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Diabetes: Part 1. R eview Part 2. Assessment

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Pierce College Summer Boot Camp. Diabetes: Part 1. R eview Part 2. Assessment. Review . Normal glucose metabolism. Diabetes is a disorder of carbohydrate metabolism. Liver produces too much glucose Pancreas secretes insufficient insulin Peripheral tissues resistant to insulin.

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Presentation Transcript
problems can occur at 3 sites in diabetes

Liver produces

too much glucose

  • Pancreas secretes

insufficient insulin

  • Peripheral tissues resistant to insulin
Problems can occur at 3 sites in diabetes
type 2 becomes more common with age

Plasma glucose levels reach higher levels after eating in older adults

  • Plasma glucose levels take longer to return to normal
  • Significantly due to:
    • Accumulated abdominal/visceral fat
    • Decreased muscle mass
Type 2 becomes more common with age
type 2 diabetes becoming increasingly common

Childhood obesity is epidemic

  • Prevalent in specific ethnic groups
  • No genets responsible for type 2 DM have been identified
Type 2 diabetes becoming increasingly common
type 2 symptoms develop gradually

Onset is NOT sudden

  • Fatigue
  • Frequent urination
  • Increased thirst
  • Increased hunger
  • Weight loss
  • Slow healing wounds or sores
Type 2 symptoms develop gradually
common symptoms signs 2

Severe dehydration causes:

    • Weakness
    • Fatigue
    • Mental status changes
  • Weight loss
  • Nausea and vomiting
  • Blurred vision
  • Predisposition to bacterial and fungal infections
Common symptoms & signs 2
complications of diabetes

Complications are primarily VASCULAR

  • GLYCOSYLATION—carbohydrate attached to a group of another molecule
  • Produces protein kinase C
  • Kinase C increases vascular permeability
  • Leads to endothelial dysfunction
Complications of diabetes
effects of diabetic neuropathy

Paresthesias

  • Loss of sense of touch, vibration, proprioception, temperature
  • Blunted perception of foot trauma
  • Carpal tunnel
  • Cranial neuropathies:
    • Diplopia
    • Ptosis
    • Anisocoria
Effects of diabetic neuropathy
diabetic macrovascular disease

Angina pectoris

  • Myocardial infarction
  • TIAs and strokes
  • Peripheral arterial disease
  • Unlike with microvascular

disease, control of glucose

alone is not effective!

Diabetic macrovascular disease
diabetes treatment goals

Plasma glucose 80-120 mg/dl (100-140 at HS)

  • HbgA1c <7%
  • May be adjusted in elderly, short life expectancy, brittle diabetics, those who cannot communicate hypoglycemic symptoms (e.g., children)
Diabetes treatment goals
education

Causes

  • Roles of diet and exercise
  • Self monitoring
  • Symptoms of hypo, hyperglycemia
  • Diabetic complications
  • Type 1—how to titrate

medication

Education
diet and exercise counseling

Low in saturated fat and cholesterol

  • Moderate amounts of carbohydrate
  • Type 1: 1 unit rapid acting insulin per each 15 grams of carbohydrate in a meal
  • Exercise should be increased to whatever level the patient can tolerate
  • All forms of exercise

are beneficial

  • Lower insulin dose may

be required before exercise

Diet and exercise counseling
cause pancreas to release more insulin

Sulfonylureas

Glipizide

Glyburide

Glimeperide

Meglitinides

Prandin

Starlix

Cause pancreas to release more insulin
improve ability to move glucose into the cell esp muscle cells

Biguanides

Metformin

Should not be used in patients with kidney

damage

Improve ability to move glucose into the cell (esp. muscle cells)
medical history

What is the patient’s age?

Why:

Diabetes becomes more common with age.

Over 90% of adults with DM have type 2 diabetes.

Older adults are less tolerant of fluctuations in blood glucose levels.

Medical history
medical history1

What is the patient’s eating pattern?

Nutritional status?

Weight history?

Why:

Is there polyphagia? Polydipsia? Poor eating habits? History of insidious weight gain? A more recent weight loss?

Medical history
medical history2

Is there a history of visual disturbance?

History of kidney problems?

History of numbness? Tingling? Pain?

Why:

Microvascular complications will predispose to diabetic retinopathy , nephropathy, and neuropathy.

Medical history
medical history3

Is there a history of chest pain? Palpitation? DOE?

History of intermittent claudication?

Why:

Macrovascular complications produce large vessel atherosclerosis resulting from hyperinsulinemia, dyslipidemias, and hyperglycemia.

Medical history
medical history4

Is there a history of smoking? Hypertension?

Why:

Smoking 1 pack of cigarettes a day increases one’s risk of developing type 2 diabetes by 61% over that of the nonsmoker. A diabetic smoker is 3 times more likely to die of cardiovascular disease than the diabetic nonsmoker.

HTN is a major risk factor for diabetes.

Medical history
medical history5

Is there a family history of diabetes? Other endocrine disorders?

Why:

Family history of diabetes increases one’s risk for developing diabetes. Many studies have shown a connection through obesity, hypertension, and metabolic syndrome. NO study has shown there is NO increased risk with a positive family history.

Medical history
medical history6

What is the patient’s educational and economic background?

Why:

Patients with diabetes with lower educational and economic levels have been shown to have less utilization of services and monitor their glucose status less frequently that patients with higher educational and economic levels.

Medical history
physical examination

Height and weight

Why:

Obesity contributes to type 2 diabetes

BMI of <25 should be maintained to lower the risk of diabetes.

Risk increases with weight circumference: All women > 31.5”, White and Black men > 37”, Asian men > 35”

Physical examination
physical examination1

Blood pressure, including orthostatic

Why:

Having diabetes makes having hypertension and other heart conditions more likely. Diabetes damages arteries and makes them susceptible to hardening.

Orthostatic hypotension can be due to diabetic neuropathy.

Physical examination
physical examination2

Fundoscopic examination

Why:

Evaluate for diabetic retinopathy as a result of nerve ischemia from microvascular disease.

Physical examination
physical examination3

Thyroid palpation

Why:

Patients with diabetes have a higher risk of thyroid disease. Both are endocrine disorders and may have common autoimmune origins.

Physical examination
physical examination4

Skin assessment

Why:

One-third of diabetic patients will develop a skin condition.

Increased glucose in the blood predisposes to skin infections.

Physical examination
physical examination5

Foot exam:

Inspection every 3-6 months

Palpation DP and PT pulses

Monofilament exam

Why:

Diabetic neuropathy leads to decreased awareness of foot trauma and foot ulceration.

Physical examination
physical examination6

Patellar and Achilles reflexes annually

Why:

Diabetic neuropathy is a late finding in type 1 diabetes but can be an early finding in type 2.

Physical examination
physical examination7

Cardiovascular assessment

Why:

Large vessel atherosclerosis results from hyperinsulinemia, dyslipidemias, and hyperglycemia.

Physical examination
physical examination8

Respiratory assessment

Why:

Complications of diabetes are generally cardiac. But, the eventual long term effects on all systems will be evident. Respiratory assessment should be part of the baseline and ongoing assessment.

Physical examination
physical examination9

Neurological assessment

Why:

Microvascular disease causes nerve ischemia and results in diabetic neuropathy.

Full assessment of cranial nerves and sensation should be performed.

Physical examination
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