CHAPTER II REVIEW OF RELATED LITERATURE This Chapter presents a review of related literature and studies both local and

foreign that provided important information and insights for conducting the present study.

Stroke Local Related Literature Foreign Related Literature Incidence /prevalence it is estimated that there are more than 4.7 million stroke survivors in the United States. About 730,000 strokes occur each year, and more than 150,000 deaths result. About 25% of strokes occur in people under 65 years of age. The number of strokes occurring in ht younger population is increasing as a result of chronic intravenous (IV) drug abuse. Those using crack cocaine experience an increase incidence of stroke resulting from changes in the clotting mechanism caused by the drugs, spasm of cerebral vessels or hemodynamic stress from the sudden increase in systolic blood pressure. Between 5% and 15% of all clients who have had strokes have a recurrence within 1 year. By 5 years, about 40% have recurrence, and half of those died from stroke complications. Strokes tends to occur more often in the southern United States (stroke belt), which is probably related to the geographic distribution of the older population, an increase use of tobacco, obesity and a diet higher in fats. (Goldszmidt & Caplan, 2003) According to Lisa Bowman stroke is a term used to describe neurologic changes cause by an interruption in the blood supply to apart of the brain. The two major types of stroke are ischemic and hemorrhagic. Ischemic stroke is cause by a thrombotic or embolic

blockage of blood flow in the brain. Bleeding into the brain tissue or the subarachnoid space causes a hemorrhagic stroke. Ischemic stroke account for about 83% of all strokes. The remaining 17% of strokes are hemorrhagic. Richard Arbour states that stroke symptoms typically start suddenly, over seconds to minutes, and in most cases do not progress further. The symptoms depend on the area of the brain affected. The more extensive the area of brain affected, the more functions that are likely to be lost. Some forms of stroke can cause additional symptoms. For example, in intracranial hemorrhage, the affected area may compress other structures. Most forms of stroke are not associated with headache, apart from subarachnoid hemorrhage and cerebral venous thrombosis and occasionally intracerebral hemorrhage. The common signs and symptoms of stoke include numbness, weakness or paralysis of the face, arms or legs, headache and vomiting, difficulty in speaking, sudden blurring of vision, loss of balance or coordination; and , disturbances in consciousness. The stroke can be massive and fatal : but sometimes it can be so mild that complete recovery is experienced by the person in a few days to a few weeks; still at times it can leave the person alive but with residual permanent neurologic deficit. In 1993, According to the World Health Organization (WHO), stroke was the third leading cause of death worldwide. The experience in first world countries is that with increasing awareness of the risk factors of stroke, in the incidence of the disease diminishes. This shows that stroke is preventable. The more important risk factors associated with stroke include high blood pressure (Hypertension) , Diabetes Mellitus, heart disease, hyperlipidemia (high blood cholesterol levels), cigarette smoking, drug abuse, heavy alcohol consumption; a previous stroke; transient ischemic attacks

(temporary reduction in blood flow to the brain giving rise to transient signs and symptoms); and, a family history of stroke. Types of stroke Strokes are generally classified as ischemic (occlusive) or hemorrhagic. Most ischemic strokes are either thrombotic strokes or embolic strokes. Ischemic Stroke An ischemic stroke is caused by the occlusion of a cerebral artery by either a thrombus or an embolus. A stroke that is caused by a thrombus is referred to as a thrombotic stroke, whereas a stroke caused by an embolus is referred to as an embolic stroke. About 80% of all strokes are ischemic. Thrombotic Stroke Account for more than half of all strokes and are commonly associated with the development of atherosclerosis of the blood vessel wall. Atherosclerosis is a complex process that includes altered function of the inner lining of arterial vessels, inflammation, and increased growth of vascular smooth muscle cells. It is the process by which plaques develop on the inner wall of the affected arterial vessel. The first step in plaque development is accumulation of low-density lipoprotein (LDL) particles within the arterial vessel wall. These may undergo chemical changes and then stimulate endothelial cells to adhere to monocytes (inflammatory cells) and T-cells (immune system cells). The endothelium produces chemical messengers, within the intimal layer.

