PATIENT BIODATA• Mr G• M/47• Businessman• ∆ DM, IHD, hyperlipidemia, HPT• Admission – 27/9/16 @ 2305HRS• Consultant – Dr M

PATIENT BIODATA

• Med History – HPT, DM, IHD (2008) & peripheral vascular disease (2010)

• Surg History – Angioplasty (2008), peripheral angiogram (2010)

• Family History – DM, HPT (mother)• Allergic – Unknown• Mode of Admission – Trolley

ASSESSMENT

• VITAL SIGN : Temperature – 37.4˚C Heart Rate – 98 bpm Respiration – 22 bpm Pain Score - 2/10 DM - 12.7 mmol/L Weight – 67 kg

ACTIVITY DAILY LIVING

• C/O extreme fatigue, giddiness and loss of appetite X 1/12 and SOB X 1/7.

• Conscious, anxious.

• Chest tightness & cough with whitish phlegm

• Heavy smoker 10 years ago

ACTIVITIES DAILY LIVING

• Frequent urination

• Insomnia

• Ambulate with assistant

• Side rail

PHYSICAL EXAMINATION

• Dry skin• Dry and flaky skin at both lower legs and

foots• IV branula 18G at left hand• Oxygen 2L nasal prong in progress

17KS, Trop T, CE, CKMB ECG CT Brain ECHO CXR (PA) TDS glucometer

S/B Dr M at casualty at 2215Hrs :

PANCREAS HORMONES :

• INSULIN BY BETA CELLS

• GLUCAGON BY ALPHA CELLS

Insulin PRODUCTION

Pancreas produce insulin according to the blood

glucose level

• Pancreas secretes 40-50 units of insulin daily in two steps:– Secreted at low levels during

fasting ( basal insulin secretion)– Increased levels after eating

(prandial)– An early burst of insulin occurs

within 10 minutes of eating– Then proceeds with increasing

release as long as hyperglycemia is present

Insulin • Insulin allows glucose to move into

cells to make energy• Inhibits glucagon activity

Diabetes mellitus (DM) is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin production, insulin action, or both.

The term diabetes mellitus describes a metabolic disorder of multiple aetiology characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both.

The effects of diabetes mellitus include long–term damage, dysfunction and failure of various organs.

What is diabetes?

Diabetes

• Diabetes describes a group of metabolic diseases in which the person has high blood glucose (blood sugar), either because insulin production is inadequate, or because the body's cells do not respond properly to insulin, or both.

• Type 1 Diabetes Mellitus • Type 2 Diabetes Mellitus• Gestational Diabetes

TYPES OF DIABETES

Types1.Type I

formerly known as Insulin – Dependent Diabetes Mellitus (IDDM)Autoimmune (Islet cell antibodies)•Early introduction of cow’s milk and cereals•Intake of medicine during pregnancy •Indoor smoking of family members

destruction of beta cells of the pancreas little or no insulin productionrequires daily insulin admin. may occur at any age, usually appears below age 15

• Type 1 Diabetes:Type 1 diabetes is usually diagnosed in children and young adults. Only 10% of people with diabetes have this form of the disease.

• In type 1 diabetes, the body does not produce insulin.

• Patients with type 1 diabetes will need to take insulin injections for the rest of their life. They must also ensure proper blood-glucose levels by carrying out regular blood tests and following a special diet.

2. Type II formerly known as Non Insulin–Dependent

Diabetes Mellitus (NIDDM) probably caused by:

disturbance in insulin reception in the cells number of insulin receptors loss of beta cell responsiveness to glucose

leading to slow or insulin release by the pancreas

occurs over age 40 but can occur in children common in overweight or obese w/ some circulating insulin present, often do

not require insulin

• Type 2 diabetes:• The body does not produce enough insulin for

proper function, or the cells in the body do not react to insulin.

Approximately 90% of all cases of diabetes worldwide are of this type.

• Overweight and obese people have a much higher risk of developing type 2 diabetes compared to those with a healthy body weight.

• The risk of developing type 2 diabetes is also greater as we get older.

• Men whose testosterone levels are low have also been found to have a higher risk of developing type 2 diabetes.

