DAIBETES MELLITUS

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DAIBETES MELLITUS
Diabetes Mellitus is a major and common condition characterized by elevated blood glucose, a situation called hyperglycemia. It a major cause of death.
Diabetes Mellitus is a disorder of carbohydrate metabolism resulting from deficiency of insulin or resistance to available insulin characterized by hyperglycemia, (elevated blood glucose or sugar).

TYPES OF DIABETES MELLITUS
Types of Diabetes Mellitus
With type 2 diabetes, the pancreas usually makes some insulin. But either the amount made isn't enough for the body's needs, or the body's cells resist it. Insulin resistance, or lack of sensitivity to insulin, happens mainly in fat, liver, and muscle cells.

Type 1 Diabetes
Type 1 diabetes is also called insulin-dependent diabetes. It used to be called juvenile-onset diabetes, because it often begins in childhood. Type 1 diabetes is an autoimmune condition. It's caused by the body attacking its own pancreas with antibodies. In people with type 1 diabetes, the damaged pancreas doesn't make insulin. This type of diabetes may be caused by a genetic predisposition. It could also be the result of faulty beta cells in the pancreas that normally produce insulin.

Type 2 Diabetes
By far, the most common form of diabetes is type 2 diabetes, accounting for 95% of diabetes cases in adults. Type 2 diabetes used to be called adult-onset diabetes, but with the epidemic of obese and overweight kids, more teenagers are now developing type 2 diabetes. Type 2 diabetes was also called non-insulin-dependent diabetes. Type 2 diabetes is often a milder form of diabetes than type 1. With Type 2 diabetes, the pancreas usually produces some insulin. But either the amount produced is not enough for the body's needs, or the body's cells are resistant to it.

Gestational Diabetes
Diabetes that's triggered by pregnancy is called gestational diabetes (pregnancy, to some degree, leads to insulin resistance). It is often diagnosed in middle or late pregnancy. Because high blood sugar levels in a mother are circulated through the placenta to the baby, gestational diabetes must be controlled to protect the baby's growth and development. Gestational diabetes usually resolves itself after pregnancy. Having gestational diabetes does, however, put mothers at risk for developing type II diabetes later in life. It can occur anywhere from a few weeks after delivery to months or years later.

Other Forms of Diabetes
A few rare kinds of diabetes can result from specific conditions. For example, diseases of the pancreas, certain surgeries and medications, or infections can cause diabetes. These types of diabetes account for only 1% to 5% of all cases of diabetes.
(Michael Dansinger, MD on February 16, 2019)

CAUSES OF DIABETES MELLITUS
  • 1  Infection especially viral
  • 2  Drugs and toxins e.g steroids and thyroid hormones that antagonizes insulin.
  • 3   Insulin resistance caused by dysfunctional insulin receptors in the cells
  • 4   Liver disease e.g Cirrhosis
  • 5   Pancreatic diseases that destroy the beta islets cells
  • 6    Genetic syndrome


PATHOPHYSIOLOGY OF DIABETES MELLITUS
In a normal human being, insulin transport glucose into the cell where it is used for energy and the remaining stored into the liver as glycogen.
In a situation whereby insulin is not much, or the insulin is not active or the cells are not responding to insulin effect, there will be accumulation of glucose in the blood- hyperglycemia and reduced glucose in the cell where it is needed. The reduced glucose in the cells leads to a negative feedback mechanism of the liver releasing the stored glycogen as glucose. This will further elevate the level of glucose in the blood. Inability for the kidneys to reabsorb glucose will lead to GLUCOSURIA. There is polyphagia (hunger) because cells lack energy and polyuria with osmotic diuresis causing dehydration. This leads to polydipsia (excessive thirst). There is metabolism of fats to fatty acids and glycerol for energy as compensatory mechanism. Excess of these will lead to ketone bodies which will accumulate in the blood causing acidosis that can lead to shock, coma, and death.

DIAGNOSTIC EVALUATIONS
  •         Fasting plasma (blood) glucose: if above 140mg/dl is abnormal. 60-120mg/dl is the normal range.
  •         Post prandial blood glucose: normal value is between 90-180mg/dl, above 200mg/dl is abnormal.
  •         Random blood glucose level: this is when blood glucose is analyzed on at least two (2) occasions and the level greater than 200mg/dl.
  •         Glycosylated hemoglobin: normal range is 4-7%.
  •         Arterial blood gas studies will reveal mild lactic acidosis.
  •         Renal function test will reveal azotemia (elevated blood urea)
  •         Urinalysis will reveal glucosuria, hypernatremia, hypokalemia.