The second step is maturation of monocytes into macrophages. The macrophages, in turn, ingest LDL particles. The third step occurs when the macrophages ingest a critical mass of LDL particles; they are the called foam cells. These cells constitute the fatty streak on the inner arterial wall, the earliest manifestation of arterial plaque. The fourth step is additional growth of the lesion through influence or inflammatory molecules, which also help from a fibrous cover a cap over the lipid core. This covering makes the plaque larger but also separates it from blood flow through the vessel. The fifth step occurs with plaque rupture. Rupture of the plaque exposes foam cells to clot promoting elements in the blood. The end result is clot formation. If the clot is of sufficient size, it may interrupt blood flow through the vessel. As the artery becomes completely occluded, blood flow to the area is markedly diminished. Decreased blood flow causes transient ischemia, which progresses to complete ischemia and infarction of the brain tissue. Within 72 hours, the area is edematous and necrotic, and cavities develop. The bifurcation (point of division) of the common carotid artery and the vertebral arteries at their junction with the Basilar artery are the most common sites involved. Because of the gradual occlusion of the arteries, thrombotic strokes tend to have a slow onset. A lacunar stroke is another type of thrombotic stroke. A lacunar stroke causes a soft area or cavity to develop in the white matter or deep gray matter of the brain.

Embolic Stroke Is caused by an embolus or a group of emboli (clots) that break off from one area of the body and travel to the cerebral arteries via the the carotid artery or vertebasilar system. Emboli occur in clients with nonvalvular atrial fibrillation, ischemic heart disease, rheumatic heart disease, and mural thrombi following a myocardial infarction (MI) or insertion of a prosthetic heart valve. Embolic tend to become lodged in the smaller cerebral blood vessels at their point of bifurcation or where the lumen narrows. Hemmorhagic stroke The second major classification of stroke. In this type of stroke, vessel integrity is interrupted, and bleeding occurs into the brain tissue or into the spaces surrounding the brain (ventricular, subdural, subarachnoid). According to Donna P. Ignatavicius, Risk factors of ischemia occur when the blood supply to apart of the brain is interrupted or totally occluded. Ultimate survival of ischemic brain tissue depends on the length of time it is deprived plus the degree of altered brain metabolism. Ischemia is commonly due to thrombosis or embolism. Thrombotic strokes are more common than embolic strokes. Strokes can also be developed large vessels and small vessels. Large vessels strokes are caused by blockage of a major cerebral artery, such as the internal carotid, anterior cerebral, middle cerebral, posterior cerebral, vertebral and basilar arteries small vessels strokes after smaller vessels that branch off the larger vessels to penetrate deep into the brain. The incidence of stroke and stroke mortalities has gradually declined in many industrialized countries in recent years as a result of increase recognition and treatment of

risk factors. Modifiable risk factors can be reduced or eliminated through lifestyle changes. Hypertension is the most important modifiable risk factors for both ischemic and hemorrhagic stroke. Adequate blood pressure controls is associated with 38% reduction in stroke incidence. Cardiovascular disease and Arial fibrillation are also associated with an increase risk of stroke. Diabetes mellitus increases the risk of stroke and morbidity and mortality after stroke. The mechanism is related macro vascular changes in people with diabetes mellitus. Prior to stroke, carotid stenosis and the history of transient ischemic attacks (TIAs) are considered modifiable risk factors for stroke. Reduction in the risk factors for initial stroke may prevent recurrence. Early recognition and treatment of carotid stenosis and treatment of TIAs with antiplatelet agents reduce the risk of stroke. Under modifiable risk factors of stroke include hyperlipidemia, cigarette smoking, heavy alcohol consumption, cocaine use, and obesity. Current research suggest that although heavy alcohol consumption increases ones risk of a stroke, light or moderate consumption may protect against ischemic stroke. Stroke is uncommon in women of childbearing age; however, high dose estrogen oral contraceptives combined with hypertension, cigarette smoking, migraine, headaches, and increasing age increase the risk of stroke in women. Local Related Studies Foreign Related Studies

