All About DiabetesAll About Diabetes

By: Shirley(My Notes)

What Causes Diabetes?What Causes Diabetes?

• Type IType I--The pancreas is unable to produce insulin. The pancreas is unable to produce insulin. Childhood and genetic tendency are two possibilities. Childhood and genetic tendency are two possibilities. There’s a change in the pancreatic function and the There’s a change in the pancreatic function and the cells that normally produce insulin are destroyed. The cells that normally produce insulin are destroyed. The body’s own immune system may think the pancreas is a body’s own immune system may think the pancreas is a foreign body! This form often appears at a time of foreign body! This form often appears at a time of physical stress or during illness when the body produces physical stress or during illness when the body produces more glucose. Unable to metabolize carbohydrates.more glucose. Unable to metabolize carbohydrates.

• Type IIType II--The pancreas can still produce insulin but the The pancreas can still produce insulin but the amount is inadequate and/or the insulin can’t be used to amount is inadequate and/or the insulin can’t be used to its full extent by the tissues. Most people who have this its full extent by the tissues. Most people who have this type are overweight. This type is the most prevalent.type are overweight. This type is the most prevalent.

*Glucose-70-110 mg/dl*

Signs & SymptomsSigns & Symptoms

• Type IType I--Polyuria Polyuria (Frequent Urination)(Frequent Urination)

--Polydipsia Polydipsia (Excessive thirst)(Excessive thirst)

--PolyphagiaPolyphagia (Excessive hunger)(Excessive hunger)

--Fatigue/WeaknessFatigue/Weakness-Weight loss-Weight loss-Ketoacidosis -Ketoacidosis ((ketonketon==form of form of acetone. Acidosis=accumulation of acetone. Acidosis=accumulation of ketones in the body resulting from ketones in the body resulting from extensive breakdown of fats extensive breakdown of fats because of bad carbohydrate because of bad carbohydrate metobolismmetobolism.).)

• Type IIType II--Often nonspecific but may Often nonspecific but may have some of the same have some of the same classic symptoms as Type I. classic symptoms as Type I. -Fatigue-Fatigue-Recurring infections-Recurring infections-Delayed wound healing.-Delayed wound healing.

-Visual disturbances.-Visual disturbances.

Type I & Type II:Type I & Type II:What’s the difference?What’s the difference?

• Type IType I(5-10%)(5-10%)--More common in young people but More common in young people but can happen at any age.can happen at any age.-Signs and symptoms have abrupt -Signs and symptoms have abrupt onset.onset.-Minimal or ABSENT endogenous -Minimal or ABSENT endogenous insulin.insulin.--Patient usually thin.Patient usually thin.--Need insulin to live!Need insulin to live!--Islet cell antibodies are often present Islet cell antibodies are often present at onset. at onset. -Virus & Toxins are environmental -Virus & Toxins are environmental factors. factors. --Prone to ketosis at onset or during Prone to ketosis at onset or during insulin insufficiency.insulin insufficiency.--Frequent neurologic and vascular Frequent neurologic and vascular complications. complications.

• Type IIType II(90%)(90%)--Patient’s are usually 35+ but it can occur at Patient’s are usually 35+ but it can occur at any age. any age. -Signs & symptoms occur gradually. -Signs & symptoms occur gradually. -Excessive endogenous insulin; may be -Excessive endogenous insulin; may be adequate but inadequate secretion and use.adequate but inadequate secretion and use.--Patient usually obesePatient usually obese; May be normal ; May be normal weight. weight. -Islet cells are absent.-Islet cells are absent.--Insulin required for some. Diet, exercise my Insulin required for some. Diet, exercise my be only necessary treatment for others.be only necessary treatment for others.--Obesity & sedentary lifestyle are Obesity & sedentary lifestyle are environmental factors. environmental factors. -Resistant to ketosis except during infection -Resistant to ketosis except during infection or stress. or stress. -Frequent neurologic and vascular -Frequent neurologic and vascular complications. complications.

• Diabetes is more often seen in Diabetes is more often seen in Hispanics, Native Americans, Hispanics, Native Americans, and African Americans. and African Americans. However, anyone can get it. However, anyone can get it.

Diagnosing DiabetesDiagnosing Diabetes

Diagnosis must be confirmed Diagnosis must be confirmed on a subsequent day by any on a subsequent day by any of the diagnostic methods of the diagnostic methods used. used.

• FPG (Fasting Plasma FPG (Fasting Plasma Glucose)-Glucose)-Preferred method Preferred method of diagnosis.of diagnosis. Exceeding 200 Exceeding 200 mg/dlmg/dl

• Random plasma glucose Random plasma glucose measurement exceeding measurement exceeding 200 mg/dl. 200 mg/dl. Must have other Must have other signs and symptoms too.signs and symptoms too.

• 2-hour OGTT (Oral-glucose 2-hour OGTT (Oral-glucose tolerance test) exceeding tolerance test) exceeding 200 mg/dl using glucose 200 mg/dl using glucose load of 75g.load of 75g.

Treatment-InsulinTreatment-Insulin• RegularRegular

(Humulin R, Novolin R, (Humulin R, Novolin R, Regular Iletin)Regular Iletin)Short-actingShort-actingOnset: ½ -1 hourOnset: ½ -1 hourPeak: 2-3 hoursPeak: 2-3 hoursDuration: 4-6 hoursDuration: 4-6 hours

• NPH or LenteNPH or Lente(Humulin N, Novolin N, (Humulin N, Novolin N, Humulin L, Novolin L)Humulin L, Novolin L)Intermediate-actingIntermediate-actingOnset: 2 hoursOnset: 2 hoursPeak: 6-8 hoursPeak: 6-8 hoursDuration: 12-16 hoursDuration: 12-16 hours

• UltralenteUltralente(Humulin U)(Humulin U)Long-actingLong-actingOnset: 2 hoursOnset: 2 hoursPeak: 16-20 hoursPeak: 16-20 hoursDuration: 24+ hoursDuration: 24+ hours

• Lispro (Humalog)Lispro (Humalog)Rapid-ActingRapid-ActingOnset: 15 minutesOnset: 15 minutesPeak: 60-90 minutesPeak: 60-90 minutesDuration: 3-4 hoursDuration: 3-4 hours

• Insulin glargine Insulin glargine (Lantus)(Lantus)Long-actingLong-actingOnset: 1-2 hoursOnset: 1-2 hoursPeak: No pronounced peakPeak: No pronounced peakDuration: 24+ hoursDuration: 24+ hours

In the past, pork and beef insulin was used. Now mostly human insulin which is derived from common bacteria or yeast cells using recombinant DNA. It is not harvested from humans.

