DEFINITION
Diabetes mellitus refers to a group of diseases that affect how your body uses blood sugar (glucose). Glucose is very important to human body because it's an important source of energy for the cells that make up the muscles, tissues, as well as brain's main source of fuel.
When a person is diagnosed with diabetes, no matter what type, it means that person have too much glucose in his/her blood, although the causes may differ. Excessive level of glucose can lead to serious health problems.
TYPES OF DIABETES
Chronic Diabetes conditions include:
1. Type 1 diabetes which is known as insulin dependent Diabetes.
2. Type 2 diabetes which is potentially reversible Diabetes conditions include Prediabetes i.e when your blood sugar levels are higher than normal, but not high enough to be classified as Diabetes.
3. Gestational diabetes: which occurs during pregnancy but may resolve after the baby is delivered.
SIGNS AND SYMPTOMS
Diabetes symptoms vary depending on how much body blood sugar is elevated. Some people, especially those with Prediabetes or Type 2 diabetes, may not experience symptoms initially. In Type 1 diabetes, symptoms tend to come on quickly and be more severe.
Some of the signs and symptoms of type 1 and Type 2 diabetes are:
- Increased thirst (polydipsia)
- Frequent/increased urination (polyuria)
- Extreme hunger (polyphagia)
- Unexplained weight loss
- Presence of ketones in the urine (ketones are a byproduct of the breakdown of muscle and fat that happens when there's not enough available insulin)
- Fatigue
- Irritability
- Blurred vision
- Slow-healing sores
- Frequent infections, such as gums or skin infections and vaginal infections.
PREVALENCE/OCCURANCE OF DIABETES
Although Type 1 diabetes can develop at any age, it typically appears during childhood or adolescence. Type 2 diabetes, the more common type, can develop at any age, though it's more common in people older than 40. Gestational diabetes develops during pregnancy and subside after delivery.
CAUSES
To understand Diabetes, first you must understand how glucose is normally processed in the body.
How insulin works
Insulin is a hormone that comes from a gland situated behind and below the stomach (pancreas). The pancreas secretes insulin into the bloodstream for systemic circulation for enabling sugar to enter your cells to lower the amount of sugar in blood stream.
As blood sugar level drops, so does the secretion of insulin from your pancreas.
The role of glucose
Glucose (sugar) is a source of energy for the cells that make up muscles and other tissues. Glucose comes from two major sources i.e food and liver.
Sugar is absorbed into the bloodstream, where it enters cells with the help of insulin. The liver stores and makes glucose.
When your glucose levels are low, such as when you haven't eaten in a while, the liver breaks down stored glycogen into glucose to keep your glucose level within a normal range.
Causes of Type 1 diabetes:
The exact cause of Type 1 diabetes is unknown, what is known is that your immune system which normally fights harmful bacteria or viruses attacks and destroys the insulin-producing cells in the pancreas. This leaves the person with little or no insulin. Instead of being transported into the cells, sugar builds up in the blood stream.
Type 1 is thought to be caused by a combination of genetic susceptibility and environmental factors, though exactly what many of those factors are is still unclear.
Causes of Prediabetes and Type 2 diabetes:
In Prediabetes (which can lead to Type 2 diabetes) and in Type 2 diabetes, the body cells become resistant to the action of insulin and the pancreas is unable to make enough insulin to overcome this resistance. Instead of moving into your cells where it's needed for energy, sugar builds up in bloodstream.
Exactly why this happens is uncertain, although it's believed that genetic and environmental factors play a role in the development of Type 2 diabetes. Being overweight is strongly linked to the development of Type 2 diabetes, but not everyone with type 2 is overweight.
Causes of Gestational diabetes:
During pregnancy, the placenta produces hormones to sustain the pregnancy. These hormones make body cells more resistant to insulin.
Normally, the pancreas responds by producing enough extra insulin to overcome this resistance but sometimes the pancreas can't keep up. When this happens, too little glucose gets into the cells and too much stays in the blood, resulting in Gestational diabetes.
RISK FACTORS
Risk factors for diabetes depend on the type of diabetes.
Risk factors for Type 1 diabetes:
Although the exact cause of Type 1 diabetes is unknown, factors that may signal an increased risk include:
- Family history
- Environmental factors
- The presence of damaging immune system cells (autoantibodies)
- Dietary factors
- Geography; ertain countries, such as Finland and Sweden, have higher rates of type 1 diabetes.
