Type 1 DM
Etiology & Pathology
Formerly known as insulin-dependent DM or
juvenile diabetes
An autoimmune ds in which autoantibodies are
directed against the islet cells
Once the islet cells are destroyed, the pancreas
can no longer produce insulin
On order to control glucose levels, daily
exogenous insulin is required.
Type 11 DM
Etiology & Pathology
Formerly known as non-insulin dependent DM
Although the amount of endogenous insulin
produced may be WNL, the problem is that
insulin cannot bind with cell receptor sites to
promote transport of glucose into the cell.
Do not usually require exogenous insulin, but if
they do, it is called insulin-requiring DM
Diabetes Mellitus
Somogyi and Dawn phenomenon
Hypoglycemia usually at night followed by
compensatory rebound hyperglycemia ( lasts 12 to 72
hours). Usually caused by too much insulin or an
increase in insulin sensitivity. Can be stabilized by
gradual lowering of insulin dose and increase in diet
at the time of the hypoglycemic reaction.
Dawn phenomenon-BS normal until 3 am-begins to
rise in early morning hours. Glucose released from
liver in early A.M.- needs to be controlled.Altering
time and dose of insulin (NPH or ultralente) by two
or two units-stabilizes the pt.
Diabetes Mellitus
Signs & Symptoms
The “ 3 P’s” (less severe in type 11 DM)
> Polyuria
> Polydipsia
> Polyphagia
Fatigue
Pruitus
Ketosis (more common in Type 1 DM)
Blurred vision (retinopathy)
Tingling, numbness, or pain in the extremities
(neuropathy).
Diabetes Mellitus
Diagnosis
Symptoms of DM plus casual plasma Glu
concentration of 200 mg/dl or higher OR
Fasting plasma Glu level of 126 mg/dl or
higher or
2-hr plasma Glu level of 200 mg/dl or greater
during an oral glucose tolerance test.
Diabetes Mellitus
Treatments
Diet – 60% CHO, 20% fats, 20% protein
Exercise
Insulin therapy: goal is to mimic the pattern of
normal insulin secretion.
Rapid-acting (e.g. Humulin R (or regular)
Intermediate-acting (e.g. NPH)
Long-acting (e.g. Humulin U)
Mixtures (e.g. Humulin 70/30)
Acute Complications of DM
Diabetic Ketoacidosis (DKA)
Usually occurs in type 1 DM
Develops when both insulin deficiency & excess stress
hormones occur
Hyperglycemia, acidosis, & ketosis must all be present
for dx
Blood Glu levels between 300-800 mg/dl
Ketones produced from lipolysis
Blood pH < 7.35
Serum osmolality < 350 mOsm/kg
This is considered a medical emergency; if untreated
coma & death can occur.
Acute Complications of DM
Diabetic Ketoacidosis (DKA) treament
Major goals include correcting the following:
Insulin therapy
Reestablish fluid balance
Replace electrolyte loss
Patient family teaching
Acute Complications of DM
Hyperosmolar Nonacidotic Diabetic (HNAD)
Usually occurs in type 11 DM
Blood Glu levels between 600-1200 mg/dl
No ketones produced
Serum osmolality > 350 mOsm/kg
Blood pH WNL
Because the onset is gradual, condition can be
missed or mis-dx for several weeks.
Acute Complications of DM
Hyperosmolar Nonacidotic Diabetic (HNAD
Signs & Symptoms:
> Neurologic abnormalities (confusion, seizures,
hemiparesis, aphasis, central hyperthermia).
> Hyperglycemia, hyperosmolality & osmotic
diuresis.
> Hypotension
Primary Goals are to:
> Reestablish fluid balance
> Replace electrolytes loss
> Insulin therapy
> Patient/family teaching
Acute Complications of DM
Hypoglycemia
Also called insulin shock or insulin reaction
Occurs when blood Glu levels fall below 50
mh/dl
Signs & symptoms:
> Range from mild to severe tremors,
diaphoresis, confusion, blurred vision,
drowsiness, convulsions.
Treatment:
> Rapid administration of glucose.
Chronic Complications of DM
Microvascular
Retinopathy- progressive impairment of retinal
circulation that eventually causes vitreous
hemorrhage with vision loss.
Assessment:
> Impaired vision.
Implementation:
Assist in ways to maintain independence &
self-esteem.
Instruct in actions that prevent or reduce
complications:stable Blood glucose levels.
Chronic Complications of DM
Microvascular
Neuropathy- general deterioration that affects the
peripheral and autonomic nervous systems.
Assessment:
Peripheral neuropathy:
> Pain in the legs
> Aching and burning sensations in lower ext.
Alterations in bowel & bladder function-constipation,
diarrhea, nocturnal fecal incontinence,infrequent
voiding, weak stream, dribbling, signs of UTI.
Autonomic nervous system- sexual dysfunction,
orthostatic hypotension, pupillary changes
Chronic Complications of DM
Microvascular
Circulatory abnormalities- skin breakdown and signs of
infection, thick toenails: suggestive of circulatory
impairment, athlete’s feet, thin, shiny, atropic skin, weak
peripheral pulses.
Implementation:
 Assist to deal with pain- encourage walking for exercise,
provide foot cradle when in bed.
 Assist to deal with bladder-bowel problems-provide
privacy,encourage fluids, administer drugs for diarrhea.
 Allow to ventilate abt. sexual impotence
 Prevent moisture from accumulation bet. toes
 Instruct in well-fitting shoes. Don’t go barefoot
Chronic Complications of DM
Microvascular
Nepropathy-intercapillary glomerulosclerosisKimmelstiel-Wilson syndrome-pathologic
changes in the kdney that reduce kidney
function-due to chronic DM.
Assessment:
> proteinuria, azotemia,frequent UTI,
neurogenic bladder.
> BUN, creatinine elevated
> Thirst and fatigue
Chronic Complications of DM
Microvascular
Implementation:
Administer meds. To prevent UTI.
Instruct to keep BS levels WNL.
Maintain adequate fluid intake
Instruct in 20 to 40 grams protein diet
Restrict sodium and potassium in diet
Prepare for dialysis therapy if appropriate.
Male erectile dysfunction (ED)- inability to maintain
an erection. Caused by neuropathy,vascular disease,
psychological disorders. Autonomic neuropathy are
responsible for persistent ED.
Chronic Complications of DM
Macrovascular
Cardiovascular- Hypertension-the goal to reduce BP less
than 130/80 mm hg.
Lifestyle modification- weight loss, Na restriction,
exercise. Ace inhibitors- Calcium channel blockers.Beta
blockers- mask hypoglycemia-worsening of insulin
resistance.
Atherosclerosis- elevated low-density
lipoprotein,elevated triglycerides.
PVD- Diabetic Foot- neuropathy- ischemia-sepsis.