Heart Attack

Local Related Literature Foreign Related Literature According to Litton, myocardial infarction is commonly known as a heart attack, is the interruption of blood supply to a part of the heart, causing heart cells to die. This is most commonly due to occlusion (blockage) of a coronary artery following the rupture of a vulnerable atherosclerotic plaque, which is an unstable collection of lipids (fatty acids) and white blood cells (especially macrophages) in the wall of an artery. The resulting ischemia (restriction in blood supply) and oxygen shortage, if left untreated for a sufficient period of time, can cause damage or death (infarction) of heart muscle tissue (myocardium). According to Janice Tazbir and Peggy Gerard, myocardial infarction, the heart is requires a balance between oxygen supply and oxygen demand in order to function properly. The integrity of the coronary arteries is an important determinant of oxygen supply to the heart muscle. Any disorder that reduces the lumen of an artery may cause a decrease in blood flow and oxygen delivery to heart muscle and may result in the acute coronary syndromes of angina, myocardial infarction, and sudden cardiac death. Coronary heart disease is the primary underlying cause of these syndromes and is he single largest killer of American can men and women. This refers to a blockage of a heart artery. It is caused by hardening of the arteries or a blood clot. Acute MI, also known as a heart attack, coronary occlusion, or simply a coronary , is a life-threatening condition characterized by the formation of localized necrotic areas within the myocardium. MI usually follows the sudden occlusion of a coronary artery and the abrupt cessation of blood and oxygen flow to the heart and

muscle. Because the heart muscle must common function continuously, necrotic areas can be lethal. Etiology and genetics risk- atherosclerosis is the primary factor in the development of coronary artery nc disease and acute coronary syndromes. Numerous

nonmodifiable and modifiable risk factors contribute to atherosclerosis. Non-Modifiable Risk Factors Nonmodifiable risk factors are personal elements that cannot be altered or controlled. These risk factors, which interact with each other, include age, gender, family history, and enthic background. The average age of a person having a first heart attack is 68.5 years of age for men and 70.4 years of age for women. Premenauposal woman have a lower incidence of MI than men do; however, for post menauposal women in their 70s, the incidence of MI equals that men. Family history is also risk factors; people whose parents had CAD are more susceptible. Incidence or prevalence- In 2000, the total mortality of those experiencing MI in the United States was 239,000. About every 29 seconds, an American suffers coronary events, and about every minute someone will die of one. About half of the people who experience an MI in a given year will die of it.

Many people die from coronary heart disease without being hospitalized. Most of these are sudden deaths caused by cardiac arrest, usually resulting from ventricular fibrillation. Ninety-five percent of sudden cardiac arrest victims die before reaching the hospital. To help combat this problem, autonomic external defibrillators are found in

many public places such as in shopping center or in airplanes. Employees i taught how to use this devices if a sudden cardiac arrest occurs. Complication of heart attack Heart failure When a large amount of heart muscle dies, the ability of the heart to pump blood to the rest of the body is diminished, and this can result in heart failure. The body retains fluid, and organs, for example, the kidneys, begin to fail. Ventricular Fibrillation Injury to heart muscle also can lead to ventricular fibrillation. Ventricular fibrillation occurs when the normal, regular, electrical activation of heart muscle contraction is replaced by chaotic electrical activity that causes the heart to stop beating and pumping blood to the brain and other parts of the body. Permanent brain damage and death can occur unless the flow of blood to the brain is restored within five minutes. Causes of Heart Attack Most heart attacks are caused by a blood clot that blocks one of the coronary arteries. The coronary arteries bring blood and oxygen to the heart. If the blood flow is blocked, the heart starves for oxygen and heart cells die. In atherosclerosis, plaque builds up in the walls of your coronary arteries. This plaque is made up of cholesterol and other cells. A heart attack can occur as a result of the following:

The slow build up of plaque may almost block one of your coronary arteries. A heart attack may occur if not enough oxygen-containing blood can flow through this blockage. This is more likely to happen when you are exercising. The plaque itself develops cracks (fissures) or tears. Blood platelets stick to these tears and form a blood clot (thrombus). A heart attack can occur if this blood clot completely blocks the passage of oxygen-rich blood to the heart. This is the most common cause. Blood clot (thrombosis) - the cause in most cases The common cause of an MI is a blood clot (thrombosis) that forms inside a coronary artery, or one of its branches. This blocks the blood flow to a part of the heart. Occasionally, sudden, significant emotional or physical stress, including an illness, can trigger a heart attack. Risk factors for heart attack and coronary artery disease include: Increasing age (over age 65) Male gender Diabetes Family history of coronary artery disease (genetic or hereditary factors) High blood pressure Smoking Too much fat in your diet

