Diabetes Mellitus: Types, Signs & Management

• Diabetes is covered in Endocrine Part II

Learning Objectives

• Differentiate between Type 1 and Type 2 Diabetes by considering modifiable versus nonmodifiable risk factors
• Discuss the three cardinal signs (the three p's) experienced in patients with Diabetes
• Recognize the pharmacological management for Diabetes, including the onset, peak, and duration of insulins
• Review the expected signs and symptoms associated with diabetes, including laboratory values
• Discuss nursing management and education considerations for patients with diabetes
• Describe hypo and hyperglycemic events and the nursing assessment, interventions, and treatments associated

Diabetes Mellitus (DM)

• A chronic disorder effects carbohydrate, protein, and fat metabolism
• A discrepancy exists between the amount of insulin required and the amount of insulin available in the body

Types of Diabetes Mellitus

• Type 1 Diabetes
• Type 2 Diabetes
• Gestational DM (GDM): Patients develop glucose intolerance
• Other types include pancreatic, hormonal, or endocrine disease, insulin resistance, or drug-induced
• Malnutrition-related DM in underdeveloped countries is a vulnerable population consideration

Laboratory Diagnostics

• HbA1c is the gold standard
• Diabetes HbA1c (percent) is ≥ 6.5, Fasting Plasma Glucose (mg/dL) is ≥ 126, and Oral Glucose Tolerance Test (mg/dL) is > 200
• Prediabetes HbA1c (percent) is 5.7-6.4, Fasting Plasma Glucose (mg/dL) is 100 - 125, and Oral Glucose Tolerance Test (mg/dL) is 140 – 199
• Normal HbA1c (percent) is ~5.7, Fasting Plasma Glucose (mg/dL) is ≤ 99, and Oral Glucose Tolerance Test (mg/dL) is < 139

Type 1 Diabetes Mellitus

• Type 1 Diabetes Mellitus affects around 1 million people
• It occurs more often in males than females
• Onset can occur at any time and is often abrupt
• The autoimmune component is heavily influenced by genetics, but not congenital
• It most commonly develops and presents in childhood before age 20

Type 1 Diabetes

• Beta cells of the pancreas have insulitis (pancreatic inflammatory response) with beta cell destruction
• Patients are dependent on insulin for prevention of hyperglycemia or ketosis
• Diabetic Ketoacidosis is the most serious life-threatening problem related to untreated Type 1 Diabetes
• Serum glucose level is greater than 250 mg per dL
• pH is less than 7.3
• Elevated ketone level in blood or urine is evident

Presentation of Type 1 Diabetes

• The three cardinal signs are polyuria, polydipsia, and polyphagia
• Symptoms include weight loss and fatigue
• Underlying, the onset can be rapid
• Glucose level is greater than 200 mg/dL

Type 2 Diabetes

• Type 2 Diabetes is far more common than type 1 DM
• It accounts for about 90% to 95% of diabetes cases
• It is more common in adults
• Obesity is a factor and it is becoming more common in juveniles, especially 10-19 year olds
• The pancreas sends insulin so body can use sugar in a person without diabetes
• Not enough insulin or cells ignore insulin in a person with type 2 diabetes

Risk Factors For Type 2 Diabetes

• Family history of diabetes
• BMI ≥ 23.0 kg/m²
• Inactive lifestyle
• High blood pressure
• Abnormal blood cholesterol/lipid levels
• History of gestational diabetes
• Age ≥ 40 years old
• Impaired glucose tolerance or impaired fasting glucose

Metabolic Syndrome

• Patients who meet the criteria for metabolic syndrome are overweight
• Metabolic syndrome is the cluster of risk factors, cardiovascular disease and type 2 diabetes
• Metabolic syndrome traits include three of the following: abdominal or central obesity, Increased serum triglycerides greater than or equal to 150 mg/dL, Decreased high-density lipoprotein less than or equal to 40 mg/dL, Hypertension greater than or equal to 130/85 mm Hg, and Fasting blood glucose greater than 100 mg/dL

Presentation on Type 2 Diabetes

• Nonspecific prolonged onset
• Fatigue
• Recurrent and recurrent yeast infections
• Prolonged wound healing
• Visual changes

Diagnostics

• HgbA1C is 6.5% or above
• Fasting blood glucose has no caloric intake for at least 8 hours and a level greater than 126 mg/dl
• Random blood glucose is greater than 200 mg/dl
• Two-hour glucose is greater than 200 after 75 g load