Risk factors for Prediabetes and Type 2 diabetes:
Researchers don't fully understand why some people develop Prediabetes and Type 2 diabetes and others don't. It's clear that certain factors increase the risk, however, including:
- Weight: the more fatty tissue, the more resistant body cells become to insulin.
- Inactivity: The less active you are, the greater your risk because physical activity helps to control body weight, uses up glucose as energy and makes body cells more sensitive to insulin.
- Family history: the risk increases if a parent or sibling has Type 2 diabetes.
- Race: although it's unclear why, people of certain races including blacks, Hispanics, American Indians and Asian-Americans are at higher risk.
- Age: the risk increases as the person get older, this may be because the person tend to exercise less, lose muscle mass and gain weight. But Type 2 diabetes is also increasing dramatically among children, adolescents and younger adults.
- Gestational diabetes: if a woman developed Gestational diabetes when she were pregnant, her risk of developing Prediabetes and Type 2 diabetes later increases. If she gave birth to a baby weighing more than 4 kilograms, she is also at risk of Type 2 diabetes.
- Polycystic ovary syndrome.
- High blood pressure
- Abnormal cholesterol and triglyceride levels.
Risk factors for Gestational diabetes:
Any pregnant woman can develop Gestational diabetes, but some women are at greater risk than are others. Risk factors for Gestational diabetes include:
- Age: Women older than age 25 are at increased risk.
- Family or personal history: The risk increases if person have Prediabetes (a precursor to Type 2 diabetes) or if a close family member, such as a parent or sibling, has Type 2 diabetes.
- Previous history of Gestational diabetes.
- Delivering a very large baby or if you had an unexplained stillbirth.
- Weight: Being overweight before pregnancy increases your risk.
- Race: For reasons that aren't clear, women who are black, Hispanic, American Indian or Asian are more likely to develop Gestational diabetes.
TESTS/INVESTIGATIONS AND DIAGNOSIS
- History taking
- Physical examination
- Glycated hemoglobin (A1C) test (An A1C between 5.7 and 6.4 percent indicates Prediabetes. Below 5.7 is considered normal).
- Random blood sugar test: A random blood sugar level of 11.1mmol/L or higher suggests Diabetes.
- Fasting blood sugar test: A Fasting blood sugar level of 5.6 mmol/L is normal, 5.6 to 6.9 mmol/L is considered Prediabetes but above 7.1mmol/L is Diabetes.
- Oral glucose tolerance test: A blood sugar level less than 7.8 mmol/L is normal, a reading of more than 11.1 mmol/L after two hours indicates Diabetes, A reading between 7.8 mmol/L and 11.0 mmol/L indicates Prediabetes.
- Urinalysis for the presence of ketones and glucose.
- Initial glucose challenge test
MANAGEMENT OF DIABETES
Medical Management:
Here are some medical interventions that are performed to manage diabetes mellitus:
- Normalize insulin activity: This is the main goal of diabetes treatment, normalization of blood glucose levels to reduce the development of vascular and neuropathic complications.
- Intensive treatment: Intensive treatment is three to four insulin injections per day or continuous subcutaneous insulin infusion, insulin pump therapy plus frequent blood glucose monitoring and weekly contacts with diabetes educators.
- Exercise caution with intensive treatment: Intensive therapy must be done with caution and must be accompanied by thorough education of the patient and family and by responsible behavior of patient.
- Diabetes management has five components and involves constant assessment and modification of the treatment plan by healthcare professionals and daily adjustments in therapy by the patient.
Pharmacotherapy
The types of drugs depend on the type of diabetes you have. Here, we can give details about drugs that treat both types of diabetes to help give you an idea of the treatment options available to you.
Medications for type 1 diabetes:
- Insulin: The most common type of medication used in type 1 diabetes treatment because the body of these patients can’t make its own insulin, and the goal of treatment is to replace the insulin that the body can’t make. Insulin is also used in type 2 diabetes treatment. It’s given by injection and comes in different types. The type of insulin you need depends on how severe the patient's insulin depletion is, insulin types include:
1. Short-acting insulin: Regular insulin (Humulin and Novolin)
2. Rapid-acting insulins: Examples are; insulin aspart (NovoLog, FlexPen, Fiasp), insulin glulisine (Apidra), insulin lispro (Humalog).
