Diabetes MellitusII Draftnew

8/6/2019 Diabetes MellitusII Draftnew

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INTRODUCTION

Diabetes is from the Greek word meaning"siphon," and "mellitus" comes from melliferous,meaning "of or relating to honey." Diabetes hasbeen recognized for centuries and was originally

diagnosed by tasting the urine and finding it sweet(melliferous). The high sugar also causes thekidneys to excrete (or siphon) large amounts ofwater. Injury to the pancreas was linked todiabetes beginning in the seventeenth century andconfirmed by animal experiments.

Type II diabetes is as mentioned earlier iscaused when the body can't process glucose evenwhen there is insulin production. This usuallyhappens due to an excessive amount of sugarpresent and the body can't produce enough insulin

to effectively process it. When this happens,extreme stress is placed on the pancreas. When this happen, the pancreas ends up being over-worked in making the amount of insulin needed to handle excessive sugar levels. If this problemisn't corrected your pancreas itself can become damaged. Several drugs, all of which can be taken bymouth, are useful in restoring better control over blood sugar in patients with type II diabetes.However, late in the course of disease, patients may have to begin to take insulin. It is as thoughafter years of pumping out insulin in an effort to overcome the patient's insulin resistance, the betacells become exhausted.

The life expectancy of people who are diagnosed with type 2 diabetes in their 40s decreasesby 5-10 years because of the disease. Heart disease is the leading cause of death for people with type2 diabetes. Excellent glycemic control, tight blood pressure control, and keeping the "bad"cholesterol (LDL) level at the recommended level of


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REVIEW OF RELATED LITERATURE

What is Diabetes?

Diabetes Mellitus, commonly referred to as "diabetes," means "sweet urine." Diabetes mellitusmeans "to flow, honey" in Greek

Diabetes that affects the body's ability to produce or respond to insulin. Insulin is a hormone thatallows blood glucose (blood sugar) to enter the cells of the body and be used for energy.

Diabetes results from defects in insulin secretion, insulin action, or both. In diabetes, too muchglucose stays in the blood. Elevated levels of blood glucose (hyperglycemia) lead to spillage ofglucose into the urine.

http://www.mamashealth.com/diabetes.asp

Diabetes in Relation to Ethnicity

Type 2 diabetes mellitus is less common in non-Western countries where the diet contains fewercalories and daily caloric expenditure is higher. However, as people in these countries adoptWestern lifestyles, weight gain and type 2 diabetes mellitus are becoming virtually epidemic.

Rates of diabetes are increasing worldwide. At least 171 million people currently have diabetes, andthis figure is likely to more than double to 366 million by 2030. The top 10 countries, in numbers ofpeople with diabetes, are currently India, China, the United States, Indonesia, Japan, Pakistan,Russia, Brazil, Italy, and Bangladesh. The greatest percentage increase in rates of diabetes will

occur in Africa over the next 20 years. However, at least 80% of people in Africa with diabetes areundiagnosed, and many in their 30s to 60s will die from diabetes there.

http://emedicine.medscape.com/article/117853-overview#aw2aab6b2b5\

Type 2 diabetes

Type 2 diabetes is usually first treated by increasing physical activity, and eliminating saturated fatand reducing sugar and carbohydrate intake with a goal of losing weight. These can restore insulinsensitivity even when the weight loss is modest, for example around 5 kg (10 to 15 lb), most

especially when it is in abdominal fat deposits. Diets that are very low in saturated fats can reverseinsulin resistance.

Testosterone replacement therapy may improve glucose tolerance and insulin sensitivity in diabetic

hypogonadal men. The mechanisms by which testosterone decreases insulin resistance is understudy.Moreover testosterone may have a protective effect on pancreatic beta cells, which is possiblyexerted by androgen-receptor-mediated mechanisms and influence of inflammatory

cytokines.Recentlly, it has been suggested that a type of gastric bypass surgery may normalize bloodglucose levels in 80-100% of severely obese patients with diabetes. The precise causal mechanismsare being intensively researched; its results may not simply be attributable to weight loss, as theimprovement in blood sugars seems to precede any change in body mass. This approach may become

a treatment for some people with type 2 diabetes, but has not yet been studied in prospective clinical

trials.This surgery may have the additional benefit of reducing the death rate from all causes by up to

40% in severely obese people. A small number of normal to moderately obese patients with type 2diabetes have successfully undergone similar operations.

http://en.wikipedia.org/wiki/Diabetes_management


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ASSESSMENT

My chosen patient is Mr. Leopoldo O. Francisco, 69 years old and currently living at 159 Sebastiancompound, San Jose Gusu, Zamboanga City. The patient is fond of eating starchy and fatty foods.

