DISORDERS OF PANCREAS

• The pancreas is an organ with a head, body, and tail, containing lobules and a pancreatic duct.
• It's closely associated with the duodenum, gallbladder, and common bile duct.
• It also has an accessory pancreatic duct and duodenal papilla.

Disorders of the Pancreas

• Glucagon maintains normal blood glucose levels during fasting and stimulates glycogenolysis.
• Insulin regulates glucose in the blood by controlling its production and storage while stimulating glycogenesis.
• Insulin increases glucose transport into cells and promotes conversion of glucose, lowering serum glucose levels.

Functions of Insulin

• Transports and metabolizes glucose for energy.
• Stimulates glucose storage in the liver and muscles as glycogen.
• Enhances storage of dietary fat energy in adipose tissue.
• Signals the liver to stop releasing glucose.

Diabetes Mellitus

• Diabetes mellitus is a chronic hereditary disease characterized by hyperglycemia.
• Hyperglycemia is caused by relative insufficiency or lack of insulin.
• It leads to abnormalities in CHO, CHON, and FAT metabolism.
• Predisposing factors include being older, obese, female, and having hereditary factors.

Type I (IDDM) vs. Type II (NIDDM) Diabetes

• Type I diabetes has a rapid onset, typically before 40 years old, or it is considered juvenile-type before age 15.
• Type I is autoimmune and involves an absolute deficiency of insulin, requiring insulin, diet, and exercise for treatment, with DKA as a complication.
• Type II diabetes has a gradual onset, typically after age 40, with a genetic predisposition and obesity as risk factors.
• Type II is adult-onset, insulin-resistant, and may be asymptomatic with relative insulin deficiency and is treated with diet, exercise, and oral hypoglycemic agents, with HHNK syndrome/coma as complications.

Pathophysiology

• During digestion, fats break down into fatty acids, CHO into glucose, and CHON into amino acids.
• These end products are stored in the liver as glycogen.
• If insulin is deficient, glucose goes directly into the bloodstream, resulting in hyperglycemia.
• Hyperglycemia leads to decreased tubular reabsorption and polyuria (excessive urination).
• This causes fluid/electrolyte imbalance and intracellular dehydration (hemoconcentration).
• Hemoconcentration then stimulates the hypothalamus, leading to polydipsia (excessive thirst).
• Lack of insulin leads to cellular starvation (polyphagia).
• This causes gluconeogenesis (glucose creation) and the breakdown of CHON and fats.
• Fat breakdown leads to lipid accumulation; CHON breakdown results in cataract formation and diabetic retinopathy.

Complications of Lipid and Protein Metabolism

• Lipid accumulation leads to atherosclerosis and decreased blood supply to major organs.
• Resulting heart conditions include MI and angina pectoris; brain conditions include CVA and lower extremity complications such as decreased blood supply, necrosis, and gangrene.
• Abnormal protein metabolism impacts eyes, potentially leading to cataract formation and diabetic retinopathy.

Hematological Studies for Diabetes Diagnosis

• Fasting Blood Sugar (FBS) is a common test.
• Normal FBS is between 70-110 mg/ml.
• A diagnosis for diabetes may be given if a patient's BGL is greater than126 mg/dL after 2 consecutive readings.
• 2-Hour Post-Prandial Blood Sugar Test (PPBS) measures the body's ability to handle a carbohydrate load.
• A blood sugar measurement is taken 2 hours after ingesting a specified amount of carbohydrates.
• High glucose levels usually remain after 2 hours (usually 100 mg CHO), which may indicate diabetes; glucose should return to normal for someone without diabetes.

Oral Glucose Tolerance Test (OGTT)

• OGTT is used to confirm diabetes diagnosis when blood tests are borderline, and can confirm gestational diabetes.
• The patient should eat at least 150mg of carbohydrates 3 days before the test and continue with normal activity.
• Patients should remain NPO for 10-12 hours pre-test
• A fasting baseline specimen of blood and urine are taken.
• Glucose (75mg) is given orally and blood and urine specimens are collected 30 minutes, 1, 2, and 3 hours after ingestion.

Glycosylated Hemoglobin (HbA1c)

• HbA1c monitors average blood glucose over a 2-3 month period.
• Normal HbA1c levels are between 3.8-6.4 mg/dl.
• The HbA1c goal for diabetic patients is <7%.
• A glucose oxidase impregnated strip is a Dextrostix and this changes color.
• A read blood cell lives for approximately 120 days.
• Glucose enters the bloodstream.
• Glucose naturally binds to hemoglobin, and this binding creates glycated hemoglobin, also known as HbA1c.