3. Intermediate-acting insulin: Examples are; insulin isophane (Humulin N, Novolin N)
4. Long-acting insulins: Examples are; insulin degludec (Tresiba), insulin detemir (Levemir), insulin glargine (Lantus), insulin glargine (Toujeo)
Medications for type 2 diabetes:
If someone have type 2 diabetes, his/her body makes insulin but no longer uses it well. The body can’t make enough insulin to keep blood sugar levels normal.
The goal of treatment is to help the body use its insulin better or to get rid of extra sugar in the blood.
Most medications for type 2 diabetes are oral drugs. However, a few come as injections though some people with type 2 diabetes may also need to take insulin. Below are some of the drugs:
- Alpha-glucosidase inhibitors: These medications help the body to break down starchy foods and table sugar, this effect lowers blood sugar levels. These drugs include: acarbose (Precose), miglitol (Glyset).
- Biguanides: These drugs decrease how much sugar the liver makes, they decrease how much sugar the intestines absorb, make body more sensitive to insulin, and help the muscles absorb glucose. The most common biguanide is metformin (Glucophage, Metformin Hydrochloride ER, Glumetza, Riomet, Fortamet).
- Dopamine agonist: It’s not known exactly how this drug works to treat type 2 diabetes but it is believe that it affect rhythms in the body and prevent insulin resistance. Bromocriptine (Cycloset) is a dopamine agonist.
- Dipeptidyl peptidase-4 (DPP-4) inhibitors:
DPP-4 inhibitors help the body continue to make insulin, they work by reducing blood sugar without causing hypoglycemia (low blood sugar). These drugs can also help the pancreas make more insulin. These drugs include: alogliptin (Nesina), alogliptin-metformin (Kazano), alogliptin-pioglitazone (Oseni), linagliptin (Tradjenta), linagliptin-empagliflozin (Glyxambi), linagliptin-metformin (Jentadueto), saxagliptin (Onglyza), saxagliptin-metformin (Kombiglyze XR), sitagliptin (Januvia), etc.
- Glucagon-like peptide-1 receptor agonists: These drugs are similar to the natural hormone called incretin. They increase B-cell growth and how much insulin the body uses. They decrease the patient's appetite and how much glucagon patient's body uses, they also slow stomach emptying.
Nutritional Management:
- Nutrition, meal planning, and weight control are the foundations of diabetes management.
- A registered dietitian who understands diabetes management has the major responsibility for designing and teaching this aspect of the therapeutic plan.
- Healthcare team should have the knowledge; Nurses and other health care members of the team must be knowledgeable about nutritional therapy and supportive of patients who need to implement nutritional and lifestyle changes.
- Weight loss is the key treatment for obese patients with type 2 diabetes. A weight loss of as small as 5% to 10% of the total body weight may significantly improve blood glucose levels.
- Other options for diabetes management. Diet education, behavioral therapy, group support, and ongoing nutritional counselling should be encouraged.
Meal Planning:
- The meal plan must consider the patient’s food preferences, lifestyle, usual eating times, and ethnic and cultural background.
- Managing hypoglycemia through meals. To help prevent hypoglycemic reactions and maintain overall blood glucose control, there should be consistency in the approximate time intervals between meals with the addition of snacks as needed.
- The patient’s diet history should be thoroughly reviewed to identify his or her eating habits and lifestyle.
- Health education should include the importance of consistent eating habits, the relationship of food and insulin, and the provision of an individualized meal plan.
- The nurse plays an important role in communicating pertinent information to the dietitian and reinforcing the patients for better understanding.
Nursing Management:
Nurses should provide accurate and up-to-date information about the patient’s condition so that the healthcare team can come up with appropriate interventions and management.
Nursing Assessment
The nurse should assess the following for patients with Diabetes Mellitus:
- Assess the patient’s history: To determine if there is presence of diabetes, assessment of history of symptoms related to the diagnosis of diabetes, results of blood glucose monitoring, adherence to prescribed dietary, pharmacologic, and exercise regimen, the patient’s lifestyle, cultural, psychosocial, and economic factors, and effects of diabetes on functional status should be performed.
