Diabetes mellitus DM Diabetes mellitus is a chronic

Diabetes mellitus (DM)

Diabetes mellitus is a chronic progressive disease characterized by the body's inability to metabolize carbohydrates, fats, and proteins, leading to hyperglycemia (high blood glucose level).

Etiology of diabetes mellitus Type 1 DM: is due to destruction of pancreatic B cells, the cause of destruction unknown.

Etiology Type 2 DM: due to impaired insulin release – basal secretion of insulin is often normal , but the rapid release of insulin follows a meal is greatly impaired , resulting in failure of normal handling of carbohydrates load

Risk Factors • Weight • Inactivity • Family history of diabetes • Race: people of certain races as blacks, Americans Indians and Asian Americans • Age : the risk of type 2 increase with aging especially after age 45

• Pre-diabetes: is a condition in which the blood sugar level is higher than normal but not high enough to be classified as type 2 diabetes, if untreated often progresses to type 2 diabetes • History of gestational diabetes and delivering heavy infant

Classification 1. Type 1→ insulin dependent diabetes mellitus 2. Type 2 → non-insulin dependent diabetes mellitus 3. Gestational Diabetes 4. Other types(secondary diabetes)

Clinical manifestations • Polyuria (excessive urination). • Polydipsia (excessive thirst). • Polyphagia (excessive appetite). • Glucosuria (glucose in urine). • Loses weight. -Weakness, lethargy and malaise -Fatigue. -Blurred vision

Diagnostic tests 1. Plasma glucose level(PG) 2. Fasting blood glucose/sugar(FBG): normal level ranges as 70 -110 mg/dl this test measure the circulating blood glucose 3. Oral glucose tolerance test(OGTT): determines the level of glucose 2 hours after dirking 75 g of glucose its normal range is <140 mg/dl (post prandial)

Complications of DM

Acute complications of DM • Diabetic Ketoacidosis(DKA), • Hyperglycemic hyperosmolar Nonketotic Syndrome • Hypoglycemia is the primary acute complications of diabetes mellitus.

(1) Diabetic Ketoacidosis (DKA)

Definition: DKA is an emergency condition in which high blood glucose and a lack of insulin leads to a breakdown of body fat for energy, resulting in the accumulation of acidic ketones in the body.

Ketones →are acidic waste products of fat metabolism that can cause serious problems when they become excessive as severe dehydration and electrolyte imbalance and acidosis → coma and death if left untreated

Causes of DKA • Decreased or missed dose of insulin, • Illness or infection, and • Undiagnosed and untreated diabetes

Symptoms of DKA Frequent vomiting, Polyuria, Severe dehydration(hypotension-poor skin turgor), Weight loss, dehydration, Flushed cheeks, deep breathing, Acetone on breath due to ketoacidosis, Disorientation, shock and hypotension.

Diagnosis of DKA • Biochemical diagnostic criteria for DKA: • Includes hyperglycemia > 300 mg/dl, • Ketonurea or ketonemia. • EWDKA is classed according to severity of acidosis as mild DKA (venous p. H < 7. 3), moderate DKA (p. H < 7. 2) and severe DKA (p. H < 7. 1).

DKA Therapy Management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis

1. Rehydration In dehydrated patients, rehydration is important for maintaining tissue perfusion.

1. Patients may need up to 6 to 10 liters of IV fluid to replace fluid losses caused by polyuria, hyperventilation, diarrhea, and vomiting.

2. Monitoring fluid volume status involves frequent measurements of vital signs (including monitoring for orthostatic changes in blood pressure and heart rate), lung assessment

3. Monitoring intake and output. 4. Plasma expanders may be necessary to correct severe hypotension that does not respond to IV fluid treatment.

5. Monitoring for signs of fluid overload is especially important for older patients, those with renal impairment, or those at risk for heart failure.

2. Restoring electrolytes • Potassium replacement is vital to avoid dysrhythmiasthat may occur with hypokalemia.

3. Reversing or correcting acidosis Ketone bodies (acids) accumulate as a result of fat breakdown and the acidosis that occurs in DKA is reversed with insulin, which inhibits fat breakdown, theraby stopping acid buildup.

