Care of Clients with Diabetes Mellitus

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Part 1 - Basics

ADA Guidelines for Diagnosis

Normal serum glucose: 70-110Diabetes FBS > 126 on 2 occasions Random glucose > 200 with symptoms

Pre-diabetes FBS > 100 Random glucose 140- 200

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Type 1 Diabetes

Autoimmune reaction in which beta cells that produce insulin are destroyed

Genetic predisposition: HLA linkage

Environmental triggers can stimulate an autoimmune response Viral infections: mumps, rubella,

coxsackievirus 3

Treatment Type 1 Diabetes

DietExerciseInsulinMonitoring

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Type 2 Diabetes- Etiology

Insulin resistanceDecreased production of insulin by

beta cellsLiver releases too much glucoseGenetics

http://www.diabetes.org

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Type 2 Diabetes- symptoms

Few symptoms initially Fatigue Altered vision Nocturia Skin infections, vaginal infections,

poor wound healing

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Type 2 Diabetes Risk Factors

Obesity Family history Over age 45 High-risk ethnic group: African, Native

American, Hispanic Delivery of baby > 9 pounds History of: gestational diabetes,

polycystic ovary syndrome Hypertension

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Type 2 diabeteschildren & adolescents

Incidence on the rise No symptoms in early stage of

disease Symptoms: frequent infections,

weight loss with increased appetite, blurry vision, polyuria, bed wetting

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Acanthosis nigricans

Area of darkened skin & velvety thickening on the child’s neck, armpits, groin, or other areas of skin folds.

Sign of insulin resistance Found in 90% of children with type 2 Most often seen in African American

& Hispanics

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Acanthosis nigricans

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Type 2 diabetes in children

Prevention: Exercise 1 hr/day, healthy diet

Test high risk groups age 10 years or more every 2 years Overweight Family history Hispanic, African American, Asian

American

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Treatment Type 2 Diabetes

DietMonitoring blood glucoseExerciseOral MedicationInsulin

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Gestational diabetes

Last half of pregnancy placenta produces insulin antagonist (human placental lactogen)

Leads to increased placental destruction of insulin

Insulin production needs to increase 2-3 X non- pregnant level

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Gestational Diabetes: Diagnosis

1 hour glucose challenge test using a 50 gram oral glucose if results > 140 mg/dl will have to retest with:

3 hour glucose tolerance test using 100 gram oral glucose: diagnosis confirmed when any 2 or more glucose values are over 140 mg/dl 14

Gestational Diabetes: Treatment

Blood glucose self-monitoringDietExerciseStress managementPharmacologic therapy: insulin

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Gestational diabetes- effects on infant

Macrosomia- 9.9 lbs or >

Hypoglycemia- for first 72 hours of life Infant accustomed to increase in

glucose which leads to hyperinsulinemia in the infant. At birth the glucose supply from mother is no longer present but infants pancreas continues to produce large amounts of insulin.

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Gestational Diabetes

No longer have diabetes after delivery of infant

Women with gestational diabetes have up to a 45% risk of recurrence with next pregnancy and up to 63% risk of developing type 2 diabetes later in life

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Diet

Food Guide Pyramid www.mypyramid.gov

Carbohydrate Counting 15 gm CHO= 1

exchange 45-60 grams per

meal

Plate MethodExchange List

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Diet education

Initially should be done by dietitian Never skip meals if on oral

sulfonylureas Learn to recognize food portions Alcohol suppresses liver production of

sugar

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Diet Education

Remember: No foods are forbidden for people

with diabetes It’s not carbs the patient should

worry about It’s the amount of carbs consumed Portion control !!!!

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Carbohydrate

Healthy carbs come from fruit, veggies, whole grains, legumes and low-fat milk

Need to monitor intake and divide throughout the day

Sugar is allowed within reason Fiber is recommended

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Food Labels

Locate serving size Locate total grams

of carbohydrate 15 g = 1 carb

choice Ignore sugar

grams

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X

Exercise

Regular Consistent Aerobic: 30 min/day most days Resistance training: 2-3

times/week Type 1- increases insulin

sensitivity Type 2- wt loss, decrease insulin resistance

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Self-Monitoring of Blood Glucose (SMBG)

Modern meters Small blood volume (0.3 to 4 L) Ability to use alternate sites Shorter results time: 5 to 10

seconds Very accurate if maintained

properly

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Monitoring Glycemic Control

A1C formerly know as Hgb A1C

Blood test measuring glycosylated Hgb A Glycosylation: glucose binds irreversibly

to Hgb A1C reflects mean glucose level past 2-3

months Check every 3-6 months

Normal < 6%Goal for diabetic < 7%

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Targets for Glucose ControlType 1 and Type 2 Diabetes

Fasting/Pre-meal glucose

Post-meal glucose2 hr. after start of

meal

Bedtime glucose

A1C

70-130 mg/dL

<180 mg/dL

100-140 mg/dL

7%

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A1C and blood sugar results

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Insulin Therapy

Type 1- always required

Type 2- during periods of stress, illness, surgery and when all other treatments fail

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Insulin

36% with type 2 diabetes use insulin within 5 years of diagnosis 50%

require Weight gain can be significant: 5-10

kg 1st yr Insulin dose needed varies Most serious side effect is

hypoglycemia

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Terms describing time & effect of insulin

Onset: time span after administration when insulin will begin to effect the blood glucose level

Peak: time span after administration when the insulin will have the greatest effect on the blood glucose level

Duration: time span after administration when insulin will continue to effect the blood glucose level

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Basal & Bolus

Basal Insulin: insulin required to suppress hepatic glucose production between meals

Bolus Insulin: insulin required to maintain normal glucose disposal after meals

Normal process of pancreas in healthy person 31

Storage of Insulin

Open vial at room temperature 30 days

No direct sunlight Do not store in freezer Keep out of glove compartment Extra vial in door of refrigerator

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Mixing Insulin

Always draw up clear first to prevent contamination of fast acting insulin

Can be pre-drawn and stored in refrigerator for 1 week Store needle upright & agitate

syringe before administering

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Box 18.3 Mixing insulin (Figures only)

Sliding Scale

Used with intensive insulin therapy and during hospitalization to maintain euglycemia

Accu-check should be no more than ½ hour prior to the administration of the corrective insulin dose

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Sites for injection

AbdomenBack of armMiddle anterior thighUpper buttocks

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Rotation of sites

Insulin injections should be given in the same region at a specific time of day & rotated within that region

Due to difference in absorption rates of sites

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Insulin devises

Insulin pump- receives rapid acting insulin continuously per subcutaneous route

Insulin pen- good for visually impaired and people with problems with dexterity

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Insulin Pumps

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Insulin Pump site

Insulin Pump: During hospitalization

Have physician write orders to leave the pump in place

Don’t discontinue the pump unless insulin therapy is given IV or subcutaneously

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Insulin Pump: During hospitalization

Patient should change their site every 2-3 days

and

Whenever blood glucose is over 240 mg/dl for 2 tests in a row

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Oral Antihyperglycemic Agentsfor Type 2 Diabetes

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ClassSulfonylureas

Biguanides

Thiazolidinediones

Meglitinides

α-Glucosidase inhibitors

DPP-4 Inhibitors