DIABETES

Diabetes is a defect in the bodys ability to convert glucose (sugar) to energy. Glucose is the main source of fuel for our body. When food is digested it is changed into fats, protein, or carbohydrates. Foods that affect blood sugars are called carbohydrates. Carbohydrates, when digested, change to glucose. Examples of some carbohydrates are: bread, rice, pasta, potatoes, corn, fruit,and milk products. Individuals with diabetes should eat carbohydrates but must do so in moderation. Glucose is then transferred to the blood and is used by the cells for energy. In order for glucose to be transferred from the blood into the cells, the hormone - insulin is needed. Insulin is produced by the beta cells in the pancreas (the organ that produces insulin). In individuals with diabetes, this process is impaired. Diabetes develops when the pancreas fails to produce sufficient quantities of insulin. People at risk: Strong Family history of diabetes African-American, Hispanic or Native American descent Obese History of delivering infants weighing > 9# (or gestational diabetes)Etiology and Pathophysiology Identical twins have 50% chance of both getting the disease (type 2) when one twin has it- but fraternal twins have 90% chance

TWO MAIN TYPES OF DIABETES Type 1 (also known as Juvenile & Insulin Dependent Diabetes)
Occurs most frequently in children and young adults, although it can occur at any age. Accounts for 5-10% of all diabetes in the United States. Type 1 (also known as Juvenile & Insulin Dependent Diabetes) 10% of diabetics - abrupt onset Usually occurs before age 40 but can happen in older people B cells dont produce insulin - must have insulin injection Clinical Manifestations Sudden onset of polyuria, polydipsia, and polyphagia. Weight loss despite increased food intake, extreme fatigue and pruitus and vaginal itching

Type 2 diabetes-(also known as non-insulin dependent or Adult onset diabetes).

More common and accounts for 90-95% of all diabetes. Usually occurs after age 40 B cells produce - maybe not enough - but most often the insulin will not bind to the receptor sites on the cells May be related to defective receptors, or not enough receptors, or the inside of the cell is defective

Insulin resistance stimulates a compensatory increased insulin production by beta cells in the pancreas These people can sometimes control their diabetes by staying on a strict diet and exercising If that doesnt work they can be prescribed Oral hypoglycemic medications. If the oral hypoglycemic meds dont work they must get insulin Many type 2 diabetics require insulin during stress but return to oral hypoglycemics when the stress is relieved (they are not insulin dependent) Hemoglobin A1c provides an overview of the glucose levels for the previous 3 months Normals are 7% - 11%. Greater than 15% indicates that the disease is out of control Clinical Manifestations Rarely develop polyuria, polydipsia or polyphagia & if they do the symptoms are less severe than type 1 patients (women do have vaginitis leading to vaginal itching) Oral Hypoglycemic Agents Sulfonylureas are used for type II diabetics who have some functioning beta cells It stimulates the beta cells to produce more insulin, reduces the accelerated rate of hepatic glucose production in type 2 diabetics, partially reduces the number of cellular insulin receptors Oral Hypoglycemic Agents First generation OHAs Orinase, Dymelor, Tolinase, Diabenese Second generation (called that because they came on the scene later) Glucotrol,Micronase, DiaBeta, Glynase 2nd generation drugs have fewer adverse effects, are about 100 times more potent by weight & have more predictable time actions and half-lives - but they are expensive Metformin (Glucophage) Not a sulfonylurea Not bound to plasma proteins, is not metabolized in the liver and is eliminated rapidly by the kidneys It lowers blood sugar but does not cause hypoglycemia

DIAGNOSIS
The diagnosis of diabetes is made by a simple blood test measuring your blood glucose level. Usually these tests are repeated on a subsequent day to confirm the diagnosis. Both forms and all stages of diabetes are serious, with many possible complications, including eye, heart, kidney, and nerve damage.

MANAGEMENT
Diet is the cornerstone of diabetic treatment - lack of adherence to the diet is the one area of selfmanagement most responsible for poor control of diabetes most widespread & currently accepted diet is the exchange diet created by the American Diabetes Association

DIABETIC DIET
55-60% of total calories should be carbohydrates (complex preferred) 15 -20% protein Less than 30% fat cholesterol should be < 300 mg/day & sodium < 3 gm some foods are free foods because they have fewer than 20 calories per serving (sugar free carbonated drinks, coffee, tea, lettuce, sugar free geletin and 1 tbsp catsup -seasonings)

DIABETIC EDUCATION
A specific # of calories is prescribed for each patient depending upon patients bodyweight, occupation, age, activities, and type of diabetes responses to the diet should be monitored & adjustments made as necessary Diet Education Never skip meals Eat at regularly spaced intervals Recognize appropriate food portions Alcohol can cause hypoglycemia in patients on glucose lowering agents but is high in calories Alcohol may produce Antabuse effect proportional to the amount ingested with certain OHAs

TEACHING ABOUT INSULIN

Store unopened insulin in the refrigerator. Do not freeze Store opened bottles that will be used within a month at room temperature Bring refrigerated insulin to room temperature before injecting Do not expose to sunlight Rotate injection sites to avoid lipodystrophy. Do not inject within 1 inch of the previous injection site. Best to use the abdomen for consistent absorption. Do not inject into a part which will be exercised that day Insulin pumps are available but they are expensive $4100 to $10,000 Blood Glucose Monitoring Patient should be matched to a machine (cognitive functioning and physical coordination) Many patients test their own blood sugar 4 times/day - but most only do it once while at home.

MONITORING SELF CARE

foot care : inspect feet daily for sores, blisters, swelling, redness, & tenderness. Wash feet daily using mild soap. Pat dry and apply Lanolin type lotion (not between toes). Test water before putting feet in it. Do not soak feet. War shoes with soft linings. Do not walk barefooted in the house or outside. Do not use hot water bottle . Cut toenails straight and even with the toe. If fungus infected have the podiatrist care for them. Have a podiatrist treat any foot problems like corns or calluses. Do not cross legs at the knees or ankles. Diabetic complications: Diabetic comas (Diabetic hypoglycemia, Diabetic ketoacidosis, Nonketotic hyperosmolar) Diabetic angiopathy Diabetic foot (ulcer, neuropathic arthropathy) Diabetic myonecrosis Diabetic nephropathy Diabetic neuropathy Diabetic retinopathy Diabetic cardiomyopathy Diabetic dermadrome (Diabetic dermopathy,Diabetic cheiroarthropathy, Neuropathic ulcer POSSIBLE NURSING DIAGNOSIS. Anticipatory grieving Ineffective individual coping Fluid volume deficit Altered peripheral tissue perfusion Risk for injury Risk for altered health maintenance References: http://www.camdenhealth.org/wp-content/uploads/2011/03/Insulin_Preparation-3-14-11.pdf http://www.nursingcenter.com smeltzer, et al. Text book of medical surgical Nursing12th edition