DIABETES MELLITUS FELIX K NYANDE DIABETES MELLITUS A

DIABETES MELLITUS FELIX K. NYANDE

DIABETES MELLITUS A metabolic disorder characterised by hyperglycaemia as a result of: Oinadequate or Oineffective insulin.

CLASSIFICATION O Pathological process • Type I: IDDM • Type II: NIDDM O Aetiology • Primary or idiopathic: O when the actual cause is unknown, however there are some predisposing factors • Secondary: O It is a kind that there is a recognised specific factor responsible for pathological process •

Etiological classification O Primary • Obesity • Hereditary • Age • Sedentary lifestyle i. e. overeating without exercising • Gender: common in females • Autoimmunity: hyperthyroidism, Addison’s disease • Viral infections e. g. hepatitis, mumps, cosakie B 4 virus

Etiological classification O Secondary DM: • Pancreatitis • Ca of head of the pancreas • Pancreatectomy • Insulin antagonists e. g. adrenaline, thyroid hormones, Drugs: steroids, e. g. prednisone, dexamethasone • Liver diseases: cirrhosis, hepatitis O Pregnancy

CLINICAL FEATURES • • Polyuria Polydipsia Polyphagia Glycosuria Infections Weight loss Nocturia Pruritus genitalia

Pathophysiology O Glucose build-up: • Exogenous sources: i. e. from food, drinks, • Endogenous sources: stimulation of glucose production by steroid hormones; lipolysis [fat breakdown to generate glucose for energy production] and gluconeogenesis [production of glucose from non-glucose sources]

Pathophysiology cont’d O Glucose build up leads to hyperglycaemia. When the renal threshold of glucose about 10 mmol/L is exceeded, glucose is not reabsorbed into the system in the renal tubules. This allows large volumes of fluid including the glucose and other substances to be passed as urine [glucosuria and polyuria]. O The excessive loss of fluid stimulates thirst in the patient [polydipsia].

Pathophysiology cont’d O The excessive loss of electrolytes as well as the impaired utilisation of glucose by the cells results in polyphagia and fatigue. It is also a factor that accounts for wasting or emaciation of the individual. O During the process, fat is broken down and degraded by the liver into ketones. The excess ketones produce ketoacidosis which induce excessive loss of body fluid resulting in other symptoms such as hyperpnoea, etc.

DIAGNOSTIC INVESTIGATIONS O Fasting Blood Sugar: O Random Blood Sugar: O Glucose Tolerance Test: Patient fasts and afterwards given 1 g/kg body of glucose. The glucose level rises up to 150160 mg/d. L and falls to normal within 2 -3 hours. O The urine is usually free from glucose. O Blood sugar is tested in the first half hour and repeated every hour for 5 hours. O Glycosylated Hemoglobin Test: Done to determine the amount of glucose that has irreversibly bound to Hb [Hb. A 1 c]. [it constitutes 5% of body Hb]. The normal value for adults is 2. 2 -4. 8. It determines the prognosis. Values between 6 and 8 indicate a poor prognosis.

Investigations O Urine ketones: Acetest tablets or ketosticks are used to test the urine. O Urine Test: multistick/ or clinitest tablets are used. O 24 -hour urine collection: the urine is collected over 24 hours and the volume estimated. normal range: 1200 -1800 ml O Ketone Test: if it is positive of the following are found: acetone, Bhydroxybutric acid and acetoacetic acid.

management • Diet • Medication • Exercise • Education • Monitoring

diet O Unmeasured diet: categorised into three • Foods to be avoided: refined sugar, ordinary sugar, biscuits laced with sugar • Foods to be taken in moderation: complex sugars, and the carbohydrates e. g. yam, cocoyam, cassava, plantain, fruits e. g. orange, pineapple • Foods to be taken as desired: protein foods and vegetables O The three main meals should be taken interspersed with snacks a such, the food should be in small amounts at frequent intervals. They should also avoid fatty foods.

Diet cont’d O Measured diet: daily basal needs: • Inactive people: weight [lbs] *10=Kcal • • • [requirements] Sedentary: weight [lbs] *15 =Kcal [requirements] Manual labourer: weight *20 =Kcal [requirements] Note: 160 lbs = 73 kg 1 g protein = 4 Kcal 1 g carbohydrate = 4 Kcal 1 g fat = 9 KCal

Medication O Drugs are given where diet alone cannot control the • • condition. There are two groups of drugs: Oral hypoglycaemics: sulphonylureas: e. g. daonil, tolbutamide, diabenase, glybenase they stimulate the production of insulin hence are given to people who produce inadequate insulin. They taken 30 minutes before meals. Biguanides e. g. metformin HCl and phenformin HCl. They stimulate the cells to absorb glucose. They are taken with food or immediately after eating.

Medication cont’d O Insulin • Regular or soluble insulin [semi-lente]: it is clear in appearance and begins working from about 30 minutes, and peaks around 2 -4 hours and terminates in about 6 -8 hours. E. g. crystalline zinc insulin • Insoluble insulin: [cloudy in appearance] • • Intermediate [lente]: onset in about 2 -3 hours, peaks around 8 -12 hours and terminates in 18 -24 hours Long acting insulin [ultra lente]: e. g. protamine zinc insulin. Onset in 6 hours peaks around 16 -18 hours and terminates in about 30 -36 hours.