Management of Diabetes

• Types of insulin can be found in Hoffman: Page 1035 Table 44.3

Rapid Acting Insulin

• Lispro(Humalog) and Aspart (NovoLog)
• Onset: 10-30 min
• Peak: 30 min-3 hr
• Duration: 3-5 hr

Short Acting Insulin

• Regular (Humulin R, Novolin R)
• Onset: 30 min-1 hr
• Peak: 2-5 hr
• Duration: 5-8 hr

Intermediate Acting Insulin

• NPH (Humulin N, Novolin N)
• Onset: 1.5-4 hr
• Peak: 4-12 hr
• Duration: 12-18 hr

Long Acting Insulin

• Glargine (Lantus) and Detemir (Levemir)
• Onset: 0.8-4 hr
• Peak: Less defined or no pronounced peak
• Duration: 16-24 hr

Inhaled Insulin

• Afrezza
• Onset: 12-15 min
• Peak: 60 min
• Duration: 2.5-3 hr

Sliding Scale Insulin

• You do not need to memorize Sliding Scale Insulin numbers- it will be different for each patient
• It is an example

Oral Hypoglycemic Agents for Pre-Diabetics and TYPE 2 DIABETES

• Metformin/Glucophage decreases the source of glucose production by inhibiting hepatic breakdown of glycogen to glucose
• Glipizide/Glucotrol stimulates beta cells to secrete insulin
• Metformin is contraindicated prior to CT scan with Contrast due to the possibility of Acute Kidney Injury

Hypoglycemia & Protocols

• There is a higher potential to occur after peak onset insulin administration
• Almost all hospitals have a PROTOCOL to initiate
• Protocol initiates if Glucose IS Less than 70.
• Protocol includes glucose 60-70 & Awake & Alert patients may drink juice, small meal (turkey sandwich,) and 15 grams of carbs, recheck in 15 minutes
• Glucose 50-60 & Awake & Alert patients should take an Oral Glucose Gel
• Glucose Less Than 50 or If Patient is Lethargic/Unconscious patients should receive an IM or IV Glucagon or IV 50% Dextrose

Hypoglycemia Symptoms

• Sweating
• Pallor
• Irritability
• Hunger
• Lack of coordination
• Sleepiness

Hyperglycemia Symptoms

• Dry mouth
• Thirst
• Weakness
• Headache
• Blurred vision
• Frequent urination

Diabetic Symptoms for Insulin Dependent Diabetics

• Hot and dry indicates sugar is high and needs insulin

• Cold and clammy indicates to much insulin, needs sugar

• Steriods increases blood sugar

• ACUTE illness: most often leads to increased blood sugar

• NPO status: Monitor for hypoglycemia – Type 1 will likely need insulin when NPO, Type 2 will likely not – Consult Provider

Nutrition Therapy

• Monitor carbohydrate intake through carbohydrate counting

• 1 unit of rapid-acting insulin will dispose of 15 grams of carbohydrate

• Eating a high amount of digestible carbohydrate leads to a large glucose spike, followed by a large insulin spike

• Insulin blocks fat breakdown and fat burning stimulating fat storage

• This result triggers HUNGER for more carbohydrates

Foods to Avoid

• Saturated fats
• Trans fats
• Cholesterol should be limited to 200 mg/day
• Sodium should be limited to 2300 mg/day, 1500 if hypertensive

Physical Activity

• Improves insulin sensitivity, blood pressure, the lipid profile, sleep quality, decreases risks for cardiovascular disease, and manages depressive symptoms
• People with diabetes should be advised to perform at least 150 minutes per week

Exercise Benefits

• Exercise helps your body use insulin better, strengthen the heart and bones, relieve stress, and improves blood circulation
• Exercise reduces risks for heart disease, lowers blood glucose, blood pressure, and improving cholesterol levels

Complications of Diabetes

• Diabetes is a silent killer
• Early treatment of Diabetes is important because NEGLIGENCE CAN CAUSE eye damage, heart and kidney diseas, brain stroke, nerve damage, and limb amputation
• Long-term complications of diabetes include the brain, cardiovascular and peripheral vascular system, eyes (retinopathy, glaucoma, cataracts), mouth (periodontal disease), kidneys, foot damage, and nerves (neuropathy)

Diabetic Complications

• Foot Ulcers
• Retinopathy
• Necrosis

Socioeconomic Factors

• Socioeconomic Factors impact 40% including education, job status, family support and income
• Physical Environment impacts 10% and includes housing
• Health Behaviors impact 30% including tobacco and alcohol use, diet, exercise and sexual habits
• Health Care impacts 20% including access & quality of care
• SDOH impact patient care