Types and Diagnosis of Diabetes

• There are three main types of diabetes: Type 1, Type 2, and Gestational Diabetes Mellitus.

Diagnosing Diabetes

• Diagnosis occurs when symptoms are present alongside a fasting blood test result at or above 7.0mmol/L.
• Diagnosis occurs when symptoms are present alongside a random blood test result at or above 11.1mmol/L.
• Diagnosis occurs when symptoms are present alongside a HbA1c blood test result at or above 6.5% (48mmol/L).
• In the absence of symptoms, diagnosis requires two abnormal blood glucose tests on separate days.
• During a 75g oral glucose tolerance test (OGTT), diabetes is diagnosed if fasting glucose is >7.0mmol/L or 2hr glucose is >11.1mmol/L.

Type 1 Diabetes

• It most frequently occurs in people under 30.
• It is the most common childhood chronic illness.
• There is no insulin produced, as beta cells in the pancreas are destroyed by the body's immune system (autoimmune disease).

Signs and Symptoms of Type 1 Diabetes

• Polyuria (frequent urination)
• Unexplained weight loss
• Polydipsia (excessive thirst)
• Polyphagia (excessive hunger)
• Fatigue
• Blurred vision
• Irritability
• Fruity smelling breath

Management of Type 1 Diabetes

• Requires lifelong insulin therapy.
• Requires BGL monitoring several times a day.
• Requires following a healthy diet.
• Requires exercise.
• Diabetoc educator and endocrinologist.
• HbA1c surveillance is a key element of ongoing care.

Type 2 Diabetes

• Characterized by insulin resistance, where insulin does not work effectively.
• Insulin receptors on cells in insulin-sensitive tissues stop responding to insulin, or there are fewer receptors.
• Glucose cannot enter skeletal and adipose tissue to be converted to ATP, or glucose is not stored as glycogen in liver cells.
• May eventually lead to reduced insulin production

Risk Factors for Type 2 Diabetes

• Age
• Hypertension
• Smoking
• Obesity
• Sedentary lifestyle
• Family history
• Aboriginal or Torres Strait Islander descent

Management of Type 2 Diabetes

• Weight loss management and lifestyle changes are crucial.
• Dietary and lifestyle changes are primary interventions.
• Oral medications may be necessary.
• Insulin may be required in some cases.

Pre-Diabetes

• Defined as blood glucose levels that are higher than normal but not high enough for a type 2 diabetes diagnosis.
• Risk factors are similar to those for type 2 diabetes.
• Treatment involves regular physical activity, healthy eating, and weight loss if necessary.

Gestational Diabetes Mellitus (GDM)

• Occurs during pregnancy and usually resolves after childbirth.
• Placental hormones that support the baby's growth can block the mother's insulin, increasing insulin demand by 2-3 times.
• GDM develops if the pancreas cannot meet this increased demand.
• Diagnosed by OGTT.

Risk Factors for Gestational Diabetes

• Being 40 years or older.
• Family history of type 2 diabetes or GDM.
• Being overweight.
• History of elevated BGL.
• GDM in past pregnancies.
• Rapid weight gain in the first half of pregnancy.

Insulin Types and Usage

• In type 1 diabetes, no insulin is produced, therefore treatment is exclusively with insulin.
• In type 2 diabetes, insulin is not usually the first line of management, but it may be necessary if BGLs cannot be managed with medication.
• Treatment is individualized based on each person's response.
• Administered by subcutaneous injection or IV in emergencies.
• There are several types of insulin including rapid-acting, short-acting, intermediate-acting, long-acting, and mixed insulin.

Rapid-Acting Insulin

• Starts working in 10-20 minutes.
• Peaks at 1-3 hours.
• May last up to 5 hours.
• Injected at meal times, and eating should occur shortly after.
• Mimics body's natural insulin response.
• Examples include Novorapid, Humalog, and Apidra.

Short-Acting Insulin

• Starts working in 30 minutes.
• Peaks at 2-4 hours.
• Lasts 6-8 hours.
• Injected 30 minutes prior to a meal.
• Often used in combination with a longer-acting insulin.
• Examples include Actrapid and Humulin R.

Intermediate-Acting Insulin

• Starts working in 2-4 hours.
• Peaks at 4-12 hours.
• Lasts 12-18 hours.
• Cloudy appearance due to the addition of zinc to delay action.
• Often given in the morning and evening, and used with shorter-acting insulins.
• Examples include Protaphane and Humulin N.

Long-Acting Insulin

• Has no defined onset or peak.
• Lasts around 18-24 hours.
• Clear in appearance.
• Provides a slow and steady release of insulin.
• Usually given once a day, but may be twice.
• Includes Lantus and Levemir.

