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NURS 2280 (11)


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NURS 2280
Shauna Houk

Diabetes Mellitus Questions  Type 2 Diabetes is more prevalent than Type 1 Diabetes. (T)  Research studies have shown that Type 2 Diabetes can be prevented or delayed in people at high risk for the disease through weight reduction and exercise. (T)  The physiological decrease in circulating insulin that normally occurs with exercise cannot occur in patients treated with insulin. (T)  Urine glucose testing is a preferred way of self monitoring for patients with decreased visual acuity or with a low income. (F)  Insulin administered by jet injector is usually absorbed faster. (T) Objectives  Understand the basic pathophysiologyof type 1 and type 2 diabetes and the difference between the diseases  Identify the clinical significance of glucose testing  Describe the relationship between diet, exercise and hypoglycemic agents.  Describe the difference between hypoglycemia and hyperglycemia and the nursing interventions to be considered.  Understand complications of diabetes and nursing interventions appropriate to deal with issues.  Develop a diabetic teaching plan History of Diabetes  1552 BC: Egyptian physician Hesy-Ra (3rd Dynasty) makes the first known mention of diabetes – found on the Ebers Papyrus – and lists remedies to combat the ‘passing of too much urine.  c120 CEGreek physicianAretaeus of Cappodocia givesthe first complete medical description of diabetes, which he likens to ‘the melting down of flesh and limbs into urine.  1425 Diabetes first appears in the English language as the Middle English word ‘diabete’.  1674 In his treatise Pharmaceutice rationalis, Professor Thomas Willis of Oxford University describes the ‘wonderfully sweet’flavour of urine in diabetes mellitus.  English physician Matthew Dobson of Liverpool evaporates two quarts of urine from a patient with diabetes. The resulting residue is granulated and smells and tastes like sugar, conclusively establishing the presence of ‘saccharine materials’as a diagnosis of diabetes  1869 German medical student Paul Langerhans discovers the islet cells of the pancreas but is unable to explain their function. The find is dubbed the ‘islets of Langerhans.  1901 American pathologist Eugene Opie of John Hopkins University establishes a connection between the failure of the islets of Langerhans in the pancreas and the occurrence of diabetes.  1919 Dr. FrederickAllen of the Rockefeller Institute in New York publishes his Total Dietary Regulations in the Treatment of Diabetes that introduces a therapy of strict dieting – dubbed the ‘starvation treatment’–- as a way to manage diabetes  Frederick Banting’s work leads to the discovery of insulin  Charles Best, a medical student assists Banting  On July 30, Dog 410 is the first to receive the extract.  OnAugust 4 the extract is called ‘Isletin’for the first time.  Leonard Thompson, 14, a ‘charity patient’at the Toronto General Hospital, becomes the first person to receive and injection of insulin to treat diabetes. Thompson lives another 13 years before dying of pneumonia at age 27.  Elizabeth Evans Hughes, 13, daughter of U.S. Secretary of State Charles Evans Hughes, arrives in Toronto to be treated by Banting for her diabetes  Weighing only 45 pounds and barely able to walk, Elizabeth responds immediately to the insulin treatment, and goes on to live a productive life  She dies in 1981 at age 73.  Oct. 25, 1923 Banting and Macleod are awarded the Nobel Prize in Physiology or Medicine. Banting shares his award with Best, while Macleod shares his with Collip. Morbidity and Mortality  Diabetes affects approximately 2.25 million Canadians  Almost one third of cases are undiagnosed  Rate is 3-5X higher amongAboriginal people.  40% will develop complications  7.1% of all Canadians ≥ 20 years have diabetes.  18% of all Canadians ≥60 years have diabetes Diabetes Mellitus:Agroup of diseases characterized by hyperglycemia attributable to defects in insulin secretion, insulin action, or both Function of Insulin-Concept inAction  Transports and metabolizes glucose for energy  Stimulates storage of glucose in the liver and muscle as glycogen  Signals the liver to stop the release of glucose  Enhances the storage of dietary fat in adipose tissue  Accelerates transport of amino acids into cells  Inhibits the breakdown of stored glucose, protein, and fat Blood Glucose Regulation Question:All of the following are functions of insulin except: A. Enhances the storage of dietary fat in adipose tissue B. Signals the liver to stop the release of glucose C. Transports and metabolizes glucose for energy D. Inhibits transport of amino acids into cells Answer: Inhibits transport of amino acids into cells Rationale: Insulin accelerates