- Assess physical condition: Assess the patient’s blood pressure while sitting and standing to detect orthostatic changes.
Assess the body mass index and visual acuity of the patient.
- Perform examination of foot, skin, nervous system and mouth.
- Laboratory examinations. HgbA1C, fasting blood glucose, lipid profile, microalbuminuria test, serum creatinine level, urinalysis, and ECG must be requested and performed.
Nursing Diagnosis
The following are diagnoses observed from a patient with diabetes mellitus:
- Risk for unstable blood glucose level related to insulin resistance, impaired insulin secretion, and destruction of beta cells.
- Risk for infection related to delayed healing of open wounds.
- Deficient knowledge related to unfamiliarity with information, lack of recall, or misinterpretation.
- Risk for disturbed sensory perception related to endogenous chemical alterations.
- Impaired skin integrity related to delayed wound healing.
- Ineffective peripheral tissue perfusion related to too much glucose in the bloodstream.
Planning and Goals
Achievement of goals is necessary to evaluate the effectiveness of all nursing therapy not only in diabetes management. Below are some planning/goals:
- Acknowledge factors that lead to unstable blood glucose.
- Maintain glucose in satisfactory range.
- Verbalize plan for modifying factors to prevent or minimize shifts in glucose levels.
- Achieve timely wound healing.
Identify interventions to prevent or reduce risk for Infection.
- Regain or maintain the usual level of cognition.
- Homeostasis achieved.
- Causative/precipitating factors corrected/controlled.
- Complications prevented/minimized.
- Disease process/prognosis, self-care needs, and therapeutic regimen understood.
- Plan in place to meet needs after discharge.
Nursing Priorities when planning goals:
- Restore fluid/electrolyte and acid-base balance.
- Correct/reverse metabolic abnormalities.
- Identify/assist with management of underlying cause/disease process.
- Prevent complications.
- Provide information about disease process/prognosis, self-care, and treatment needs.
Nursing Interventions:
The healthcare team must establish cooperation in implementing the following interventions:
- Educate about home glucose monitoring: Discuss glucose monitoring at home with the patient according to individual parameters to identify and manage glucose variations.
- Review factors in glucose instability: Review client’s common situations that contribute to glucose instability because there are multiple factors that can play a role at any time like missing meals, infection, or other illnesses.
- Encourage client to read labels: The client must choose foods described as having a low glycemic index, higher fiber, and low-fat content.
- Discuss how client’s antidiabetic medications work: Educate client on the functions of his or her medications because there are combinations of drugs that work in different ways with different blood glucose control and side effects.
- Check viability of insulin: Emphasize the importance of checking expiration dates of medications, inspecting insulin for cloudiness if it is normally clear, and monitoring proper storage and preparation because these affect insulin absorbability.
- Review type of insulin used: Note the type of insulin to be administered together with the method of delivery and time of administration. This affects timing of effects and provides clues to potential timing of glucose instability.
- Check injection sites periodically: Insulin absorption can vary day to day in healthy sites and is less absorbable in lipohypertrophic tissues.
Evaluation
To check if the regimen or the interventions are effective, evaluation must be done afterward.
- Evaluate client’s knowledge on factors that lead to an unstable blood glucose level.
- Evaluate the client’s level of blood glucose.
- Verbalized achievement of modifying factors that can prevent or minimize shifts in glucose level.
- Achieved timely wound healing.
- Identified interventions that can prevent or reduce risk for infection.
- Evaluate maintenance of the usual level of cognition.
DISCHARGE AND HOME CARE GUIDELINES
The responsibility of the healthcare team members does not end when the patient is discharged. The following are guidelines that should be discussed before the patient is discharged from the hospital:
- Patient empowerment is the focus of diabetes education.
- Patient education should address behavior change, self-efficacy, and health beliefs.
- Address any underlying factors that may affect diabetic control.
- Simplify the treatment regimen if it is difficult for the patient to follow.
- Adjust the treatment regimen to meet patient requests.
- Establish as specific plan or contract with the patient with simple, measurable goals.
- Provide positive reinforcement of self-care behaviors performed instead of focusing on behaviors that were neglected.