Mixed Insulin

• Combination of rapid or short-acting insulin with an intermediate-acting insulin.
• Offers two types of insulin in one injection.
• Has a cloudy appearance.
• Rapid-acting examples: Novomix, Humalog Mix.
• Short-acting examples: Mixtard, Humulin.

Insulin Storage

• Vials in current use can be kept at room temperature, not in the fridge, as it works better and is less painful when injected.
• Unopened stock should be kept in the fridge until needed.

Administering Insulin

• Injected into the subcutaneous layer (fatty tissue).
• Absorption rate varies based on the injection site.
• The abdomen is the fastest absorption site.
• Site rotation is important to prevent lipohypertrophy.

Administration Devices

• Syringes are commonly used in hospitals, are for single-use only, and can hold 50 or 100 units.
• Insulin pens are disposable, allow for multiple uses, and use a dial to achieve dosing.
• Syringe pumps are small, computerized devices that deliver a present dose of rapid-acting insulin under the skin.

Hypoglycemia

• Blood glucose level drops below 4 mmol/L.
• Commonly referred to as a "hypo."

Causes of Hypoglycemia

• Too much insulin or oral hypoglycemics.
• Delaying or missing a meal.
• Not eating enough carbohydrates.
• More strenuous exercise than usual.
• Drinking alcohol.

Signs and Symptoms of Hypoglycemia

• Shaking, trembling
• Sweating
• Pallor
• Hunger
• Light-headedness
• Dizziness
• Mood change
• Tachycardia, irritability, restlessness, excessive hunger, diaphoresis (TIRED)

Treatment of Hypoglycemia

• Test BGL; if below 4 mmol/L, give jelly beans or a sugary drink.
• Retest BGL after 15 minutes and repeat if still below 4 mmol/L.
• If above 4 mmol/L, give long-acting carbs like bread.
• If the person is unable to swallow, it is a medical emergency.
• Position the person on their side and call a code blue or ambulance.
• Prepare for intravenous dextrose infusion and give an injection of glucagon if available.
• Never administer insulin to someone who is hypoglycemic.

Hyperglycemia

• Characterized by high blood glucose levels.

Treatment of Hyperglycemia

• Correct high glucose levels with short-acting insulin.
• Exercise.

Diabetic Ketoacidosis (DKA)

• A serious medical condition that develops over hours or days when there is insufficient insulin.
• The body burns fat for energy, leading to an accumulation of ketones in the blood and urine.
• Ketones are acidic, causing acidosis.

Causes of DKA

• Undiagnosed type 1 diabetes.
• Mixed insulin doses.
• Poor insulin compliance.
• Alcohol.
• Pregnancy.
• Acute illness, infection, or stress.

Symptoms of DKA

• Hyperglycemia
• Ketonaemia
• Ketonuria
• Deep and rapid breathing
• Vomiting
• Dehydration
• Hypotension

Medical Treatment for DKA

• IV normal saline
• IV electrolyte replacement
• IV insulin

Nursing Interventions for DKA

• Monitor hourly: GCS, pulse, RR, BP, BGL, temperature.
• Maintain fluid balance charts.
• Monitor for signs of infection.

Prevention of DKA

• Learn signs of deteriorating diabetes control and general health deterioration.
• Recognize signs of DKA and know when to seek medical advice or go to the hospital.
• Establish a good self-monitoring system at home: blood glucose testing, urine ketones.
• Implement "sick-day" management.
• Manage medications and alcohol consumption.
• Maintain regular contact with a diabetes educator, dietician, endocrinologist, or GP.

Sick Day Management for Type 1 Diabetes

• Always take insulin, never withhold a dose unless directed by a doctor.
• Test BGL regularly.
• Test for ketones.
• Rest.
• Keep drinking and (if possible) eating.

Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)

• Extreme hyperglycemia with normal ketone levels (often between 33-110mmol/L).
• More common in type 2 diabetics.
• Often occurs due to illness/trauma.
• Treatment is similar to DKA (IV fluids, insulin, and electrolytes).
• Acidosis is not common.
• Evolves over many days.
• Has a high mortality rate.

Causes of HHNS

• Infection (most common cause).
• Acute major illnesses (pancreatitis, heart attack, stroke).
• Dehydration.
• Non-compliance with type 2 medications.
• Trauma.
• Undiagnosed type 2 diabetes.

Symptoms of HHNS

• Extreme hyperglycemia (33-110mmol/L).
• Altered mental state/GCS.
• Critical dehydration.
• Polyuria, polydipsia.
• Weight loss.
• Glycosuria.
• Severe hypovolemia (HR > 100bpm and hypotension).
• Fever.

HHNS/DKA Complications

• Hyperglycemia and dehydration lead to mineral imbalances, especially sodium and potassium.
• Imbalances can lead to arrhythmias, cerebral edema, pulmonary edema, hypokalemia/hyperkalemia, hypoglycemia, seizures, coma, and organ failure.
• Without rapid treatment, HHNS can cause death.

