benefits: Strength Training and Type 2 Diabetes The latest findings show that exercise such as strength training has a profound impact on helping people manage their diabetes. In a recent study of Hispanic men and women, 16 weeks of strength training produced dramatic improvements in glucose control that are comparable to taking diabetes medication. Additionally, the study volunteers were stronger, gained muscle, lost body fat, had less depression, and felt much more self-confident. For more detail, see WebMD's article Strength Training and Diabetes. Aerobic Fitness and Type 2 Diabetes Any activity that raises your heart rate and keeps it up for an extended period of time will improve your aerobic fitness. Aerobic exercise helps decrease the risk of type 2 diabetes and helps those with diabetes to better manage their blood glucose levels. Besides the health benefits, exercise is fun and boosts your mood.  It’s hard to feel stressed when you’re walking fast on a treadmill or swimming laps in a pool. For more detail, see WebMD's article Aerobic Fitness and Diabetes.

33 Drug Therapy Insulin Oral Antidiabetic Agents TypesRapid-acting or regular insulin are used to lower blood sugar after eating a meal. Intermediate or long-acting types of insulin are used to lower blood sugar throughout the day and night Onset - how soon it starts to work in the blood Peak - when the insulin has the greatest effect on blood sugar levels Duration – how long it keeps working Oral Antidiabetic Agents

34 Drug Therapy Cont: Goal of Insulin TherapyBasal and Bolus Insulin Coverage

35 Drug Therapy Cont: Sample Insulin Regimen

36 Drug Therapy Cont: Rapid Acting: Lispro/AspartIdeal for meal coverage “Give the shot while the plate is hot!”

37 Drug Therapy Cont: Fast Acting: Regular Insulin♪ It’s time give you your regular insulin ♪ ♪ It’s time to give it 30 minutes before your plate is in ♪ ♪ Come back to check you in 2 (hours) ♪ ♪ Watch out for shakes and sweats too ♪ ♪ If your lucky you’ll have no clue!!!! ♪

38 Insulin – Acute Complication Hypoglycemia

39 Drug Therapy Cont: Intermediate acting: NPH Insulincovers blood sugar between meals satisfies overnight insulin requirement Need snack if NPH given at 5 pm Ideal to be given at 9 pm (HS) to address Dawn Phenomenon

40 Peakless Insulins!!! *Do not mix with other insulinsLantus (insulin glargine) Levimir (insulin detimir)

41 Drug Therapy Cont: Other Methods of Administration

42 Oral Antidiabetic agents (see handout)Drug Treatment: Cont. Oral Antidiabetic agents (see handout)

43 Administer meds (see Simon’s MAR)Things to Ponder Look at MAR and decide which meds you’ll administer at what time. What are your concerns with Simon’s schedule of meds? Hint: look at onset/peak of Diabetes meds It is now 0745 and the BS at 0700 = 173 mg/dL, what would you do? What do you need to monitor for and when? Why is Simon on insulin and oral diabetes meds?

44 Discussion (see Simon’s MAR)Nurse decided to administer 4 units of Reg insulin at 0800 and Glyburide and Metformin at 1000 as scheduled. Simon calls at 11:30 c/o shaking, sweating. (What do you do?) BS at 11:30 = 62 mg/dL (What do you do?)

45 Insulin Acute Complication: Hypoglycemia Tx: (15/15 or 20/20 Rule)Give 15/20 g simple carb and recheck BG in 15/20 minutes

46 Discussion (see Simon’s MAR)Nurse decided to hold PO meds. At 11:30 BS=489 What do you do?

47 Hyperglycemia

48 Diabetic Teaching NeedsDisease process S/S of hyperglycemia and hypoglycemia Blood sugar monitoring Diet Exercise Drug therapy Sick Day Rules Complications (acute and chronic) Prevention: Foot care, eye exam etc.

49 DIABETES can be controlled!!!Prevention of Complications…. Tight BS control