Gestational Diabetes This type affects females during pregnancy. The majority of gestational diabetes patients can

control their diabetes with exercise and diet. Undiagnosed or uncontrolled gestational diabetes can raise the risk of complications during childbirth. The baby may be bigger than he/she should be.

What causes diabetes?

• Diabetes causes vary depending on your genetic makeup, family history, ethnicity, health and environmental factors.

• There is no defined diabetes cause because the causes of diabetes vary depending on the individual and the type.

Who are at risk? ?

Risk Factors• Obesity • Race • History of CVD• HPT • Physical inactivity• Familial history • Polycystic Ovary Syndrome• Gestational Diabetes

? ? ? ? ? ? ?

What happens if there is a problem with the production of insulin?

• Glucose in blood is not able to go into the cells.

• The cells can’t meet energy needs and energy is tried to be provided from ‘fat’ and protein’.

• Using ‘fat’ as the energy source results the increasing of keton in the body.

Physiology

The symptoms of diabetes

• With the usage of protein as energy source,the patient feels themselves tired and sluggish.

• If blood glucose is to high,It is tried to be thrown away by kidneys so the patients begin to urinate so often.

• As a result, the patients feel thirsty and start to drink a lot.

• On the other hand,despite eating so often and a lot,the patients lose weight.

Fasting Plasma Glucose

Oral Glucose Tolerance Test (OGTT)

Glycoselated Hemoglobin (HbA1c)

• HbA1c is a test that measures the amount of glycated hemoglobin in your blood. Glycated hemoglobin is a substance in red blood cells that is formed when blood sugar (glucose) attaches to hemoglobin.

(HbA1c)

Glycoselated Hemoglobin (HbA1c)

Immediate past month

50%

2nd month 25%3rd month 15%4th month 10%

Urinalysis

• Glycosuria • Ketone bodies

Diagnostic Criteria • Classic signs of HYPERGLYSEMIA with CPG ≥200mg/dL• OGTT ≥200mg/dL• FPG ≥126mg/dL• A1C ≥ 6.5%

• CKMB- 45 (< 25 U/L)• ESR- 20 (0-15 mm/hr)• White blood cell count- 20.2 (4.3 – 10.5 10³/uL)• Neutrophil- 87.3% (40-75%)• Lymphocyte- 5.3% (20-45%• Glucose- 13.9 (3.9 – 6.1mmol/L)

17KS, Trop T, CE, CKMB

• Glucose- 13.9 (3.9 – 6.1mmol/L)• Creatinine- 134 (51 – 124umol/L)• Urea- 6.9 (2.0 – 6.8umol/L)• Sodium- 131 (135 – 155mmol/L)

17KS, Trop T, CE, CKMB

• Total cholesterol- 7.2mmol/L (<5.2)• Triglycerides- 2.04mmol/L (<1.71)• HDL cholesterol- 1.05mmol/L (>1.42)• LDL cholesterol- 5.2mmol/L (<2.6)• Chol/HDL Chol- 6.8 (up to 4.0)

17KS, Trop T, CE, CKMB

• Protein, urine- ++ (Negative)

• Glucose, urine- Trace (Negative)

• Bacteria, urine- Occasional (Nil)

Urine FEME

• Normal

CXR (PA)

• Old infarct of right occipital region.

CT BRAIN

• Old ant/apical MI

ECG

• LV apical deterioration• Moderate LVAD

ECHO

• The major components of the treatment of diabetes are:

Management of DM

Diet is a basic part of management in every case. Treatment cannot be effective unless adequate attention is given to ensuring appropriate nutrition.

Dietary treatment should aim at:◦ ensuring weight control◦ providing nutritional requirements◦ allowing good glycaemic control with blood glucose

levels as close to normal as possible◦ correcting any associated blood lipid abnormalities

Diet

Physical activity promotes weight reduction and improves insulin sensitivity, thus lowering blood glucose levels.

Together with dietary treatment, a programme of regular physical activity and exercise should be considered for each person. Such a programme must be tailored to the individual’s health status and fitness.

People should, however, be educated about the potential risk of hypoglycaemia and how to avoid it.