• Administration of Insulin intravenously at a slow, continuous rate (eg, 5 units per hour). • Hourly blood glucose values must be measured.

• IV fluid solutions with higher concentrationsof glucose, such as normal saline (NS) solution are administered when blood glucose levels reach 250 to 300 mg/d. L to avoid too rapid a drop in the blood glucose level.

Nursing care of the patient with DKA

1. Monitoring fluid and electrolyte status as well as blood glucose levels; 2. Administering fluids, insulin, and other medications; 3. Preventing other complications such as fluid overload.

4. Urine output is monitored to ensure adequate renal function before potassium is administered to prevent hyperkalemia. 5. The electrocardiogram is monitored for dysrhythmias indicating abnormal potassium levels.

6. Vital signs, arterial blood gases, and other clinical findings are recorded on a flow sheet. 7. The nurse documents the patient’s laboratory values and the frequent changes in fluids and medications that are prescribed and monitors the patient’s responses.

(2) Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS): Is a syndrome of severe hyperglycemia and profound dehydration in person with type 2 diabetes, ketosis does not occur because there is enough insulin present to prevent excessive fat metabolism.

Nursing care of the patient with HHNS Close monitoring of vital signs, fluid status, and laboratory values. Fluid status and urine output are closely monitored

• Careful assessment of cardiovascular, pulmonary, and renal function important throughout the acute and recovery phases of HHNS

Hypoglycemia is a state of blood glucose level below 70 mg/d. L; often caused by skipped meals, excessive doses of insulin or oral medications such as sulfonyl ureas, increased exercise.

Clinical Manifestations In mild hypoglycemia: - as the blood glucose level falls. This causes symptoms such as sweating, tremor, tachycardia, palpitation, nervousness, and hunger.

In moderate hypoglycemia: inability to concentrate, headache, confusion, numbness of the lips and tongue, impaired coordination, emotional changes, double vision, and drowsiness.

In severe hypoglycemia: - CNS function is so impaired that the patient needs the assistance of another person for treatment of hypoglycemia. Symptoms may include disoriented behavior, seizures or loss of consciousness

Management of hypoglycemia

Management of hypoglycemia: Immediate treatment must be given when hypoglycemia occurs. The usual recommendation is for 15 g of a fast-acting concentrated source of carbohydrate

The blood glucose level should be retested in 15 minutes and retreated if it is less than 70 to 75 mg/d. L.

If the symptoms persist more than 10 to 15 minutes after initial treatment, the treatment is repeated even if blood glucose testing is not possible. Once the symptoms resolve, a snack containing protein and starch (e. g. , milk or cheese) is recommended unless the patient plans to eat a regular meal within 30 to 60 minutes

Chronic complications of DM

(A)Macro complications vascular Refer to changes in the moderate to large sized arteries and veins that supply the heart, brain, and peripheral tissue as (stroke).

(B) Micro vascular complications: 1. Diabetic Retinopathy : persons with type 1 DM are more likely to develop and then furthering progress of blindness

2. Diabetic Neuropathy. Persons with diabetes have some degree of nervous system damage. Severe diabetic nerve disease is a major factor in development of problems leading to lower limb amputation.

3. Diabetic nephropathy: Result from damage to the small blood vessels which supply the filtering components of the nephron, known as glomeruli

Management of DM

Medical management The major goal in treating diabetes is to minimize any elevation of blood glucose without causing abnormal low levels of blood glucose. Type 1 DM is treated with insulin, exercise, and adiabatic diet. Type 2 DM is treated first with weight reduction, a diabetic diet and exercise.

Medical management When these measures fail to control the elevated blood sugars, oral medications are used. If oral medications are still insufficient, treatment with insulin is considered.

Medications Oral Antidiabetic agents Drugs for treating type 2 diabetes, other than insulin, lies into five categories: Sulfonylureas to stimulate the pancreas to secrete more insulin.

• Drugs that principally lower glucose levels by their actions on liver, skeletal muscle or adipose tissue (metformin), • Drugs that principally affect absorption of glucose (αglucosidase inhibitors)