Insulin RegimensInsulin Regimens

RegimenRegimenTypeType

of insulin of insulinTime Time

intervalintervalPositivesPositives NegativesNegatives

Single DoseSingle Dose IntermediateIntermediate 7 AM to a little 7 AM to a little after 6 PMafter 6 PM

One injection One injection should cover should cover

lunch and lunch and dinner.dinner.

No coverage of No coverage of fasting, breakfast, fasting, breakfast,

or nighttime or nighttime coverage of coverage of

hyperglycemia is hyperglycemia is available. available.

Split-MixedSplit-Mixed

70/3070/30Intermediate & Intermediate &

Regular or Regular or HumalogHumalog

2 injections 2 injections cover 24 hours.cover 24 hours.

2 injections are 2 injections are required. Patient required. Patient has to have set has to have set meal pattern. meal pattern.

Split-MixedSplit-Mixed Intermediate & Intermediate & Regular or Regular or HumalogHumalog

3 injections cover 3 injections cover 24 hours, especially 24 hours, especially

during early AM during early AM hours. Reduced hours. Reduced

potential for 2-3 AM potential for 2-3 AM hypoglycemiahypoglycemia..

3 injections are 3 injections are required. required.

Multiple DoseMultiple Dose Intermediate & Intermediate & Regular or Regular or HumalogHumalog

More flexibility More flexibility allowed at allowed at

mealtimes and mealtimes and for how much for how much

eaten. eaten.

4 injections are 4 injections are required. Need required. Need

premeal glucose premeal glucose checks. Pts. checks. Pts.

W/Type I will need W/Type I will need basal insulin.basal insulin.

Multiple DoseMultiple Dose(Split-Dose long-(Split-Dose long-

acting) acting) UltralenteUltralente

Regular or Regular or Humalog and Humalog and long-acting long-acting

insulininsulin

Insulin delivery Insulin delivery more like normal more like normal insulin delivery. insulin delivery.

Requires 3 or 4 Requires 3 or 4 injections, premeal injections, premeal

glucose checks; glucose checks; retiring too.retiring too.

Mixing InsulinsMixing Insulins• Wash Hands.Wash Hands.• After inspection, carefully After inspection, carefully

rotate NPH insulin bottle to rotate NPH insulin bottle to mix insulin. mix insulin.

• Wipe off tops of insulin vials Wipe off tops of insulin vials with alcohol swab. with alcohol swab.

• Draw back air into the syringe Draw back air into the syringe that will equal the total dose. that will equal the total dose. Ex: 36 U of air/36 U of NPH Ex: 36 U of air/36 U of NPH insulin.insulin.

• Inject that equal amount of air Inject that equal amount of air into NPH vial.into NPH vial.

• Inject same amount of air Inject same amount of air equal to regular dose of equal to regular dose of regular insulin. Ex. 12 U of regular insulin. Ex. 12 U of air/12 U of Regular insulin.air/12 U of Regular insulin.

• Invert regular insulin bottle Invert regular insulin bottle and withdraw regular insulin and withdraw regular insulin dose.dose.

• Don’t add more air to NPH vial Don’t add more air to NPH vial but follow Regular by but follow Regular by withdrawing NPH. withdrawing NPH.

• 36 + 12=48 U (Total Dose)36 + 12=48 U (Total Dose)

Injection SitesInjection Sites• Most commonly by Most commonly by

subcutaneous (SQ). Given subcutaneous (SQ). Given by intravenous (IV) when by intravenous (IV) when immediate action needed. immediate action needed.

• Fastest absorption in the Fastest absorption in the abdomenabdomen, then the arm, , then the arm, then the thigh, and lastly then the thigh, and lastly the buttock.the buttock.

• Do not inject into a site that Do not inject into a site that is going to be exercised.is going to be exercised.

• Prevent lipodystrophy Prevent lipodystrophy (lumps & dents in the skin-(lumps & dents in the skin-Human insulin reduces risk) Human insulin reduces risk) by rotating sites. Rotate by rotating sites. Rotate injection within one injection within one particular site. Think of the particular site. Think of the abdomen as a abdomen as a checkerboard.checkerboard.

Insulin syringesInsulin syringes• Most are U100 which equal 1 ml. Most are U100 which equal 1 ml. • 0.5 ml used for 50 U or less. 0.5 ml used for 50 U or less. • 0.3 ml used for 30 U or less. 0.3 ml used for 30 U or less. • Smaller syringes=More advantagesSmaller syringes=More advantages• No need to use alcohol swab on site before No need to use alcohol swab on site before

injection when self-injecting. injection when self-injecting. • Insulin pens are good too. Usually Insulin pens are good too. Usually

preloaded with insulin and look less preloaded with insulin and look less medical. “InDuo” combines an insulin medical. “InDuo” combines an insulin syringe with a blood glucose monitor! syringe with a blood glucose monitor!

• Insulin pumps-Continuous SQ insulin Insulin pumps-Continuous SQ insulin infusion. Looks like a pager. Catheter infusion. Looks like a pager. Catheter inserted into SQ tissue in the abdominal inserted into SQ tissue in the abdominal wall. wall.