He is also a heavy smoker and a heavy drinker before. Two years ago, he was been confined to the

hospital due to mild stroke. A week after, he was been diagnosed with type II Diabetes Mellitus.

Upon assessment, signs and symptoms of diabetes are easily noticeable. The general appearance of

the patient is obese. The patients skin color is light brown and is generally uniform throughout,

except in areas exposed to the sun. The skin is warm to touch with temperature of 36.9 c.

Thickness on some of the fingernails and toenails are noted. When Blanch test is performed, the

nails turned to its original color after 3-4 seconds. Regarding with the patients eyes, the eyebrows

are symmetrically aligned with equal movement. The eyelashes are equally distributed and are

curled slightly outward. The eyelid is intact with no discharge and discoloration. It closes

symmetrically. The sclera appears white with small capillaries evident. There is no edema over the

lacrimal gland, as well as tearing. The cornea is transparent, shiny and smooth with details of iris

visible. The client blinks automatically, indicating that the trigeminal nerve is intact. The pupil is

black and rounded and equal in size. When illuminated, the pupil constricts. Both eyes are

coordinated and move in unison with parallel alignment. Despite of this, the patient complains of

blur vision at times. The auricles have the same color as the facial skin, symmetric, mobile and firm.

It recoils after it folded and there is presence of a sticky cerumen. The patient has decreased sense

of hearing. He has a history of ear infection four months after he was diagnosed with diabetes. The

sinuses are not tender. His lips are dark pink and uniform in color. The gums are dark pink as a

result of prolong smoking. He has no teeth anymore and is remedied by false teeth. The patientoften experience excessive thirst and extreme hunger especially at night. Frequent urination has

been also reported most of the time. The patient number of breaths per minute is 19 with no

wheezing or crackles heard. The heart rhythm is regular with no murmurs heard upon auscultation.

The peripheral pulse was symmetric and full. The carotid artery was symmetric with no signs of

distention in the jugular vein. The pulse rate is 73 beats per minute taken at the left radial artery.

The blood pressure when lying down is 130/90 taken at the left brachial artery. The patient has

altered mental status as manifested by unexplained irritability, inattention and extreme lethargy.

He is coherent to place and persons except to time. Mostly, the patient needs someone to remind

him the time of the day. Patient responds appropriately to verbal stimuli incorporated with

gestures. Patient shows some signs of memory loss. Concerning his musculoskeletal system, the

patient is mobile. Hand grasp was equal and strong. There were no contractures or tremors

present. Bones were palpable for normal contour and prominence except on the right foot as a

result of Rheumatoid arthritis.


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CONTENT

Pathophysiology

Type 2 diabetes is characterized bythe combination of peripheral insulin

resistance and inadequate insulinsecretion by pancreatic beta cells.Insulin resistance, which has beenattributed to elevated levels of freefatty acids in plasma, leads todecreased glucose transport intomuscle cells, elevated hepatic glucoseproduction, and increased breakdownof fat.

For type 2 diabetes mellitus to occur,both defects must exist. For example,

all overweight individuals have insulinresistance, but diabetes develops onlyin those who cannot increase insulinsecretion sufficiently to compensatefor their insulin resistance. Theirinsulin concentrations may be high, yet inappropriately low for the level of glycemia.

Beta cell dysfunction is a major factor across the spectrum of pre-diabetes to diabetes. A study ofobese adolescents by Bacha et al confirms what is increasingly being stressed in adults as well: Betacell function happens early in the pathological process and does not necessarily follow stage ofinsulin resistance. Singular focus on insulin resistance as the "be all and end all" is graduallyshifting, and hopefully better treatment options that focus on the beta cell pathology will emerge to

treat the disorder early.In the progression from normal glucose tolerance to abnormal glucose tolerance, postprandialblood glucose levels increase first; eventually, fasting hyperglycemia develops as suppression ofhepatic gluconeogenesis fails.

