DIABETES MELLLITUS

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CRISIS 5
WEEK 2 AND 3 COMPILATION
DIABETES MELLITUS

Exercise 1.1
What is diabetes mellitus?
Answer:
Diabetes mellitus is a group of metabolic diseases characterized by increased levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both.
It occurs when beta cells either are unable to produce insulin (Type I diabetes mellitus) or produce an insufficient amount of insulin (Type II diabetes mellitus). As a result, glucose does not enter cells but remains in the blood

Exercise 1.2
Outline the major classification of diabetes mellitus?
Answer:
There are four types of diabetes mellitus. These are:
·         Type I: known as insulin-dependent (IDDM)
o   Type 1 diabetes has a sudden onset, usually before the age of 30 years because no insulin is being produced.
o   About 5% to 10% of patients with diabetes have type 1 diabetes.
o   Etiology includes genetic, immunologic, and environmental factors (e.g. virus)
o   It is characterized by destruction of the pancreatic beta-cells due to genetic, immunologic, and possibly environmental (e.g. viral) factors. Hence, pancreatic beat cells are unable to produce insulin.
o   Insulin injections are needed to control the blood glucose levels.

·         Type 2: known as non-insulin-dependent (NIDDM)
o   Type 2 diabetes has a slow onset and occurs most frequently in patients older than 30 years and in patients with obesity because insulin is being produced.
o   About 90% to 95% of patients with diabetes have type 2 diabetes.
o   Causes include obesity, heredity, and environmental factors
o   It results from a decreased sensitivity to insulin (insulin resistance) or from a decreased / insufficient amount of insulin production.
o   Type 2 diabetes is first treated with diet and exercise, and then with oral hypoglycemic agents as needed.

·         Gestational diabetes mellitus (DM that occurs during pregnancy).
o   Gestational diabetes is characterized by any degree of glucose intolerance with onset during pregnancy (second or third trimester).
o   It occurs as a result of hormones secreted by the placenta, which inhibit the action of insulin
o   Risks for gestational diabetes include marked obesity, a personal history of gestational diabetes, glycosuria, previously large baby, age older than 30 years, or a strong family history of diabetes.
o   Treated with diet and, if needed, insulin to strictly maintain normal blood glucose levels
o   It increases their risk for hypertensive disorders of pregnancy.
·         Diabetes secondary to other conditions or syndromes
o   Accompanied by conditions known or suspected to cause the disease: pancreatic diseases, hormonal abnormalities, medications such as corticosteroids and estrogen-containing preparations.

Exercise 1.3
Describe etiologic factors associated with diabetes
Answer:
·         Genetic (hereditary)
·         Immunologic (autoimmune)
·         Environmental factors (e.g. virus)
·         Obesity

Exercise 1.4
Outline the risk factors of diabetes mellitus
Answer:
·         Family history of diabetes (i.e. parents or siblings with diabetes)
·         Obesity (i.e. 20% over desired body weight or BMI 27 kg/m2)
·         Race/ethnicity (e.g. African Americans, Hispanic Americans, Native Americans, Asian Americans, Pacific Islanders)
·         Age 45 year
·         Previously identified impaired fasting glucose or impaired glucose tolerance
·         Hypertension (140/90 mm Hg)
·         HDL cholesterol level 35 mg/dL (0.90 mmol/L) and/or triglyceride level 250 mg/dL (2.8 mmol/L)
·         History of gestational diabetes or delivery of babies over 9 lb


Exercise 1.5
Describe the pathophysiology of diabetes mellitus.
Answer:
·         Insulin is an anabolic or storage hormone.
·         It is secreted by the pancreatic beta cells from the islet of Langerhans.
·         When a person eats a meal, insulin secretion increases and moves glucose from the blood into muscle, liver, and fat cells.
·         In those cells, insulin
o   transports and metabolizes glucose for energy
o   Stimulates storage of glucose in the liver and muscle (in the form of glycogen)
o   Signals the liver to stop the release of glucose
o   Enhances storage of dietary fat in adipose tissue
o   Accelerates transport of amino acids (derived from dietary protein) into cells
o   Insulin also inhibits the breakdown of stored glucose, protein, and fat.
·         During fasting periods (between meals and overnight), the pancreas continuously releases a small amount of insulin (basal insulin).
·         Another pancreatic hormone called glucagon (secreted by the alpha cells of the islets of Langerhans) is released when blood glucose levels decrease and stimulates the liver to release stored glucose by a process called glycogenolysis.
·         The insulin and the glucagon together maintain a constant level of glucose in the blood by stimulating the release of glucose from the liver.
·         Defects in insulin secretion by the pancreatic beta cells from the islet of Langerhans or defect in insulin action on target cells, or both accounts for increase in blood glucose level (hyperglycemia) resulting in imbalance blood glucose concentration causing the various types of diabetes mellitus.