Exercise

• There are currently four classes of oral anti-diabetic agents:

i. Biguanidesii. Insulin Secretagogues – Sulphonylureasiii. Insulin Secretagogues – Non-sulphonylureasiv. α-glucosidase inhibitorsv. Thiazolidinediones (TZDs)

Oral Anti-Diabetic Agents

Oral Antidiabetic Agents

ORAL HYPOGLYCAEMIC MEDICATIONS

Short-term use:Acute illness, surgery, stress and emergencies Pregnancy Breast-feedingInsulin may be used as initial therapy in type 2 diabetes in marked hyperglycaemia Severe metabolic decompensation (diabetic

ketoacidosis, hyperosmolar nonketotic coma, lactic acidosis, severe hypertriglyceridaemia)

C. Insulin Therapy

Long-term use:If targets have not been reached after optimal

dose of combination therapy, consider change to multi-dose insulin therapy. When initiating this,insulin secretagogues should be stopped and insulin sensitisers e.g. Metformin or TZDs, can be continued.

C. Insulin Therapy

The majority of patients will require more than one daily injection if good glycaemic control is to be achieved. However, a once-daily injection of an intermediate acting preparation may be effectively used in some patients.

Twice-daily mixtures of short- and intermediate-acting insulin is a commonly used regimen.

In some cases, a mixture of short- and intermediate-acting insulin may be given in the morning. Further doses of short-acting insulin are given before lunch and the evening meal and an evening dose of intermediate-acting insulin is given at bedtime.

Other regimens based on the same principles may be used.

A regimen of multiple injections of short-acting insulin before the main meals, with an appropriate dose of an intermediate-acting insulin given at bedtime, may be used, particularly when strict glycaemic control is mandatory.

Insulin regimens

Overview of Insulin and Action

Insulin Insulin injection injection

sites sites

Factors that influence the body’s need for insulin

11 need : trauma, infection, fever, severe psychological or physical stress, other illnesses

2. need : active exercise

DRUGS DATE ORDERED

IV Nootropil 1gm TDS 27/9/16

Janumet (50/500) 1/1 BD 27/9/16

Diamicron MR 1/1 BD 27/9/16

IV Cefrex 1gm STAT & BD 27/9/16

Brilinta 11/11 STAT & 1/1 BD 27/9/16

Vasteral MR 1/1 BD 27/9/16

Vytorin (10/20) 1/1 ON 27/9/16

Tanakan 1/1 TDS 27/9/16

Bioquinol 1/1 TDS 27/9/16

Diabetes Management

Algorithm

• Hypoglycemia low blood glucose (usually

below 60mg/dl) results from too much insulin,

not enough food, and/or excessive physical activity

may occur 1-3 hrs after regular insulin injection

Management of Hypoglycemia

1.Give simple sugar orally if pt. is conscious and can swallow – orange juice, candy, glucose tablets, lump of sugar2.Give Glucagon (SQ or IM) if pt. is unconscious or cannot take sugar by mouth3.As soon as pt. regains consciousness, he should be given carbohydrate by mouth4.If pt. does not respond to the above measures, he is given 50 ml of 50% glucose I.V. or 1000 ml of 5%-10% glucose in water I.V.

Preventing Hypoglycemic Reactions Due to Insulin

Instruct the pt. as follows:1.Hypoglycemia may be prevented by maintaining regular exercise, diet and insulin2.Early symptoms of hypoglycemia should by recognized and treated3.Carry at all times some form of simple carbohydrate (orange juice, sugar, candy)4.Extra food should be taken before unusual physical activity or prolonged periods of exercise5.Between-meal and bedtime snacks may be necessary to maintain a normal glucose level.