• Intensive insulin therapy-An alternative to Intensive insulin therapy-An alternative to the insulin pump. Consists of multiple daily the insulin pump. Consists of multiple daily insulin injections with frequent self-insulin injections with frequent self-monitoring of blood glucose. monitoring of blood glucose.

Insulin, Insulin, InsulinInsulin, Insulin, Insulin

• After you open the After you open the insulin, write the date on insulin, write the date on the vial.the vial.

• Insulin can be stored at Insulin can be stored at room temperature for 30 room temperature for 30 days. After that, throw it days. After that, throw it away even if there is away even if there is some still left.some still left.

• Do not store insulin in Do not store insulin in very cold places or very very cold places or very warm places. warm places.

• Don’t store it in direct Don’t store it in direct light.light.

• Take your insulin before Take your insulin before you eat. If you take you eat. If you take

LantusLantus, take it at bedtime., take it at bedtime. Also, never mix Also, never mix LantusLantus with another insulin.with another insulin.

• Take Take HumalogHumalog or or NovologNovolog 15 minutes before eating.15 minutes before eating.

• Take your insulin and eat Take your insulin and eat at the same time every at the same time every

single day.single day. • Side Effects? Side Effects?

Hypoglycemia, weight Hypoglycemia, weight gain.gain.

MedicineMedicine• SulfonylureasSulfonylureas--Primary use is to increase insulin production Primary use is to increase insulin production

from the pancreas. Examples: tolbutamide (Orinase), from the pancreas. Examples: tolbutamide (Orinase), acetohexamide (Dymelor), tolazamide (Tolinase), and acetohexamide (Dymelor), tolazamide (Tolinase), and chlorpropamide (Diabinese).chlorpropamide (Diabinese).

• MeglitinidesMeglitinides--Also increases insulin production. Offers reduced Also increases insulin production. Offers reduced potential for hypoglycemia because of fast absorption. potential for hypoglycemia because of fast absorption. Examples: repaglinide (Prandin), and nateglinide (Starlix).Examples: repaglinide (Prandin), and nateglinide (Starlix).

• BiguanidesBiguanides--Primary action is to reduce glucose production Primary action is to reduce glucose production from the liver. Also enhances insulin sensitivity at tissue level from the liver. Also enhances insulin sensitivity at tissue level and improves the transport of glucose to the cells. Example: and improves the transport of glucose to the cells. Example: metformin (Glucophage). Combinations include metformin metformin (Glucophage). Combinations include metformin with glyburide (Glucovance), rosiglitazone (Avandia), and with glyburide (Glucovance), rosiglitazone (Avandia), and glipizide (Metaglip).glipizide (Metaglip).

• aa-Glucosidase inhibitors-Glucosidase inhibitors--Starch blockers.Works by slowing down the absorption of Starch blockers.Works by slowing down the absorption of carbohydrates in the small intestine. Most effective in lowering post-prandial blood carbohydrates in the small intestine. Most effective in lowering post-prandial blood glucose when taken glucose when taken with the first bitewith the first bite of each main meal. Not effective against of each main meal. Not effective against fasting hyperglycemia. Examples: acarbose (Precose), and miglitol (Glyset).fasting hyperglycemia. Examples: acarbose (Precose), and miglitol (Glyset).

• ThiazolidinedionesThiazolidinediones-Insulin sensitizers. Most effective with people who have insulin -Insulin sensitizers. Most effective with people who have insulin resistance. Improve insulin sensitivity, transport, and utilization of target tissues. resistance. Improve insulin sensitivity, transport, and utilization of target tissues. Will not cause hypoglycemia when used alone but still risky if used with a Will not cause hypoglycemia when used alone but still risky if used with a sulfonylurea or insulin. This med may even improve lipid profiles and blood sulfonylurea or insulin. This med may even improve lipid profiles and blood pressure levels! Examples: pioglitazone (Actos), and rosiglitazone (Avandia).pressure levels! Examples: pioglitazone (Actos), and rosiglitazone (Avandia).

Complications of Complications of DiabetesDiabetes

• HypoglycemiaHypoglycemia• Diabetic Ketoacidosis (DKA)Diabetic Ketoacidosis (DKA)• Hyperosmolar Hyperglycemic Hyperosmolar Hyperglycemic

Nonketotic Syndrome (HHNS)Nonketotic Syndrome (HHNS)• If the patient is sick, make sure If the patient is sick, make sure

they know to stay on their insulin they know to stay on their insulin or meds for diabetes and to or meds for diabetes and to continue their nutritional therapy.continue their nutritional therapy.

Acute ComplicationsAcute Complications• Diabetic Ketoacidosis (DKA)Diabetic Ketoacidosis (DKA)

-Also known as diabetic acidosis and diabetic coma. -Also known as diabetic acidosis and diabetic coma. -Caused by a major deficiency of insulin.-Caused by a major deficiency of insulin.-Is characterized by hyperglycemia, ketosis, acidosis, and -Is characterized by hyperglycemia, ketosis, acidosis, and dehydration.dehydration.-Most often seen in Type I but can occur in Type II also.-Most often seen in Type I but can occur in Type II also.-Factors that cause it include illness, infection, inadequate insulin -Factors that cause it include illness, infection, inadequate insulin dose, undiagnosed Type I diabetes, poor self-care and management.dose, undiagnosed Type I diabetes, poor self-care and management.-Renal failure may occur from hypovolemic shock. -Renal failure may occur from hypovolemic shock. -Patient may become comatose from dehydration, electrolyte -Patient may become comatose from dehydration, electrolyte imbalance, and acidosis. If untreated, the patient would die. imbalance, and acidosis. If untreated, the patient would die. -Signs and Symptoms of DKA include poor skin turgor from -Signs and Symptoms of DKA include poor skin turgor from dehydration, dry mucous membranes, tachycardia, and orthostatic dehydration, dry mucous membranes, tachycardia, and orthostatic hypotension. Early symptoms may show lethargy and weakness. hypotension. Early symptoms may show lethargy and weakness. Skin may become dry and loose and the Skin may become dry and loose and the eyeballs may become eyeballs may become soft and sunken in. Abdominal pains is another symptomsoft and sunken in. Abdominal pains is another symptom. . There may be anorexia and vomiting. Breath may have a fruity, There may be anorexia and vomiting. Breath may have a fruity, acetone odor.acetone odor.--Kussmaul respirationsKussmaul respirations (rapid, deep breathing) will be another (rapid, deep breathing) will be another ultimate sign. ultimate sign. Lab:Blood Glucose >250 mg/dl, pH <7.35, serum bicarbonate

<15 mEq/L, ketones in blood and urine.