Although the pathophysiology of the disease differs between the types of diabetes, most of thecomplications, including microvascular, macrovascular, and neuropathic, are similar regardless ofthe type of diabetes.

Etiology

Presumably, type 2 diabetes mellitus develops when a diabetogenic lifestyle (ie, excessive caloricintake, inadequate caloric expenditure, obesity) is superimposed upon a susceptible genotype. Thebody mass index at which excess weight increases risk for diabetes varies with different racialgroups. For example, compared with persons of European ancestry, persons of Asian ancestry areat increased risk for diabetes at lower levels of overweight. Hypertension and prehypertension areassociated with greater risk of developing diabetes in whites compared with African Americans.

In addition, an in utero environment resulting in low birth weight may predispose some individualsto develop type 2 diabetes mellitus.

About 90% of patients who develop type 2 diabetes mellitus are obese. However, a large,population-based, prospective study has shown that an energy-dense diet may be a risk factor forthe development of diabetes that is independent of baseline obesity.

The major risk factors for type 2 diabetes mellitus are the following:

y Obesity or being overweight ( Weight greater than 120% of desirable body weight)y Family history of type 2 diabetes in a first-degree relative (eg, parent or sibling)y Ethnicity,such as Hispanic, Native American, African American, Asian American, or Pacific

Islander descent


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y History of previous impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)y Hypertension (>140/90 mm Hg) or dyslipidemia (high-density lipoprotein [HDL]

cholesterol level < 40 mg/dL or triglyceride level >150 mg/dL)y History of gestational diabetes mellitus or of delivering a baby with a birth weight of >9 lby Polycystic ovarian syndrome (which results in insulin resistance)y High-fat diety High alcohol intakey Sedentary lifestyle

The genetics of type 2 diabetes are complex and not completely understood. Evidence supports theinvolvement of multiple genes in pancreatic beta-cell failure and insulin resistance.

Some forms of diabetes, however, have a clear association with genetic defects. The syndromepreviously known as maturity onset diabetes of youth (MODY) has now been reclassified as avariety of defects in beta-cell function. These defects account for 2-5% of individuals with type 2diabetes who present at a young age and have mild disease. The trait is autosomal dominant and

can be screened for through commercial laboratories. To date, 6 mutations have been identified:

y HNF-4-alphay Glucokinase geney HNF-1-alphay IPF-1y HNF-1-betay NEUROD1

In addition, the SURI-1 gene causes hyperglycemia in infancy, which is often misdiagnosed as type1 diabetes. Variants in mitochondrial DNA have been proposed as an etiologic factor. A specificmitochondrial point mutation has been identified as a rare cause of maternally inherited type 2diabetes and sensorineural hearing loss.

Signs and symptoms

Fatigue: In diabetes, the body is inefficientand sometimes unable to use glucose for fuel.The body switches over to metabolizing fat,partially or completely, as a fuel source. Thisprocess requires the body to use more energy.The end result is feeling fatigued or

constantly tired.

Unexplained weight loss: People withdiabetes are unable to process many of thecalories in the foods they eat. Thus, they maylose weight even though they eat anapparently appropriate or even excessiveamount of food. Losing sugar and water in theurine and the accompanying dehydration alsocontributes to weight loss.

Excessive thirst (polydipsia): A person with diabetes develops high blood sugar levels, which

overwhelms the kidney's ability to reabsorb the sugar as the blood is filtered to make urine.Excessive urine is made as the kidney spills the excess sugar. The body tries to counteract thisby sending a signal to the brain to dilute the blood, which translates into thirst. The bodyencourages more water consumption to dilute the high blood sugar back to normal levels and tocompensate for the water lost by excessive urination.


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Excessive urination (polyuria): Another way the body tries to get rid of the extra sugar in theblood is to excrete it in the urine. This can also lead to dehydration because excreting the sugarcarries a large amount of water out of the body along with it.

Poor wound healing: High blood sugar levels prevent white blood cells, which are important indefending the body against bacteria and also in cleaning up dead tissue and cells, from

functioning normally. When these cells do not function properly, wounds take much longer toheal and become infected more frequently. Also, long-standing diabetes is associated withthickening of blood vessels, which prevents good circulation including the delivery of enoughoxygen and other nutrients to body tissues.

