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Diabetes mellitus Diabetes mellitus (DM) is a set of related diseases in which the body cannot regulate the amount

of sugar (specifically, glucose) in the blood. Glucose in the blood gives you energy to perform daily activities, walk briskly, run for a bus, ride your bike, take an aerobic exercise class, and perform your day-to-day chores.

Type 2 diabetes: The pancreas secretes insulin, but the body is partially or completely unable to use the insulin. This is sometimes referred to as insulin resistance. The body tries to overcome this resistance by secreting more and more insulin. People with insulin resistance develop type 2 diabetes when they do not continue to secrete enough insulin to cope with the higher demands. y At least 90% of patients with diabetes have type 2 diabetes. y Type 2 diabetes is typically recognized in adulthood, usually after age 45 years. It used to be called adult-onset diabetes mellitus, or non-insulin-dependent diabetes mellitus. These names are no longer used because type 2 diabetes does occur in younger people, and some people with type 2 diabetes need to use insulin. Type 2 diabetes is usually controlled with diet, weight loss, exercise, and oral medications. More than half of all people with type 2 diabetes require insulin to control their blood sugar levels at some point in the course of their illness. Complications of diabetes Both forms of diabetes ultimately lead to high blood sugar levels, a condition called hyperglycemia. Over a long period of time, hyperglycemia damages the retina of the eye, the kidneys, the nerves, and the blood vessels. y y y Damage to the retina from diabetes (diabetic retinopathy) is a leading cause of blindness. Damage to the kidneys from diabetes (diabetic nephropathy) is a leading cause of kidney failure. Damage to the nerves from diabetes (diabetic neuropathy) is a leading cause of foot wounds and ulcers, which frequently lead to foot and leg amputations. Damage to the nerves in the autonomic nervous system can lead to paralysis of the stomach (gastroparesis), chronic diarrhea, and an inability to control heart rate and blood pressure during postural changes. Diabetes accelerates atherosclerosis, (the formation of fatty plaques inside the arteries), which can lead to blockages or a clot (thrombus). Such changes can then lead to heart attack, stroke, and decreased circulation in the arms and legs (peripheral vascular disease). Diabetes predisposes people to high blood pressure and high cholesterol and triglyceride levels. These conditions independently and together with hyperglycemia increase the risk of heart disease, kidney disease, and other blood vessel complications. In the short run, diabetes can contribute to a number of acute (short-lived) medical problems.

Many infections are associated with diabetes, and infections are frequently more dangerous in someone with diabetes because the body's normal ability to fight infections is impaired. To compound the problem, infections may worsen glucose control, which further delays recovery from infection. y y y Hypoglycemia Diabetic ketoacidosis Hyperosmolar hyperglycemic nonketotic syndrome Diabetes Causes Type 2 diabetes has strong genetic links, meaning that type 2 diabetes tends to run in families. Several genes have been identified and more are under study which may relate to the causes of type 2 diabetes. Risk factors for developing type 2 diabetes include the following: y y y y y y y y High blood pressure High blood triglyceride (fat) levels Gestational diabetes or giving birth to a baby weighing more than 9 pounds High-fat diet High alcohol intake Sedentary lifestyle Obesity or being overweight Ethnicity, particularly when a close relative had type 2 diabetes or gestational diabetes: certain groups, such as African Americans, Native Americans, Hispanic Americans, and Japanese Americans, have a greater risk of developing type 2 diabetes than non-Hispanic whites. y Aging: Increasing age is a significant risk factor for type 2 diabetes. Risk begins to rise significantly at about age 45 years, and rises considerably after age 65 years. Symptoms are often subtle and may be attributed to aging or obesity. y y y y A person may have type 2 diabetes for many years without knowing it. People with type 2 diabetes can develop hyperglycemic hyperosmolar nonketotic syndrome. Type 2 diabetes can be precipitated by steroids and stress. If not properly treated, type 2 diabetes can lead to complications like blindness, kidney failure, heart disease, and nerve damage. Common symptoms of both major types of diabetes: y y y y y y y y Fatigue Unexplained weight loss Excessive thirst (polydipsia) Excessive urination (polyuria) Excessive eating (polyphagia) Poor wound healing Infections Altered mental status Blurry vision