Emergency Treatment Emergency Treatment for DKAfor DKA

• Initial InterventionsInitial Interventions-Ensure patent airway.-Ensure patent airway.-Administer O2 via nasal -Administer O2 via nasal cannula or non-rebreather cannula or non-rebreather mask.mask.-Establish IV access with -Establish IV access with large-bore catheter.large-bore catheter.-Begin fluids with 0.9% NaCl -Begin fluids with 0.9% NaCl solution 1L/hr until blood solution 1L/hr until blood pressure is stable and urine pressure is stable and urine output is 30-60 ml/hr.output is 30-60 ml/hr.Begin continuous regular Begin continuous regular insulin drip. 0.1 U/kg/hr.insulin drip. 0.1 U/kg/hr.-Identify history of diabetes, -Identify history of diabetes, time patient last ate, and time patient last ate, and time/amount of last insulin time/amount of last insulin injection.injection.

• MonitoringMonitoring-Monitor VS, level of -Monitor VS, level of consciousness (LOC), consciousness (LOC), cardiac rhythm, O2 Sat., cardiac rhythm, O2 Sat., and urine output. and urine output. -Assess breath sounds for -Assess breath sounds for fluid overload. fluid overload. -Monitor serum glucose and -Monitor serum glucose and serum potassium. serum potassium. -Give potassium to -Give potassium to correct hypokalemia.correct hypokalemia. -Give sodium bicarbonate if -Give sodium bicarbonate if acidosis is severe. (acidosis is severe. (pH pH <7.0<7.0))

Another ComplicationAnother Complication• Hyperosmolar hyperglycemic Hyperosmolar hyperglycemic

nonketotic syndrome (HHNS)nonketotic syndrome (HHNS)--Life-threatening!Life-threatening!-May occur in the diabetic who can produce enough insulin to -May occur in the diabetic who can produce enough insulin to prevent DKA but not enough to avoid severe hyperglycemia, prevent DKA but not enough to avoid severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion.osmotic diuresis, and extracellular fluid depletion.-Unlike the patient with DKA, the patient with HHNS usually -Unlike the patient with DKA, the patient with HHNS usually has enough insulin so that ketoacidosis does not occur. has enough insulin so that ketoacidosis does not occur. -In the early stages of HHNS, there are few symptoms which -In the early stages of HHNS, there are few symptoms which means that blood glucose levels can get really high before the means that blood glucose levels can get really high before the problem is noticed. problem is noticed. -Often occurs in the older Type II diabetes patient. -Often occurs in the older Type II diabetes patient. -Signs & Symptoms of HHNS include extreme hyperglycemia, -Signs & Symptoms of HHNS include extreme hyperglycemia, severe osmotic diuresis, decreased sodium, potassium, and severe osmotic diuresis, decreased sodium, potassium, and phosphorous, dehydration, decreased renal perfusion, phosphorous, dehydration, decreased renal perfusion, hypotension, hemoconcentration, oliguria, thrombosis, hypotension, hemoconcentration, oliguria, thrombosis, increased lactic acid. increased lactic acid. -Ultimately seizures, shock, coma, and death. -Ultimately seizures, shock, coma, and death.

Lab: Blood glucose >400 mg/dl, marked increase in serum osmolality. Ketone bodies are absent or minimal in blood or urine.

Emergency Treatment Emergency Treatment for HHNSfor HHNS

• High mortality rate. Needs greater fluid replacement than DKA.High mortality rate. Needs greater fluid replacement than DKA.• Therapy is similar to that of DKA and includes immediate IV Therapy is similar to that of DKA and includes immediate IV

administration of 0.9% or 0.45% NaCl at a rate dependent on the administration of 0.9% or 0.45% NaCl at a rate dependent on the patient’s cardiac status and the degree of fluid volume deficit.patient’s cardiac status and the degree of fluid volume deficit.

• Regular insulin given by IV bolus. Afterwards it’s given as an Regular insulin given by IV bolus. Afterwards it’s given as an infusion after fluid replacement therapy is begun to help in infusion after fluid replacement therapy is begun to help in reducing the hyperglycemia. reducing the hyperglycemia.

• After the blood glucose levels fall to about 250 mg/dl the IV fluids After the blood glucose levels fall to about 250 mg/dl the IV fluids that contain glucose are given to prevent hypoglycemia.that contain glucose are given to prevent hypoglycemia.

• Electrolytes are monitored and will be replaced if necessary. Electrolytes are monitored and will be replaced if necessary. • Hypokalemia (low potassium) is not as significant in HHNS as in Hypokalemia (low potassium) is not as significant in HHNS as in

DKA although there may still be potassium deficits that need DKA although there may still be potassium deficits that need replacement. replacement.

• VS, I&O, skin turgor, lab values, and cardiac monitoring are VS, I&O, skin turgor, lab values, and cardiac monitoring are constantly assessed to keep a check on the fluid and electrolyte constantly assessed to keep a check on the fluid and electrolyte replacement.replacement.

• Patients with renal or cardiac problems need special monitoring to Patients with renal or cardiac problems need special monitoring to avoid fluid overload. avoid fluid overload.

HypoglycemiaHypoglycemia• Low blood glucose. This occurs when there is too much Low blood glucose. This occurs when there is too much

insulin in proportion to available glucose in the blood, insulin in proportion to available glucose in the blood, causing the blood glucose level to fall to <70mg/dl. causing the blood glucose level to fall to <70mg/dl.

