Diabetes Mellitus Part 2

• Diabetes Mellitus is covered
• Rowena A. Bautista, MSN, RN, CMSRN is the presenter

US Data & Statistics

• Overview & Pathophysiology
• Clinical Manifestations
• Contributing Factors
• Screening Tests
• Pathological Outcomes
• Clinical Management

Pathological Outcomes

• Acute and Chronic consequences of Long Term Diabetes
• Diabetic Ketoacidosis (DKA)
• Hyperosmolar Hyperglycemic State (HHS)
• Microvascular (Chronic): Dermopathy, Nephropathy, Retinopathy, Neuropathy
• Macrovascular (Chronic): Atherosclerosis, Peripheral Vascular, Cardiovascular, Cerebrovascular

DKA vs HHS

• Common in Type I DM: DKA
• Typically, > 300 mg/dL: DKA
• Osmolality > 340 mOsm/L: DKA & HHS
• Kussmaul's respiration: DKA
• Confusion: DKA
• Develops quickly: DKA
• Common in Type II DM: HHS
• Typically, > 600 mg/dL: HHS
• Shallow breaths: HHS
• Lethargy: HHS
• Develops slowly: HHS

Long-Term Effects of Diabetes

• Diabetic Retinopathy is the leading cause of blindness in adults
• Diabetic Nephropathy is the leading cause of end-stage renal disease
• Stroke has a 2 to 4-fold increase in cardiovascular mortality
• 8/10 individuals with diabetes die from a cardiovascular event
• Diabetic peripheral Neuropathy is a key initiating factor of diabetic foot ulceration

Diabetic Dermopathy

• Shin spots or diabetic skin spots
• Manifests as small, round, oval patches of discolored skin
• Causes include microvascular damage and trauma or injury

Nephropathy

• Damages small blood vessels in the kidney, including glomeruli
• Albuminuria (protein) in urine occurs
• 70% of patients with nephropathy also have hypertension (HTN)

Retinopathy

• Microvascular damage and occlusion of the retina
• Associated with other ocular disorders like glaucoma and cataracts
• Glaucoma affects the optic nerve
• Cataracts affect the lens

Peripheral Neuropathy

• Peripheral nerves transmit signals from the CNS to the rest of the body.
• Sensory Neuropathy involves loss of sensation, numbness, and tingling.
• Motor Neuropathy involves weakness and cramps.

Autonomic Neuropathy

• ANS controls involuntary functions
• Cardiovascular System: Postural hypotension
• Nervous System: Erectile dysfunction
• Gastrointestinal System: Gastroparesis

Peripheral Vascular Disease

• Narrowing or blockage of blood vessels
• Clotting disorders - often BLE's
• Poses risks of infection, gangrene, and amputation

Cardiovascular Disease

• Coronary heart disease affects blood vessels supplying the heart muscle
• Cerebrovascular disease affects blood vessels supplying the brain
• Peripheral arterial disease affects blood vessels supplying the arms and legs, leading to diabetic foot

Pharmacotherapy

• Major Classes
• Control of Hepatic Glucose Production: Biguanides, Thiazolidinediones
• Stimulation of Pancreas to Make More Insulin: Sulfonylureas, Meglitinides
• Slows Absorption of Starches/CHO: α-Glucosidase inhibitors

Biguanides - Metformin

• Metformin is a preferred initial pharmacological agent
• Decreases the rate of hepatic glucose production
• Increases glucose uptake in the muscles
• Should not be used in patients with kidney, liver, or heart failure
• Hold for 48 hours after procedures using contrast dye.

Sulfonylureas

• They're the oldest class of oral hypoglycemics.
• Stimulates the pancreas to make more insulin
• Take with meals
• Watch for hypoglycemia
• Drugs include glyburide (Micronase, Diabeta), glipizide (Glucotrol), and glimepiride (Amaryl).

Alpha-Glucosidase Inhibitors

• Starch Blockers
• Best used for patients with normal FBS but elevated Post Prandial Plasma Glucose (PPG)
• Take with the first bite of a meal
• Monitor liver enzymes
• Drugs include: -acarbose (Precose) -miglitol (Glyset)

Dipeptidyl Peptidase-4 Inhibitor (DPP-4)

• Boosts incretin, hormones produced by the gut in response to food intake
• Drugs in this class include: -sitagliptin (Januvia) -linagliptin (Tradjenta) -alogliptin (Nesina) -saxagliptin (Onglyza)

Incretin Mimetics (GLP-1 RA)

• Mimic the effects of incretin
• May combine with oral agents
• Do not use with Insulin
• Drugs include: -dulaglutide (Trulicity) -exenatide (Byetta/Bydureon) -liraglutide (Victoza) -semaglutide (Ozempic)

Semaglutide

• It is a peptide similar to the hormone GLP-1, promotes insulin secretions

Insulin Overview

• Injectable drugs to control: -Type 1 diabetes (dependent) -Type 2 diabetes (if not controlled by other means)
• 1920's - Banting & Best invented
• 1980's - recombinant DNA