Infections: Certain infection syndromes, such as frequent yeast infections of the genitals, skininfections, and frequent urinary tract infections, may result from suppression of the immunesystem by diabetes and by the presence of glucose in the tissues, which allows bacteria to growwell. They can also be an indicator of poor blood sugar control in a person known to havediabetes.

Altered mental status: Agitation, unexplained irritability, inattention, extreme lethargy, or

confusion can all be signs of very high blood sugar, ketoacidosis, hyperosmolar hyperglycemianonketotic syndrome, or hypoglycemia (low sugar). Thus, any of these merit the immediateattention of a medical professional. Call your health care provider or 911.

Blurry vision: Blurry vision is not specific for diabetes but is frequently present with high bloodsugar levels.

Complications

Common complications of diabetes are:

y Heart diseasey Strokey Diabetic retinopathyy Kidney diseasey Sciatica

Treatment

Self-Care at Home

If you or someone you know has diabetes, they would be wise to make healthful lifestyle choices indiet, exercise, and other health habits. These will help to improve glycemic (blood sugar) controland prevent or minimize complications of diabetes.

Diet: A healthy diet is key to controlling blood sugar levels and preventing diabetes complications.


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If the patient is obese and has had difficulty losing weight on their own, talk to a healthcareprovider. He or she can recommend a dietitian or a weight modification program to help thepatient reach a goal.

Eat a consistent, well-balanced diet that is high in fiber, low in saturated fat, and low inconcentrated sweets.

A consistent diet that includes roughly the same number of calories at about the same times ofday helps the healthcare provider prescribe the correct dose of medication or insulin.

It will also help to keep blood sugar at a relatively even level and avoid excessively low or highblood sugar levels, which can be dangerous and even life-threatening.

Exercise: Regular exercise, in any form, can help reduce the risk of developing diabetes. Activitycan also reduce the risk of developing complications of diabetes such as heart disease, stroke, kidneyfailure, blindness, and leg ulcers.

As little as 20 minutes of walking three times a week has a proven beneficial effect. Any exercise

is beneficial; no matter how light or how long, some exercise is better than no exercise.

If the patient has complications of diabetes (eye, kidney, or nerve problems), they may be limitedboth in type of exercise and amount of exercise they can safely do without worsening theircondition. Consult with your health care provider before starting any exercise program.

Alcohol use: Moderate or eliminate consumption of alcohol. Try to have no more than sevenalcoholic drinks in a week and never more than two or three in an evening. One drink is considered1.5 ounces of liquor, 6 ounces of wine, or 12 ounces of beer. Excessive alcohol use is a known riskfactor for type 2 diabetes. Alcohol consumption can cause low or high blood sugar levels, nerve paincalled neuritis, and increase in triglycerides, which is a type of fat in our blood.

Smoking: If the patient has diabetes, and you smoke cigarettes or use any other form of tobacco,they are raising the risks markedly for nearly all of the complications of diabetes. Smoking damagesblood vessels and contributes to heart disease, stroke, and poor circulation in the limbs. If someoneneeds help quitting, talk to a healthcare provider.

Self-monitored blood glucose: Check blood sugar levels frequently, at least before meals and atbedtime, and record the results in a logbook.

This log should also include insulin or oral medication doses and times, when and what thepatient ate, when and for how long they exercised, and any significant events of the day such ashigh or low blood sugar levels and how they treated the problem.

Better equipment now available makes testing blood sugar levels less painful and lesscomplicated than ever. A daily blood sugar diary is invaluable to the healthcare provider inseeing how the patient is responding to medications, diet, and exercise in the treatment ofdiabetes.

Medical Treatment

The treatment of diabetes is highly individualized, depending on the type of diabetes, whether thepatient has other active medical problems, whether the patient has complications of diabetes, andage and general health of the patient at time of diagnosis.

A healthcare provider will set goals for lifestyle changes, blood sugar control, and treatment.

Together, the patient and the healthcare provider will devise a plan to help meet those goals.Education about diabetes and its treatment is essential in all types of diabetes.

When the patient is first diagnosed with diabetes, the diabetes care team will spend a lot of timewith the patient, teaching them about their condition, treatment, and everything they need toknow to care for them on a daily basis.