• As the brain needs a constant supply of glucose, mental As the brain needs a constant supply of glucose, mental functioning can be compromised. functioning can be compromised.

• Signs & Symptoms: confusion, irritability, diaphoresis, Signs & Symptoms: confusion, irritability, diaphoresis, tremors, hunger, weakness, and visual disturbances. tremors, hunger, weakness, and visual disturbances.

• Can look a lot like drunkenness.Can look a lot like drunkenness.

• If untreated, it can progress to loss of consciousness, If untreated, it can progress to loss of consciousness,

seizures, coma, and death.seizures, coma, and death. • Hypoglycemic UnawarenessHypoglycemic Unawareness-Patient may not have any -Patient may not have any

warning signs or symptoms. Autonomic diabetic neuropathy warning signs or symptoms. Autonomic diabetic neuropathy interferes with the secretion of the hormones that cause the interferes with the secretion of the hormones that cause the symptoms. symptoms. Also at risk are elderly patients who are on Also at risk are elderly patients who are on BB--adrenergic blockers.adrenergic blockers. -If patient has a risk factor for hypoglycemic unawareness -If patient has a risk factor for hypoglycemic unawareness they shouldn’t aim for intense blood glucose control.they shouldn’t aim for intense blood glucose control.

Hypoglycemia CareHypoglycemia Care• Get a blood glucose immediately. Get a blood glucose immediately. • Get patients history if possible and physical Get patients history if possible and physical

examination.examination.• Try and find out what caused the Try and find out what caused the

hypoglycemia after you correct the problem. hypoglycemia after you correct the problem. • To the conscious patient, give 15-20g of a To the conscious patient, give 15-20g of a

quick-acting carb (Ex: 6-8 oz Coke, 8-10 Life quick-acting carb (Ex: 6-8 oz Coke, 8-10 Life Savers, a tablespoon of syrup or honey, or Savers, a tablespoon of syrup or honey, or frosting in a tube.) frosting in a tube.) Avoid sweet foods that Avoid sweet foods that also contain fat. also contain fat. Monitor blood glucose.Monitor blood glucose.

• Repeat the treatment in 15 minutes if first Repeat the treatment in 15 minutes if first treatment didn’t work. treatment didn’t work.

• Give more food of longer-acting carbs (Ex: Give more food of longer-acting carbs (Ex: slice of bread, crackers) after symptoms slice of bread, crackers) after symptoms calm down. calm down. Be careful not to overtreat! Be careful not to overtreat! (Hyperglycemia!)(Hyperglycemia!)

• If patient outside hospital, notify HCP If patient outside hospital, notify HCP immediately if symptoms don’t subside immediately if symptoms don’t subside after 2 or 3 administrations of quick-acting after 2 or 3 administrations of quick-acting carbs. carbs.

• Worse symptoms or comatose patientWorse symptoms or comatose patient::

-SQ or IM (quickest in deltoid) injection of -SQ or IM (quickest in deltoid) injection of 1 1 mg glucagonmg glucagon. Watch for rebound effect of . Watch for rebound effect of hypoglycemia.hypoglycemia.

-IV administration of -IV administration of 50 ml 50%50 ml 50% glucose. glucose.

Once blood glucose is >70 mg/dl the patient should eat the regularly scheduled meal or snack to keep hypoglycemia from happening

again.

Chronic ComplicationsChronic Complications• End-organ disease from chronic End-organ disease from chronic

hyperglycemia. Possible causes include:hyperglycemia. Possible causes include:-The accumulation of damaging by-products of glucose -The accumulation of damaging by-products of glucose metabolism, like sorbitol, which is associated with nerve cell metabolism, like sorbitol, which is associated with nerve cell damage.damage.-Abnormal glucose molecules forming in the basement -Abnormal glucose molecules forming in the basement membrane of small blood vessels like those that circulate to membrane of small blood vessels like those that circulate to the eye and kidney.the eye and kidney.-Derangement of red blood cell function that leads to a -Derangement of red blood cell function that leads to a decrease in oxygen to tissues. decrease in oxygen to tissues.

• AngiopathyAngiopathy-Blood vessel disease. -Blood vessel disease. -Estimated to account for the majority of -Estimated to account for the majority of deaths from diabetes.This chronic blood vessel deaths from diabetes.This chronic blood vessel dysfunction is divided into two categories:dysfunction is divided into two categories:--Macrovascular ComplicationsMacrovascular Complications

-Microvascular Complications-Microvascular Complications

AngiopathyAngiopathy• Macrovascular Macrovascular

Complications:Complications:-Diseases of the large and medium--Diseases of the large and medium-sized blood vessels that happen more sized blood vessels that happen more often and earlier in people with often and earlier in people with diabetes. diabetes. -Even though the formation of -Even though the formation of atherosclerotic plaque is believed to atherosclerotic plaque is believed to have a genetic origin, its development have a genetic origin, its development appears related to the altered lipid appears related to the altered lipid metabolism common in diabetes. metabolism common in diabetes. -Tight glucose control may help. -Tight glucose control may help. -These diseases include -These diseases include cerebrovascular, cardiovascular, and cerebrovascular, cardiovascular, and peripheral vascular diseases. peripheral vascular diseases. -Risk factors are smoking, obesity, -Risk factors are smoking, obesity, HTN, high fat intake, and sedentary HTN, high fat intake, and sedentary lifestyle. lifestyle. -Insulin resistance plays an important -Insulin resistance plays an important role in the development of CV disease role in the development of CV disease and is implicated in the pathogenesis and is implicated in the pathogenesis of essential HTN and dyslipidemia.of essential HTN and dyslipidemia.-The term insulin resistance syndrome -The term insulin resistance syndrome is clinically associated with insulin is clinically associated with insulin resistance, HTN, increased very-low-resistance, HTN, increased very-low-density lipoprotein (VLDL) and density lipoprotein (VLDL) and decreased high-density lipoprotein decreased high-density lipoprotein (HDL).(HDL).