Symptoms of Heart Attack Although chest pain or pressure is the most common symptom of a heart attack, heart attack victims may experience a variety of symptoms including: Pain, fullness, and/or squeezing sensation of the chest Jaw pain, toothache, headache Shortness of breath Nausea, vomiting, and/or general epigastric (upper middle abdomen) discomfort Sweating Heartburn and/or indigestion Arm pain (more commonly the left arm, but may be either arm) Upper back pain General malaise (vague feeling of illness) No symptoms (Approximately one quarter of all heart attacks are silent, without chest pain or new symptoms. Silent heart attacks are especially common among patients with diabetes mellitus.) Classification of Myocardial Infarction The clients response to an MI also defense in which coronary artery or arteries were obstructed and which part of the left ventricle wall was damage: anterior, lateral, septal, inferior, or posterior. Obstruction of the left Anterior descending artery causes anterior or septal MIs because the LAD artery perfuses the arterial wall and most of the septum of the left

ventricle. Anterior wall MIs (AWMIs) account for 25% of all MIs and have the highest mortality rate. Clients with anterior MIs are most likely to experience left ventricular heart failure and ventricular dysrythmias because the large segment of the left ventricle wall may have been damaged. The circumflex artery supplies the lateral wall of the left ventricle and possibly portions of the wall or the sinoatrial (SA) and atrioventricular (AV) nodes. Clients with obstruction of the circumflex artery may experience a posterior wall MI (PWMIs) or a lateral wall MI (LWMIs) and sinus dysrythmias. And most people, the right coronary artery perfuses the SA and AvV nodes as well as the right ventricle and inferior or diaphragmatic portion of the left ventricle. Clients with obstruction of the right coronary artery often have inferior wall MIs. Inferior wall MIs (IWMIs) accounts for about 17% of all mIs and have a mortality rate of about 10%. Clinical Manifestation The clinical manifestation associated with MI result ischemia of the heart muscle and the decrease and function and acidosis associated with it. The major clinical manifestation of MI is chest pain which is similar to angina pectoris but more severe and unrelieved by nitroglycerin. The pain may radiate to the neck, jaw, shoulder, or left arm. The pain also present near epigastrium, simulating indigestion. MI may also be associated with les common clinical manifestation, including the following: atypical chest, stomach, back, or abdominal pain nausea and dizziness shortness of breath and difficulty of breathing unexplained anxiety or fatigue

palpitation, cold, sweat, or paleness Women experiencing MI frequently present with one or more of the less common clinical manifestation.

Local Related Studies Foreign Related Studies

Diabetes The term diabetes, without qualification, usually refers to diabetes mellitus, which roughly translates to excessive sweet urine (known as "glycosuria"). Several rare conditions are also named diabetes. The most common of these is diabetes insipidus in which large amounts of urine are produced (polyuria), which is not sweet (insipidus meaning "without taste" in Latin). The term "type 1 diabetes" has replaced several former terms, including childhood-onset diabetes, juvenile diabetes, and insulin-dependent diabetes mellitus (IDDM). Likewise, the term "type 2 diabetes" has replaced several former terms, including adult-onset diabetes, obesity-related diabetes, and non-insulin-dependent diabetes mellitus (NIDDM). Beyond these two types, there is no agreed-upon standard nomenclature. Various sources have defined "type 3 diabetes" as: gestational diabetes, insulin-resistant type 1 diabetes (or "double diabetes"), type 2 diabetes which has progressed to require injected insulin, and latent autoimmune diabetes of adults (or LADA or "type 1.5" diabetes)