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The diabetes care team includes the healthcare provider and his or her staff. It may includespecialists in foot care, neurology, kidney diseases, and eye diseases. A professional dietitian anda diabetes educator also may be part of the team.

The healthcare team will see you at appropriate intervals to monitor your progress with your goals.

Depending on how elevated the patient's blood sugar and glycosylated hemoglobin (HbA1c) are atthe time of diagnosis, they may be given a chance to lower blood sugar level without medication.

The best way to do this is to lose weight if obese and begin an exercise program.

This will generally be tried for three to six months, then blood sugar and glycosylatedhemoglobin will be rechecked. If they remain high, the patient will be started on an oralmedication, usually a sulfonylurea or biguanide [metformin Glucophage)], to help control bloodsugar level.

Even if the patient is on medication, it is still important to eat a healthy diet, lose weight if theyare overweight, and engage in moderate physical activity as often as possible.

The healthcare provider will monitor the patient's progress on medication very carefully at first.It is important to get just the right dose of the right medication to get the blood sugar level inthe recommended range with the fewest side effects.

The doctor may decide to combine two types of medications to get blood sugar level undercontrol.

Gradually, even people with type 2 diabetes may require insulin injections to control their bloodsugar levels.

It is becoming more common for people with type 2 diabetes to take a combination of oral

medication and insulin injections to control blood sugar levels.

Medications

Many different types of medications are available to help lowerblood sugar levels in type 2 diabetes. Each type works in adifferent way. It is very common to combine two or more typesto get the best effect with fewest side effects.

Sulfonylureas: These drugs stimulate the pancreas to makemore insulin.

Biguanides: These agents decrease the amount of glucoseproduced by the liver.

Alpha-glucosidase inhibitors: These agents slow absorption of the starches one eats. Thisslows down glucose production.

Thiazolidinediones: These agents increase sensitivity to insulin.

Meglitinides: These agents stimulate the pancreas to make more insulin.

D-phenylalanine derivatives: These agents stimulate the pancreas to produce more insulin

more quickly.

Amylin synthetic derivatives: Amylin is a naturally occurring hormone secreted by thepancreas along with insulin. An amylin derivative, such as pramlintide (Symlin), is indicatedwhen blood sugar control is not achieved despite optimal insulin therapy. Pramlintide isadministered as a subcutaneous injection along with insulin and helps achieve lower blood sugarlevels after meals, helps reduce fluctuation of blood sugar levels throughout the day, andimproves hemoglobin A1C levels.


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Incretin mimetics: Incretin mimetics promote insulin secretion by the pancreas and mimic otherblood sugar level lowering actions that naturally occur in the body. Exenatide (Byetta) is thefirst incretin mimetic agent approved in the United States. It is indicated for diabetes mellitustype 2 in addition to metformin or a sulfonylurea when these agents have not attained bloodsugar level control alone.

Insulins: Human insulin is the only type of insulin available in the United States; it is less likelyto cause allergic reactions than animal-derived varieties of insulin. The type of insulin chosen tocustomize treatment for an individual is based on the goal of providing optimal blood sugarcontrol. Different types of insulin are available and categorized according to their times of actiononset and duration. Commercially prepared mixtures of some insulins may also be used toprovide constant (basal) control and immediate control.

Prevention

Type 2 diabetes, however, can be prevented in some cases.

Control weight to normal or near-normal levels by eating a healthy low-fat, high-fiber diet.

Keep alcohol consumption low.

Quit smoking.

If you have high blood fat levels (such as high cholesterol) or high blood pressure, take yourmedication as directed.

Lifestyle modification and/or certain medications can be used in people with prediabetes toprevent progression to diabetes. Pre-diabetes can be diagnosed by checking fasting glucose andtwo hours after ingesting 75 grams of glucose.

If you or someone you know already have diabetes, your focus should be on preventing thecomplications, which can cause serious disabilities such as blindness, kidney failure requiringdialysis, amputation, or even death.

Tight glucose control: The single best thing the patient can do is to keep their blood sugar levelwithin the suggested range every day. The only way to do this is through a combination ofregular blood sugar checks, a balanced diet low in simple sugars and fat and high in complexcarbohydrates and fiber, and appropriate medical treatment. Please consult a nutritionist orcheck with the doctor with questions in regard to diet.