the transport of amino acids into cells. Pathophysiology of Diabetes  Many food including turn into glucose when digested  In a non-diabetic individual insulin carries glucose into the cells where it is used to fuel many different reactions  However, diabetic patients often experience two main problems: Problem #1-Lack of Insulin  Not enough insulin is manufactured to match the glucose (carbs) consumed  This allows glucose to continue circulating in the blood  Leads to Hyperglycemia Problem #2-Insulin Resistance  Condition where insulin becomes less effective at lowering blood glucose  Cells fail to respond adequately to circulating insulin, blood glucose levels rise How can you tell if a patient has insulin resistance?  Apple shape: waistline>hip  Waist circumference: ≥100 cm♂ ≥ 88 cm ♀ Classifications of Diabetes  Type 1 diabetes  Type 2 diabetes  Gestational diabetes  Diabetes mellitus associated with other conditions or syndromes  See Table 41-1 Type 1 Diabetes: 5%-10%  Insulin-producing ß cells in the pancreas are destroyed by an autoimmune process  Requires insulin, as little or no insulin is produced  Onset is acute and usually occurs before age 30 Type 2 Diabetes: 90% -95%  Decreased sensitivity to insulin (insulin resistance) and impaired ß cell function results in decreased insulin production  Slow, progressive glucose intolerance  Treated initially with diet and exercise  Oral hypoglycemic agents and insulin may be used Risk Factors-DM 2  Obesity  First degree relative with diabetes  Pre-diabetes  >30 years of age  Hypertension and/or high cholesterol  Aboriginal,African, Hispanic,Asian, SouthAsian descent  History of gestational diabetes Other Risk Factors  Overweight  Abdominal obesity  Polycystic Ovary disease  Acanthosis nigricans  Schizophrenia Pathophysiology of Diabetes Type 1 Diabetes vs. Type 2 Diabetes Type 1-10% Type 2-90% Onset •Usually <30 years of age •Usually > 30 year of age •Increasing incidence in obese pediatric population Epidemiology •More common in Caucasians •More common in Blacks, Hispanics, Aboriginals, Asians Etiology •Autoimmune (circulating Ab) •Complex and multifactorial Body habitus •Normal to wasted •Typically overweight with central obesity Treatment •Insulin •Oral hypoglycemic agents •Insulin when oral hypoglycemics not effective •Lifestyle modifications Acute •Diabetic Ketoacidosis •Hyperglycemic hyperosmolar Complications nonketotic syndrome •Ketosis rare except during stress or infection Signs and Symptoms of DM  Three Ps” 1. Polyuria 2. Polydipsia 3. Polyphagia Other Signs & Symptoms  Fatigue, weakness, vision changes, tinglingor numbness in hands or feet, dryskin, skin lesions or wounds that are slow to heal, and recurrent infections  Type 1 may have sudden weight loss, nausea, vomiting, and abdominal pain if DKAhas developed Diagnostic Findings- Chart 41-3  FPG ≥7.0 mmol/L OR  Casual PG ≥11.1 mmol/L+ symptoms of diabetes (classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss) OR  2hPG in a 75-g OGTT ≥11.1 mmol/L  Aconfirmatorylab glucose test (FPG, casual PG, or 2hPG in a 75-gOGTT) must be done in all cases on another day in the absence of unequivocal hyperglycemia accompanied by acute metabolic decompensation. Components of Diabetes Management Dietary Management—Goals  Provide optimal nutrition including all essential food constituents  Meet energy needs  Achieve and maintain a reasonable weight  Prevent wide fluctuations of blood glucose levels  Decrease serum lipids, if elevated Role of the Nurse  Be knowledgeable about dietary management  Communicate important information to the dietitian or other management specialists  Reinforce patient understanding  Support dietary and lifestyle changes Meal Planning  Consider food preferences, lifestyle, usual eating times, and cultural or ethnic background  Review diet history and need for weight loss, gain, or maintenance  Consider caloric requirements and calorie distribution throughout the day  Carbohydrates: 50% -60% carbohydrates, emphasize whole grains  Fat: 20% to 30%, with >10% from saturated fat and >300 mg of cholesterol  Fibre  Provide exchange lists Glycemic Index  Describes how much a food increases blood glucose  Combining starchy food with protein- and fat-containing food slows absorption and glycemic response  Raw or whole foods tend to have lower response than cooked, chopped, or pureed foods  Eating whole fruits rather than juices decreases the glycemic response owing to fibre slowing absorption  Adding food with sugars may produce lower response if eaten with foods that are more slowly absorbed Other Dietary Concerns  Alcohol  Nutritive and nonnutritive sweeteners  Reading labels Exercise  Lowers blood sugar  Aids in weight loss  Lowers cardiovascular risk Exercise Precautions  Exerc
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