Exercise 1.6
Carefully distinguish glycogenolysis from gluconeogenesis.
Answer:
Glycogenolysis is the process whereby glucagon released by the pancreatic alpha cells from the islet of Langerhans stimulates the liver to release stored glucose for use by the body in situation when blood glucose level is low
While
Gluconeogenesis is the process the liver forms glucose from the breakdown of non-carbohydrate substance, including amino acids after a period of fasting (period between meal and overnight)
It is the process whereby glucagon released by the pancreatic alpha cells of the islet of Langerhans stimulates the liver to stored non carbohydrate substances together with stored glycogen and breaks them down to form glucose when blood glucose is low or when cellular demand for ATP is high.



Exercise 1.7
Relate the general clinical manifestations of diabetes to the associated pathophysiologic alterations
Answer:
Classic clinical manifestations of all types of diabetes include the “three Ps”:
·         Polyuria (increased urination)
o   Increased glucose levels in the blood results in excess loss of fluid associated with osmotic diuresis which signal to the patient to increase intake of fluid in an effort to flush glucose out of the body in urine
o   Hence, increased fluid intake will result in increased urination
·         Polydipsia (increased thirst)
o   Increased glucose level in the blood results in excess loss of fluid associated with osmotic diuresis which signal to the patient to increase intake of fluid
·         Polyphagia. (increase appetite)
o   When the pancreatic beta cells are unable to produce insulin or produce insufficient amount of insulin to perform high demand metabolic function or insulin produced are unable to perform their usual action by transporting and metabolizing glucose from blood to cells in the liver, muscles and adipose tissues, cells become starved for energy because of the lack of glucose and signal to the patient to eat, causing the patient to experience an increase in hunger.
o   Patients therefore experience polyphagia (increased appetite) that results from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats
·         Other symptoms include
o   fatigue and weakness since cells are starved of energy
o   sudden vision changes
o   tingling or numbness in hands or feet
o   dry skin
o   skin lesions or wounds that are slow to heal because elevated blood glucose hinder healing process
o   Recurrent infections as bacteria feeds on excess glucose
·         The onset of type 1 diabetes may also be associated with
o   sudden weight since glucose is unable to enter cells
o   loss or nausea,
o   vomiting, or abdominal pains, if DKA has developed
·         Gestational
o   Asymptomatic
o   Some patients may experience increased thirst (polydipsia) from the body attempting to rid itself of glucose.


Exercise 1.8
Discuss how you will assess a patient with diabetes mellitus
Answer:
·         Take health history
o   Symptoms related to the diagnosis of diabetes:
*      Symptoms of hyperglycemia
*      Symptoms of hypoglycemia
*      Frequency, timing, severity, and resolution
o   Results of blood glucose monitoring
o   Status, symptoms, and management of chronic complications of diabetes: Eye; kidney; nerve; genitourinary and sexual, bladder, and gastrointestinal Cardiac; peripheral vascular; foot complications associated with diabetes
o   Adherence to/ability to follow prescribed dietary management plan
o   Adherence to prescribed exercise regimen
o   Adherence to/ability to follow prescribed pharmacologic treatment (insulin or oral anti-diabetic agents)
o   Use of tobacco, alcohol, and prescribed and over-the counter medications/drugs
o   Lifestyle, cultural, psychosocial, and economic factors that may affect diabetes treatment
o   Effects of diabetes or its complications on functional status (e.g. mobility, vision)

·         Physical Examination
o   Blood pressure (sitting and standing to detect orthostatic changes)
o   Body mass index (height and weight)
o   Fundoscopic examination and visual acuity
o   Foot examination (lesions, signs of infection, pulses)
o   Skin examination (lesions and insulin-injection sites)
o   Neurologic examination
o   Vibratory and sensory examination using monofilament
o   Deep tendon reflexes
o   Oral examination

Exercise 1.9
Outline available diagnostic tests for evaluating diabetes mellitus and their interpretation.
Answer:
·         Urinalysis
o   Results: Increased glucose in urine (glucosuria).
·         Fasting blood glucose test.
o   Results: Fasting plasma blood glucose test with a serum glucose level of 126 mg/dL (7.0mmol/l) on three different tests.
·         Random plasma glucose test
o   Results: random plasma glucose at or above 200mg/dL (11.1mmol/l)
·         Oral glucose tolerance test.
o   Results: Oral glucose tolerance test (OGTT) with plasma glucose of 200 mg/dL (11.1mmol/l) two hours after ingesting 75 grams oral glucose.
·         Glycosylated hemoglobin test
o   Result: Glycosylated hemoglobin A1C 6.0 percent or higher.

Exercise 2.1
Outline the medical management for patients with the following types of diabetes mellitus
·         Type 1 diabetes
·         Type 2 diabetes
·         Gestational diabetes
Answer:
·         Type 1 diabetes
o   Regular monitoring of blood glucose.
o   Administer insulin to maintain normal blood glucose levels.
o   Maintain a diabetic diet.
o   Administer:
*      Rapid acting insulin
*      Short acting insulin
*      Intermediate insulin
*      Long acting insulin
·         Type 2 diabetes
o   Maintain ideal body weight through diet and exercise.
o   Regular monitoring of blood glucose.
o   Administer oral sulfonylureas to stimulate secretion of insulin from the pancreas
o   Administer oral biguanides to reduce blood glucose production by the liver:
*      metformin
·         Gestational diabetes
o   Maintain weight through diet and exercise.
o   No oral diabetes medication; most are contraindicated in pregnancy.
o   Administer insulin if diet and exercise fail to control blood glucose levels.