• Microvascular Microvascular Complications:Complications:-Results from thickening of the -Results from thickening of the vessel membranes in the capillaries vessel membranes in the capillaries and arterioles in response to and arterioles in response to conditions of chronic conditions of chronic hyperglycemia. hyperglycemia. -Differs from macrovascular in that -Differs from macrovascular in that it is specific to diabetes. it is specific to diabetes. -Areas most affected are the eyes -Areas most affected are the eyes (retinopathy), the kidneys (retinopathy), the kidneys (nephropathy), and the skin (nephropathy), and the skin (dermopathy). (dermopathy). -Thickening of cap basement -Thickening of cap basement membrane has been found in some membrane has been found in some people. people. -Clinical manifestations usually -Clinical manifestations usually don’t appear until 10-20 years don’t appear until 10-20 years following the onset of diabetes. following the onset of diabetes.

Diabetic RetinopathyDiabetic Retinopathy• This refers to the process of microvascular damage to the retina This refers to the process of microvascular damage to the retina

because of chronic hyperglycemia in patients with diabetes. because of chronic hyperglycemia in patients with diabetes. Very common in people who have had diabetes for a long time, Very common in people who have had diabetes for a long time, more-so in those with Type I. more-so in those with Type I.

NonproliferativeNonproliferative ProliferativeProliferative-Most common form.-Most common form.-Partial occlusion of the small -Partial occlusion of the small blood vessels in the retina causes blood vessels in the retina causes microaneurysms in the capillary microaneurysms in the capillary walls.walls.-Capillary fluid may leak out -Capillary fluid may leak out causing retinal edema, hard causing retinal edema, hard exudates, and intraretinal exudates, and intraretinal hemorrhaging. If the macula is hemorrhaging. If the macula is involved, vision may be affected.involved, vision may be affected.

TreatmentTreatment-Early photocoagulation of the -Early photocoagulation of the retina. retina. -Cryotherapy-Cryotherapy-Vitrectomy-Vitrectomy

-Most severe form.-Most severe form.-Involves the retina and the -Involves the retina and the vitreous. vitreous. -Neovascularization-When the -Neovascularization-When the body tries to compensate by body tries to compensate by forming new blood vessels to forming new blood vessels to supply the retina the blood. supply the retina the blood. --Glaucoma may result from this.Glaucoma may result from this. -These new vessels are extremely -These new vessels are extremely fragile and hemorrhage easily fragile and hemorrhage easily which produces vitreous which produces vitreous contraction. contraction. -Light can’t reach the retina.-Light can’t reach the retina.-Patient sees black or red spots -Patient sees black or red spots or lines. or lines. -Complete retinal detachment can -Complete retinal detachment can occur. occur. -If the macula is involved, vision -If the macula is involved, vision is lost. is lost. -Without treatment, more than -Without treatment, more than half the patients will go blind. half the patients will go blind.

NephropathyNephropathy• A microvascular complication that is associated with A microvascular complication that is associated with

damage to the small blood vessels that supply glomeruli damage to the small blood vessels that supply glomeruli of the kidney. of the kidney.

• Leading cause of end-stage renal disease in the U.S.A!Leading cause of end-stage renal disease in the U.S.A!• Risk about the same in either Type I or Type II.Risk about the same in either Type I or Type II.• Risk factors for diabetic nephropathy are HTN, genetic Risk factors for diabetic nephropathy are HTN, genetic

predisposition, smoking, and chronic hyperglycemia. predisposition, smoking, and chronic hyperglycemia. • Kidney disease can be reduced a lot with maintenance Kidney disease can be reduced a lot with maintenance

of near-normal blood glucose. of near-normal blood glucose. • HTN can speed up nephropathy. Patient may be put on HTN can speed up nephropathy. Patient may be put on

ACE inhibitors (ex.lisinopril). Patient may be put on ACE ACE inhibitors (ex.lisinopril). Patient may be put on ACE inhibitors even if they’re not hypertensive.inhibitors even if they’re not hypertensive.

• This is because ACE inhibitors have a protective effect This is because ACE inhibitors have a protective effect on the kidney.on the kidney.

• Angiotensin II receptor agonists (losartan)Angiotensin II receptor agonists (losartan) may also be may also be used to protect the kidney.used to protect the kidney.

• Need yearly screening for presence of microalbuminuria Need yearly screening for presence of microalbuminuria (MAU) in the urine. (MAU) in the urine.

NeuropathyNeuropathy• This is nerve damage that is associated with diabetes. About 60%-This is nerve damage that is associated with diabetes. About 60%-

70% of diabetics have some degree of neuropathy. 70% of diabetics have some degree of neuropathy. • Most common is sensory neuropathy which can lead to the Most common is sensory neuropathy which can lead to the loss of loss of

sensationsensation in the lower extremities. The other major classification is in the lower extremities. The other major classification is autonomic neuropathy.autonomic neuropathy.

• Coupled with other factors, this increases the risk of complications Coupled with other factors, this increases the risk of complications that can result in a lower limb amputation.that can result in a lower limb amputation.

• May be caused by an accumulation of sorbitol and fructose in the May be caused by an accumulation of sorbitol and fructose in the nerves from persistant hyperglycemia.nerves from persistant hyperglycemia.

• Sensory Characteristics besides loss of feeling (numbness) are Sensory Characteristics besides loss of feeling (numbness) are abnormal sensations (feeling like you’re walking on pillows), pain, abnormal sensations (feeling like you’re walking on pillows), pain, and paresthesias.and paresthesias.