Urine Tests

• Benedict's Test involves placing 5 cc (or 1 tsp) of Benedict's solution in a test tube, adding 5-10 drops of urine, and heating for 5 minutes, which results in the following:
• Blue: No sugar
• Green: +1
• Yellow: +2
• Orange: +3
• Brick Red: +4
• Clinitest has false positives with certain drugs like Nalidixic Acid (Negram), Keflex, Keflin, Salicylates, Vitamin C, and Penicillin.
• Tes Tape and Diastix urine strips are more reliable and specific for glucose than clinitest.
• Acetone tests, using Ketostix/Acetix, require the patient to void 30min before the test, drink some fluid, then void again before testing for better accuracy.

Diet for Patients with Diabetes

• Should consist of 12-20% CHON, 55-60% CHO, 20-30% Fats.
• It contains a lower proportion of saturated fats and increase the amount of fiber (20 g/day).
• The goal is to attain Ideal Body Weight and ensures normal growth.
• Most adults require 30 calories per kilogram of Ideal Body Weight.
• High CHO, high fiber diets significantly reduce blood sugar by increasing glucose absorption and lowering cholesterol and fats

Glycemic Index

• It describes how a blood glucose level will change from ingestion of specific foods.
• It measures how much the food will raise the blood sugar level.

Calculation of Diabetic Diet

• Must consider ethnic, religious & cultural background, person height x weight (Basal Caloric Requirments), the kilocalories (Kcal) required in the resting state, and a person's occupation and normal activity level.
• Ideal Body Weight is calculated using the following formulas for males: IBW=106 lbs + [6 x (height in inches-60)], and females IBW=100 lbs + [5 x (height in inches-60)].
• Basal Caloric Activity (BCA): Sedentary/Slow: IBW x 3, Moderately Active: IBW x 5, and Very Active: IBW x 10
• Basal Caloric Requirement (BCR) BCR = IBW x 10
• Total Caloric Requirement (TCR): BCA + BCR = TCR
• Determination of CHON, CHO & Fat content: 15% of calorie from CHON x TCR x 1 gm CHON (4 calories), 30% of calorie from fat x TCR x 1 gm fat (9 calories), 55% of calorie from CHO x TCR x 1 gm CHO (4 calories)

Activity/Exercise

• Activity and Exercise determines the client's need for nutrition and insulin.
• It used extra calories and does not put demand of the insulin supply to convert ingested glucose for storage.
• A patient needs a complete cardiovascular examination before beginning an exercise program.
• Safe timing and duration of an exercise benefit patients using Self Blood Monitoring
• Exercise during hyperglycemia is best (but with BGL of below 250 mg/dL).
• Exercise is not recommended during the peak action of insulin.
• Exercise frequency should be 3-5 times a week.
• Benefits include decreased blood glucose and cardiovascular risks, improved circulation/muscle tone, decreased cholesterol/triglyceride levels, and weight loss.

Pharmacological Therapy: Oral Anti-Diabetic Agents

• These agents are not hormones such as insulin but stimulate the release of insulin to the pancreas to retard the release of glucose from the liver.
• Are dangerous to the fetus, so pregnant clients are generally maintained on insulin
• Sulfonylureas stimulate beta cell production of insulin (Tolbutamide (Orinase), Tolazamide (Tolinase), Chlorpropamide (Diabinese), Acetohexamide (Dymelor, and Glyburide (Diabeta, Micronase), but side effects include headache and gastric upset.
• Research shows an increased risk of death in individuals using oral hypoglycemic agents with cardiovascular disease, so it is only used by those that cannot or will not use insulin.
• Agonists for this medication class include Butazolidin, MAO inhibitors, Sulphonamides, Anticoagulant & high dose of Aspirin and Alcohol, and Antagonists Corticosteroids, Oral Contraceptives, Thiazide, Diuretics & Furosemide.
• Non-Sulfonylureas (Avandia, Actos, Starlix and Prandin) are not on the market due to CVD.
• Biguanide Compounds include Phenformin (DBI) and Metformin (Glucophage).

Insulin Therapy

• Acts primarily acts in liver, muscle & adipose tissue by attaching to receptors on the cells & facilitates passage of glucose, K, and Mg.
• Lower blood glucose by facilitating the uptake & utilization of glucose by muscle and fat cells and decreases the release of glucose from the liver.
• Sourced from beef or pork pancreas & biosynthetic human insulin produced by using genetically altered bacteria

Types of Insulin Preparation

• Rapid acting/short acting: Regular (Humulin R and Semilente (Semitard, Semilente insulin)
• Intermediate Acting (NPH, Lente or “L”)
• Long acting (PZI Ultralente or “UL”)
• Mixed types (70% NPH, 30% Regular)

Types of Insulin: Onset, Peak of Action, Duration and Appearance.