Exercise 2.2
Outline possible nursing diagnosis for a patient with diabetes mellitus
Answer:
·         Risk for imbalanced nutrition: less than what body requires
·         Risk for injury related to sensory alterations
·         Risk for delayed surgical recovery
·         Knowledge deficit for disease process
·         Body image disturbance
·         Nutrition self-care deficit

Exercise 2.3
Outline possible nursing intervention for patients with diabetes mellitus
Answer:
Educate the patient about:
·         The disease and the importance of maintaining normal glucose levels.
·         Blood glucose monitoring.
·         Diet and food choices, including portion sizes.
·         Appropriate exercise and precautionary measures pertaining to exercising.
·         Coping skills to reduce stress.
·         Self-injection of insulin (Type I).
·         Urge smoking cessation.
·         Self-care.
·         Acute management.
·         The Prevention of complications, such as hyperglycemia and hypoglycemia.
·         The importance of daily medications.
·         Hypoglycemia signs and symptoms and interventions.
·         Sweating, lethargy, confusion, hunger, dizziness, weakness as signs of (Type I).
·         The management of hypoglycemia: glucose tablets, or 4 ounces of fruit juice, several hard candies, or a small amount of a carbohydrate.
·         The signs and symptoms of hyperglycemia: fatigue, headache, blurry vision, dry itchy skin.
·         The management of hyperglycemia: a change in medication or dosage, increase in regular exercise, more careful food intake and meal planning, an increase in the number of fingersticks, discussion with the MD/NP/PA.
·         Glucagon injection for hypoglycemic events.

Exercise 2.4
Outline the complication associated with diabetes mellitus
Answer:
·         Acute complication
o   Three major acute complications of diabetes related to short-term imbalances in blood glucose levels are
*      Hypoglycemia
*      Diabetic ketoacidosis (DKA)
*      Hyperglycemic hyperosmolar non-ketotic syndrome (HHNS).
·         Chronic complication
o   Long-term hyperglycemia may contribute to chronic
*      Microvascular complications (kidney and eye disease)
*      Macro vascular complication (coronary artery and peripheral vascular disease)
*      Neuropathic complications


Exercise 2.5
Describe the clinical manifestations, nursing interventions, and medical management for diabetes insipidus.
Answer:
·         Clinical manifestation of diabetic insipidus
o   Polyuria:
*      Increase urination as the kidneys fail to concentrate urine
*      Enormous daily output of very dilute urine (specific gravity 1.001 to 1.005). Primary diabetes insipidus may have an abrupt onset or an insidious onset in adults.
o   Polydipsia:
*      Increase thirst as the body attempts to replace lost of fluid
*      Patient experiences intense thirst, drinking 2 to 20 L of fluid daily, with a special craving for cold water.
o   Polyuria continues even without fluid replacement.
o   If diabetes insipidus is inherited, the primary symptoms may begin at birth; in adults, onset may be insidious or abrupt.
·         Nursing intervention diabetic’s insipidus
o   Maintain fluid and electrolyte balance.
o   Monitor intake and output.
o   Weigh the patient each day using the same scale, at the same time of day, wearing similar clothing.
o   Explain to the patient:
*      Medication must be taken every day.
*      Wear a medical alert necklace/bracelet to alert health care providers that you have diabetes insipidus.
*      Instruct patient and family members about follow-up care and emergency measures.
*      Provide specific verbal and written instructions, including the actions and adverse effects of all medications; demonstrate correct medication administration and observe return demonstrations.
·         Medical management diabetic insipidus.
o   The objectives of therapy are:
*      To replace ADH (which is usually a long-term therapeutic program),
*      To ensure adequate fluid replacement
*      To identify and correct the underlying intracranial pathology.
*      Nephrogenic causes require different management approaches.
All these includes:
ü  Administer replacement ADH hormone such as desmopressin to return normal urination.
ü  Administer a diuretic such as hydrochlorothiazide to decrease urination.
ü  Place the patient on a low-salt diet to reduce urine production in the kidneys.
ü  Increase fluid intake until urination returns to normal.

Exercise 2.6
Distinguish between four diagnostic thyroid tests: serum thyroid-stimulating hormone, serum free T4, serum T3 and T4, and the T3 resin uptake test.
Answer:

Exercise 2.7
Draft six nursing diagnoses and related goals for a patient with hypothyroidism.
Answer:

Exercise 2.8
Explain how radiation can induce thyroid cancer.
Answer:

Exercise 2.9
Compare and contrast the etiology and clinical manifestations of Addison’s disease and Cushing’s syndrome

Answer:

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