According to the Public Health Nurse, Diabetes Mellitus is one of the leading causes of disability in persons over 45. More than half of diabetic persons will die of coronary heart disease. CAD tends to occur at an earlier age and with greater severity in persons with diabetes. It also increases the risk of dying cardiovascular disease like heart attack or stroke among women. It is not a single disease. It is a genetically and clinically heterogenous group of disorders characterized by glucose intolerance, with

hyperglycemia present at time of diagnosis. Diabetes mellitus is a condition which results from a lack of insulin. Insulin is a hormone produced by the pancreas. It is needed for the assimilation of glucose for energy or storage. Deficiency of or ineffectiveness of insulin results in high glucose level of the blood. The disease cannot be cured but it can be controlled with lifelong treatment. Diabetes Mellitus, a metabolic disorder of the pancreas, affects carbohydrate, fat and protein metabolism. Some believe that diabetes in adults is one consequence of metabolic syndrome, which includes obesity, especially in abdominal area; high blood pressure; elevated triglyceride low density lipoprotein, and blood glucose levels; and a low high- density lipoprotein level. Although no age group is exempt from diabetes, the American diabetes association (2002) indicates that 90% to 95% of affected persons acquire the disease as adults. Estimates for 2002 are that 18.3 million people in the United States have diabetes. According to the Centers for Disease Control and Prevention (CDC) (1998), there are 10.3 million Americans diagnosed as having diabetes mellitus. This is an increase from 8 million in 1995 and another 5 million in 1995. Another 5 million are estimated to be undiagnosed. Diabetes was the seventh leading cause of death in the United States and

associated with many serious complications (CDC, 1999). diabetes is the leading cause of new blindness among adults, the leading cause of new cases of renal failure, and is present in more than half of person's experiencing non-traumatic lower extremity amputations. Diabetes and its complications shorten a person's life span, create disability, and impose an economic burden on persons who have the disease (CDC, 1999) Symptoms: Constant thirst Polyuria or frequent urination Frequent hunger, strong appetite Weight loss despite a hearty appetite Tiredness, weakness. Tingling sensation and numbness in the hands and feet. Blurred vision Recurrent skin infections The first symptoms are related to the direct effects of high blood sugar levels. When the blood sugar level rises above 160 to 180 mg/dL, sugar spills into the urine. When the level of sugar in the urine rises even higher, the kidneys excrete additional water to dilute the large amount of sugar. Because the kidneys produce excessive urine, people with diabetes urinate large volumes frequently (polyuria). The excessive urination creates abnormal thirst (polydipsia). Because excessive calories are lost in the urine,

people lose weight. To compensate, people often feel excessively hungry. Other symptoms include blurred vision, drowsiness, nausea, and decreased endurance during exercise. Classification Pre-Diabetes Mellitus The National Health Institute of Diabetes and Digestive and kidney diseases (2004) have developed criteria that identify people with pre-diabetes, which can lead to Type II diabetes, heart disease and stroke. Peoplke with pre-diabetes may have impaired fasting glucose (IFG) or impaired glucose tolerancen (IGT), or both. A person with IFG has a fasting blood glucose level of 100 to 125 mg/dL after an overnight fast. In IGT, a person has a blood glucose level of 140 to 199 mg/dL after a glucose tolerance test lasting 2 hours. The NIDDK (2004) estimates there are 41 million Americans who have prediabetes. A significant number of those with pre-diabetes will develop the disease; however, many can delay or avoid Type 2 diabetes with weight loss and increased physical activity. The World Health Organization recognizes three main forms of diabetes mellitus: type 1, type 2, and gestational diabetes, which have different causes and population distributions The expert committee on the Diagnosis and Classification of Diabetes Mellitus (1997) has identified and described the two major forms of diabetes mellitus. Type I- insulin dependent diabetes mellitus (IDDM), also referred to as juvenile diabetes because it affects children and adolescents, is characterized by no insulin production by the beta cells in the islets of langerhans of the pancreas.

Type II- more common in aging adults. It is also being detected in obese children. The incidence of NIDDM now accounts for 20% of all newly diagnosed cases (Kimball, 2004) Type I diabetes is insulin dependent diabetes mellitus (IDDM) and Type II is non insulin dependent diabetes mellitus (NIDDM). Gestational diabetes is diabetes that develops during pregnancy. It may develop into full-blown diabetes. NIDDM is more common, occurring in about 90-95% of all persons with diabetes. It is also more preventable because it is associated with obesity and diet. Type I DM Characterized by absolute lack of insulin due to damaged pancreas, prone to develop ketosis, and dependent on insulin injections.