• Pain usually described as burning, crushing, cramping, or tearing. Pain usually described as burning, crushing, cramping, or tearing. • Control of blood glucose is the only treatment. Control of blood glucose is the only treatment. • Drug therapy: Topical creams (capsaicin), antiseizure meds Drug therapy: Topical creams (capsaicin), antiseizure meds

(gabapentin), Tricyclic antidepressants (to control the symptoms).(gabapentin), Tricyclic antidepressants (to control the symptoms).• AutonomicAutonomic: Bowel incontinence and diarrhea, urinary retention; : Bowel incontinence and diarrhea, urinary retention;

complication is delayed gastric emptying. complication is delayed gastric emptying. Can trigger Can trigger hyperglycemia by delaying food absorption!hyperglycemia by delaying food absorption!

• Sexual dysfunction in men and women. Is the problem organic or Sexual dysfunction in men and women. Is the problem organic or physiologic?physiologic?

• Patient may need to learn self-catheterization. Patient may need to learn self-catheterization.

Complications of the Complications of the feet and lower feet and lower

extremitiesextremities• The most common cause of hospitalization in the person The most common cause of hospitalization in the person

with diabetes. with diabetes. • Results from a combination of macrovascular and Results from a combination of macrovascular and

microvascular diseases.microvascular diseases.• Sensory neuropathySensory neuropathy (remember, loss of feeling) and (remember, loss of feeling) and

peripheral vascular diseaseperipheral vascular disease are risk factors, along with are risk factors, along with clotting problems, impaired immunity, and autonomic clotting problems, impaired immunity, and autonomic neuropathy.neuropathy.

• Smoking and PVD increase the risk for amputation.Smoking and PVD increase the risk for amputation.• Reduce and manage risk factors, especially smoking, high Reduce and manage risk factors, especially smoking, high

cholesterol, and HTN.cholesterol, and HTN.• LOPS-Loss of Protective SensationLOPS-Loss of Protective Sensation. Person may not know . Person may not know

they hurt their foot! Need to check daily!they hurt their foot! Need to check daily!• Neuropathic arthropathy (Charcot foot): Ankle and foot Neuropathic arthropathy (Charcot foot): Ankle and foot

changes; abnormal distribution of weight over the foot. changes; abnormal distribution of weight over the foot. Increases chance of foot ulcers from new pressure points. Increases chance of foot ulcers from new pressure points. Neuropathic ulcers look like a BB shot or punched out. Neuropathic ulcers look like a BB shot or punched out.

• Danger of infection!Danger of infection!

Foot Care!Foot Care!• Wash feet daily with mild soap Wash feet daily with mild soap

and warm water. and warm water. • Test water temp with hands Test water temp with hands

first!first!• Pat them dry gently, especially Pat them dry gently, especially

between the toes. between the toes. • Examine daily for cuts, blisters, Examine daily for cuts, blisters,

swelling, and tender areas. Don’t swelling, and tender areas. Don’t forget to look on the bottoms!forget to look on the bottoms!

• Protect against frostbite. Protect against frostbite. • Exercise feet daily by walking or Exercise feet daily by walking or

flexing. Don’t sit or stand for flexing. Don’t sit or stand for long time or cross legs. long time or cross legs.

• Use lanolin on feet to keep from Use lanolin on feet to keep from drying but not between toes. drying but not between toes.

• Use mild foot powder for sweaty Use mild foot powder for sweaty feet.feet.

• Do not use OTC remedies to get Do not use OTC remedies to get rid of calluses or corns. rid of calluses or corns.

• Do not use iodine, rubbing Do not use iodine, rubbing alcohol, or strong adhesives on alcohol, or strong adhesives on cuts.cuts.

• Report skin infections or sores Report skin infections or sores that don’t heal to HCP right away!that don’t heal to HCP right away!

• Cut toenails straight across. Do Cut toenails straight across. Do not cut down corners. not cut down corners.

• Overlapping toes? Use lamb’s Overlapping toes? Use lamb’s wool to separate them. wool to separate them.

• Don’t wear open-toe, open-heel, Don’t wear open-toe, open-heel, or high-heel shoes. Leather shoes or high-heel shoes. Leather shoes are preferred over plastic.are preferred over plastic.

• Wear cotton or wool socks. If you Wear cotton or wool socks. If you wear colored, make sure they’re wear colored, make sure they’re colorfast.colorfast.

• Don’t wear clothing that leaves Don’t wear clothing that leaves fabric impressions-Circulation!fabric impressions-Circulation!

• Don’t use hot water bottles or Don’t use hot water bottles or heating pads to warm the feet.heating pads to warm the feet.

Don’t go barefoot!

Skin ComplicationsSkin Complications

• Diabetic dermopathyDiabetic dermopathy• Necrobiosis lipoidica diabeticorumNecrobiosis lipoidica diabeticorum

-believed to be a result of the breakdown of collagen in the skin.-believed to be a result of the breakdown of collagen in the skin.

• Shin spotsShin spots• Mechanisms for susceptibility to infection include Mechanisms for susceptibility to infection include

defective mobilization of inflammatory cells and defective mobilization of inflammatory cells and impaired phagocytosis by neutrophils or impaired phagocytosis by neutrophils or monocytes.monocytes.

• May see recurring or persistent infections, boils, May see recurring or persistent infections, boils, and furuncles.and furuncles.

• LOS (loss of sensation) may delay detection of LOS (loss of sensation) may delay detection of infection.infection.

• Need prompt, vigorous, antibiotic therapy.Need prompt, vigorous, antibiotic therapy.

Nutritional Therapy for Nutritional Therapy for DiabetesDiabetes

• Type IType I-May need to increase-May need to increase calories to gain weight calories to gain weightand restore body tissues.and restore body tissues. -Glucose control is via diet -Glucose control is via diet and insulin.and insulin.-Equal distribution of carbs -Equal distribution of carbs via meals or adjusting the via meals or adjusting the amount of carbs for insulin amount of carbs for insulin activity.activity.-Consistency needed for -Consistency needed for glucose control.glucose control.--Timing of meals very Timing of meals very important for NPH/lente important for NPH/lente insulin programs.insulin programs. Need Need flexibility with multidose flexibility with multidose rapid-acting insulin.rapid-acting insulin.-Snacks throughout day and -Snacks throughout day and at bedtime are frequently at bedtime are frequently needed.needed.-Need 20 g/hr of carbs for -Need 20 g/hr of carbs for regular physical activity.regular physical activity.