Macrovascular Complications

• Diabetes increases the likelihood of atherosclerosis.
• Macrovascular disease increases the risk of myocardial infarction, stroke, and peripheral vascular disease.

Pathophysiology of Macrovascular Disease

• Hyperglycemia causes glucose to attach to proteins in arterial walls, forming advanced glycation end-products (AGEs).
• AGEs bind with collagen, making arteries stiff and less flexible.
• Results in increased blood pressure (hypertension), which further damages blood vessels and speeds up vascular disease.

Peripheral Vascular Disease (PVD)/ Peripheral Artery Disease (PAD)

• Results from narrowing of the arteries that carry blood to the peripheries, caused by atherosclerosis.
• Increases the risk of foot ulcers and amputations.

Diagnosis of PVD

• Doppler ultrasound to assess blood flow.
• Angiography.
• Symptoms assessment (skin discoloration, intermittent claudication, poor healing wounds, cool skin).

Intermittent Claudication

• Painful cramping, usually in the legs, during mild exercise.

Management of PVD

• Cholesterol surveillance and management.
• Semi-regular Dopplers.
• BP monitoring and management.
• Vasodilators.
• Antiplatelets +/- antithrombotics.
• Exercise and rehabilitation.
• Limb observation.
• Long-term pain management plan.

Risk Factors for Macrovascular Disease

• Age
• Duration of diabetes
• Poor glycemic control
• Genetics
• Hypertension
• Obesity
• Smoking
• High cholesterol
• Inactive lifestyle

Prevention and Management of Macrovascular Complications

• BP management (antihypertensives).
• Cholesterol monitoring and management.
• Implementation of a healthy diet (low glycemic index, high fiber foods).
• Maintaining fitness and regular physical activity.
• Tight control of diabetes (monitor blood glucose levels, adherence to medications).
• Regular review by GP, Endocrinologist & Cardiologist.
• Smoking cessation.
• Reduce alcohol consumption.
• Antiplatelets +/- antithrombotics.

Microvascular Complications

• Diabetic retinopathy
• Diabetic nephropathy
• Diabetic neuropathy

Diabetic Retinopathy

• In early stages, there may be no symptoms.
• May not be diagnosed until it is advanced.

Symptoms of Diabetic Retinopathy

• Blurred, distorted, or patchy vision that can’t be corrected with glasses.
• Problems with balance, reading, watching television, and recognizing people.
• Photophobia or light sensitivity.
• Poor night vision.
• Seeing spots or floaters.
• Dark spot in center of vision.

Preventative and Management Measures for Diabetic Retinopathy

• Treat hyperglycemia and hypertension.
• Screen for retinal changes yearly.
• Laser treatment seals leaking blood vessels and reduces growth of new fragile vessels.
• Surgery may be required for severe cases unresponsive to laser treatment.
• Intravitreal steroid injections control macular edema unresponsive to laser.

Diabetic Neuropathy

• Irreversible damage to the nerves of the peripheral nervous system.
• Diabetes is the most common cause.
• Commonly affects the nerves in the feet and hands (somatic), but can relate to any nerves, including those that control internal organs (autonomic).
• The cause is still not completely understood.
• Affects up to 50% of people with diabetes.
• Closely associated with the development of diabetic foot ulcers.

Symptoms of Diabetic Neuropathy

• Most people are unaware they have nerve damage until picked up on routine screening.
• Symptoms include numbness, tingling, discomfort, pain, and pins and needles.
• About half of people with diabetic neuropathy experience significant pain in their feet (neuropathic pain).
• Neuropathic pain is often worse at night and can disrupt sleep patterns.
• Can lead to impaired balance and increased risk of falls and weakness leading to deformities in the feet.

Treatment and Management of Diabetic Neuropathy

• Foot care by a podiatrist.
• Education about daily foot care (inspection, washing and careful drying, moisturizer for dry skin and cracked heels, nail-care, soft socks, choice, and use of supportive footwear).
• Exercise regularly.
• Maintain a healthy weight.
• Smoking cessation.
• BP management and cholesterol management.
• Care with heaters and hot water.
• Never walk barefoot.
• Ongoing management of neural pain.
• Tight glycemic control.

Diabetic Nephropathy

• Prolonged high blood glucose levels and hypertension can damage the micro-vessels in the glomerulus of the kidneys.
• Microalbuminuria is generally the first clinical manifestation of kidney dysfunction.
• Diabetes is the leading cause of end-stage renal failure worldwide.
• Impaired renal function accelerates retinopathy and CVD.

Nephropathy Management

• Intensive glycemic control.
• Multiple studies involving T1DM and T2DM patients prove that intensive control and aiming for HbA1c.