Banting and Best

• In 1920, Frederick Banting, a Canadian surgeon, and Charles Best, a medical student, successfully isolated the hormone insulin for the first time

Insulin Types

• Rapid-acting – bolus
• Short-acting - bolus/prandial
• Intermediate-acting
• Long-acting - basal
• Premixed – combination

Mixing Insulins in a Syringe

1. Draw air into syringe.
2. Inject air into NPH insulin:
3. Inject air into Short-Acting Insulin.
4. Draw Short-Acting Insulin
5. Draw NPH Insulin

Insulin Pump

• Delivers Insulin via an infusion set through a thin tube that goes under the skin
• Mimics a healthy pancreas, delivering basal and bolus doses
• Safety related to Insulin Pump and MRI

Phases of Insulin Action

• Onset is when the effect of Insulin first begins
• Peak is when the Insulin is working at its “optimal" level
• Duration is how long the Insulin persists in the system
• The image shows when the different types start to work and their peaks, it also shows the differing intensity of the insulin types

Type 2 Diabetes Drug Treatment

• Pancreas is stimulated to produce insulin through drugs

Beyond Blood Sugar Control

• Exercise
• Diet
• Medications
• Blood Pressure & Cholesterol Management
• Managing High blood Sugar

Blood Vessel Damage

• Using Risk Reduction Approach & Attack -Stroke -Kidney Damage -Nerve Damage

Dietary Recommendations

• Non-starchy Veggies (spinach, carrots, broccoli)
• Protein (chicken, salmon, eggs)
• Carbohydrates (whole grain foods, pasta, potatoes)
• Water is the best beverage choice -Add: serving of fruit & dairy.
• Choose healthy fats

Fiber in Diabetes Management

• Fiber is the best source of carbs from veggies, fruits, and legumes
• Fiber binds and delays entry into the bloodstream

Benefits of Fiber

• Improves blood sugar control
• Digestive health
• Weight management
• Heart health

Physical Activity Recommendations

• Aerobic
• Anaerobic
• Mixed

Aerobic Exercise

• Lower intensity, longer duration
• Expect a drop in glucose levels

Anaerobic Exercise

• Higher intensity, shorter duration
• Expect spikes in glucose levels

Mixed Exercise

• Combination of aerobic and anaerobic activity
• Expect glucose levels to fluctuate; they can drop or spike

Essential Foot Care

• Wash daily & Dry well between toes
• Feel for bumps or temperature changes
• Look between toes & check each toenail
• File toenails straight across
• Check for dry &cracked skin
• Examine bottom of feet
• Track what you find

Tips for Healthy Feet

• Check feet every day for cuts, redness, swelling, sores, blisters, corns, or calluses
• Wash feet every day in warm (not hot) water and dry them well
• Never go barefoot, even inside
• Wear shoes that fit well and always wear socks
• Trim toenails straight across and smooth out sharp edges with a nail file
• Do not try to remove corns or calluses yourself
• Get feet checked at every health care visit and visit a podiatrist at least once a year

Vision Care

• Complete a dilated eye exam every year to watch for retinopathy
• Call a doctor immediately with -Blurred or double vision -Narrowed field of vision -Seeing dark spots -Feeling pressure in the eyes -Unusual difficulty seeing in dim light
• Those with diabetes are more likely to develop both cataracts (60%) and glaucoma (40%)

Managing Skin Care

• Bathe daily with mild soap and lukewarm water
• Avoid scratches or bruises
• Use gardener gloves
• Wear Sunscreen
• Avoid long exposure to very cold weather
• Treat skin injuries quickly

Sick Days

• S- Sugar
• I- Insulin
• C- Carbohydrates
• K- Ketones

Patient Education

• TRACK
• T: Take your medications as prescribed by your doctor.
• R: Reach and maintain a healthy weight.
• A: Add more physical activity to your daily routine.
• C: Control your ABC's- A1C, blood pressure, and cholesterol levels.
• K: Kick the smoking habit.

Generate Solutions

• Patient/Caregiver
• Demonstrates blood glucose test on self
• Verbalize proper foot care
• Verbalizes exercise guidelines
• Verbalizes importance of outpatient DM education after discharge. Verbalizes target glucose ranges and A1C levels

Blood level Chart

• Normal fasting: 70-100. less than 140 2 hours later
• Pre-diabetes fasting: 101-125. 140-200 2 hours later
• Diabetes fasting: greater than 126. greater than 200 2 hours later

Generate Solutions: Patient/Caregiver

• Patient will demonstrate SQ injection
• States appropriate time schedule for insulin
• Verbalizes sick day guidelines
• States one day meal plan
• States drug/drug and drug/nutrient interactions.
• States symptoms, treatment of hypoglycemia.
• States symptoms, treatment of hyperglycemia.
• Meals include equal portions of high-fiber vegetables and protein, and a smaller portion of grains