Pathophysiology Insulin resistance means that body cells do not respond appropriately when insulin is present. This is a more complex problem than type 1, but is sometimes easier to treat, especially in the early years when insulin is often still being produced internally. Severe complications can result from improperly managed type 2 diabetes, including renal failure, erectile dysfunction, blindness, slow healing wounds (including surgical incisions), and arterial disease, including coronary artery disease. The onset of type 2 diabetes has been most common in middle age and later life, although it is being more frequently seen in adolescents and young adults due to an increase in child obesity and inactivity. A type of diabetes called MODY is increasingly seen in adolescents, but this is classified as a diabetes due to a specific cause and not as type 2 diabetes. In the 2008 Banting Lecture of the American Diabetes Association, DeFronzo enumerates eight main pathophysiological factors in the type 2 diabetic organism Diabetes mellitus with a known etiology, such as secondary to other diseases, known gene defects, trauma or surgery, or the effects of drugs, is more appropriately called secondary diabetes mellitus or diabetes due to a specific cause. Examples include diabetes mellitus such as MODY or those caused by hemochromatosis, term steroiduse). Recent studies of pancreatic beta cells have indicated a molecular connection between diet, obesity that involves the role of fat in activating a pathway to type 2 diabetes In this mechanism, loss of beta cell glucose sensing contributes substantially to the early manifestation of diabetes, and beta cell dysfunction is responsible for the onset and severity of multiple systemic disease signs including impaired glucose tolerance, hyperglycemia, hepatic steatosis and insulin resistance in muscle and adipose cells. Previous work published in past decades by the laboratories of Roger Unger, Jerrold Olefsky, and Bernard Thorens alluded to the possibility of the importance of beta cell function and glucose sensing in these disease signs. This mechanism of beta cell dysfunction may be contributing substantially to the current epidemic of type 2 diabetes. Diagnosis A number of laboratory tests are available to confirm the diagnosis of diabetes. Finger stick blood glucose: This is a rapid screening test that may be performed anywhere, including community-based screening programs. Fasting plasma glucose: The patient will be asked to eat or drink nothing for 8 hours before having blood drawn (usually first thing in the morning). If the blood glucose level is greater than or equal to 126 mg/dL without eating anything, they probably have diabetes. pancreatic insufficiencies, or certain types of medications (e.g., long-

Oral glucose tolerance test: This test involves drawing blood for a fasting plasma glucose test, then drawing blood for a second test at two hours after drinking a very sweet drink containing 75 grams of sugar. Glycosylated hemoglobin or hemoglobin A1c: This test is a measurement of how high blood sugar levels have been over about the last 120 days (the average life-span of the red blood cells on which the test is based). Diagnosing complications of diabetes If you or someone you know has diabetes, the patient should be checked regularly for early signs of diabetic complications. The healthcare provider can do some of these checks; for others, the patient should be referred to a specialist. y The patient should have their eyes checked at least once a year by an eye specialist (ophthalmologist) to screen for diabetic retinopathy, a leading cause of blindness. The patient's urine should be checked for protein (microalbumin) on a regular basis, at least one to two times per year. Protein in the urine is an early sign of diabetic nephropathy, a leading cause of kidney failure. Sensation in the legs should be checked regularly using a tuning fork or a monofilament device. Diabetic neuropathy is a leading cause in diabetic lower extremity ulcers, which frequently lead to amputation of the feet or legs. The healthcare provider should check the feet and lower legs at every visit for cuts, scrapes, blisters, or other lesions that could become infected. The patient should be screened regularly for conditions that may contribute to heart disease, such as high blood pressure and high cholesterol. Management Management of type 2 diabetes focuses on lifestyle interventions, lowering other cardiovascular risk factors, and maintaining blood glucose levels in the normal range. Self-monitoring of blood glucose for people with newly diagnosed type 2 diabetes was recommended by theNational Health Services in 2008 however the benefit of self monitoring in those not using multi-dose insulin is

questionable. Managing other cardiovascular risk factors including hypertension, high cholesterol, and microalbuminuria improves a person's life expectancy. Lifestyle Aerobic exercise is beneficial in diabetes with a greater amount of exercise yielding better results. It leads to a decrease in HbA1C, improved insulin resistance, and a better V02 max. Resistance training is also