Genetic, environment, or may be acquired due to viruses (e.g. mumps, congenital rubella) and chemical toxins (e.g. Nitrosamines).

Type 1 diabetes is believed to be an autoimmune disease. The body's immune system attacks the cells in the pancreas that produce insulin.

Type 1 diabetes is most common in people of non-Hispanic, Northern European descent (especially Finland and Sardinia), followed by African Americans, and Hispanic Americans. It is relatively rare in those of Asian descent. Type 1 diabetes is slightly more common in men than in women

Type 1 diabetes is the end result of a long-standing process in which the body's own T cells at attack and destroy pancreatic beta cells, which are the source of the body's insulin. Auto antibodies to the islet cells cause a reduction of 80% to 90% of normal beta cell function before hyperglycemia and other manifestations occurs. A genetic predisposition and exposure to a virus are factors that may contribute to the pathogenesis of immune-related type-1 diabetes. Occasionally, type 1 diabetes may be caused by non immune factors of unknown etiologies. This type of diabetes is known as type 1B diabetes. When type1 diabetes is caused by an immune mechanism, the disease is known as type 1A. Predisposition to type1 diabetes is believed to be related to human leukocyte antigen (HLAs). Theoretically, when an individual with certain HLA types is exposed to viral infections, the beta cells of the pancreas are destroyed, either directly or through an autoimmune process. Type II DM Characterized by fasting hyperglycemia despite availability of insulin. Possible causes include impaired insulin secretion, peripheral insulin resistance and increase hepatic glucose production. Usually occurs in older and overweight persons (about 80%), High blood pressure, High blood triglyceride (fat) levels, gestational diabetes or giving birth to a baby weighing more than 9 pounds, Highfat diet, high alcohol intake, Sedentary lifestyle, Obesity or being overweight , Ethnicity, particularly when a close relative had type 2 diabetes or gestational diabetes: certain groups, such as African Americans, Native Americans, Hispanic Americans, and Japanese Americans, have a greater risk of developing type 2

diabetes than non- Hispanic whites. , Aging: Increasing age is a significant risk factor for type 2 diabetes. Risk begins to rise significantly at about age 45 years, and rises considerably after age 65 years. Risk factors of Type II DM Family history of diabetes (i.e., parents or siblings with diabetes) Overweight (BMI 23kg/m) and obesity (BMI > 30 kg/m) Sedentary lifestyle Hypertension HDL cholesterol <35 mg/dl (0.90 mmol/L) and/or triglyceride level > 250 mg/dl (2.82 mmol/L) History of Gestational diabetes mellitus (GDM) or delivery of a baby weighing 9 lbs (4.0 Kgs) Previously identified to have impaired Glucose tolerance (IGT) Gestational diabetes mellitus (GDM) resembles type 2 diabetes in several respects, involving a combination of relatively inadequate insulin secretion and responsiveness. According to our research, it occurs in about 2%5% of all pregnancies and may improve or disappear after delivery. Gestational diabetes is fully treatable but requires careful medical supervision throughout the pregnancy. About 20%50% of affected women develop type 2 diabetes later in life. Metabolic syndrome (also referred to as syndrome X) is a set of abnormalities in which insulin-resistant diabetes (type 2 diabetes) is almost always present along with hypertension, high fat levels in the blood (increased serum lipids, predominant elevation of LDL cholesterol, decreased HDL cholesterol, and elevated triglycerides), central

obesity, and abnormalities in blood clotting and inflammatory responses. A high rate of cardiovascular disease is associated with the metabolic syndrome. PATHOPHYSIOLOGY AND ETIOLOGY Insulin has three functions: (1) it carries glucose into body cells as their preferred source of energy, (2) it promotes the livers storage of glucose as glycogen, and (3) it inhibits the breakdown of glycogen back into glucose. In type I diabetes, the islet cells or endocrine portion of the pancreas, cease to produce insulin, Without insulin, the blood glucose level rises beyond its normal range sometimes to 300 to 1000 mg/dL, and the body breaks down fat and protein as alternative sources of cellular energy (Porth 2004). The breakdown of fat, known as lipolysis, results in the accumulation of fatty acids and ketones, metabolic by products of fat metabolism. When ketones accumulate in the blood, Clients with diabetes are prone to developing of metabolic acidosis known as ketoacidosis. COMPLICATIONS Acute complications includes