- Encourage the patient to pursue life goals and interests, and discourage an undue focus on diabetes.
- Educate client on wound care, insulin preparation, and glucose monitoring.
- Instruct client to comply with the appointment with the healthcare provider at least twice a year for ongoing evaluation and routine nutrition updates.
- Remind the patient to participate in recommended health promotion activities and age-appropriate health screenings.
- Encourage participation in support groups with patients who have had diabetes for many years as well for those who are newly diagnosed.
COMPLICATIONS
Long-term complications of Diabetes develop gradually. The longer you have Diabetes and the less controlled your blood sugar the higher the risk of complications.
Eventually, Diabetes complications may be disabling or even life-threatening. Possible complications include:
- Cardiovascular disease: Diabetes dramatically increases the risk of various cardiovascular problems, including Coronary artery disease with Chest pain (Angina), Heart attack, Stroke and narrowing of arteries (atherosclerosis).
- Nerve damage (neuropathy): Excess sugar can injure the walls of the tiny blood vessels (capillaries) that nourish your nerves, especially in your legs. This can cause tingling, numbness, burning or pain that usually begins at the tips of the toes or fingers and gradually spreads upward. Left untreated, you could lose all sense of feeling in the affected limbs. Damage to the nerves related to digestion can cause problems with nausea, vomiting, Diarrhea or Constipation. For men, it may lead to Erectile dysfunction.
- Kidney damage (nephropathy): The kidneys contain millions of tiny blood vessel clusters (glomeruli) that filter waste from your blood. Diabetes can damage this delicate filtering system. Severe damage can lead to kidney failure or irreversible end-stage kidney disease, which may require dialysis or a kidney transplant.
- Eye damage (retinopathy): Diabetes can damage the blood vessels of the retina (Diabetic retinopathy), potentially leading to blindness. Diabetes also increases the risk of other serious vision conditions, such as Cataracts and Glaucoma.
- Foot damage: Nerve damage in the feet or poor blood flow to the feet increases the risk of various foot complications. Left untreated, cuts and blisters can develop serious infections, which often heal poorly. These infections may ultimately require toe, foot or leg amputation.
- Skin conditions: Diabetes may leave the person more susceptible to skin problems, including bacterial and fungal infections.
- Hearing impairment: Hearing problems are more common in people with Diabetes.
- Alzheimer's disease.
Most women who have Gestational diabetes deliver healthy babies but untreated or uncontrolled blood sugar levels can cause problems for woman and her baby. Complications the baby can developes as a result of Gestational diabetes includes:
- Excess growth: Extra glucose can cross the placenta, which triggers the baby's pancreas to make extra insulin which definitely can cause the baby to grow too large (macrosomia). Very large babies are more likely to require a C-section birth.
- Low blood sugar: Sometimes babies of mothers with Gestational diabetes develop low blood sugar (Hypoglycemia) shortly after birth because their own insulin production is high. Prompt feedings and sometimes an intravenous glucose solution can return the baby's blood sugar level to normal.
- Type 2 diabetes later in life: Babies of mothers who have Gestational diabetes have a higher risk of developing obesity and Type 2 diabetes later in life.
- Death: Untreated Gestational diabetes can result in a baby's death either before or shortly after birth.
Complications in the mother can also occur as a result of Gestational diabetes, including:
- Preeclampsia: This condition is characterized by high blood pressure, excess protein in the urine, and swelling in the legs and feet. Preeclampsia can lead to serious or even life-threatening complications for both mother and baby.
- Subsequent Gestational diabetes: Once a woman have had Gestational diabetes in one pregnancy, she is more likely to have it again with the next pregnancy. She is also more likely to develop Diabetes (typically Type 2 diabetes ) as she get older.
- Complications of Prediabetes
Prediabetes may develop into Type 2 diabetes.
COPING AND SUPPORT
Living with Diabetes can be difficult and frustrating. Sometimes, even when you've done everything right, your blood sugar levels may rise.
Because good Diabetes management can be time-consuming, and sometimes overwhelming, some people find it helps to talk to someone. Your nurse can probably recommend a mental health professional for you to speak with, or you may want to try a support group. Sharing your frustrations and your triumphs with people who understand what you're going through can be very helpful. And you may find that others have great tips to share about Diabetes management.
0 Comments