• Regular: Onset less than 1 hour, Peak Action 2-4 hours, Duration 4-6, Clear appearance.
• Semilente: Onset less than 1 hour, Peak Action 4-7 hours, Duration 12-16, Cloudy appearance.
• NPH: Onset 1-2 hours, Peak Action 8-12 hours, Duration 18-24, Cloudy appearance.
• Lente: Onset: 1-4 hours, Peak Action 8-12 hours, Duration 18-24 hours, Cloudy appearance.
• Ultralente: Onset 4-8 hours, Peak Action 16-18 hours, Duration 36, Cloudy appearance.
• Extreme temperature should be avoided when storing insulin and should not be in sun or frozen.
• It can be stored at room temperature for 1 month

Administration of Insulin

• The proper order would be to inject air to NPH, inject air to regular, aspirate regular, and aspirate NPH.
• Insulin syringes should be gauge 27-29 and 1/2 inch long.
• The injection should be at 90 degrees SQ.
• Possible Injection Sites are the abdomen, arm (deltoid), thigh, buttocks, and upper back.
• The locations with medium speed are abdomen and upper back, the locations with a fast speed are the arm (deltoid), the locations with slow speed are the thigh and buttocks.
• Factors increasing absorption are: Exercising the site of insulin injection, injecting the insulin deep into the SQ, massaging the site, and taking an injection after a warm bath or shower
• The absorption rate of insulin will vary.
• Rotation of sites within one anatomical area is recommended. Use abdomen and arms in the AM and thighs & buttocks for PM.
• Complications include a local/systemic allergic reactions, insulin resistance and insulin Lipodystrophy.
• Lipoatrophy is the loss of subcutaneous fat or lipohypertrophy is the development of fibro-fatty masses at the injection site.
• Prevent these by rotating the site and do not over use it for over 2-3 weeks 1 1/2 inches apart.

Nursing Interventions for Hypoglycemia

• Monitor for hypoglycemia, which happens when there is lower blood glucose levels, due to too much insulin/OHA, too little food, or excessive activity.
• Obtain a blood glucose level if a hypoglycemic reaction is suspected and if it can be done quickly.
• Encourage patients to use Self-Blood Monitoring and not to rely on subjective feelings alone.
• Conscious patients should be administered a quickly absorbed sugar (10-15 gms of CHO such as 1/2 cup fruit juice, 1/2 cup gelatine dessert,4 cubes sugar, candies (no chocolate), and 2 packets of Sugar.
• Unconscious or severe hypoglycaemia, give IV bolus of 50% glucose.
• After recovery, the patient should eat a snack consisting of complex CHO and CHON to help increase their blood sugar.To facilitate prompt treatment for unconsciousness, patients should carry identification cards with their diagnosis.
• MED-ALERT bracelets or necklaces can alert others of the diabetic status.

Somogyi Phenomenon

• A sequence of increasing peaks and valleys in blood glucose levels, usually triggered by an excess dosage of insulin.
• Consists of night time sweats, nightmares and a headache on arising.
• Treatment includes a bedtime snack and decreasing the evening dose of intermediate/long acting insulin.

Acute Complications of Diabetes Mellitus

• Diabetic acidosis (DKA) is a condition due to an insulin deficiency resulting in a derangement of CHON, CHO and fat metabolism with dehydration and electrolyte imbalance.
• Ketoacidosis occurs when fatty acids are broken down to ketone bodies due to a deficiency of insulin.
• Signs and symptoms include: Hyperglycemia, Glycosuria, Polydipsia, DHN, Dry Skin, Sunken Eyeballs, Flushed Skin, Tachycardia, Circulatory Collapse,Lactic Acidosis and Coma.
• Management includes adequate ventilation, fluid replacement (NaCO3, NaCl seldom given & fluids corrects acidosis), administer insulin according to level of acidosis, Indwelling catheter to monitor urine output, and ECG (electrolyte imbalance).

Managing Somogyi

• Refers to nocturnal hypoglycemia that leads to rebound hyperglycemia.
• Normal or elevated glucose may be present at bedtime with hypoglycemia occurring at 2 AM -3 AM
• Secretion of contra-insulin hormone (glucagon) then follows leading to hyperglycemia @ 7AM.
• The way to treat this is to administer a snack before bedtime or to decrease the dose of evening insulin.