useful and the combination of both types of exercise may be most effective. A diabetic diet that promotes weight loss is important. While the best diet type to achieve this is controversial alow glycemic index diet has been found to improve blood sugar control. Culturally appropriate education may help people with type 2 diabetes control their blood sugar levels, for up to six months at least. Medications There are several classes of medications available. Metformin is generally recommended as a first line treatment as there is good evidence that it decreases mortality.Injections of insulin may either be added to oral medication or used alone. Other classes of medications used to treat type 2 diabetes are sulfonylureas, nonsulfonylurea secretagogues, alpha glucosidase inhibitors, and thiazolidinediones. Insulin When insulin is used, a long-acting formulation is usually added initially, while continuing oral medications. Doses of insulin are increased to effect. The initial insulin regimen is often chosen based on the patient's blood glucose profile. Initially, adding nightly insulin to patients failing oral medications may be best. Nightly insulin combines better with metformin than with sulfonylureas. When nightly insulin is insufficient, choices include:  Premixed insulin with a fixed ratio of short and intermediate acting insulin; this tends to be more effective than long acting insulin, but is associated with increased hypoglycemia. Initial total daily dosage of biphasic insulin can be 10 units if the fasting plasma glucose values are less than 180 mg/dl or 12 units when the fasting plasma glucose is above 180 mg/dl". A guide to titrating fixed ratio insulin is available.  Long acting insulins include insulin glargine and insulin detemir. A meta-analysis of randomized controlled trials by the Cochrane Collaboration found "only a minor clinical benefit of treatment with long-acting insulin analogues for patients with diabetes mellitus type 2". More recently, a randomized controlled trial found that although long acting insulins were less effective, they were associated with reduced hypoglycemic episodes. Surgery Gastric Bypass procedures are currently considered an elective procedure with no universally accepted algorithm to decide who should have the surgery. In the diabetic patient, certain types result in 99-100% prevention of insulin resistance and 80-90% clinical resolution or remission of type 2 diabetes. In 1991, the NIH (National Institutes of Health) Consensus Development Conference on Gastrointestinal Surgery for Obesity proposed that the body mass index (BMI) threshold to consider surgery should drop from 40

to 35 in the appropriate patient. More recently, the American Society for Bariatric Surgery (ASBS) and the ASBS Foundation suggested that the BMI threshold be lowered to 30 in the presence of severe comorbidities.Debate has flourished about the role of gastric bypass surgery in type 2 diabetics since the publication of The Swedish Obese Subjects Study. The largest prospective series showed a large decrease in the occurrence of type 2 diabetes in the post-gastric bypass patient at both 2 years (odds ratio was 0.14) and at 10 years (odds ratio was 0.25). A study of 20-years of Greenville (US) gastric bypass patients found that 80% of those with type 2 diabetes before surgery no longer required insulin or oral agents to maintain normal glucose levels. Weight loss occurred rapidly in many people in the study who had had the surgery. The 20% who did not respond to bypass surgery were, typically, those who were older and had had diabetes for over 20 years.

NURSING INTERVENTIONS:           Advice patient about the importance of an individualized meal plan in meeting weekly weight loss goals and assist with compliance. Assess patients for cognitive or sensory impairments, which may interfere with the ability to accurately administer insulin. Demonstrate and explain thoroughly the procedure for insulin self-injection. Help patient to achieve mastery of technique by taking step by step approach. Review dosage and time of injections in relation to meals, activity, and bedtime based on patients individualized insulin regimen. Instruct patient in the importance of accuracy of insulin preparation and meal timing to avoid hypoglycemia. Explain the importance of exercise in maintaining or reducing weight. Advise patient to assess blood glucose level before strenuous activity and to eat carbohydrate snack before exercising to avoid hypoglycemia. Assess feet and legs for skin temperature, sensation, soft tissues injuries, corns, calluses, dryness, hair distribution, pulses and deep tendon reflexes. Maintain skin integrity by protecting feet from breakdown. Advice patient who smokes to stop smoking or reduce if possible, to reduce vasoconstriction and enhance peripheral flow.