Increase physical activity levels. Aim for moderately vigorous physical activity for at least 30minutes every day.

Drink an adequate amount of water and avoid taking too much salt.

The skin should be taken care of; keep it supple and hydrated to avoid sores and cracks that canbecome severely infected.

Brush and floss the teeth every day. See a dentist regularly to prevent gum disease.

The feet should be washed and examined daily, looking for small cuts, sores, or blisters that maycause problems later. The toenails should be filed rather than cut to avoid damaging thesurrounding skin. A specialist in foot care (podiatrist) may be necessaryto help care for the feet.

Home remedies

Diabetes treatment using Bitter Gourd

Among the several home remedies that have proved beneficial incontrolling diabetes, perhaps the most important is the use of bitter


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gourd. It has lately been established that bitter gourd contains a hypoglycaemic or insulin-likeprinciple, designated as 'plantinsulin', which has been found valuable in lowering the blood andurine sugar levels. It should, therefore, be included liberally in the diet of the diabetic. For betterresults, the diabetic should take the juice of about four or five bitter gourd every morning on anempty stomach. The seeds can be added to food in a powdered form. Diabetics can also use bittergourd in the form of a decoction by boiling the pieces in water or in the form of dry powder.

Diabetes treatment using Indian Gooseberry

Indian gooseberry, with its high vitamin C content, is considered valuable in diabetes. A tablespoonof its juice, mixed with a cup of bitter gourd juice, taken daily for two months, will stimulate theislets of Langerhans, that is, the isolated group of cells that secrete the hormone insulin in thepancreas. This mixture reduces the blood sugar in diabetes.

Diabetes treatment using Jambul Fruit

Black berry fruit is another effective home remedy. It is regarded in traditional medicine as aspecific against diabetes because of its effect on the pancreas. The fruit as such, the seeds, and fruitjuice are all useful in the treatment of this disease. The seeds contain a glucoside 'jamboline' whichis believed to have the power to check the pathological conversion of starch into sugar in cases ofincreased production of glucose. The seeds should be dried and powdered. One teaspoon of thispowder should be mixed in one cup of milk or water or half a cup of curd, and taken twice daily.The inner bark of the black berry tree is also used in the treatment of diabetes. The bark is driedand burnt. It will produce an ash of white colour. This ash should be pestled in mortar, strained andbottled. The diabetic patient should be given ten grams of this ash on an empty stomach with waterin the morning, and twenty grams in the afternoon, and in the evening an hour after taking meals.An equal quantity of indian gooseberry powder, jamun powder, and bitter gourd powder also makesa very useful remedy for diabetes. A teaspoon of this mixture once or twice a day would be effectivein checking the progress of the disease.

Diabetes treatment using Grapefruit

Grapefruit is a splendid food in the diet of a diabetic patient. If grapefruits were eaten moreliberally, there would be much less diabetes. If you have sugar, use three grapefruits three times aday. If you do not have sugar, but a tendency towards it and want to prevent it, use three a day.

Diabetes treatment using Mango Leaves

The tender leaves of the mango tree are considered useful in diabetes. An infusion is prepared by

soaking 15 gm of fresh leaves in 250 ml of water overnight, and squeezing them well in the water inthe morning. This filtrate should be taken every morning to control early diabetes. As analternative, the leaves should be dried in the shade, powdered and preserved for use whennecessary. Half a teaspoon of this powder should be taken twice a day.

Diabetes treatment using Other Foods

Besides bitter gourd, certain other vegetables have been found useful in diabetes. These includestring beans, cucumber, onion, and garlic. Tea made of the pods of string beans is valuable indiabetes.


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Management and

Control

of

Type II Diabetes

Mellitus

Submitted by: Christelle Brookshiel Joy D. Marba

BSN II- E

Submitted to: Mr. Aaron A. Mendoza, R.N.


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BIBLIOGRAPHY

http://www.emedicinehealth.com/diabetes/page3_em.htm

http://emedicine.medscape.com/article/117853-overview#aw2aab6b2b5\

http://www.mamashealth.com/diabetes.asp

http://www.home-remedies-for-you.com/remedy/Diabetes-Mellitus.html

http://www.emedicinehealth.com/diabetes/page7_em.html

http://journal.diabetes.org/clinicaldiabetes/v17n11999/Pg19.htm

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