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This chapter is from the book

Diabetes Mellitus

There are two types of diabetes: type 1 and type 2. Type 1, also called insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes, is a condition where the islets of Langerhans in the pancreas do not produce needed insulin. Insulin is necessary for food to be metabolized. Antibodies have been found in the majority of clients with type 1 diabetes. These antibodies are proteins in the blood that are part of the client’s immune system. It is believed that type 1 diabetes is in part genetically transmitted from parent to child. At stressful times in life, such as when infection is present, pregnancy or environmental toxins might trigger abnormal antibody responses that result in this autoimmune response. When this happens, the client’s body stops producing insulin. Type 1 diabetes tends to occur in young, lean individuals, usually before 30 years of age; however, it can occur in older individuals. These individuals are referred to as latent autoimmune diabetes in adults (LADA). Diabetes occurs in about 6% of Caucasians, 10% of African Americans, 20–50% of Native Americans, and 15% of Hispanics.

Type 2 diabetes was referred to as non–insulin-dependent, adult-onset diabetes mellitus (ADDM). However, in recent years, more and more children have been diagnosed with ADDM. This trend can be attributed to obesity and sedentary lifestyle. In ADDM, the cells of the body, particularly fat and muscle cells, become resistant to insulin. This leads to increased insulin production with increased insulin resistance. Tests have also shown that this increased insulin resistance leads to a steady decline in beta cell production further worsening glucose control. This problem along with gluconeogenesis, a process in which the liver continues to produce glucose, leads to further hyperglycemia, metabolic acidosis, and deterioration of the client’s health.

Signs and symptoms associated with diabetes mellitus include

  • Weight loss: Insulin is required for carbohydrates to be converted into useable glucose; a lack of insulin results in a lack of glucose with cellular starvation.
  • Ketonuria: The breakdown of fats leads to the production of ketones that causes characteristic fruity breath.
  • Polyphagia: Cellular starvation causes the diabetic to increase food consumption.
  • Polyuria: The kidneys attempt to regulate pH by increasing urinary output of ketones and glucose.
  • Polydipsia: The loss of large amounts of fluid leads to metabolic acidosis and dehydration. To compensate for the fluid loss, the client drinks large amounts of water.
  • Delayed wound healing: Increased blood sugar contributes to poor wound healing.
  • Elevated blood glucose: Normal is 70–110 mg/dl. Uncorrected or improperly managed diabetes mellitus leads to coma and death.

Diagnosis of diabetes mellitus is made by checking blood glucose levels. Several diagnostic tests that can be performed to determine the presence and extent of diabetes are as follows:

  • Glucose tolerance test: The glucose tolerance test is the most reliable diagnostic test for diabetes. Prior to the glucose tolerance test, the client should be instructed to eat a diet high in carbohydrates for three days and remain NPO after midnight the day of the test. The client should come to the office for a fasting blood glucose level, drink a solution high in glucose, and have the blood tested at one and two hours after drinking the glucose solution (glucola) for a test of glucose in the serum. A diagnosis of diabetes is made when the venous blood glucose is greater than 200 mg/dl two hours after the test.
  • Fasting blood glucose levels: The normal fasting blood glucose is 70–110 mg/dl. A diagnosis of diabetes can be made if the fasting blood glucose level is above 140 mg/dl or above on two occasions. A blood glucose level of 800 mg/dl or more, especially if ketones are present, indicates a diagnosis of hyperosmolar hyperglycemic nonketoic syndrome (HHNKS).
  • Two-hour post-prandial: Blood testing for glucose two hours after a meal.
  • Dextrostix: Blood testing for glucose.
  • Glycosylated hemoglobin assays (HbA1c): The best indicator of the average blood glucose for approximately 90–120 days. A finding greater than 7% indicates non-compliance.
  • Glycosylated serum proteins and albumin levels: Become elevated in the same way that HbA1c does. Because serum proteins and albumin turn over in 14 days, however, glycosylated serum albumin (GSA) can be used to indicate blood glucose control over a shorter time.
  • Urine checks for glucose: Ketonuria occurs if blood glucose levels exceed 240 mg/dl.
  • Antibodies: Checked to determine risk factors for the development of type 1 diabetes. Measurement of the cells’ antibodies can also determine the rate of progression to diabetes.

Management of the client with diabetes mellitus includes the following:

  • Diet: The diet should contain a proper balance of carbohydrates, fats, and proteins.
  • Exercise: The client should follow a regular exercise program. He should not exercise if his blood glucose is above 240 mg/dl. He should wait until his blood glucose level returns to normal.
  • Medications: Oral antidiabetic agents or insulin. Medications used to treat diabetes mellitus include sulfanylurea agents, alpha-glucosidase inhibitors, nonsulfanylurea agents, D-phenylalanine derivatives, and thiazolidinediones. Insulins are also used to treat clients with type 1 diabetes. Insulin can be administered subcutaneously, intravenously, or by insulin pump. An insulin pump administers a metered dose of insulin and can provide a bolus of insulin as needed. Byetta is an injectable medicine used to improve blood sugar control in adults with type 2 diabetes. This drug can be used with metformin (Glucophage) or other sulfonylureas. Other more recent medications used to treat type II diabetes mellitus are Januvia (sitagliptin), Onglyza (saxagliptin), Prandin (repaglinide), Starlix (nateglinide), and Victoza (liraglutide).

Hyperglycemia

When there is lack of the hormone insulin, the glucose can’t move from the outside of the cell to the inside of the cell where it can be used. It is very important that the nurse be aware of the signs of hyperglycemia to teach the client and family. Signs and symptoms of hyperglycemia are as follows:

  • Headache
  • Nausea/vomiting
  • Coma
  • Flushed, dry skin
  • Glucose and acetone in urine

Hypoglycemia

When there is a lack of glucose, cell starvation occurs. This results in hypoxemia and cell death. Signs and symptoms of hypoglycemia are as follows:

  • Headache
  • Irritability
  • Disorientation
  • Nausea/vomiting
  • Diaphoresis
  • Pallor
  • Weakness
  • Convulsions

Managing Hyperglycemia and Hypoglycemia

Management of hypoglycemia includes giving glucose. Glucagon, a 50% glucose solution, is an injectable form of glucose given in emergency. Cake icing, orange juice, or a similar carbohydrate can be administered if the client is still conscious. The best bedtime snack is milk and a protein source, such as peanut butter and crackers. Fluid and electrolyte regulation is also a part of the treatment of both hyperglycemia and hypoglycemia.

Unchecked hyperglycemia leads to microangiopathic and macroangiopathic changes. These lead to retinopathies, nephropathy, renal failure, cardiovascular changes, and peripheral vascular problems.

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