The role of the nurse in insulin administration • Know the dosage to administer according • • • to the blood glucose level Know the type of insulin Identify the syringe [100 IU/ml or 50 IU/1/2 ml. Given at 90 degrees Organise the items needed for the injection Ensure aseptic techniques Know the sites for injection

Insulin administration cont’d • Do not rub the injection site. • A meal should be ready before the injection is given • Observe the patient signs of hypoglycaemia Sites of injection: thigh, lower abdomen i. e. around the umbilicus and buttocks

Exercise • Usually prescribed for obese patients. • They are supposed to engage in vigorous exercise. E. g. : brisk walking, jogging, press-ups, cycling, swimming, skipping • Exercise helps in glucose absorption, and also reduces lipid levels as a result of utilisation of energy and mopping of glucose by the cells. • They must always carry glucose source before engaging in exercise. • They should also exercise with other people and not engage in exercise alone.

Education focuses on the following areas: • Condition: manifestations and complications and management • Medication: OHA, insulin. • Storage of the insulin • Diet • Exercise • Protection from injury • Should carry an identification band/card • how to test the blood and urine glucose levels • follow-up: routine check-up • they should also attend the diabetic clinic

Education cont’d • Protection from injury: ü Put on footwear all the time ü Well fitting shoes ü Nail care: nails must be cut across preferably with a nail clipper, where callous or corns are present, they must see a chiropodist ü Foot care: the feet should be washed at least twice daily and vaseline applied to keep the moist since dry feet crack ü Avoid handling of very hot or cold substances, it necessary, they should use gloves

Monitoring O The patient must attend the diabetic clinic for various examinations and tests to be done. O The blood sugar level monitoring O Eye examination and kidney examinations are also routinely carried out.

COMPLICATIONS • • Hypoglycaemic or insulin coma Hyperglycaemic or diabetic coma • Macro-angiopathic disorders: • • hypertension CADs CVA heart failure Micro-angiopathic disorders • • retinopathy [blindness] renal disorders [kidney failure] impotence

HYPOGLYCEMIC COMA An immediate complication of diabetes characterised by abnormally low blood sugar with accompanying signs and symptoms

Precipitating factors • Hunger/starvation/fasting • Insulin(medication) overdose • exertive activities • loss of blood • vomiting or diarrhoea

Clinical features • severe headache • extreme hunger • tremours • cold clammy skin • dizziness • shallow respirations • steterous respiration • unconsciousness

Management Managed at levels O if patient is conscious and can swallow; • dissolve 2 cubes or 2 table spoons of sugar in water for them to drink • they can also be given half a bottle of soft drink O if patient cannot swallow; administer the solution per NG tube

HYPOGLYCAEMIC COMA • If patient is unconscious; • give 50 ml of 50% dextrose bolus. • If they do not recover after 15 minutes, repeat the treatment • in the absence of the 50% detrose, patient can be given 1 g glucagon O ** patient should be given a meal immediately they recover O ***monitor the blood sugar until the condition is stable.

Hyperglycemic coma O Two types: • Diabetic Ketoacidosis [DKA] • diabetic hyperosmolar hyperglycaemic acidosis [DHHA]

DKA O A state of absolute or relative insulin deficiency aggravated by ensuing hyperglycemia, dehydration, and acidosis; producing derangements in intermediary metabolism, including production of serum ketones O An acute and dangerous complication that is always a medical emergency.

DKA cont’d O Caused by profound lack of insulin and is characterised by hyperketosis, acidosis and dehydration. O Low insulin levels cause the liver to breakdown fat for energy; ketone bodies are produced as by-products in that metabolic sequence. Elevated levels of ketone bodies in the blood decrease the blood's p. H, leading to DKA. It is common in type 1 diabetes.

Hyperosmolar Hyperglycemic State (HHS) O With very high (>16 mmol/L) blood glucose level, water is osmotically drawn out of cells into the blood and the kidneys eventually begin to dump glucose into the urine. This results in loss of water and an increase in blood osmolality. O If fluid is not replaced, the osmotic effect of high glucose levels, combined with the loss of water, will eventually lead to severe dehydration. The body's cells become progressively dehydrated as water is taken from them and excreted. O common in type 2 diabetics

Precipitating factors • skipping or not taking enough • • insulin/OHA. over eating Stress from illness Psychological stress the dawn phenomenon Infections Alcoholism Medications

Clinical manifestations • • • • Hyperglycemia Frequent urination Increased thirst Blurred vision Fatigue Headache Fruity-smelling breath Nausea and vomiting Shortness of breath Dry mouth Weakness Confusion Coma Abdominal pain

Management O Albertis regime: • Check blood sugar then • give 1 L N/S with the first 30 minutes, • followed by 1 L N/S every hour for the next 5 hours. • Blood sugar is checked every 2 -3 hours and insulin given accordingly. • When blood sugar gets to normal or low, dextrose saline is given. Sometimes, KCl is added to the solution to maintain electrolyte balance.

Assignment Tabulate six difference between hypoglycemic and hyperglycemic comas