SIGNS AND SYSMPTOMS
  •          Polyphagia
  •          Polydipsia
  •          Polyuria
  •          Glucosuria
  •          Dehydration
  •          Weight loss
  •          Fatigue
  •          Weakness
  •          Visual disturbances
  •          Dry itching skin
  •          Acetone breadth
  •          Poor skin turgor


MANAGEMENT
AIMS;
  •         To maintain blood sugar close to normal.
  •         To prevent complications and emergencies.

      
     NURSING MANAGEMENT
COMPONENT

N- Nutritional management
A-activity and exercise
A-appropriate monitoring
P- Pharmacological management
P-patient and family education

Nutritional management; for individuals with type II diabetes, the purpose is for weight reduction and this implies significant carbohydrates restriction. For people with type I diabetes there is need for day to day consistency in dietary and exercise observation to prevent hypoglycemia.
For all type of diabetes mellitus, refined and simple sugar should be reduced and complex carbohydrate should be encouraged.

Activity and exercise; regular exercise is considered as an essential part of DM. the exercise program must be consistent and patient should be given physical examination and encourage to perform daily exercises because it lowers blood glucose level and cholesterol. It also improves insulin sensitivity, reduces weight and promotes circulation and also increases strength.

Appropriate monitoring; Self-monitoring by patient and nurses have been effective in reducing complications in type I DM. these can be facilitated by the use of glucose monitoring devices designed to provide timely measurement of glucose level. e.g use of glucometer and performing urinalysis to reveal glucose level.

Pharmacological Approach/ medical management
This involves insulin replacement in type I and the use of oral hypoglycemic agents in type II, insulin can also be used in some type II

Insulin replacement; there are 3 basic type of insulin replacement
  •         The rapid or short acting insulin ( regular insulin or Humuline)
  •         Intermediate acting insulin ( Neural Prostamine Hagedon )
  •         Long acting insulin (Ultralente)


Oral hypoglycemic agents
They are used for individuals with type II DM which diet cannot control the high blood glucose. Examples include, Sulfonylureas, Biguanides, Alpha-glycosidase inhibitors.
NOTE
  •         Insulin replace endogenous insulin and maintain blood glucose level
  •    Glucose is the antidote for insulin so should be given after insulin use before breakfast
  •         Absorption of insulin is best in the abdomen
  •         Injection site should regularly be rotated


Family and patient education on DM
  •         How to recognize the signs of complications
  •   Teach them about drugs that potentiates hyperglycemia ego estrogen, corticosteroids

  •       Advice patient on home monitoring of blood glucose
  •             Importance of daily exercise must be stressed
  •         Diet should be low in fat and high in fibers
  •         Teach foot care and protection instruct client to properly bath, dry, and lubricates the feet.
  •         Instruct client in the care of minor wounds to clean wounds with soap and waters, apply antibiotics ointment and notify physician if sign of infection is present
  •        Teach patient and family that diabetes patient are susceptible to infection so should use preventive measures.
  •         Teach patient indicators of hypo and hyperglycemia and importance of receiving prompt treatment to any occurring symptom.

COMPLICATIONS
·        Retinopathy
·        Gangrene
·        Infection
·        Diabetes keto acidosis (DKA)
·        Hypertension
·        Neuropathy
·        Cardiovascular disorders
·        Hyperosmolarity hyperglysemic non ketotic syndrome (HHNS)

NURSING DIAGNOSIS
  •        Fluid and electrolyte imbalance related to fluid loss evidenced by dehydration
  •          Imbalanced nutrition less than body requirements related to rapid metabolism evidenced by weight loss
  •          Anxiety related to disease process evidenced by restlessness.
  •          Knowledge deficit regarding disease process and therapy evidenced by non compliance to management.
  •          High risk of infection related to disease process.


REFERENCES
(Michael Dansinger, MD on February 16, 2019)
www.explicit.net explicit of medical surgical nursing by Oloriegbe Ofunami

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