CHRONIC COMPLICATIONS OF DM• Degenerative changes in the vascular

system– Undernourishment– Atherosclerosis

• Neuropathy from:– Vascular insufficiency–Hyperglycemia

• Eye complications from anoxia– Cataract–Diabetic retinopathy– Retinal detachment

• Nephropathy– Damage & obliteration of capillaries

supplying the kidney• Heart disease–Mi from atherosclerosis

• Skin changes– DIABETIC DERMOPATHY –

HYPERPIGMENTED & SCALY PRETIBIAL AREAS (acanthosis nigricans)

• Liver changes– Enlargement & fatty infiltration

CHRONIC COMPLICATIONS OF DM

SOME COMPLİCATİONS LİNKED TO BADLY CONTROLLED DİABETES:

Eye complications - glaucoma, cataracts, diabetic retinopathy, and some others.

Foot complications - neuropathy, and sometimes gangrene which may require that the foot be amputated

Heart problems - heart disease when the blood supply to the heart muscle is diminished

Hypertension - common in people with diabetes, which can raise the risk of kidney disease, eye problems, heart attack and stroke

Mental health - uncontrolled diabetes raises the risk of suffering from depression, anxiety and some other mental disorders

• Hearing loss - diabetes patients have a higher risk of developing hearing problems

• Gastroparesis - the muscles of the stomach stop working properly• Stroke - if blood pressure, cholesterol levels, and blood glucose

levels are not controlled, the risk of stroke increases significantly

D.K.A.PATHOPHYSIOLOGY

NO INSULIN

MARKED HYPERGLYCEMIA

GLUCOSURIA

WEIGHT LOSS

OSMOTICDIURESIS

POLYURIA

CELLULAR HUNGER

POLYPHAGIA

POLYDIPSIA

LIPOLYSIS

OSMOTICDEHYDRATION

D.K.A.S/SX:• S/SX OF DM +• KETONURIA• METABOLIC ACIDOSIS• KUSSMAUL’S RESPIRATION• ACETONE BREATH• DHN• FLUSHED FACE• TACHYCARDIA• CIRCULATORY COLLAPSE COMA DEATH

D.K.A.

MANAGEMENT:

• ADEQUATE VENTILATION• FLUID REPLACEMENT• INSULIN – RAPID ACTING• ECG

GENERAL STRATEGY• Assessment• Analysis• Planning and

Implementation/Intervention• Evaluation and Ongoing monitoring• Documentation

ASSESSMENT• Primary and secondary

assessment• Focused assessment –Subjective data collection–Objective data collection

Diabetes MellitusNursing Process

• Assessment – Medicines, Allergies, Symptoms, Family Hx

• Nursing Diagnosis- Anxiety and Fear, Altered Nutrition, Pain, Fluid Volume Deficit

• Planning – Address the nursing diagnosis• Implementation – Prevent complications,

monitor blood sugars, administer meds and diet, teach diet and meds, Asess , Assess, Assess

• Evaluation- Goals, EOC’s

Risk for Injury Related to Sensory Alterations

• Interventions and foot care practices:–Cleanse and inspect the feet daily.–Wear properly fitting shoes.–Avoid walking barefoot.–Trim toenails properly.–Report nonhealing breaks in the

skin.

Risk for Impaired Skin Integrity

Wound Care• Wound environment• Debridement• Elimination of pressure on

infected area• Growth factors applied to

wounds

Chronic Pain

• Interventions include:–Maintenance of normal blood

glucose levels–Analgesics –Capsaicin cream

Risk for Injury Related to Disturbed Sensory Perception: Visual

• Interventions include:–Blood glucose control–Environmental management• Incandescent lamp•Coding objects•Syringes with magnifiers•Use of adaptive devices

Ineffective Tissue Perfusion: Renal

• Interventions include:– Control of blood glucose levels– Yearly evaluation of kidney function– Control of blood pressure levels– Prompt treatment of UTIs– Avoidance of nephrotoxic drugs–Diet therapy– Fluid and electrolyte management

Health Teaching

• Assessing learning needs• Assessing physical, cognitive, and

emotional limitations• Explaining survival skills• Counseling• Psychosocial preparation• Home care management• Health care resources

Patients should be educated to practice self-care. This allows the patient to assume responsibility and control of his / her own diabetes management. Self-care should include:

◦ Blood glucose monitoring◦ Body weight monitoring◦ Foot-care◦ Personal hygiene◦ Healthy lifestyle/diet or physical activity◦ Identify targets for control◦ Stopping smoking

Self-Care