Diabetic ketoacidosis (DKA) s a serious condition in which uncontrolled hyperglycemia (usually due to complete lack of insulin or a relative deficiency of insulin) over time creates a buildup in the blood of acidic waste products called ketones. High levels of ketones can be very harmful. This typically happens to people with type 1 diabetes who do not have good blood glucose control. Diabetic ketoacidosis can be precipitated by infection, stress, trauma, missing medications like insulin, or medical emergencies like stroke and heart attack.

Hyperosmolar hyperglycemic nonketotic coma (HHNK) is a serious condition in which the blood sugar level gets very high. The body tries to get rid of the excess blood sugar by eliminating it in the urine. This increases the amount of urine significantly and often leads to dehydration so severe that it can cause seizures, coma, and even death. This syndrome typically occurs in people with type 2 diabetes who are not controlling their blood sugar levels, who have become dehydrated, or who have stress, injury, stroke, or are taking certain medications, like steroids.

hypoglycemia especially in type I diabetes or low blood sugar, occurs from time to time in most people with diabetes. It results from taking too much diabetes medication or insulin (sometimes called an insulin reaction), missing a meal, doing more exercise than usual, drinking too much alcohol, or taking certain medications for other conditions. It is very important to recognize hypoglycemia and be prepared to treat it at all times. Headache, feeling dizzy, poor concentration, tremors of hands, and sweating are common symptoms of hypoglycemia. You can faint or have a seizure if blood sugar level gets too low.

Poor healing of wounds Severe skin infection, gangrene (tissue death) Numbness, due to nerve damage with loss of sensation especially the feet.

Chronic complications cause most of the disability associated with the disease. These include chronic renal disease (neuropathy), blindness (retinopathy), coronary artery disease and stroke, neuropathies and foot ulcers. PREVENTION AND CONTROL

Maintain body weight and prevent obesity through proper nutrition and physical activity/exercise.

Encourage proper nutrition Eat more dietary fiber, reduce salt and fat intake, avoid simpke sugars like cakes and pastries; avoid junk foods.

Promote

regular

physical

activity

and

exercise

to

prevent

obesity

hypercholesterolemia and enhance insulin action in the body. Advise smoking cessation for active smokers and prevent exposure to secondhand smoke. Smoking among diabetics increases risk for heart attack and stroke.

The Diabetic patients are increasing according to studies so we must do a way to prevent or stop it. In our study, we will show the connection of Diabetis Mellitus to Heart Attack and Stroke. We will give knowledge to prevent further complications. We will inform the DM patients that they are more prone to heart attack and stroke and we will help them to prevent and maintain a healthy lifestyle without experiencing a heart attack or stroke.

In 2000, according to the World Health Organization, at least 171 million people worldwide suffer from diabetes, or 2.8% of the population. Its incidence is increasing rapidly, and it is estimated that by the year 2030, this number will almost double.

Scientific studies have found out that being diabetic doubles up the CVD risk and the risk to have a stroke, compared to those, who are non-diabetics. In fact, the onset of heart disease or stroke has been noticed even for younger people with diabetic condition. According to certain studies, the risk of having a heart failure for a diabetic person aged in his 40-50s is similar with the risk of a heart attack for a non-diabetic person, who already has suffered a heart attack. For women, the risk is comparatively less than the men of similar age group; provided they have not attained menopause. However, the CVD risk is pretty high for diabetic women, as it obstructs the protective effects of premenopause period. There is a high risk of second heart attack for a person, who has diabetes and already has had one heart attack. In these situations, most of the patients go through a critical condition, which often leads to death. All these health conditions are very much related to high level of blood glucose, as this leads changes in the walls of the blood vessels. When the blood vessels are affected, the proper circulation of blood gets prohibited and as a result the heart or brain gets damaged. If you have already had a heart attack or a stroke, taking care of yourself can help prevent future health problems. Lets see the comparison of Diabetes, Heart Attack and Stroke.