• Type IIType II-Need to reduce caloric intake; -Need to reduce caloric intake; lose weight. lose weight. -Control of diet may be only -Control of diet may be only thing necessary for glucose thing necessary for glucose control.control.-Need equal distribution. Best -Need equal distribution. Best to have low-fat diet. Need to have low-fat diet. Need consistency of carbs during consistency of carbs during meals. meals. -Consistency necessary for -Consistency necessary for weight loss and controlling weight loss and controlling blood glucose levels. blood glucose levels. --Timing of meals would be Timing of meals would be good but not absolutely good but not absolutely essential.essential.-Snacks throughout the day -Snacks throughout the day and at bedtime not and at bedtime not recommended. recommended. -May need nutritional -May need nutritional supplements of patient’s supplements of patient’s diabetes is controlled with diabetes is controlled with sulfonylurea or insulin. sulfonylurea or insulin.

Food GroupsFood Groups• ProteinProtein-15% to 20%. If the patient has -15% to 20%. If the patient has

nephropathy(disorder of the kidney). nephropathy(disorder of the kidney). • FatFat-Less than 10% from saturated fat. -Less than 10% from saturated fat.

Cholesterol needs to be lower than 300 Cholesterol needs to be lower than 300 mg/day.mg/day.

• CarbohydratesCarbohydrates-Should make up the -Should make up the remaining necessary calories after meeting remaining necessary calories after meeting protein and fat needs. Should be whole grains, protein and fat needs. Should be whole grains, and fresh vegetables and fruit. Simple sugar is and fresh vegetables and fruit. Simple sugar is acceptable in small amounts when counted as acceptable in small amounts when counted as

part of the carb intake.part of the carb intake. • SodiumSodium-Should be lower than 2400 mg/day.-Should be lower than 2400 mg/day.• FiberFiber-25 to 30 g/day needed from a variety of -25 to 30 g/day needed from a variety of

food sources. food sources. Meal planning: Learn the “plate method”, the amount of necessary food that will fill a 9-inch plate.

Alcohol?Alcohol?•It’s high in calories and has no nutritional value. It also promotes hypertriglyceridemia (an excess of glycerides, especially triglycerides, in the blood.)

•Had really bad effects on the liver. Alcohol can inhibit glucose production and cause severe hypoglycemia in patients who are on insulin or oral hypoglycemic agents that increase insuline secretion.

•It can increase the risk of lactic acidosis.

•If glucose is well-controlled then alcohol could possibly be safe if glucose under control and if the patient is not on meds that can cause reactions.

•If you’re going to drink alcohol, eat carbs!

•Drink with food, use sugar-free mixes, and drink dry, light wines.

ExerciseExercise• Increases insulin sensitivity Increases insulin sensitivity

and can help lower blood and can help lower blood glucose levels.glucose levels.

• May also help lower May also help lower triglyceride and LDL triglyceride and LDL cholesterol levels, lower cholesterol levels, lower blood pressure, and improve blood pressure, and improve circulation.circulation.

• Schedule exercises about 1 Schedule exercises about 1 hour after a meal if on meds hour after a meal if on meds that cause hypoglycemia or that cause hypoglycemia or have a 10-15g carbohydrate have a 10-15g carbohydrate snack before exercising. snack before exercising.

• If on meds that place the If on meds that place the patient at risk or if already patient at risk or if already hypoglycemic, advise to hypoglycemic, advise to carry glucose tablets, hard carry glucose tablets, hard candy like Life Savers, or candy like Life Savers, or frosting in a tube, when frosting in a tube, when exercising.exercising.

•Strenuous exercise can be perceived by the body as stress so don’t overdo it.

•Don’t exercise at the time of the day when insulin action is waning.

Patient TeachingPatient Teaching• Monitor blood glucose at Monitor blood glucose at

home and record in log. home and record in log. • Take insulin and oral meds Take insulin and oral meds

as prescribed. as prescribed. • Get a HgB1c blood test Get a HgB1c blood test

every 3-6 months.every 3-6 months.• Carry some form of glucose Carry some form of glucose

at all times to treat at all times to treat hypoglycemia.hypoglycemia.

• Instruct family members in Instruct family members in giving glucagon in case of giving glucagon in case of emergencies. emergencies.

• Don’t skip doses of insulin, Don’t skip doses of insulin, even if sick. even if sick.

• Don’t run out of insulin!Don’t run out of insulin!

• Don’t get involved in fad diets.Don’t get involved in fad diets.• Don’t rub area where injection Don’t rub area where injection

was given. was given. • Follow diet, regular meals-Follow diet, regular meals-

regular times.regular times.• Learn cholesterol level and Learn cholesterol level and

don’t eat fried foods. don’t eat fried foods. • Don’t exercise if blood glucose Don’t exercise if blood glucose

levels very high.levels very high.• Get annual eye exam. Get annual eye exam. • Get annual urine protein Get annual urine protein

exam.exam.• Treat other medical problems, Treat other medical problems,

especially high blood pressure.especially high blood pressure.• Know the symptoms of Know the symptoms of

hyperglycemia and hyperglycemia and hypoglycemia.hypoglycemia.

• Quit smoking. Quit smoking. Carry

Identification that says you have Diabetes!

Diabetes LinksDiabetes Links

• http://www.diabetes.orghttp://www.diabetes.org• http://www.diabetes.comhttp://www.diabetes.com• http://www.cdc.gov/diabetes/http://www.cdc.gov/diabetes/• http://www.diabetes.ca/Section_Main/wehttp://www.diabetes.ca/Section_Main/we

lcome.asplcome.asp• http://www.niddk.nih.gov/http://www.niddk.nih.gov/• http://www.jdf.org/http://www.jdf.org/