Hypoglycemia/Insulin Shock

• Occurs due to different causes.
• It can result from over doing exogenous insulin.
• When an individual is omitting a meal/eating less.
• Or if an individual is overexerting themselves without compensation of CHOL
• Symptoms Include hunger, nausea, hypotension, bradycardia, lethargy, lassitude, yawning, trembling, inability to concentrate and sensorium changes.
• Irritability, sweating, increased systolic BP, increased PR, and pallor.
• Patients who have a blood sugar is below 55 to 60 mg/100 mL could potentially suffer from Low blood pressure.
• Treatment: Hard candy or sugar, Orange juice or soft drinks, as well as commercially prepared sugar products/Glucose/Monogel (if the patient can swallow)/Glucagon (injected SQ.
• If a patient is hypoglycemic they are tired.

Hyperglycemia, Hyperosmolar Nonketotic Coma/Syndrome (HHNKS)

• A condition resulting to elevated concentration of blood glucose level which increases the osmolality of blood without ketoacidosis.
• Causes include kidney issues (polyuria) which leads to dehydration (8 - 10ldue to serum osmotic pressure) and can be caused by a Large Sodium Bicarbonate infusion.
• A marked case of Hyperglycemia.
• Uremia with increased BUN.
• Also if your body is retaining Sodium because of the adrenal gland you can cause this.
• Treatment with renal impairment is dialysis.

Lactic Acidosis

• A condition resulting from a severe generalized type cases of tissue anoxia accompanied by the production of large amount of lactic acid.
• It adds more hydrogen ions to the the body with increasing the acid load.
• Signs include Low Serum HCO3' ,low PH and Elevated Co2
• Labs might display No Ketones.
• This is treated by first and formost starting medication and fixing the issues, this includes fluids, fixing an patients insulin and treating acidosis.

Dawn Phenomenon

• Reduced tissue sensitivity to insulin and characterized levels that are considered fine until 3.am.
• This causes some problems such as a Nocturnal surge which results in a lack of Insulin being unable to sustain to body.
• to treat provide 10.PM dose.

Chronic Complications

• Due to degenerative changes in the vascular system, which impacts proper nutrition.
• Blood vessels becoming thickened, sclerosed.

Neuropathy

• Disease of the peripheral nerves can also cause a risk for infection.
• When Hyperglycemia it does effect specialized cells to destroy Bacteria which can be dangerous

Eye Complications

• Can result in blindness
• Complication such as Cataracs Diabetic Retinopathy and Retinal Detachment do result in blindness
• The changes can affect the small blood vessels of the Retina.
• Hearts can also be effect with the most common issue to cause.

Heart Diseases

• Myocardial Infarction results in Atherosclorosis.

Diabetic Nephropathy

• Secondary results in vascular lessions this does lead to the damaging and the loss of tiny capparlies.
• This can cause glomerulus issues.
• Kidneys can also effect as well as pressure of your bodies renal (ESRF), in this case Dialysis can be used, kidneys can also be taken out for transplant since this can turn into renal kidney's can cause you issues.

Diabetic Neuropathy

• Affects all types of nerves including; periphery, sensory, autonomic, spinal etc.
• Found on pretibial areas with high hyperpigmentations in the area's consisting of red brown papules.
• Might cause nerve issues with a great reduction in pain and paresthesia, in the numbest parts, or in area's of reduced blood flow.
• Liver problems, enlargement can occur due to the bodies inflitations might occur.
• Feet often have a sense of tingling in the area's, pricks area cause by needles.
• Burning sensation, in the feet which are known to heal slow, and lead to feet problems, and damage of vessels in the area.

Feet Assessment Tests

• Check Lesions or anything out the ordinary.
• Do also take action to check there colour.
• Temp test and check nails for fungal infections.
• Check Epidermophytosis and for calluses,blisters, cracks or abrasions or anything you might see on the feet.
• Check you pulses.

Diabetic feet care

• Give the patient a meticulous and care plan for skin problems.
• Inform them to remove excess from legs and feet before getting in bed and to inform the AP if you are to see "red" skin coming or being infected.
• Also before informing them is key to not treat these things without medical consent since the patient may just worsen the issue.
• You can buy cream to use this treatment to reduce your issues.
• Also check to see if using cotton can effect you.
• Also provide a plan to cut you toe nails.

Management Before Undergoing Surgery

• You are meant to follow up with all the steps since they might cause a change in Insulin requirements.
• Your main goal is to understand these issues to achieve a nutritional balance to these individuals.
• Also obtain pre-operative evaluation studies.
• Tests, and see how a patient's usual meals might effect them.

Explore the counter-regulatory functions of insulin and glucagon in maintaining blood glucose homeostasis. Learn about insulin's mechanisms, including stimulating glucose uptake and glycogen synthesis. Understand diabetes mellitus, its metabolic abnormalities, and the classic symptoms of polyphagia, polydipsia, and polyuria.